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A CASE OF CYSTIC DEGENERATION OF THE

KIDNEYS, WITH REMARKS.

BY JOHN A. OCTERLONY, A.M., M.D.

D. Hays, a laborer, aged forty years, born in Ireland, was admitted to the Louisville City Hospital on the 5th of February, 1874, on account of syphilitic disease of the bones of the nose.

He was not emaciated, but his complexion was sallow and somewhat cachectic, and the expression of his countenance was dull and heavy. His breath was exceedingly offensive. The tongue was heavily coated with a whitish fur, the skin was dry, and the bowels were constipated.

His pulse was of good quality, and 80 to the minute. The heart and lungs were apparently healthy. The urine was not examined. He did not complain of pain of any kind.

Little or nothing could be gleaned of his previous history, and, for some time after his admission, the medical officer wbose patient be was, seems to have had no suspicion that there was any other disease than caries of the nasal bones.

On the 13th of February, 1874, and without any marked premonitory symptoms, he became comatose; his breathing was slow and stertorous, with flapping of the cheeks; but there were no convulsions. He remained in this condition nearly five days, at the end of which time he died.

The opinion was expressed by those who saw him during this period that he had compression of the brain from syphilitic nodes on the internal surface of the cranium.

I did not have charge of the patient, and saw him only after his death.

The autopsy was performed by me with the assistance of the resident graduates of the hospital. The body was well nourished, rigor mortis not well marked. No cicatrices could be discovered either on the genitals or in the groins, or on other parts of the

skin. There was unusual prominence of both lumbar regions, which gave to the abdominal surface a square and flat appearance. Percussion gave a dull sound over both these regions, from the liver almost down to the crest of the ilium; and there was increased resistance on palpation, as if there were a soft solid mass under the hand.

On removing the calvarium, both its internal and external surfaces were found entirely free from nodes. There was considerable arachnoid effusion of serous character, and the pia mater was congested. A small quantity of serum was found in the lateral ventricles, and a great number of small pearly cysts with clear watery contents covered the choroid plexus. The brain substance appeared healthy. The bones forming the right nasal cavity were carious, but those of the left and the cranial surface of the ethmoid bone were perfectly healthy.

On opening the chest the right lung was found hypostatically congested and firmly attached posteriorly by old pleuritic adhesions. The left lung was similarly congested, and bad old adhesions to the pericardium and the diaphragm.

The heart was pale, flaccid, and much dilated; large and firm dark clots occupied the cavities. The mitral valve was somewhat rough and thickened by atheroma. Both large and small intestine appeared healthy. The liver was of normal size, but of dark color. The spleen was quite small, and had become pushed up against the diaphragm by the LEFT KIDNEY which descended to a level with the crest of the ilium. It lay in front of the descending colon; the upper border and the supra-renal capsule pressed against the diaphragm. The lower portion protruded above the coils of intestine, and was composed of a very large cyst (see wood-cut) four inches in its largest diameter, and having a thin delicate wall with clear transparent amber-colored contents. On removing this kidney, it was found measuring twelve inches in length, ten inches in circumference, and four inches across at its widest point. The weight was fifty.two ounces.

It was composed of closely aggregated cysts of various sizes; some had almost colorless contents, others held an amber or straw. colored liquid, and still others were of a dark chocolate color with grumy opaque contents. These cysts were separate and distinct, and were bound together by large quantities of connective tissue. The ureter and pelvis were perfectly open. The pelvis presented no trace of papillæ, the calices were deep and funnel-shaped, com

[graphic]

inunicating with cysts. On bisecting the mass, not a particle of secreting structure could be detected.

The Right KIDNEY formed a large tumor lying in front of the ascending colon; its upper border in contact with the liver, and its inferior extremity lying almost on a line with the crest of the ilium. It measured eight inches in length, four and a quarter

[graphic]

inches in width, and eleven inches in circumference. Its weight was forty-eight ounces. The renal parenchyma was entirely lost. The pelvis and ureter were open, the former presenting the same appearance as on the opposite side. The cysts seen on the surface were smaller and more uniform in size than those of the left kid. ney, and the connective tissue was less abundant.

The interior, however, as seen in bisecting the mass, was made up of large cysts, many of them having chocolate-colored contents. The septa were quite thick here, and there was a large amount of connective tissue stroma.

The bladder contained six ounces of pale fluid, having a faintly urinous odor; reaction neutral; sp. gr. 1010; and with a trace of albumen.

Microscopic Examination.—Muscular fibres from the ventricular walls and from the musculi papillares were in a state of granular degeneration.

The cyst walls were composed of white fibrous tissue lined with epithelial cells, which were also found in great number in the fluid of the cysts. The latter also contained blood-discs, fat granules, and plates of cholesterine. The blood discs, many of which were disintegrating, were most abundant in the cysts with dark contents. The fluid was distinctly albuminous.

REMARKS.-Cystic Degeneration of the Kidneys is a rare affection, and the literature on the subject is quite meagre. These considerations will, I hope, be remembered in extenuation of the probable defects of this brief essay.

The obscurity of the disease in question, as well as the wonder. ful changes wrought by it in the kidneys, contribute to render it deeply interesting to the pathologist and clinician.

Illustrative of the rarity of this disease is a passage in Dr. Loomis' recent book on “Diseases of the Respiratory Organs, Heart, and Kidneys.” In it he expresses the opinion that cystic degeneration of the kidneys is interesting only on account of its rarity, and then dismisses the whole subject, saying the disease is so rare that he will not detain his reader by a description of it.

Renal cysts may occur under very different conditions, and a brief review of them will be found useful in promoting a comprehensive view of the particular form under consideration.

Cysts in otherwise perfectly healthy kidneys are not unfre. quently met with in post-mortem examinations; they are usually either single or few in number, and vary in size from that of a pea to that of a walnut. Their most common seat is the surface of the

VOL. XXVI.-10

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