Document nmvpbJQN7xVdLm8Kxb7eR1Ea

, .Oc t o ber 10 1931 /* ija-*'. a,'"Yv4--^-</ ^. ^-v.. ; ' "A * THE MEDICAL JOURNAL OP AUSTRALIA. >ru /? 453 Cas e II: Mrs. M.M., aged eighty-Bix years, was ill for one week. She noticed a lump protruding from the vulva a few weeks before admission on June 1, 1931. She had been walking about and had had no pain. She had some on the essential kidney tissue. Thus patients are seen in whom the blood pressure is rising steadily, although urea concentration and blood nrea are almost within, normal limits. urinary incontinence. The swelling was not bleeding on The following case report, however, is an instance of admission, but caused a slight purulent discharge. tubular injury, with renal failure such as Fishberg states On examination the lump was irreducible and appeared is produced in laboratory animals by prolonged feeding to be a proliferative type of cervical carcinoma in a senile with white lead. uterus, completely prolapsed. ---- She had had two children and menstruation, according to her statement, continued until she was sixty years of age. There was no other noticeable abnormality in her history or on examination. The pathologist. Dr. Bull, reports the section of growth M.B., aged three years ana eleven months, a female, was first seen by me on March 6, 1930. I later learned that she had been attending the oat-patient department at the Hospital for Sick Children with great irregularity. There was one younger healthy child in the family. as a squamous-celled carcinoma. For eighteen months the patient had suffered from During the week after admission the patient exhibited abdominal pain, weakness in the knees, clumsiness of the mental disturbance of a senile type. The growth .has feet, weakness of the hands and increasing pallor. For increased in size, partly from congestion, and has now an extensive area of necrosis from friction, strangulation and degeneration. The condition appeared unsuitable for radium treatment on account of the difficulties of nursing and incontinence et cetera. Deep X ray therapy was considered appropriate, and will be carried out if the condition of the patient the past three days she had had a slight cough and was feverish at night. The parents stated that she neither bit her nails nor sucked her fingers (these statements were disproved by the most cursory examination of the child), but that there was ample powdered lead on the veranda. Examination revealed a thin, limp and anaemic child, a permits of it. mouth breather with slightly enlarged cervical glands. The teeth were good; there was no blue line. The tonsils were Discussion. enlarged and adenoids appeared to be present. Heart and On consulting the literature, there are reports of cases in young and old women. One may quote Fairbairn, who states: The greatest liability to cervical cancer occurs towards the end of a woman's reproductive life. It is very rare before 25, rare before 35, the vast majority arise between 35 and 65 ... It is unusual to- see cases above the age of 75. Virgins are very rarely and nulliparae rarely affected. The great majority occur in parous women. Wilson (Birmingham) supports these opinions and remarks that: lungs were normal. The systolic blood pressure was 90 and the diastolic pressure 60 millimetres of mercury. These figures were approximate only, owing to the size of the cuff. This figure is normal according to Fishberg. In the abdomen nothing was palpable; the child offered no objection to deep pressure. The parents stated that during attacks of pain she preferred deep pressure to any other form of relief. The urine had a specific gravity of 1-015; it contained a definite cloud of albumin and many granular casts. The blood gave no reaction to the Wassermann test. Slight double wrist drop, very marked double foot drop and weakness in extensors of knees were present, so that Cancer of the cervix is very rare in extreme old age. the child was unable to stand. The deep reflexes wore However, cancer of the cervix occasionally is seen at absent. The plantar reflexes were sluggish and flexor in extremes of age. Joseph Adams relates a case in a type. child of 2 years; de Rouville a case in a girl of 18; Blood examination revealed a secondary anaemia and the Findlay records a case in a woman of 93 who had film showed gross basophilic stippling and polychromasia. borne eight children, one of whom died at the age of The red cells numbered 4,000,000, and the leucocytes 12,800 48 of uterine cancer. per cubic millimetre; the haemoglobin value was 70%. Nevertheless, these are extreme rarities. tt will be noticed that the senile patient had had two children. On the other hand, the youthful patient had had no children nor any miscarriages. The youthful patient had had a. radical Wertheim hysterectomy followed by deep X ray" therapy and two years later appears quite free from local recurrence or distant metastases. Her general health, she The parents were instructed to bring the child in two days for splinting and treatment by intravenous injection of sodium thiosulphate. They were also instructed to bring up a litre of. urine. They returned a week lat.er-with the child gravely ill, after being apparently much better for five days. (Hence their non-return.) She now had "pains all over" and general loss of power. recently, remarked at a post-graduate cllnic.-was.better^than for four years. In this caseAt-seems^mn interesting possibility, that. .the-inamrfiatbry'cSndiflbn' accompanying the cervical' carcinoma might have had a protective influence against malignant spread. The case also illustrates, as Dr. Ralph Worrall has sug gested, that the most unpromising case sometimes may yield a great victory to the surgeon who does his best. The temperature was 37-8 C. (100 F.) and the pulse rate 140 (the child was much distressed by examination). Slight basal bronchitis was present. The abdomen was clear. All limbs were completely paralysed. No strabismus, no head ache and no papillcedema was present. The patient could not be cared for at home, so she was sent to the Hospital for Sick Children. There she became rapidly worse and the paralysis became general; the abdomen -was affected, so that her breathing Referepces. was greatly distressed. Blood urea was found to be 125 > Fairbairn: "Gyntecology and Obstetrics," 1928, page 667. `Wilson: Eden and Lockyer's "Gynaecology," Volume II, 1917, page 449. milligrammes per 100 cubic centimetres. The temperature rose to 39-4 C. (103 F.). There was almost complete suppression of urine, but no cause for the condition could be determined, though a deeply placed pneumonia was thought-the most likely cause. Delirium supervened and PRIMARY KIDNEY INJURY, APPARENTLY DUE TO she grew rapidly worse. LEAD. The child died almost immediately after blood trans fusion on April 16, 1930, from 270 to 300 cubic centimetres By S. F. Mc Do w al o , M.D. (Melbourne), M.R.C.P. (London), of citrated blood being Introduced. Honorary Physician, Hospital for Sick Children, Examination of - the kidneys Only was permitted. Dr. Brisbane. J. V. Duhig, Pathologist to the Brisbane and South Coast Hospitals Board, kindly made the following report: In those instances of chronic nephritis in young people in which lead is held to have been the cause, it is com monly supposed that the action of the lead was rather primarily on' the vascular system and only secondarily The striking feature of the section is the severe damage done to the tubules, while the glomeruli remain to a great extent unaffected. This is well shown in the photomicrograph (see figure in supplement). It N36944 DU PO 50314316 THE MEDICAL JOURNAL OP AUSTRALIA. Oc t o ber 10, 1931. will be seen that the convoluted tubules show distinct change, the epithelium having undergone the whole range of change from cloudy swelling, granularity of the cytoplasm without much nuclear change to complete necrosis with pyknosis and karyorrhexis of the nuclei. The tubules are filled with granular casts in which can he detected nuclear debris. The picture is fairly repre sentative of the section in general, which also shows in parts: (i) A secondary glomerular change, in areas where the tubular lesion is most advanced, consisting of epithelial proliferation of tuft and capsule, fusion and occasionally crescentic hyalinization. (ii) Such inter stitial change as has occurred is scanty and confined to the areas about the interlobular arteries. The vessels themselves have escaped gross damage. Note the healthy ' state of the afferent vessel of the glomerulus in the to the prevertebral muscles, the aia of the thyreoid and the great cornu of the hyoid were removed, and the pharynx was .opened. A mass the size of a hen's egg was found in the pyriform foBsa overlapping the aryepiglottic fold and pushing the larynx over to the left. It was covered with pharyngeal mucosa, except at its attachment below, it apparently originated from the cricoid cartilage internal to the cricothyreoid joint, being extrapbaryngeal in origin. It had then ihvaginated the pharyngeal mucosa and. filled up the pyriform fossa. Some of the fibres of the crico arytenoideus lateralis and the oblique fibres of the cricothyroideus were damaged in removing it. Sections show a fibro-sarcoma. The tumour possesses a capsule in some parts, hut there does not appear to be any .definite invasion of normal tissues, however, the tumour pushing them aside rather than invading them. There are .picture, ,C':. This appears to me a case of acute tubular (catarrhal) nephritis. areas of' degeneration and sclerosis, and in the cellular areas mitotic figures are rarely to be Seen. The feeding tube was removed on the twelfth day and The foregoing illustrates two-points: 1. The rapid increase of paralysis in cases of plumbism on the advent of an acute febrile illness. In some' cases when a paralysis has appeared de novo this has led to a the tracheotomy tube on the thirteenth day.. Convalescence Was uneventful,- except for some coughing with his earlier feeds after removal of the tube. _/ W,;i? ' ' diagnosis of acute anterior poliomyelitis. r 2. The evidence of early tubular damage, shown clinically REMOVAL OF CLINICAL THERMOMETER (HALF by the albuminuria and casts, without evidence of vascular MINUTE) FROM THE BLADDER BY damage. MANUAL MANIPULATION. 3. It is probable that the grave condition here described is an advanced form of the kidney damage which produces ' the albuminuria so commonly seen in juvenile plumbism. : Thus of twenty-two patients with plumbism shown at a clinical meeting at the Hospital for Sick Children -in-- February, 1922, no less than Beven showed albuminuria, By Ab o h ie As p in a l l , M.B., Ch.M, (Sydney), F.R.A.C.S., Honorary Surgeon, Sydney Hospital; Honorary ---j-----0imelting nwrgeon, Royal South Sydney Hospital. ---- - sometimes with granular casts. Bibliography. ' -- "Wh il s t looking through some papers I came across the notes of this case and thought it might be of interest. M.. A. Fishberg: "Hypertension and Nephritis," 1931. In 1924 a married woman, aged thirty-five years, was ..admitted under my care at Sydney Hospital with the "history of having attempted to take her temperature in FIBRO-SARCOMA-O the vulva and having lost the theremometer. She was examined by her family doctor and an unsuccessful attempt was made to recover the thermometer. On admission the By K. M. Gl y n n , M.B., B.S. (Adelaide), . F.R.C.S. (Edinburgh), Honorary Assistant Surgeon, liar. Nose and Throat Department, Adelaide Hospital. patient had no pain, but could not micturate properly, only a few drops of urine being passed at a time: X ray examination revealed the thermometer lying transversely in tlie bladder. As the patient was thin, it was quite easy under general anaesthesia to palpate the thermometer with one hand on . F.K., ag ed fifty-eight years, was first attended by Dr. Rice in an attack of dyspnoea on April 12. The attack lasted half an hour. He had another attack next day, lasting about three-quarters of an hour, after which I saw him. Three weeks previously he had a little shortness of breath when he first started to play tennis. This had gradually worn off after playing for a Bhort while. His voice has the abdomen and a .finger in the vagina. The bladder contained several ounces of urine. With patience it was found possible to work the rounded upper end of the thermometer towards the urethra and to get the thermo meter in the long axis of the pelvis. As it could not be made to. enter the urethra, I placed the tip of my little finger in the urethra and gently dilated it. and with my been getting a little husky for the last twelve months and Assistant's finger in the rectum I was able to press the the family had complained that he made a slight , noise on swallowing. He thinks- he has lost weight. He says he has always been liable to colds in his throat and similar complaints. . On examination I found a smooth and firm looking mass filling up the whole of the right side of the pharynx and larynx as far as but not overlapping the left aryepiglottic fold. Apparently it was not attached to, the pharyngeal wall laterally or posteriorly; it was cedematous. On hook thermometer by the hand on the abdomen against the tip of the finger in the urethra and, maintaining the pressure. I gentiy withdrew my finger from the urethra with the thermometer still pressed' against it. It was a tedious manoeuvre, and the successful termina-; tion was enhanced by the quiet remark of the theatre sister as she looked at the thermometer, to the effect that "the temperature was normal." The patient made an uninterrupted recovery. ing the mass aside after swabbing with cocaine, the glottis could be seen pushed over to the left, but apparently normal. I could not determine if the mass originated in the pyriform , fossa or from the right aryepiglottic fold, Besrietog. nor whether the latter was involved or merely overlapped. Externally the.thyreoid cartilage was rotated to the left and forwards. No glands were palpated. It was PROGRESS IN OBSTETRICS AND GYNAECOLOGY. decided to do Trotter's transthyreoid pharyngotomy. "Avertin'' was given half an hour before by Dr. Gilbert Brown. Tracheotomy was performed and a skin incision for glands" was made before ether was necessary; ether was then given through a tracheotomy tube. The deep cervical glands were enlarged, but subsequent inspection showed them to be normal. - -The sternomastoid muscle was sutured "OhsTETBica an d Gy n aec o l o g y " (Practical Medicine Series, 1930) is one of a series of eight year books issued at various intervals during each year by "The Year Book Publishers" Of Chicago! They cover the entire field of recent medicine and surgery and each volume is complete on the subject of which it treats for the year prior to the time of its PUP!