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less often invaded than the other organs. It usually involves both
kidneys, and is found in the cortex as miliary granulomata. In
the chronic form the parenchyma is the frequent seat of marked
degenerative changes, in which very often the calicos and pelvis
are implicated. Not infrequently but a single organ is involved ;
so, too, where the urinary invasion is general, the genital apparatus
is also apt to be invaded. An interesting example of the path of
infection in one of these chronic cases was demonstrated by
KiimmeljiJ.in the tubercular kidney of a young female, aged
22 years, of excellent family record. There was a history of a
previous vesical catarrh, followed by pain in the right lumbar
region, the development of a floating kidney, which, upon operation,
was found to be caseated, and was removed, the operation being
followed by recovery and improvement. Cases not showing any
marked difference from the above in the appearance of the organ
or the diameter of co-existing lesions of the bladder and ureter are
mentioned by Reilley,J^„Gemmell,SJ. Ritchie,,^ and Anderson,^ as
instances of primary renal tuberculosis, with extension by the ureter
to the bladder. The true sequence would apparently be directly
the opposite, arising from some overlooked urinary infection. The
precedence of vesical symptoms in all these cases is apparently
overlooked, although the post-mortem ^evidence clearly indicates
considerable duration of vesical inflammation from the intense
thickening of the walls as described. The fact that but a single
organ in these (as, too, in many other instances) showed evidences
of tubercular invasion is by no means inconsistent with the upward
advance of tlie process, and would be directly opposed to urinary
infection through the general system. Why vesical tubercular
inflammation should advance to the invasion of but a single ureter,
])elvis, and kidney should not be regarded as difficult of explana-
tion. Either the inflammatory process affects one ureter by acci-



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''ofKldi'ey!'] DISEASES OP THE KIDNEYS, ETC. G-31

dent or because of less resistive power of the tissue due to passing
ureteral dilatation following vesical spasm ; or as a result of spasm
of the bladder the downward flow of urine is seriously interfered
with and slowed, and in the direction of least resistance the infec-
tion is borne. A case occurring in a young girl mentioned by
DrummMvi!Sp».»is referred to a cystitis the etiology of which pos-
sibly depends upon infection occurring during excessive onanism.
In this instance a large perinephritic tubercular abscess was devel-
oped finally. Bonneau ^i, records a case occurring in a carter, aged
35 years, in which the sequence of infection is clearly an upward
extension from the bladder; the opposite kidney was unaffected,
but in a condition of compensator)' hypertrophy. Stone ^t^ men-
tions a case occurring in a woman, aged 22 years, following a cys-
titis which had its origin at least six years prior to death. Not
until a few months before death were there signs of renal involve-
ment, although it had probably existed some time.

Baudet^lSii'^cords a case, in a 15-year-old boy, in which the
earliest point of invasion, so far as detennined, was the testicle,
then the prostate and bladder, thence along the ureter to the kidney.
Faure^^ mentions a case in a man, aged 24 years, who, upon en-
trance into the hospital, showed symptoms of an intense cystitis;
and at the autopsy, a year or more later, the prostate was found
involved, the bladder thickened and ulcerated, the right ureter
thickened, ulcerated, and the seat of cheesy change at several
points, and the kidney enlarged and in a cheesy and purulent state.
Philip 4y had met a case of marked tubercidar ulceration of the
bladder, in which, at autopsy, the left kidney was found enlarged
and tubercular. Schmittj^Jf^ reports a similar case in a woman
aged 53 years. Of the 12 cases of cheesy renal tuberculosis men-
tioned above, 5 cases occurred before 20 years of age, 3 between
20 and 30, 2 between 30 and 40, and 1 above 50 years, the
age of one case not being recorded. Iscovesco,^^^in an article
upon scrofulosis of the kidney, recognizes, among the changes,
those of cheesy and tubercular kidneys, amyloid change, and dif-
fuse nephritis. Contrary to the usual opinion, he believes that
amyloid change is exceptional in the scrofulous, but a diffuse
nephritis is quite frequent. He states that it is possible to find
the amyloid change associated with inflammatory process, however.
This diffuse nephritis manifests itself to the naked eye as a large



19-^



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G-32 TYSON AND SMITH. [

white kidney, the lesions being parenchymatous and interstitial.
Clinically, such a condition may remain latent indefinitely or may
manifest itself promptly by albuminuria and the ordinary symp-
toms of the large white kidney. Death in such cases usually
takes place by uraemia in from six months to two years. Striib-
ing,.^6.A^. reports 2 cases of renal struma. He defines heterologous
struma of the kidneys (which, according to this writer, springs
really from tlie adrenals) as characterized by the formation in the
kidneys of large cysts filled with peculiar bloody and fatty contents.
The writer classes it with the malignant tumors ; he states that
both kidneys may be involved, tliough this is unusual, and that
metastasis is frequent. Where it is clearly limited to a single
kidney, extupation of the organ is to be performed. In the removal
of the kidney, or its inability from whatever cause to perform its
functions, the fellow-organ undergoes a compensating hypertrophy
(Svensson,Tij?^ quoted by Eklund, coiTesponding editor). This
hypertrophy, according to Tuffier, 2?. consists in both numerical
and simple enlargements of the remaining renal tissue, with new
formation of glomerules and tubules.

UREMIA.

Thudichum,H.S.^ reviewing his methods in the isolation of the
urinary alkaloids, attributes the phenomena of uraemia as probably
caused either by these alkaloids — creatin, urochrom, urotheo-
bromin, and several others combining with platinic or zinc chloride
—or by the products of their decomposition. LepineM^i,,2;ii
has succeeded in producing uraemic-like phenomena by injecting
into the ureters steiilized salt water, thus producing counter-
pressure to the secretion. This procedure, at first, after several
hours, provokes, in a healthy dog, a progressive and considerable
rise in temperature, then dyspnoea, and finally death. This forcible
retention of the urine very probably leads to a resorption into the
system of the toxic principles of the urine— one of which, perhaps,
possesses thermogenic properties. Bouveret,,S»with the above
experiments in mind, reviews two instances in which well-marked
hyperthermia was a feature; and in a case published by Holland, ,ijt,
dying of uraemia during utero-gestation, the temperature is recorded
as ranging between 102° and 105° F. (38.88° and 41° C.) ; as, too,
in cases reported by Moore, ^ and Stallard. ,2. Debove, JSJ^ investi-



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Cyrtitu.] DISEASES OF THE KIDNEYS, ETC. G-33

gating the cause of slowness of pulse, attributed by Charcot to
bulbar lesions, has not succeeded in demonstrating any such lesion,
but has met in conjunction with slow pulse-action evident renal in-
sufficiency, and suggests that the condition of uraemia bears some
influence upon the production of this phenomenon. Girodej^ calls
attention to the early occurrence of uraemia in a child of 8
years, presenting a predominance of bulbar symptoms, tetaniform
convulsions, sialorrhoea, hyperthermia, and death in a short time.
Another case occurred in a boy, aged 15 years, in whom there was
a marked alcoholic history. These cases indicate that, while the
condition is usually of late appearance, under favorable circum-
stances it may set in early, and that its usual late manifestation is
not so much due to the age of the renal organs as to tlieir lessened
vital resistive power. Dunin^iu publishes the notes of 5 cases of
uraemia, all showing phenomena pointing to local cerebral disease,
4 simulating the lesions of Jacksonian epilepsy, the fifth evinc-
ing symptoms of the optic functions indicating lesions of the corpora
quadrigemina and posterior cerebral lobe.

In cases of uraemic intoxication, Peter ^recommends, for the
purpose of sympathetic stimulation, the subcutaneous administra-
tion of ether, with a view of hastening the excretory processes.
Partzevsky^ commends benzoate of soda in uraemia, believing it
to lessen the duration and the severity of the convulsive attacks.
Mackenzie, A^^jjAi.!© following Loomis and others, urges the use of
morphia in those cases of chronic uraemia in which there is need
to counteract the effects of the retained urinary poisons. He
narrates several cases in which progressive and urgent symptoms,
as headache and dyspnoea, were at once relieved by administration
of this drug.

DISEASES OP THE BLADDER.
CYSTITIS.

Silcock^JJu demonstrated a case of vesiculated bladder, a speci-
men obtained from a male dead aftier nephrectomy (a calculus
being found later, impacted in the lower part of the ureter,
which was dilated and thickened). The vesicles varied from
the size of a pin-head to that of a small shot, and were espe-
cially scattered over the trigone. They contained blood-stained,
serous fluid at the autopsy. They seemed to have originated ui



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G-34 TYSON AND SMITH. [cyititto.

small foci of leucocytes or young epidermal cells, the result of
rapid focal epidermal proliferation, with secondary degeneration
and solution. Przewoski,, Sunder the term "nodular or follicular
cystitis," des(iil)es a process which may hold some relation to the
foregoing, but which the author has demonstrated to be tubercular.
Brown Si calls attention to the fact that many of the chronic
cases of cystitis in females are really due to the irritation of the
bladder by the " hysterical urine " of low gravity and almost devoid
of salts. He further makes a timely suggestion as to the etiology
in referring to the lack of proper frequency in the emptying of the
viscus in these cases from false modesty or a lack of accommodation.
The same end is brought about in those cases in which there exists
atony of the bladder, with the retention of a part of the contents
( White, JIJ Casper,, It), the residual urine being particularly prone
to fermentative changes. Where the retention is complete, from
obstruction or other causes, an especial liability to vesical inflam-
mation results, the dilatation of the viscus leading to rupture of
its mucous coat, and thus affording numerous foci for the invasion
by micro-organisms that may gain entrance into the bladder
(Guyon, JlJtjJS). Fenwick,^« looks upon the presence in a bladder
of residual urine as more or less predisposing to cancerous involve-
ment. In pathological conditions the normal sensibility of the
bladder to tension is exaggerated, causing frequent micturition;
and, according to Guyon,M2»this sensibility of the desire to mictu-
rate is not in any way local to one point of the mucous membrane,
but is situated in all parts of tlie organ. There is also added a
sensibility to contact, and actual pain not infrequently manifests
itself Hartmann,,if„in considering the neuralgias of the bladder,
divides them into two great classes, idiopathic and symptomatic.
The latter class depends either upon some lesion of the nervous
apparatus, as in tabes (Weir Mitchell), or general paralysis
(Vemeuil), or to some lesion of the urinary tract or of the neigh-
boring organs. The former are those dependent upon either a
localized cause (as the constant pressure and trembling motion
transmitted by certain forms of seats to the perinaeum) or general,
as gout or rheumatism. A case of exfoliation of the vesical
mucous surface in an old man is mentioned by Semeleder, of
Mexico, corresponding editor, ^ there being a layer of embryonic
tissue replacing the epithelium. CallionzisJJJ publishes the notes



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Cystitu.] DISEASES OF THE KIDNEYS, ETC. G-35

of a case of chronic cystitis, the walls of the bladder having become
encrusted with a phosphatic deposit. Relief was obtained by
thoroughly scmping the walls with a blade of a lithotrite, and
afterward wasliing with a hot solution of boric acid. BrjsoUjJ^
calls attention to the existence of rings (curvations) about the neck
of the bladder, as a result of chronic cystitis. Tricomi,, it; S. study-
ing the absorptive power of the bladder in rabbits, guinea-pigs,
and dogs, states that in healthy states of the viscus the absorption
is the same as in hypodermic injections for strychnia, prussic acid,
chloroform, and sulphuretted hydrogen, less rapid for cantharidin,
carbolic acid, corrosive subUmate, morphia, and especially cocaine.
Putrefied Hquids are not readily absorbed. Where the mucous
coat is in a pathological condition, the absorption of the first series
of substances is the same as in a normal state of the coat; of the
second series, less rapid. Injection of micro-organisms is always
followed by signs of intoxication. In suppurative cystitis the ab-
sorption of gases is as rapid as in hypodermic injections of the same.
Lavaux^pr^.^S* writes against the indiscriminate employment of
hypodermics of morphia in the treatment of painful cystitis, having
observed cases of eclampsia and other untoward effects. He com-
mends instead the use of cocaine. FreyMjy^?,.,2?M regards iodoform
as a drug of value in cystitis of the chronic form, of almost any
origin, combhiing with its antiseptic and deodorizing powers styptic
and analgesic properties. It is his practice to thoroughly wash
out the cavity with lukewarm water, and then throw in a solution
containing iodofoim, glycerin, and a little gum tragacanth, making
injection as often as every third day. Vansant^., commends the
use of salol in cases of ordinary chronic cystitis; Smith „*,» recom-
mends saccharin as a means of rendering acid the alkaline urine
of chronic suppurative cystitis. Pichi is recommended by Nash,^
in the same class of cases; as, too, is Pareira brava by McNulty.,^
The use of di-y heat, apphed by using a hollow double bougie,
through which passes hot water, guarded throughout the urethral
length, is recommended by^HoytJ^in cystitis in the female. It is
claimed that marked improvement follows almost immediately, the
pelvic congestion, weight, and soreness being readily relieved, a
better circulation being established in tlie vesical walls and pelvic
organs generally. The complete cure of a case of cystitis of five
years' standing in a girl aged 11 years, by the employment of



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G-36 TYSON AND SMITH. [cyitltto.

balsam of copaiba, is reported by McMechan. J^*„ Palmer^com-
inends highly the use of corrosive-sublimate solution, as weak as 1
to 30,000, in the treatment of gonorrhcea and gonorrhoeal cystitis.
Hot irrigations of from 30 to 60 fluidounces (930 to 1860 grammes)
of tlie solution, gradually increasing the strength from day to day,
are employed twice a day where practicable, the average cure of
all cases occurring in six to seven weeks.

Where there is paresis or any insufficiency of the detrusor
muscle, leading to the presence of residual lu-ine in the bladder,
Heddaeus^J^.A^e ad vises the following method of manual evacua-
tion : The patient lying upon his back, his thighs flexed, the
physician faces the patient, the thumbs being brought over the
symphysis, the fingers placed over the upper portion of the blad-
der and downward pressure employed ; or the physician may face
away from the patient, placing the ulnar borders of the hands
along Poupart's ligament and produce downward pressure by the
thumbs. The method should not be used where the retention is
from obstruction or is very marked, or where inflammatory con-
ditions prevail, lest i-upture of the viscus result. Chico,J:„ claims
priority in the practice of this method for the late Francisco Bas-
setti, of the medical faculty of Mexico, the latter having performed
and taught it as early as 1874. Madden, mL as a rapid curative
method for cystitis in women, recommends operative procedure
where every ordinary course has been clearly eliminated. He does
not advise the formation of a vesico-vaginal fistula (Emmet and
Sims), but urges the dilatation of the urethm and the swabbing of
the surface of the vesical and urethral mucous membrane with a
glycerole of carbolic acid, repeated several times at intervals of a
week. Bazyj^je recommends in these cases, when far advanced,
particularly where the surface is encrusted with lime-salts, the
scraping of the mucous surface with the blade of a lithotrite, and
then wasliing or mopping the surface with some mild antiseptic
solution, as of boric acid. Following Maguire, Foy,^„ recommends,
in cases of advanced cystitis with ammoniacal urine, that supra-
pubic cystotomy be performed with a view of providing a means
of washing the bladder with antiseptic solutions, — a practice also
commended by Fehleisen. jj,^ A case in which this proceeding was
successfully earned out is reported by Davis. JJ^ BelinlJ;^ advises for
the same object ordinary tipping of the bladder, washing out the



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tS'SfhSder.] DISEASES OF THE KIDNEYS, ETC. G-37

visciis through the cannula. In the cases of alkahne fermentation
Smith r2?i« suggests the internal administration of saccharine as a
means of acidifying and as an antiseptic, the drug being eliminated
almost entirely by the kidneys.

TUMORS OF THE BLADDER.

Vincent ^ describes a cyst removed from the posterior wall of
the bladder of a girl of 9 years. It was pedicnlated and about
the size of a walnut, and apparently grew from the glandular
structures encountered about the neck of the viscus. Fenwickj^^
believes that by the use of the electric endoscope a precancerous
condition of the vesical membrane may be recognized, in which
the surface is somewhat blurred, lumpy, and gelatinous, and most
frequently seen between the ureteral oi)enings, — the usual seat of
cancer. Paul J2? mentions a case of cancer of the bladder of a male,
aged 39 years, which, upon section, was to all appearances a myxo-
sarcoma ; careful examination of the growth in other parts decided
its cancerous nature. Symj^ reports a case of a large cancerous
growth of the posterior wall of the bladder, not invading the
ureters of the neck of the viscus, occurring in a woman aged 73
years. Four years previously hsematuria was present, and some
months prior to the death she had a large amount of papilloma-
tous material removed with temporary relief. There were no sec-
ondary growths. Stokes jii reports the death of a case from cancer
of the bladder three years after the removal of several papilloma-
tous tumors from her bladder, which were regarded as benign.
Cabot,jJ,„failhig to catch a suspected stone in the lithotrite after
rejieated attempts, jierformed supm-pubic cystotomy, cutting into a
large, hard tumor-mass immediately over the pelvic arch. The
wound was closed and healed, but death followed within a year.
A large scirrhus of the bladder was found, a portion of which, pro-
jecting into the viscus, was encrusted with salts, and gave the
impression of stone. Another growth, from examination a scirrhous
cancer, is reported by Southamj^,as occurring in the bladder of a
male aged 66 years. The growth scarcely in^'aded the bladder-
cavity, but grew in the thickened bladder-walls, with little ulcer-
ative tendency. Because of this, haematuria was absent until
within a few days of death, and the other symptoms were like-
wise postponed. The growth apparently was primarily from the



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G-38 TYSON AND SMITH. ["SJSlS:*

bladder, but invaded the cellular tissue between the bladder and
rectum, the prostate, and tlie tissue about the base of the bladder.

Lamarque,^JSi exhibiting the bladder of a chronic cystitis case,
a man aged 55 years, a hemiplegic with urinary retention, called
attention to the existence, besides the usual appearances of chronic
cystitis, of numerous small papillomata visible beneath a layer of
lymph, probably of recent origin, inasmuch as haematuria was a
recent symptom. The scattered distribution of these growths was
also somewhat anomalous. Cabot ,^1, mentions a case illustrating
a possible error in diagnosis. The case was one of severe cystitis,
with erosion of the vesical membrane over the prostate, laying
bare the proliferating gland-acini. Some of these, becoming sepa-
rated, were found in the urine and mistaken for the villi of a
papillomatous growth.

Englischwff^has collected 23 cases of idiopathic pericystitis of
the cavity of Retzius, 18 men and 5 women. Early life, between
8 and 30 years, seems especially liable to the occurrence ; perhaj^
tuberculosis should be looked upon as a predisposing condition.
At any rate, any existing or previous attack of cystitis is highly
predisposing. The usual local symptoms are vesical pain and
tumefaction, appearing above the symphysis and sometimes reach-
ing the umbilicus. The inflammation may disappear spontaneously
or go on to sclerotic changes or suppuration; the diagnosis is
especially liable to be confused with that of local peritonitis, cystitis,
or abdominal myositis. The vast majority recover, if properly cared
for, the treatment involving no special features from that of other
inflammations.

CALCULOUS DISEASE.

In an elaborate study of calculous formation in the prostate,
PosnerB.il!^i^ states that these concretions so frequent in old men are,
in a certain sense, allied to starch of the vegetable kingdom and to
ordinary amyloid material, but present essential differences. They
are, further, composed of crystalline elements, as of lecithin, and
may form within a crypt by degeneration of its retained secretion,
or may be caused by a degeneration of a mass of cells.

Bruce ?2J states, as his opinion of the formation of urinary cal-
culi, that a chronic or subacute catarrh is necessary, the perverted
viscid secretion resulting acting as a means of agglutinating the
crystalline elements. Ebstein and Nicolaierjil?,have produced



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^Di^J?.T DISEASES OF THE KIDNEYS, ETC. G-39

renal calculi by feeding to dogs oxamid (an oxalic derivative of
ammonia). The largest stones were always in the renal pelvis,
but small ones were frequently scattered through the renal
structure. The oxamid was found to form these calculi and
could be dissolved from them, leaving behind an organic skeleton.
The calculi had the usual concentric layer, and were of a greenish
color, the oxamid having taken up a urinary pigment. An
enormous calculus from the renal pelvis of a woman at autopsy is
reported.^ It weighed 180 grammes (5| ounces), was large and
branched ; the kidney was also quite large, the entire weight of
organ and calculus being 3^ pounds (about 2 kilos). A large
vesical calculus is mentioned by Duret,,^^ removed from the
bladder of a child aged 6 years ; the weight was 60 grammes (2
ounces), the stone being of the size of a mandarin, smooth, with
a centre of brown surrounded by concentric layers of white.
Box S2. reports a case of oxalic calculus passed after several
attacks of colic, not of the usual mulberry form, but ciystalline,
built upon the combination of two large octahedrals. Wiedp.?^„
demonstrated the left kidney of a man, aged 43 years, who had
never suffered any symptoms of renal calculi. The organ was filled
with several large arborescent calculi; the ureter was plugged
by a large stone, and practically no secreting tissue was uninvaded
by the stones or the results of degeneration due to their presence.
Billings }i£ reports a case of nephrotomy, 8 calculi being removed
and a small amount of pus washed from the wound. The patient
died, and upon examination the opposite kidney was found to con-
tain a large number of calculi also, but little secreting tissue re-
maining. Chiene,^ demonstrated several vesical calculi, removed,
1 from a boy of 4 J years, 2 from men aged 52 and 60, respectively,
and the last from a woman, the result of the encrustation of a
foreign substance introduced into the urethm. Davis JSJa^d
Flint ^l.,e both caU attention to the fact that the passage of very
small concretions may cause intense renal colic, quoting cases and
presenting specimens illustrating their remarks. Potain/J^» reports
a case of left-sided renal colic, in which there were present a



Online LibraryGeorgia. Treasury DeptAnnual of the universal medical sciences and analytical index. A yearly report of the progress of the general sanitary sciences throughout the world. [1888-1896.] ... → online text (page 25 of 48)