ORIGINAL CONTRIBUTIONS

A CASE OF PYONEPHROSIS DUE TO NEPHROLITHIASIS; OPERATION; DEATH; AUTOPSY *

By RAMON GUITERAS, M.D.

Professor of Anatomy and Operative Surgery at the New York Postgraduate Medical School and Hospital; Consulting Surgeon, French Hospital; Attending Surgeon, Columbus and City Hospitals

M

RS. C. J., aged 49; occupation, housewife; entered the Columbus Hospital on May 20, 1895, complaining of pain in the back. and pain and swelling in the right lumbar region. Previous History. The patient had always enjoyed good health, and had never been sick until the commencement of her present trouble.

About a year and a half ago she began to have pains and a feeling of distress in the umbilical and right lumbar region, which a physician told her was dyspepsia and for which she was treated for some time without obtaining relief.

Some six months later she noticed a small tumor in the region where she had been experiencing her pain and distress. This was sensitive to the touch, and at times there was a good deal of pain and heaviness present. These symptoms, however, were by no means constant, as at times she would feel relieved for periods of several days.

The tumor continued to increase slowly in size, while at the same time her general condition seemed to be growing constantly worse. The symptoms of dyspepsia for which she was being treated became more marked; her periods of vomiting, which at first had been only occasional, then became much more frequent; her appetite began to fail, and her bowels. moved with the greatest irregularity, several days intervening occasionally between the movements.

During all this time the tumor was slowly increasing in size, and in proportion as the size of the tumor increased the patient lost her strength and weight, until at the time when she entered the hospital she had been confined to her bed for several weeks and had lost over forty pounds in weight.

In answer to questions, she stated that her periods had always been regular up to one year ago, when they had ceased; that she had given birth to four children, who were alive and well, the youngest of whom was now fourteen years of age. She stated that her habits had always been good, and that she never indulged in stimulants, excepting at her meals, when she usually drank a little red wine.

Condition on Entering the Hospital.-The patient appeared very weak and emaciated. Her temperature on the morning of entering was 98.6 deg., and on the same evening was somewhat elevated. This variation in night and morning temperature continued during the entire time that she was under observation before the operation. Her appetite was poor, her tongue coated, and she vom

* Read before the Genito-Urinary Section of the Academy of Mediicine, Dec. 9, 1895.

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 contained a slight amount of albumin. Macroscopical examination showed no casts, but some pus.

Locally on the right side the tumor was observed extending from under the free margin of the ribs, forming the right side of the subcostal triangle, down into the right iliac region. Laterally it extended from the umbilicus beyond the lateral line of the loin, which it bulged out somewhat. The tumor was hard, tense, and apparently non-fluctuating. Various diagnoses, such as perirenal abscess, impaction of feces, etc., had been made by her former physicians.

Notes of the Case While in the Hospital.May 21.-Gave sulphate of magnesia, 3 dr.; this followed some calomel which had been given the night before.

May 22.-Bowels moved slightly; gave castor oil, after which there was a free movement. May 23.-Bowels moved twice.

May 24. She vomited several times. May 25.-Up to this date the urine had been about the same, when it was found to contain a good deal of pus in the morning, although later in the day it was again clear, with a specific gravity of 1014.

.

May 26. Her urine was clear at intervals, and during the remainder of the time clouded with pus.

Diagnosis. The case was evidently one pyonephrosis, due to one or more renal calculi, which tended to clog the ureter in the pelvis of the kidney, preventing the escape of pus for intervals of different duration. As the urine was comparatively normal at times, it indicated that the other kidney was in good condition, and was successfully doing the bulk of the work.

Operation.-May 27 nephrectomy was performed. A combined or curved incision was made from the twelfth rib along the outer border of the erectorspinæ muscle to the crest of the ilium, and then curved forward.

The

The muscular walls of the abdomen were found to be much atrophied. The lumbar fascia and the quadratus-lumborum muscle having been cut through, the capsule of the kidney was immediately brought into view, and, as there was no perirenal fat present, it closely resembled one of the layers of the lumbar fascia. By slipping the fingers over its surface, however, the difference was quickly noticed. ileo-inguinal and ileo-hypogastric nerves were seen stretched tightly across it, like two cords. The kidney was observed to be very large and tense. Fluctuation was not evident on palpation, although the characteristic feel of a fluid tumor, extremely dilated, and with a thickened wall, was present. The capsule was of a bluish-gray color.

The tissues in relation to the kidney anteriorlythat 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 the thumb of the right hand, while the organ was

Questions for Consideration. The fatal result of the operation in this case brings up certain important questions for consideration: First, Should nephrectomy or nephrotomy have been performed? It was evident that the other kidney was healthy, from the character of the urine that was passed at intervals. The patient was cachectic, which condition was due to the continuous pus formation, the pressure on the colon and other soft parts of the alimentary canal by the tumor, and the slight absorption of pus and fecal matter. On account of this cachectic condition, might it not have been better, having cut down quickly on to the kidney, and noted its condition, to have opened its capsule immediately and evacuated the pus and removed the stones, and then to have washed it out carefully with a solution of bichloride of mercury or peroxide of hydrogen, and inserted a tube and gauze drainage ? Such an operation could have been performed in one-half the time, as the greatest amount of difficulty was experienced in freeing the organ from its adhesions, prior to removing it. In this way there would have been less ether used (which has been ascribed as a frequent cause for congestion of the kidney), and less shock to the patient.

The next important question which arises is this: The patient being in the condition that she was after the operation, what might have been done other than the measures adopted, to bring on a flow of urine? Would it have been better not to have given diuretics, which might have irritated the kidney and increased the congestion, but to have worked the skin or the bowels, vicariously for the former by means of pilocarpine and the hot pack, and the latter by doses of the compound jalap powder ?

The following is a report of Dr. Ira Van Giesen, of the College of Physicians and Surgeons, to the museum of which institution this specimen was presented:

"Gross Appearances of the Kidney.-The kidney, with the calculi, weighs (after hardening in alcohol) 690 gme. It measures 16 ctm. in its longest diameter, is 8 ctm. wide, and 5 ctm. thick. The development of the calculi has therefore enlarged the diameter of the organ somewhat, especially in its thickness.

"Longitudinal section of the kidney discloses four unusually large and curiously arranged calculi. One of these, situated at the upper pole of the kidney, measures 61⁄2 32X11⁄2 ctm. in diameter. The remaining three are situated in the lower pole of the organ, and consist of two smaller stones, which have an irregular ellipsoid shape and measure about 11⁄2 ctm. in diameter.

"The fourth calculus is cylindrical, and is bent double or V-shaped, and measures 61⁄2 ctm. in length, with an average thickness of 2 ctm.

"All of these calculi have various tuberosities, and also facets where they lie in proximity to each other. The kidney is molded to fit the several calculi, with their irregular nodular extremities and

surfaces, and so great is the volume of the calculi that the kidney is really hollowed out into a mere shell, with pouches and pockets to accommodate the configuration of the stones. Thus the kidney tissue, including both the medullary and cortical portions, measures but from 4 to 5 mm. in diameter; while in many places very dense bands and sheets of dense connective tissue inclose and separate the several calculi from each other."

New York: 23 West 53d street.

[For discussion hereon, see p. 53 of the present issue.]

CONDYLOMATA

By WM. S. GOTTHEIL, M.D.,

Dermatologist to the Lebanon Hospital, and the German West-Side and Northwestern Dispensaries, New York.

TH

HE term "condyloma " is applied in common medical parlance to certain excrescences and tumors of the skin, situated mostly on the genitals and in their neighborhood, exceptionally found in other areas, and popularly supposed to be connected in some way with venereal diseases. Among laymen they are known as "venereal warts"— a name that designates both their external resemblance to the ordinary verruca, and a commonly held theory as to their mode of origin. They are of fairly frequent occurrence. I find in my records the histories of some 30 cases seen in public and private practice during the last few years.

The prominent location of these tumors, and the discomfort and pain that they cause, bring them early to the notice of the patient; while their disgusting appearance and odor, when at all extensive, lead the sufferers to clamor for relief from their disagreeable deformity. Nevertheless, they are treated of but cursorily in the textbooks, and by no means receive the attention that their frequency and importance entitle them to. In none that I know of can all the various points relating to the diagnosis and treatment of these lesions be found. A brief consideration of the subject as now understood, illustrated by a few cases in point, may not be out of place.

First and foremost, however, we must recognize the fact that under the designation of condyloma, or venereal wart, two entirely distinct and separate affections are included. They have no points in common, save that the lesion in both cases is a dermal excrescence. Their minuter symptomatology, their etiology, and their treatment are entirely different. It is unfortunate that a mere external resemblance, of no greater diagnostic weight than the resemblance of the diarrhea of a tubercular intestinal inflammation to that of an entero-colitis, shouldhave fixed the nomenclature of the affections. They are distinguished from one another by the addition of the words "acuminatum" and "latum " respectively. Condylomata acuminata are idiopathic non-malignant papillomatous tumors of the skin; while condylomata lata are papules marking the secondary stage of constitutional syphilis.

Condylomata Acuminata.-Condylomata acuminata, or papillomata acuminata, are connectivetissue new-growths that appear under certain circumstances in the skin that surrounds the orifices of the body, and the integument of the genito-anal region. They begin as smaller or larger pointed elevations or papillae, which grow rapidly and branch dendritically. Springing from a comparatively thin

in the furrows and depressions; decomposition and pus infection set in; and the entire tumor is finally, in most cases, continuously bathed in a foul and ichorous discharge. The odor from it is horrible, and renders the patient an object of disgust to himself and to others. The discharge macerates the surface of the tumor, and denudes it of its epidermis; 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

FIG. I

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. In 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 coalescence of a varying number of distinct tumors. The sulci on the surface mark the divisions between them. They are dry at first, and may remain so if the patient is exceptionally cleanly. But the secretion from the delicate surface soon accumulates

FIG. 2.

ed to these regions, however, for they are found occasionally on the general integument, and have even been seen in the mouth.

They are met with in about equal frequency in both sexes, though some writers claim that females are most commonly affected. Of my own cases 16

were females and 14 males. Young adults, between the ages of 15 and 35, are most often the subjects of the disease; my youngest case was 17 months old, and my oldest 36 years.

Etiology. The popular designation of these tumors testifies to the belief that they are manifestations of venereal disease. The gynecologists (Luther, Witte, Broese) still seem to regard gonorrhea as the only cause for their appearance, which Thimm1 regards as curious. It is in no way the case. Gonorrhea is present in many, perhaps in most, cases; but often there are other causes, and sometimes none is discoverable at all. We are dealing with a simple hypertrophic disease process on an inflammatory basis; all the elements of the skin, of the papillæ, the vessels, the nerves, and the epithelium are equally involved. There is no reason why gonorrhea should be the only irritant to cause it. Indeed the etiology is obscure. Contagion has been supposed to be at the bottom of it, and F. Currier believes them to be highly so. There are a number of observations that seem to bear out that view. The case shown in Fig. 2 concealed the fact of her disease from her lover during its early stages; and he acquired similar warty growths on his penis. Contiguous points are almost always affected, as is shown in Fig. 2 and in Fig. 3. It is not uncommon to find isolated warts on the sides of the buttocks or on the perineal region, with others exactly opposite and touching them. And, finally, the evidence in favor of the contagiousness of ordinary warts would lead us to suspect the same of these similar formations.

Ducrey and Oro3 have been so impressed with these facts that they examined a number of these growths for micro-organisms. After careful disinfection of the tumors and the surrounding tissue, they excised them, and sowed them in various culture media. They obtained only negative results. Various microbes were developed and isolated. Some were undoubtedly accidental; but others were so constant that they were suspected to be the causal agent of the disease. But inoculation experiments on man and animals were alike fruitless. They were struck, however, with the clinical analogies between condylomata acuminata and the psoro-spermosis of Darier; and they claim to have found bodies very like the psoro-sperms in their sections. They were round and oval bodies lying between the cells of the stratum corneum and of the stratum Malpighii, some being found even within the epithelial cells. Osmic acid showed cystic forms. Ducrey and Oro concluded Ducrey and Oro concluded that the condylomata acuminata belonged to the psoro-spermoses; but subsequent investigations have not confirmed their results. As E. Martin says, all the etiological finds of the protozoa are as yet speculative.

Lang claims, and he is undoubtedly correct, that

"Kurze Bemerkungen zu einigen neueren Arbeiten über Condylomata acuminata, etc." Reichs-medicinal Anzeiger, Nos. 13 to 15, 1896. 2 Morrow: "System of Dermatology."

3 Riforma medica, June, 1892.

4 E. Lang: "Das venerische Geschwur," p.

long-continued venereal ulceration of any description may cause irritation of the papillæ of the skin, and excite them to overgrowth. The discharge from a chancre or a chanchroid, the pus from a balano-postheitis, with or without a gonorrhea, the secretions of ulcerative secondary lesions, will all undoubtedly cause their appearance.

In point of fact, the lesion is in its origin an inflammatory one; and an irritating discharge, whatever its origin, may set the papillary hypertrophy in motion. Mere mechanical stimuli may also be the cause. Once started, heat, moisture, and friction are the factors that keep it advancing. The initial irritant very frequently, perhaps most commonly, is a gonorrhea; but non-gonococcal pus from any source will do the same if the conditions are otherwise favorable. Predisposition plays some part, and I am convinced that in some individuals mere neglect and uncleanliness will cause sufficient irritation to determine their development. It is of interest in this connection that condylomata acuminata of the penis rarely appear in persons that have been circumcised or that have very short prepuces.

I have kept no exact record in regard to this; but out of my 30 cases there is not a single one whose name unmistakably testifies to his Jewish origin.

Anatomy.As Thimm5 correctly observes, neither textbooks nor monographs tell us much about the anatomy of these growths. They are papillomata, and belong to the class that includes warts, horns, polypi, and the SOcalled cauliflower excrescences. As the result of irritation and maceration, or without apparent cause, the papillæ and the rete mucosæ commence to hypertrophy. The papillæ elongate and give off lateral branches; and the blood-vessels and nerves grow pari passu.

The epidermis, however, as Unna has demonstrated, is not usually more voluminous in condylomata acuminata than it is in the normal skin; hyperkeratosis is entirely absent. In this it differs from the verruca, or wart, a closely related papillomatous growth. This latter shows a similar hyperthropy of the papillæ and the rete, with a like overgrowth of the vessels and nerves contained therein; but with the addition of a great increase in the epidermal lay

ers.

This difference, however, is probably rather accidental than fundamental; as is shown by the occurrence of condylomata acuminata with horny tops, or even complicated with cornua cutanea. Kaposi's explanation is plausible and sufficient. Both growths are papillomata in which all the elements of the skin participate in the hypertrophic process. But the verrucæ, or warts, are always so situated that the epidermis has an opportunity to accumulate and become horny; they are dry and hard, and covered with a thick corneous layer. The condylomata acuminata, on the other hand, are generally so placed that their surfaces are macerated; the soft

5 Loc. cit.