John Roberts Phillips

Papilloma of the gall bladder

B ENIGN tumors of the gaII bIadder were considered rare unti1 MacCarty described choIecystitis catarrhaIis papiIIomatosa in rgr o; he was the first in this country to describe the condition. About the time of his report, choIecystectomy began to be recognized more and more as the best procedure in treating many cases of disease of the gaI1 bIadder. With this change in surgica1 procedure, more thorough examination of the interior of the gaI1 bIadder couId be carried out, and papiIIomas began to be seen more frequentIy by the surgica1 pathoIogist. This increasing incidence of recognition of the condition is evident in the papers of Irwin and MacCarty, C. H. Mayo, Keene, M8IIe, AbeII, and MacCarty. My study was of a group of 500 gaI1 bIadders, surgicaIIy removed at The Mayo Clinic between 1923 and rg2g which proved to contain one papiIIoma or more. These gaI1 bIadders were taken consecutiveIy as they appeared in the course of a11 operations on the gaI1 bIadder. SpeciaI attention was given to the reIationship of papiIIoma t.o maIignancy, and to other diseases of the gaII bIadder. The corresponding cIinica1 histories were reviewed. The incidence by age of patients was found to be as foIIows: ten to twenty years, 0.4 per cent; twenty to thirty years, 6.2 per cent; thirty to forty years, 2g per cent; forty to fifty years, 30.8 per cent; fifty to sixty years, 27.6 per cent, and sixty to seventy years, 6 per cent. Of the patients from whom the gaII bIadders were derived, 68.4 per cent were femaIes. From these figures the high incidence of papiIIomas among patients of the comparativeIy earIy age group of thirty to forty years wiI1 be noted. PapiIIomas rareIy occur before the third decade of Iife. Records of post-mortem examinations made at the cIinic from 1922 to 1930 in cases in which death was from other causes than disease of the gaI1 bIadder discIose that onIy 3 cases of papiIIoma of the gaI1 bIadder were found among patients who were Iess than thirty years of age. These three patients were, respectiveIy, twentytwo, twenty-four and twenty-six years of age. Mentzer, in his study of 633 consecutive postmortem examinations, found onIy one patient Iess than thirty years of age who had papiIIomatous choIecystitis. AI1 the sections studied microscopicahy gave evidence of inflammation, either in an acute, subacute, or chronic form, but by far the greatest number were exampIes of so-caIIed chronic catarrha1 choIecystitis, as is shown by infiItration of the submucosa by smaI1 round ceIIs. EtioIogicaIIy I think two factors present themseIves in the formation of papiIIomas: in one group infection pIays the important part; in a second group, infection and metaboIic disturbances work together. By far the Iarger number of cases wiI1 faI1 in the Iatter group. In the cases of true inffammation, the gross appearance is that of papiIIary projections from the mucous membrane of the gaI1 bladder; the coIor of the papilloma resembIes that of the mucous membrane. The pedicIe is of about the same size as the growth (Fig. I). The growth, therefore, does not break off easiIy, but, as wiI1 appear, papiIIomas of the type next to be described do break off. MicroscopicaIIy, the papiIIomas appear as projections with many branches, with very Iittle stroma,

Clostridial myonecrosis of the abdominal wall: Management after extensive resection

Abstract A method of temporary and permanent containment of abdominal viscera after extensive clostridial myonecrosis is described. Debridement is carried out through parallel incisions with maximal preservation of skin and subcutaneous tissue. Marlex mesh is used temporarily until the infection is completely controlled. The skin and subcutaneous tissue are then reapproximated, giving excellent wound coverage and markedly shortening the hospital stay.

Paroxysmal hypertension due to paraganglioma

Abstract The most prominent feature of this syndrome is sudden dramatic episodes of paroxysmal hypertension which are believed to be due to the outpouring of large amounts of adrenalin into the systemic circulation by these tumors. Attacks vary widely in duration from a few minutes to many days. Intermittent attacks of hypertension, developing without apparent cause, accompanied by vertigo, nausea and vomiting, headaches, palpatation, dyspnea, and pain of anginal type may be considered characteristic of this syndrome. A case of the chromafin cell type associated with paroxysmal episodes of hypertension is reported. The case was further complicated by marked sickle cell type of anemia which has required repeated transfusions to combat it.

Acute mesenteric occlusion.

Abstract A case of successful resection of sixty-six inches of the ileum for acute mesenteric occlusion is reported. The prompt resection was the chief reason for success.

Tumors of the adrenal gland: Carcinoma of the adrenal cortex

Abstract Tumors arising in the adrenal gland represent a very interesting group. Since the adrenal is divided into two anatomic portions, the cortex and the medulla, we can have tumors arising from either of these component parts. Those arising from the adrenal cortex which are benign rarely cause any symptoms and are found only at autopsy. The other great group of cortical tumors are malignant and give rise in children to a marked precocious development as characterized by marked growth of sexual organs, increased osseous growth and in the female in sexual development which often tends toward the masculine side. In the adult a chain of symptoms commonly called Cushings syndrome may develop consisting of plethoric adiposity of the face, neck and trunk, purplish striae, acrocyanosis, polycythemia and vascular hypertension, frequently accompanied by hyperglycemia and osteoporosis, and in women by amenorrhea and hypertrichosis. Other glands of internal secretion such as the ovaries, testicle, thymus and pituitary may also give rise to symptoms which so closely resemble adrenal cortical tumors that it is practically impossible to distinguish between them. This is the reason that so often surgical exploration of both adrenal glands is necessary to prove or disprove its presence, and exploration should be encouraged even though a certain number of patients will be disappointed because no adrenal disorder will be found. Otherwise tumors of the adrenal will be overlooked. Tumors arising from the medulla (pheochromocytoma) are usually benign. Symptomatology includes attacks of paroxysmal hypertension and tachycardia, characterized by sweating, nausea, headache and glycosuria. Their removal produces satisfactory results provided they have not caused a severe cardiovascular damage. Most tumors of the adrenal cortex which produce symptoms have been malignant and the prognosis, of course, has been bad. In contrast, tumors of the medulla are usually benign.