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ited occasionally. Her bowels were constipated, and had not moved for several days. Her urine was
light in color, of a specific gravity of 1016, and A CASE OF PYONEPHROSIS DUE TO NEPHROLITHIASIS; contained a slight amount of albumin. MacroOPERATION; DEATH; AUTOPSY *
scopical examination showed no casts, but some pus.
Locally on the right side the tumor was observed By RAMON GUITERAS, M.D.
extending from under the free margin of the ribs, Professor of Anatomy and Operative Surgery at the New York Post
forming the right side of the subcostal triangle, graduate Medical School and Hospital; Consulting Surgeon, French Hospital ; Attending Surgeon, Columbus and City Hospitals
down into the right iliac region. Laterally it extendRS. C. J., aged 49 ; occupation, housewife; ed from the umbilicus beyond the lateral line of entered the Columbus Hospital on May
the loin, which it bulged out somewhat. The tumor 20, 1895, complaining of pain in the back was hard, tense, and apparently non-fluctuating. and pain and swelling in the right lumbar region. Various diagnoses, such as perirenal abscess, impac
Previous History.—The patient had always tion of feces, etc., had been made by her former enjoyed good health, and had never been sick until physicians. the commencement of her present trouble.
Notes of the Case While in the Hospital.About a year and a half ago she began to have May 21.-Gave sulphate of magnesia, 3 dr.; this pains and a feeling of distress in the umbilical and followed some calomel which had been given the right lumbar region, which a physician told her was
night before. dyspepsia and for which she was treated for some
May 22. —Bowels moved slightly; gave castor oil, time without obtaining relief.
after which there was a free movement. Some six months later she noticed a small tumor May 23. — Bowels moved twice. in the region where she had been experiencing her
May 24.-She vomited several times. pain and distress. This was sensitive to the touch, ,
May 25.-Up to this date the urine had been about and at times there was a good deal of pain and
the same, when it was found to contain a good deal heaviness present. These symptoms, however,
of pus in the morning, although later in the day it were by no means constant, as at times she would
was again clear, with a specific gravity of 1014. feel relieved for periods of several days.
May 26.--Her urine was clear at intervals, and The tumor continued to increase slowly in size, during the remainder of the time clouded with pus. while at the same time her general condition seemed
Diagnosis.—The case was evidently one pyoneto be growing constantly worse. The symptoms of phrosis, due to one or more renal calculi, which dyspepsia for which she was being treated became
tended to clog the ureter in the pelvis of the kidney, more marked; her periods of vomiting, which at first preventing the escape of pus for intervals of differhad been only occasional, then became much more ent duration. As the urine was comparatively frequent; her appetite began to fail, and her bowels normal at times, it indicated that the other kidney moved with the greatest irregularity, several days
was in good condition, and was successfully doing intervening occasionally between the movements.
the bulk of the work. During all this time the tumor was slowly increas
Operation.—May 27 nephrectomy was performed. ing in size, and in proportion as the size of the
A combined or curved incision was made from the tumor increased the patient lost her strength and
twelfth rib along the outer border of the erectorweight, until at the time when she entered the hos
spinæ muscle to the crest of the ilium, and then pital she had been confined to her bed for several
curved forward. weeks and had lost over forty pounds in weight.
The muscular walls of the abdomen were found to In answer to questions, she stated that her periods
be much atrophied. The lumbar fascia and the had always been regular up to one year ago, when
quadratus-lumborum muscle having been cut through, they had ceased; that she had given birth to four
the capsule of the kidney was immediately brought children, who were alive and well, the youngest of
into view, and, as there was no perirenal fat present, whom was now fourteen years of age. She stated
it closely resembled one of the layers of the lumbar that her habits had always been good, and that she
fascia. By slipping the fingers over its surface, never indulged in stimulants, excepting at her meals,
however, the difference was quickly noticed. The when she usually drank a little red wine.
ileo-inguinal and ileo-hypogastric nerves were seen Condition on Entering the Hospital.—The pa
stretched tightly across it, like two cords. The tient appeared very weak and emaciated.
kidney was observed to be very large and tense. perature on the morning of entering was 98.6 deg.,
Fluctuation was not evident on palpation, although and on the same evening was somewhat elevated.
the characteristic feel of a fluid tumor, extremely This variation in night and morning tempera
dilated, and with a thickened wall, was present. ture continued during the entire time that she was
The capsule was of a bluish-gray color. under observation before the operation. Her appe
The tissues in relation to the kidney anteriorlytite was poor, her tongue coated, and she vom
that is, the colon, mesocolon, and duodenum-were all closely adherent, so that the greatest care was
necessary in shelling them off, which was done with * Read before the Genito-Urinary Section of the Academy of Medi. icine, Dec. 9, 189.5.
the thumb of the right hand, while the organ was
steadied with the left. The artery and vein were after the operation.—The patient had passed no
The kidney then hung by the ureter alone, which that half a drachm of sweet spirits of niter be given
much worse. She twitched occasionally, and her sutures, and the ends caught and squeezed by pulse was weak. Ordered hypodermic injections of sterilized gauze. The kidney having been removed, digitaline and strychnine, and later digitalis poultice the remaining end of the ureter was washed care- over the remaining kidney. The patient continued fully, and then the inside of the end of the canal to fail rapidly, however, and died early in the followwas touched with the Paquelin cautery.
ing morning, without having excreted any urine. The wound was washed out with hot water and The Autopsy.—The operation wound was clean,
packed with iodoform gauze. It was then closed by healthy, and dry. The gauze packing was clean, deep sutures going entirely through the abdominal being only partially discolored by blood. There wall. The patient was quite weak at the end of the was no disagreeable odoror fetor present. No operation. She was therefore stimulated, and put connection was found between the posterior space to bed, with hot bottles at her feet.
from which the kidney had been removed and the The kidney which had been removed was 8 in. cavity of the peritoneum. The peritoneum was long, 5+ wide, and 44 thick. A vertical incision healthy. The small intestines were moderately diswas made through its pelvis, which opened the mouth tended, but the transverse colon of the large intesof the ureter in its long diameter. Through this tine was greatly distended, due perhaps to a incision about a pint of thick pus escaped. The constriction which was found at the splenic flexure. kidney was then seen to be sacculated, and to The remaining kidney was normal in size. Its contain a number of phosphatic calculi, the largest capsule was non-adherent; the surface was smooth; of which was about twice the size of an English the cortex normal in thickness; the markings diswalnut. The capsule of the kidney was very much tinct; the organ appeared congested. No microhypertrophied, and the parenchyma was entirely scopical examination was made. It was probable atrophied. A collapse of the kidney wall followed that the patient had died of anuria, and that there the escape of pus.
were acute congestion and granular degeneration of Condition after the Operation.—May 28, the day the parenchyma of the kidney.
Questions for Consideration.—The fatal result of surfaces, and so great is the volume of the calculi the operation in this case brings up certain important that the kidney is really hollowed out into a mere questions for consideration: First, Should shell, with pouches and pockets to accommodate phrectomy or nephrotomy have been performed ? It the configuration of the stones. Thus the kidney was evident that the other kidney was healthy, from tissue, including both the medullary and cortical the character of the urine that was passed at inter- portions, measures but from 4 to 5 mm. in diameter; vals.
The patient was cachectic, which condition while in many places very dense bands and sheets was due to the continuous pus formation, the pres- of dense connective tissue inclose and separate the sure on the colon and other soft parts of the alimen- several calculi from each other." tary canal by the tumor, and the slight absorption New York: 23 West 53d street. of pus and fecal matter. On account of this cachec- [For discussion hereon, see p. 53 of the present tic condition, might it not have been better, having issue.] cut down quickly on to the kidney, and noted its condition, to have opened its capsule im
CONDYLOMATA mediately and evacuated the
By WM. S. GOTTHEIL, M.D., moved the stones, and then to have washed
Dermatologist to the Lebanon Hospital, and the German West-Side and it out carefully with a solution of bichloride of mer
Northwestern Dispensaries, New York. cury or peroxide of hydrogen, and inserted a tube
HE term “condyloma " is applied in common and gauze drainage ? Such an operation could
medical parlance to certain excrescences have been performed in one-half the time, as the
and tumors of the skin, situated mostly on greatest amount of difficulty was experienced in the genitals and in their neighborhood, exceptionally freeing the organ from its adhesions, prior to remov- found in other areas, and popularly supposed to be ing it. In this way there would have been less ether
connected in some way with venereal diseases. used (which has been ascribed as a frequent cause Among laymen they are known as “venereal warts"for congestion of the kidney), and less shock to the
a name that designates both their external resempatient.
blance to the ordinary verruca, and a commonly The next important question which arises is this: held theory as to their mode of origin. They are The patient being in the condition that she was after
of fairly frequent occurrence. I find in my records the operation, what might have been done other than the histories of some 30 cases seen in public and the measures adopted, to bring on a flow of urine ? private practice during the last few years. Would it have been better not to have given diuret- The prominent location of these tumors, and the ics, which might have irritated the kidney and discomfort and pain that they cause, bring them increased the congestion, but to have worked the early to the notice of the patient; while their disskin or the bowels, vicariously for the former by gusting appearance and odor, when at all extensive, means of pilocarpine and the hot pack, and the lat- lead ihe sufferers to clamor for relief from their dister by doses of the compound jalap powder ?
agreeable deformity. Nevertheless, they are treated The following is a report of Dr. Ira Van Giesen, of but cursorily in the textbooks, and by no means of the College of Physicians and Surgeons, to the receive the attention that their frequency and museum of which institution this specimen was pre- importance entitle them to. In none that I know sented:
of can all the various points relating to the diagno“Gross Appearances of the Kidney.-The kid- sis and treatment of these lesions be found. . A ney, with the calculi, weighs (after hardening in brief consideration of the subject as now underalcohol) 690 gme. It measures 16 ctm. in its longest stood, illustrated by a few cases in point, may not diameter, is 8 ctm. wide, and 5 ctm. thick, The be out of place. development of the calculi has therefore enlarged First and foremost, however, we must recognize the diameter of the organ somewhat, especially in the fact that under the designation of condyloma, its thickness.
or venereal wart, two entirely distinct and separate “Longitudinal section of the kidney discloses affections are included. They have no points in four unusually large and curiously arranged calculi. common, save that the lesion in both cases is a derOne of these, situated at the upper pole of the mal excrescence. Their minuter symptomatology, kidney, measures 6% 372X112 ctm. in diameter. their etiology, and their treatment are entirely difThe remaining three are situated in the lower pole ferent. It is unfortunate that a mere external reof the organ, and consist of two smaller stones, semblance, of no greater diagnostic weight than the which have an irregular ellipsoid shape and measure resemblance of the diarrhea of a tubercular intesabout 14/2 ctm. in diameter.
tinal inflammation to that of an entero-colitis, should“The fourth calculus is cylindrical, and is bent have fixed the nomenclature of the affections. They double or V-shaped, and measures 672 ctm. in are distinguished from one another by the addition of length, with an average thickness of ctm.
the words “acuminatum" and “latum "respectively. "All of these calculi have various tuberosities, Condylomata acuminata are idiopathic non-maligand also facets where they lie in proximity to each nant papillomatous tumors of the skin; while conother. The kidney is molded to fit the several dylomata lata are papules marking the secondary calculi, with their irregular nodular extremities and stage of constitutional syphilis.
Condylomata Acuminata.-Condylomata acu- in the furrows and depressions; decomposition and minata, or papillomata acuminata, are connective- pus infection set in; and the entire tumor is finally, tissue new-growths that appear under certain cir- in most cases, continuously bathed in a foul and cumstances in the skin that surrounds the orifices of ichorous discharge. The odor from it is horrible, the body, and the integument of the genito-anal and renders the patient an object of disgust to himregion. They begin as smaller or larger pointed self and to others. The discharge macerates the elevations or papillae, which grow rapidly and branch surface of the tumor, and denudes it of its epidendritically. Springing from a comparatively thin dermis; hence the extreme liability of these lesions
to suffer injury from external causes.
Their color varies. Being extremely vascular, they are of a more or less deep red in locations where, as in the vulva, the surface epithelium is readily macerated and lost. On the penis and around the anus, on the other hand, where the conditions for maceration are not quite so favorable, the epidermic layer is thicker, and they have a grayish pink or flesh color.
The masses bleed very easily, and readily become inflamed. Sloughing sometimes occurs, and cases have been reported in which a spontaneous cure has been effected in that way.
They occur, as has been said, most commonly at the muco-cutaneous junctions of the body, especially in the anal and genital regions. They are frequently found springing from the sulcus coronarius, the inner surface and the margin of the prepuce, and from the frenum in males.
In women they most commonly affect the urethra, the labia majora and minora, and the anus. In the male, if situated in the urethra, they may cause some dysuria and a muco-purulent discharge, thus simulating a gonorrhea. Condylomata acuminata are not limit
stalk, they soon assume a cauliflower-like shape, and spread laterally over an area greater than that occupied by their base.
They vary greatly in size and shape, depending upon the length of time that they have been present, and the nature of the surrounding parts. the earlier stages they appear as threads, single or branched; later they form tuberous excrescences; and, finally, the confluence of neighboring masses may lead to the formation of large raspberry- or cauliflower-like growths. If the surface is free, and the growing papillomata are not much pressed upon, they develop into flat tuberous masses; but the pressure of surrounding parts may cause them to assume an elongated or irregular shape. Thus, on the glans penis such a papilloma is evenly rounded (Fig. 1); while on the labia majora the pressure of the thighs, etc., cause them to assume a cockscomb shape (Fig. 2).
The surface of these. tumors is papillary and ridged; for all but the smallest are formed by the ed to these regions, however, for they are found coalescence of a varying number of distinct tumors. occasionally on the general integument, and have The sulci on the surface mark the divisions between even been seen in the mouth. them. They are dry at first, and may remain so if They are met with in about equal frequency in the patient is exceptionally cleanly. But the secre- both sexes, though some writers claim that females tion from the delicate surface soon accumulates are most commonly affected. Of my own cases 16
were females and 14 males. Young adults, between long-continued venereal ulceration of any descripthe ages of 15 and 35, are most often the subjects tion may cause irritation of the papillæ of the skin, of the disease; my youngest case was 17 months and excite them to overgrowth. The discharge old, and my oldest 36 years.
from a chancre or a chanchroid, the pus from a Etiology.— The popular designation of these tu- balano-postheitis, with or without a gonorrhea, the mors testifies to the belief that they are manifes- secretions of ulcerative secondary lesions, will all tations of venereal disease. The gynecologists undoubtedly cause their appearance. (Luther, Witte, Broese) still seem to regard gon- In point of fact, the lesion is in its origin an orrhea as the only cause for their appearance, which inflammatory one; and an irritating discharge, Thimmè regards as curious. It is in no way the whatever its origin, may set the papillary hypercase. Gonorrhea is present in many, perhaps in trophy in motion. Mere mechanical stimuli may most, cases; but often there are other causes, and also be the cause. Once started, heat, moisture, sometimes none is discoverable at all. We are deal- and friction are the factors that keep it advancing. ing with a simple hypertrophic disease process on The initial irritant very frequently, perhaps most an inflammatory basis; all the elements of the skin, commonly, is a gonorrhea; but non-gonococcal pus of the papillæ, the vessels, the nerves, and the from any source will do the same if the conditions epithelium are equally involved. There is no are otherwise favorable. Predisposition plays some reason why gonorrhea should be the only irritant part, and I am convinced that in some individuals to
it. Indeed the etiology is obscure. mere neglect and uncleanliness will cause suffiContagion has been supposed to be at the bottom cient irritation to determine their development. of it, and F. Currier2 believes them to be highly so. It is of interest in this connection that condyloThere are a number of observations that seem to mata acuminata of the penis rarely appear in perbear out that view. The case shown in Fig. 2 sons that have been circumcised or that have very concealed the fact of her disease from her lover
I have kept no exact record in dnring its early stages; and he acquired similar regard to this ; but out of my 30 cases there is warty growths on his penis. Contiguous points are not a single one whose name unmistakably testifies almost always affected, as is shown in Fig. 2 and in to his Jewish origin. Fig. 3.
It is not uncommon to find isolated warts Anatomy.--As Thimmø correctly observes, neion the sides of the buttocks or on the perineal ther textbooks nor monographs tell us much ab region, with others exactly opposite and touching the anatomy of these growths. They are papillothem. And, finally, the evidence in favor of the mata, and belong to the class that incontagiousness of ordinary warts would lead us to cludes warts, horns, polypi, and
the suspect the same of these similar formations.
called cauliflower excrescences. As the Ducrey and Oro3 have been so impressed with sult of irritation and maceration, or without these facts that they examined a number of these apparent cause, the papillæ and the rete mucosæ growihs for micro-organisms. After careful disinfec- commence to hypertrophy. The papillæ elongate tion of the tumors and the surrounding tissue, they ex- and give off lateral branches; and the blood-vessels cised them, and sowed them in various culture me
and nerves grow pari passu. dia. They obtained only negative results. Various The epidermis, however, as Unna has demonmicrobes were developed and isolated. Some were strated, is not usually more voluminous in condyloundoubtedly accidental; but others were so constant mata acuminata than it is in the normal skin; hyperthat they were suspected to be the causal agent of keratosis is entirely absent. In this it differs from the disease. But inoculation experiments on man the verruca, or wart, a closely related papillomatous and animals were alike fruitless. They were struck, growth. This latter shows a similar hyperthropy of however, with the clinical analogies between condy- the papillæ and the rete, with a like overgrowth of lomata acuminata and the psoro-spermosis of Darier; the vessels and nerves contained therein; but with and they claim to have found bodies very like the
the addition of a great increase in the epidermal laypsoro-sperms in their sections. They were round This difference, however, is probably rather and oval bodies lying between the cells of the stratum
accidental than fundamental; as is shown by the occorneum and of the stratum Malpighii, some being currence of condylomata acuminata with horny tops, found even within the epithelial cells. Osmic acid or even complicated with cornua cutanea. Kaposi's showed cystic forms. Ducrey and Oro concluded explanation is plausible and sufficient. Both growths that the condylomata acuminata belonged to the
are papillomata in which all the elements of the skin psoro-spermoses; but subsequent investigations have participate in the hypertrophic process. But the not confirmed their results. As E. Martin says, all verrucæ, or warts, are always so situated that the the etiological finds of the protozoa are as yet specu- epidermis has an opportunity to accumulate and lative.
become horny; they are dry and hard, and covered Lang" claims, and he is undoubtedly correct, that with a thick corneous layer. The condylomata
acuminata, on the other hand, are generally so 1"Kurse Bemerkungen zu einigen neueren Arbeiten über Condylomata acuminata, etc. Reichs-medicinal Anzeiger, Nos. 13 to 15, 1896.
placed that their surfaces are macerated; the soft2 Morrow: “System of Dermatology." 3 Riforma medica, June, 1892. 4 E. Lang : "Das venerische Geschwur," p.