ner that there are two layers of each with the mucosa on the outside and the fibrosa on the inside with the muscularis between. Usually the fibrous layers are fused together as one and in case of absence of the fibrous layer, the two layers of muscularis are fused. The mucous membrane of each side is continuous with that of the gall bladder of the respective sides throughout the entire length of the fold. This fold or septum always obstructs the lumen to quite an extent, and in some cases it produces almost a complete obstruction. The way in which this deformity occurs is not difficult to understand, when it is remembered that the three inner coats: mucosa, muscularis, and fibrosa, differ in origin from the two outer: the serosa and the subserosa. At first the gall bladder has only the three inner coats. It develops in comparatively a straight line. Later the peritoneum fuses to the under surface, giving this surface its two outer coats. In the cases of the elbow deformity the fundus, either because of a too early fusing to it of the peritoneum or due to its meeting an obstruction, becomes folded downward upon the gall bladder. In these cases when the peritoneum fuses to the under surface, it does not extend into the crevice, but instead, passes directly over, making the deformity become permannt. Acquired strictures vary from those producing practically no perceptible obstruction to the lumen, to those which produce almost complete obstruction. They may arise from— 1. Destructive lesions beginning with the mucosa. 2. Intramural infections. 3. Pathological processes beginning with the serosa. 4. Adhesions. 5. Chronic indurative processes. 6. Perforating wounds. 7. Malignant tumors. The destructive lesions beginning in the mucosa belong usually to one of two types. In one of these the necrosis of tissue is due to the action of bacteria or their toxins. This forms a very frequent cause of ulcer and in some cases they are very extensive. In one of my cases there was a marked stricture about four centimeters from the fundus. On opening the gall bladder, a fold was found at this place diminishing the lumen to about one-fourth that below the stricture. A large scar was present upon the upper surface of the septum and another below, involving a large portion of the surface of the gall bladder. In all, over one-half of the inner surface was occupied by the scars. No stones were present. In the other type of this first variety of acquired strictures the preceding ulcer begins as the result of pressure necrosis from stones. The pressure necrosis, together with the resulting infection, may not produce as extensive an ulcer as the first type, but it often produces a deeper ulcer and one that more often leads to perforation. Ulcers of the gall bladder, when superficial, may heal without deformity, but in the majority of cases there is some deformity which may vary from a slight constriction to the typical hour-glass contraction in which the lumen may be almost completely obstructed. The second form of acquired stricture results from intramural infections originating either from infected Luschka ducts or from bacteria or infected emboli brought through the cystic artery. Strictures due to lesions beginning on the serosa are by no means rare. The pathological process may be a part of a general peritonitis or a local peritonitis arising from any one of numerous causes. Those cases of stricture in which adhesions exist between the gall bladder and other organs or the abdominal wall, are grouped under the fourth class. Some times connective tissue bands are seen extending crosswise, producing constriction of the gall bladder. Sometimes, as in one of my cases, there was a newly formed membrane similar to the so-called Jackson's membrane covering the gall bladder. Chronic indurative processes are responsible for strictures as well as for shrunken or so-called atrophic gall bladders. Under perforating wounds are included strictures resulting from operation, gunshot wounds, stab wounds, etc. Malignant strictures are usually carcinomatous, but I saw one case in which there was a developing metastatic melanosarcoma in the gall bladder wall. A careful study of the gall bladder and cystic duct at the time of operation will usually show if any of these lesions are present. Mucous glands do not occur in the normal gall bladder or in the gall bladder whose walls are not thickened. An inspection of the lumen of the gall bladder will disclose the presence of strictures, and thickening of the valves of Heister is disclosed by an increase in the size of the cystic duct. CASE REPORTS METHAEMOGLOBINEMIA DUE TO VERONAL AND GAS PIOSONING G. L. Hynson, M.D., Portland, Oregon History: Mrs. J. G., housewife, age 51, married. Previous History: Diphtheria at 14, typhoid at 35, mother of two children, hysterectomy three years ago for malignancy. Family History: Mother died of breast disease, father of typhoid fever, one sister of tuberculosis. Present illness: Patient presents herself for treatment at the request of friends and members of the family who tell her she is turning black, not because she feels ill. The only complaint being that she feels weak, becomes tired easily, and that she notices her finger tips, lips, toes and ears are darker. Leading up to the present trouble the patient says that she felt well until six weeks ago, when she contracted the grippe, at which time she lost her appetite, had pain in her head, ached all over, and had fever. For the restlessness and loss of sleep she took liberal doses of veronal, but does not know the exact dosages. During this illness it was also discovered that the gas pipes in her house were leaky, and electricity was installed. Gas was diccarded. Has some pain in the left side of her chest and a little dry cough. Bowels regular; appetite fair, but a small quantity of food suffices. No vomiting. No bleeding or leucorrhea. Physical examination: Tall, slender woman of about 50 years. The observer is at once impressed with the marked cyanosis present, the lips, finger nails and ears being almost purplish-black and the skin a grayish color. The mucous membranes of the mouth, throat, and conjunctiva are slate color. Patient is not dyspoenic, but is guarded in her activity. Laughs and converses without effort. Thorax: Heart normal in size and position; sounds of good quality; no valvular lesions detected. Lungs: Normal to all tests; no adventitious sounds. Abdomen: Firm to the touch, but no masses palpable; no rigidity or distention. Vaginal examinations: No discharge, mucous membrane slate colored. Transverse scar in vault, no masses or ulcerations. Extremities: Negative except for dusky discoloration of toes and nails. X-Ray: Plate of entire chest shows nothing abnormal. Feces: No blood. 2 Blood: Hemoglobin could not be estimated. Red cells 4,673,000. White cells, 5,160. Differential count: polynuclears, 63 per cent; large lymphocytes, 5 per cent; small lymphocytes, 29 per cent; transitional, 0; eosinophiles, 2 per cent; basophiles, 1 per cent. Diagnosis: Methaemoglobinemia due to veronal and gas poisoning. Treatment: Patient was placed in bed for four days, oxygen inhalations for 30 minutes every two hours during waking hours, light diet. On this treatment there was little or no improvement, and a blood transfusion was decided upon. One pint of blood was transfused from a healthy daughter by the citrate method. Patient stood operation well and was returned to her bed in good condition. Oxygen inhalations resumed. Within a few days a marked improvement was noted, the lips becoming pink, the strength and appetite returning. Subsequent blood counts approximately normal in all details. Patient remained at the hospital four weeks and returned to her home with pink lips and rosy cheeks. UNIVERSITY OF OREGON MEDICAL SCHOOL W. F. Allen, M.D., Professor of Anatomy, University of Oregon Medical School Plans for the first unit of the new buildings are now completed, and it is hoped that the new building will be under construction within a month and completed for the commencement of the school term 1918-19. Funds in the neighborhood of $117,000 are available for this building, which, according to the plans, is to be a two-story and a basement, to be constructed out of white brick with terra cotta trimmings and to cover an area of 67x100 feet. The building, which will be ample for the present laboratory needs, will house the departments of anatomy, bacteriology, pathology and surgery on the top floor; biochemistry, pharmacology, physiology, administration and library on the first floor; and lecture rooms, students' room, dark room, cold storage, heating plant, etc., in the basement. The building will be exceptionally well lighted and provided with everything essential for efficient work. The new campus, on the heights above South Portland, consists of about 20 acres, easily reached by country road and street cars, and is unquestionably the most scenic campus in America. It is divided by deed into two parts. An upper plot of 7 acres to be used for laboratory buildings, and the remaining 13 acres for hospital buildings. |
