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Here, then, we find an obstruction in the center of the pelvis of the kidney, in the form of a narrow opening which is closed by a movable valve, and the question arises how this obstruction developed. The answer is closely connected with the development of hydronephrosis in general, and on this account I wish briefly to discuss it.

Dilatation of the kidney takes place in the following way: The renal pelvis dilates uniformly and retains in general its original form, the walls being, however, a little more rounded, while the calices change their shape considerably, as the renal tissue first yields to the pressure, so that the papillæ of the pyramids first become flat, later somewhat concave, while the mucous membrane and fibrous tissue around the papillæ do not yield very much. Consequently the calices at first become ball shaped, and appear like a cluster of grapes, with thick stems, about the pelvis. As the pyramids yield to the pressure, while the intervening columns of Bertini persist longer, the single cavities, corresponding each to a pyramid, remain separated by partitions which are never absent, even when the dilatation has reached the highest degree, and which are recognized as semilunar valves with sharp margins surrounding the individual dilatations. These folds or partitions vary very much in width, which depends upon the different depth and size of the single calices, and in the case in hand a fold of this sort was sufficiently broad to cover over the opening below it.

But why did we find in this case this relatively narrow opening between the sac and the dilated pelvis below? We found that the entrance to the calices is dilated less than their floor and walls. It lies near at hand to assume that the same may be the case at the entrances from the pelvis to the principal branches. It is exceedingly probable that the two principal branches in this case have behaved in such a way that the upper furnished the calices of the cyst, and the lower the calices of the lower two-thirds of the kidney, and that the origin of the upper branch is the opening covered by the valve.

The development of the hydronephrosis may be sketched as follows: The primary lesion is inflammation about the cecum. From the history we observe that the attacks of pain in the abdomen were older than the origin of the swelling, as there had been perityphlitis and diarrhea two months before swelling was noticed. From the very beginning of the perityphlitis the right ureter became compressed more or less, thus causing a moderate degree of dilatation of the pelvis and of both principal branches. At this time the wall between the first and second calyx of the upper branch, the valve that formed later, commenced to close the angle of division. This is not so remarkable when one considers the variations in form and size observed in the single calices, as well as the movability between the single parts of other soft organs lying in the abdominal cavity, together with the movable intestines. If at first only a temporary closure was effected, then conditions are present for a greater dilatation, and the valve, by falling down over the opening, would protect this against pressure which otherwise would dilate it. In favor of the view that closure by the valve in the beginning of the development of the

egg, the single calices, each one of which is related to two or three of these valves or trabeculæ. The inner surface of the sac is smooth, being covered here and there by a layer of clear mucus; the wall is composed of two layers-an inner, 1⁄2 to 1 mm. thick, grayish and soft, and an outer 2 to 3 mm. thick, white, glistening, firm. The inner layer is formed by atrophic renal tissue, the microscope showing villi surrounded by fine connective tissue,

[graphic][subsumed][subsumed][subsumed]

Fig. 8.-I. Vertical section through the hydronephrosis, the valve, the kidney, and the ureter (half natural size): 1, The hydronephrotic sac; 2, dilatations corresponding to the individual calices; they are surrounded by 3, the semilunar partitions, of which the lower forms 4, the valve, which covers 5, the opening to the rest of the somewhat dilated pelvis, 6; 7, calices; 8, the calyx seen from its entrance to the pelvis; 9, the ureter, which is somewhat narrowed in its course through 10, the perityphlitic abscess. II, The bottom of the sac with the opening into the pelvis of the kidney and the valve, seen from above (natural size): 1, The valve, which is lifted up somewhat; 2, the opening; 3, the calices; 4, partitions.

but without any distinct renal epithelial cells. Here and there is seen a single glomerulus. The outer layer is a solid fibrillar connective tissue, poorly provided with nuclei and vessels. The diagnosis consequently was perityphlitis cæci, abscessus fossæ iliacæ et femoris dextri, hydronephrosis localis renis dextri.

Here, then, we find an obstruction in the center of the pelvis of the kidney, in the form of a narrow opening which is closed by a movable valve, and the question arises how this obstruction developed. The answer is closely connected with the development of hydronephrosis in general, and on this account I wish briefly to discuss it.

Dilatation of the kidney takes place in the following way: The renal pelvis dilates uniformly and retains in general its original form, the walls being, however, a little more rounded, while the calices change their shape considerably, as the renal tissue first yields to the pressure, so that the papillæ of the pyramids first become flat, later somewhat concave, while the mucous membrane and fibrous tissue around the papillæ do not yield very much. Consequently the calices at first become ball shaped, and appear like a cluster of grapes, with thick stems, about the pelvis. As the pyramids yield to the pressure, while the intervening columns of Bertini persist longer, the single cavities, corresponding each to a pyramid, remain separated by partitions which are never absent, even when the dilatation has reached the highest degree, and which are recognized as semilunar valves with sharp margins surrounding the individual dilatations. These folds or partitions vary very much in width, which depends upon the different depth and size of the single calices, and in the case in hand a fold of this sort was sufficiently broad to cover over the opening below it.

But why did we find in this case this relatively narrow opening between the sac and the dilated pelvis below? We found that the entrance to the calices is dilated less than their floor and walls. It lies near at hand to assume that the same may be the case at the entrances from the pelvis to the principal branches. It is exceedingly probable that the two principal branches in this case have behaved in such a way that the upper furnished the calices of the cyst, and the lower the calices of the lower two-thirds of the kidney, and that the origin of the upper branch is the opening covered by the valve.

The development of the hydronephrosis may be sketched as follows: The primary lesion is inflammation about the cecum. From the history we observe that the attacks of pain in the abdomen were older than the origin of the swelling, as there had been perityphlitis and diarrhea two months before swelling was noticed. From the very beginning of the perityphlitis the right ureter became compressed more or less, thus causing a moderate degree of dilatation of the pelvis and of both principal branches. At this time the wall between the first and second calyx of the upper branch, the valve that formed later, commenced to close the angle of division. This is not so remarkable when one considers the variations in form and size observed in the single calices, as well as the movability between the single parts of other soft organs lying in the abdominal cavity, together with the movable intestines. If at first only a temporary closure was effected, then conditions are present for a greater dilatation, and the valve, by falling down over the opening, would protect this against pressure which otherwise would dilate it. In favor of the view that closure by the valve in the beginning of the development of the

egg, the single calices, each one of which is related to two or three of these valves or trabeculæ. The inner surface of the sac is smooth, being covered here and there by a layer of clear mucus; the wall is composed of two layers-an inner, 11⁄2 to 1 mm. thick, grayish and soft, and an outer 2 to 3 mm. thick, white, glistening, firm. The inner layer is formed by atrophic renal tissue, the microscope showing villi surrounded by fine connective tissue,

[graphic][subsumed][subsumed][subsumed]

Fig. 8.-I. Vertical section through the hydronephrosis, the valve, the kidney, and the ureter (half natural size): 1, The hydronephrotic sac; 2, dilatations corresponding to the individual calices; they are surrounded by 3, the semilunar partitions, of which the lower forms 4, the valve, which covers 5, the opening to the rest of the somewhat dilated pelvis, 6; 7, calices; 8, the calyx seen from its entrance to the pelvis; 9, the ureter, which is somewhat narrowed in its course through 10, the perityphlitic abscess. II, The bottom of the sac with the opening into the pelvis of the kidney and the valve, seen from above (natural size): 1, The valve, which is lifted up somewhat; 2, the opening; 3, the calices; 4, partitions.

but without any distinct renal epithelial cells. Here and there is seen a single glomerulus. The outer layer is a solid fibrillar connective tissue, poorly provided with nuclei and vessels. The diagnosis consequently was perityphlitis cæci, abscessus fossæ iliacæ et femoris dextri, hydronephrosis localis renis dextri.

Here, then, we find an obstruction in the center of the pelvis of the kidney, in the form of a narrow opening which is closed by a movable valve, and the question arises how this obstruction developed. The answer is closely connected with the development of hydronephrosis in general, and on this account I wish briefly to discuss it.

Dilatation of the kidney takes place in the following way: The renal pelvis dilates uniformly and retains in general its original form, the walls being, however, a little more rounded, while the calices change their shape considerably, as the renal tissue first yields to the pressure, so that the papillæ of the pyramids first become flat, later somewhat concave, while the mucous membrane and fibrous tissue around the papillæ do not yield very much. Consequently the calices at first become ball shaped, and appear like a cluster of grapes, with thick stems, about the pelvis. As the pyramids yield to the pressure, while the intervening columns of Bertini persist longer, the single cavities, corresponding each to a pyramid, remain separated by partitions which are never absent, even when the dilatation has reached the highest degree, and which are recognized as semilunar valves with sharp margins surrounding the individual dilatations. These folds or partitions vary very much in width, which depends upon the different depth and size of the single calices, and in the case in hand a fold of this sort was sufficiently broad to cover over the opening below it.

But why did we find in this case this relatively narrow opening between the sac and the dilated pelvis below? We found that the entrance to the calices is dilated less than their floor and walls. It lies near at hand to assume that the same may be the case at the entrances from the pelvis to the principal branches. It is exceedingly probable that the two principal branches in this case have behaved in such a way that the upper furnished the calices of the cyst, and the lower the calices of the lower two-thirds of the kidney, and that the origin of the upper branch is the opening covered by the valve.

The development of the hydronephrosis may be sketched as follows: The primary lesion is inflammation about the cecum. From the history we observe that the attacks of pain in the abdomen were older than the origin of the swelling, as there had been perityphlitis and diarrhea two months before swelling was noticed. From the very beginning of the perityphlitis the right ureter became compressed more or less, thus causing a moderate degree of dilatation of the pelvis and of both principal branches. At this time the wall between the first and second calyx of the upper branch, the valve that formed later, commenced to close the angle of division. This is not so remarkable when one considers the variations in form and size observed in the single calices, as well as the movability between the single parts of other soft organs lying in the abdominal cavity, together with the movable intestines. If at first only a temporary closure was effected, then conditions are present for a greater dilatation, and the valve, by falling down over the opening, would protect this against pressure which otherwise would dilate it. In favor of the view that closure by the valve in the beginning of the development of the

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