TUBERCULAR NEPHRITIS, RESULTING IN ABSCESS OF BOTH KIDNEYS. B T JOHN LAMBERT, M.D. SALEM, NEW YORK, CORRESPONDING MEMBER OF THE GYNAECOLOGICAL SOCIETY OF BOSTON, AND MEM- BER OF THE WASHINGTON COUNTY MEDICAL SOCIETY. REPRINTED FROM THE JOURNAL OF THE GYNAECOLOGICAL SOCIETY OF BOSTON. BOSTON: JAMES CAMPBELL, Publisher, 18 TREMONT STREET, MUSEUM BUILDING. 1871. The Gynaecological Record: A BOOK of blank forms, intended as an aid to tlie busy practitioner in recording Gynecological cases; with an appendix of blank leaves, and tables for the ready analysis of the contents of the book. Prepared by Joseph G. Pixkiiam, A.M., M.D., &c. Approved by the Gynecological Society. One volume, quarto, half bound in leather. Price, $2.50. EXTRACT FROM THE PREFACE. “This book is intended to aid the busy practitioner in making detailed and systematic records of cases occurring in his Gynaecological practice. Its scope will be obvious on inspection. Blank forms are fur nislied which can be filled out with comparative little labor. As the same method and order of examina- tion is preserved in each case, a proper basis for comparison is secun d; and the minuteness of detail re- • quired to fill out the forms, renders the physician less liable to overlook points of interest. Under the head of “ History” is supposed to be given the patient’s own account of her clinical life previous to date, so far as otherwise not brought out. The diagrams will serve the purpose of illustrating the case. On the one representing the anterior aspect of the body, may be given the outline of any tumor, area of tender- ness, &c.; on the other, the relative position of the several pelvic organs, as seen on a median section. , The tables for the analysis of cases are few in number and simple in their plan.” "Tlie forms are very carefully brought out, and will be of great advantage. They will serve not only us a lecord, but as a complete lemmder of v\ hat to observe in these cases, and will mid much to the accuracy of the diagnosis, and consequently to the success of the treatment.”—Medical and Sur- gical Reporter, Bee. ‘A, 1870. " it seems to us to fill most of the requirements, and we cordially recommend it.’,’—Sew l or/: Med- ical Journal, Jail., 1871. “ The book is neat, and neatly gotten up.”— Lan- cet and Observer. "If these cases be well selected and carefully kept, even should only one book be tilled by each practitioner, it would make a contribution to Gyn- acology which, before many ) ears, would enable us to settle detinitely many points in tlie natural his- tory and therapeutics of uterine diseases which me now most obscure and unsettled.”—Medical Times. “We note with pleasure (he use of diagrams with each blank, representing, in oulline, tne anterior aspect of tlie abdomen, and a section of 1 he pelvis.” — Boston Medical and Sure/ical Journal. SURGICAL CLINIC OF LA CHARITE. Upon the Diagnosis and Treatment of Surgical Diseases, Delivered in the month of August, 1865, by Prof Velpoau. Coll*ot*d »nd Kdited by A. REGNARD, Intern* da* Uoepitaux. REVISED BY THE PR0FE880R. TRANSLATED BY W. C. B. FIFIELD, M.D. 1 volume, lAmo. Cloth. 91.00. LESSONS NOTICES OP THE PRESS. "Th!* modeit little book eonUlnt * itatlitlcal rfsumi, bv the author, of hli inrrleal experience In the boo- sts! ward! under hit care during the year, lie treat! hli auoject under the lucceialve heading!: Generalities, Vracturei, AOectlom of the Joint!, Inflammation and AbaceMea, A flection! of the Lymphatic Syitem, Kura* and Contualoni, A flection! of the Genito-Urinary Organ!, A flection! of the Aural Region, A flection! of the Eyei, Statistic! of Operation!. We have a ipecial liking for «uch worki, which give ni the moit authoritative ipinloni of the elder! of the medical profeaxion, who have reached the time when the Judgment la leait biased >y the rivalriea and personal influence! which are 10 apt to mislead younger mimii. It li of vaally more valM ban many more ambitious and bulky worki.”—/lotion Medical and Suryxcal Journal. “ He not nnfrequently lurpriaei ni by the ilmpllcity of hii expedient! for the aid of ‘ Nature In Disease,’ and •mrelr, It ever, fail! in making out hii caie. Ai a whole, the work li not only instructive, but entertaining, and nay be regarded ai one of our landmark! of minor lurgery, upon our ikill In which much of our lucceai will M bund to depend.”—Medical Record. “ It li rare that 10 imall a book oontalna 10 many inggeitlom of great practical worth, and throw! io much t(ht on certain debated point!, ai Velpeau'! Leaioni. I hough nominally a review of cue year’! practloe, It U a reality an epitome of tlie experience of a liietime.”—lttiroil Renew. “All who value the teaching! of thla great man will not lone the opportunity of obt alalnf them, u pro noted lx thli brief and economical form.”—Richmond Medical Journal. Beni bj vn all, poo taco prepaid, on receipt of advertised price. JAMES CAMPBELL, Publisher, 18 Tremont St, Museum Building, Boston, Mass. TUBERCULAR NEPHRITIS, RESULTING IN ABSCESS OF BOTH KIDNEYS B Y JOHN LAMBERT, M.D. SALEM, NEW YORK, CORRESPONDING MEMBER OF THE GYNAECOLOGICAL SOCIETY OF BOSTON, AND MEM- BER OF THE WASHINGTON COUNTY MEDICAL SOCIETY. REPRINTED FROM THE JOURNAL OF THE GYNAECOLOGICAL SOCIETY OF BOSTON. BOSTON: JAMES CAMPBELL, Publisher, 18 TREMONT STREET, MUSEUM BUILDING. 1871. A CASE OF TUBERCULAR NEPHRITIS OF BOTH KIDNEYS, RESULTING IN ABSCESS. [ Communicated to the Society, and read April 18, 1871.] By John Lambert, Salem, Washington Co., N.Y., Corresponding Member. In December, 1861, Mr. J. H. D., of Salem, merchant tailor, aet. thirty-three, married; a native of Vt.; ner- vous temperament; average weight one hundred and fif- teen pounds; habits good; consulted me regarding a painful swelling in the right hypochondrium, and in the region of the right kidney. He stated that he had had urinary troubles since an at- tack of scarlatina in early childhood, and that he had suffered, for eight years, from frequent and difficult mic- turition, accompanied by occasional hematuria, and an abundant "brick-dust” urinary deposit, induced, as he thought, by having retained his urine, from feelings of delicacy, until urination became exceedingly difficult and distressing. From the history of the case, the symptoms, and a careful examination of the tumor in the loin, I was led to diagnose an abscess of the kidney. His general health was not greatly impaired; his ap- petite was good; he continued at his occupation till within two weeks of the opening of the abscess; did not take his bed; was cheerful, and his sufferings were not sufficient to require medication; indeed, my exami- nation of the case was incidental, and I had no oppor- tunity of testing the urine. 4 The tumor continued to enlarge outward and down- wards until January 11th, 1863, when, fluctuation being distinctly felt, I opened an abscess, which discharged fully three pints of thin purulent matter. The discharge continued abundant for a few days; he resumed his business in about two weeks, and in eight weeks the discharge had ceased and the opening healed. From this time onward his health continued ap- parently as good as usual. Virility was impaired. He practised hunting, trouting in our cold mountain streams, camping out, and violent gymnastics. Urinary sediments were thrown down, quite abun- dantly at times (the nature of which I had no oppor- tunity of ascertaining); and dysuria was somewhat pronounced, from which he was relieved by the oc- casional use of gin. Quantity of urine said to have been nearly or quite normal. In March, 1870, he began to experience a sense of weight, pain and tenderness in the region of the left loin, with an increase of urinary difficulties; micturition became frequent and painful; and ischuria renalis was evidently a prominent symptom. "Walking and riding augmented his sufferings. Hematuria manifested it- self, attended by the passage of large blood-clots. In- appetency; general health failing. April 30th. Examination revealed slight tumefac- tion, and considerable tenderness of the left kidney on deep pressure. His condition was somewhat improved by the daily application of sedative liniments and sina- pisms to the loin, and the employment of tonics and bromide of potash. The hematuria readily yielded to tannic acid. 5 By advice of friends, he visited Saratoga and Middle- town, "Vt., hoping for beneficial results from a free use of mineral waters; but he returned without improve- ment. July 25th. His symptoms were much more marked- ly pronounced. He was suffering from excruciating pain in the vicinity of the kidney, greatly increased on pressure, and extending down the ureter to the bladder, and to the extremity of the urethra. This latter symp- tom was exceedingly annoying throughout. There was a distressing sense of weight and dragging in the perineum. Urine scanty, and voided with urgent frequency and little relief. Loss of appetite was almost total; and nausea and vomiting now became a prominent symp- tom, and obtained till the end. Rapid emaciation; insomnia; night-sweats; rigors; pulse considerably accelerated; fever. He obtained little and unsatisfactory relief from local applications, — from morphia, codeine, chloroform, chlo- ral hydrate, or other remedies employed; in fact, the amount of medicine deemed advisable in his case, or which he could bear, was small. The tumor in the left hypochondrium, an examination of which very much aggravated his symptoms, was now well defined, and presented a broad convex surface, with a perceptible bulging posteriorly. From the gravity of the symptoms, and in view of the former history of the case, I was forced to the diagnosis of suppurative disease of the kidney, and to an unfavorable prognosis. September 25th. The case having become more urgent in all its aspects, the bulging being decidedly more pronounced, and believing that I distinctly felt fluctuation, I proposed to use the exploring trocar, as 6 a diagnostic measure, and to evacuate the abscess, should my views be confirmed. To this he would not consent. On the thirtieth, his urine became cloudy, and, in a few days, a white creamy deposit was observed, which, on examination, proved to be pus. This increased in quantity and consistency until from two to six ounces were discharged daily. The urine was slightly albuminous. No microscopic examination was had. lie could readily distinguish the passage of pus from the kidney by the agonizing, burning pain produced by it along the track of the ureter into the bladder, where cystitis was evidently developed by the presence and decomposition of pus and urine. The odor of this, when voided, was intol- erably offensive. The ropy consistency of the urinary passages gave him no little trouble at times. He absolutely refused at this time,' as at an earlier date, to allow the introduction of a sound or catheter for the purpose of dilating any existing strictures, re- lieving the bladder of its contents, or washing it out with plain or medicated injections. Directly on the free passage of pus, per urethra, the tumor in the hypochondrium abated, as did the severer painful symptoms, although great tenderness still ex- isted in the loin and kidney, and there was no improve- ment in his general condition. Several times subsequent to the appearance of pus in the urine, an obstruction of it in the ureter was evi- denced by an almost entire cessation of its flow, special tenderness in the track of the ureter, increased swelling of the tumor, and an augmentation of all the local symptoms until it again found exit. The case was seen in consultation, Nov. 20th, by Dr. 7 Chas. II. Allen, of this place, who fully concurred in the views taken. The patient voided during his sickness from sixteen to twenty-eight ounces of urine daily, of a specific gravity of from 1012 to 1020, until within about ten days of death, from which time the quantity passed guttatim, and with great suffering, was from six to ten ounces. The cerebral indications of the so-called uroemic poi- soning, were not manifested until the last three or four weeks of life, and then only in a mild form, resembling the gentle narcotic effects of opium, coma and con- vulsions being entirely wanting. He insisted upon rising to urinate, and was able to do so, with slight assistance, till the last effort, five minutes previous to death. There were no indications of calculi discovered dur- ing life. No general or local dropsy. We discovered no symptoms of, and careful explora- tion of the chest did not disclose, pulmonary tuber- culosis. Perfectly conscious, he died without a struggle at four o’clock A. M., Dec. 24. SECTIO CADAVEKIS. Twelve hours after death. Present and assisting, Dr. E. H. Ware, U. S. Navy, and Dr. Chas. H. Allen. We found the body greatly emaciated. Rigor mortis moderate. On opening the abdomen, its walls were found very thin, and contained only a trace of adipose tissue. The viscera appeared in their natural position, except in the left hypochondrium, where they were considera- 8 bly displaced by a large tumor, which bulged high up into the abdominal cavity, over which the descending Left Kidney, Ureter, and small portion of the Bladder, 6j inches in length. 4 inches in breadth. 3$ inches in thickness. Weight, 22 oz. colon was found lying very much contracted, and ad- hered for about five inches in extent. 9 On examination the tumor was found to be the left kidney greatly enlarged and firmly adherent, the fibrous adhesions of which were so firm that the entire organ required to be dissected out with the scalpel before it could be removed. It had an elastic or boggy feel, and measured five and three-fourths inches in length, four inches in breadth, three and three-fourths inches in thickness, and weighed twenty-two ounces (being about three times as large as the normal kidney). On being laid open, its capsule was found very much thickened, being nearly one-fourth inch in thickness at the pelvis, and firmly adhered to the surrounding tis- sues; but it could easily be detached from the organ, leaving its surface smooth. The greater portion of the renal tissue, both cortical and medullary, was found to have degenerated into a white cheesy substance, and to contain several large abscesses filled with pus, and opening into the pelvis, while the formation of several other abscesses was indi- cated by a thick, putty-like deposit, not yet broken down. In one instance, this deposit was two inches in length, and one and one-half inch in breadth. A portion of the renal substance, equal to about one- third of a normal kidney, appeared rather pale, but comparatively healthy. The pelvis of the kidney was almost completely ob- literated; its-contracted cavity was filled with the cheesy substance, mingled with pus and urine in a state of incipient decomposition. The coats of the ureter were much thickened through- out its whole extent, and its canal was very much di- lated. At its termination in the bladder, its lining membrane 10 was found ulcerated, and presented a granular appear- ance for an inch or so in extent. The right kidney was found in its normal position, but firmly adherent posteriorly, in apposition with a cicatrix, the result of the opening which I made in January, 1863. Hight Kidney, 1J inches in diameter. Weight, oz. On removing what appeared to be the kidney, it was found to have degenerated into two fibrous bodies (sug- gesting the idea of two kidneys), loosely connected, each measuring one and a half inch in diameter, and together weighing two and a half ounces. Their cut surfaces presented a very firm, compact, and shining texture. The capsule was closely adher- ent to these bodies. The ureter was perfectly occluded. The bladder contained about six ounces of urine and pus. Its coats were greatly thickened, and its lining membrane was in a condition of extreme ulceration. Ho calculi were perceptible in either the kidneys or bladder. 11 Liver and spleen were found slightly enlarged, but appeared healthy. The other abdominal viscera were in a normal con- dition. No further examination was permitted. PATHOLOGICAL CHARACTER. My friend, Dr. Edmund R. Peaslee, writes, March 18th: — "From the best assistance I can obtain, I judge you are correct in supposing the case, one of nephritis, with tu- bercular deposit. It is of great interest, and should be laid before the profession.” Through the politeness of Dr. Peaslee, I am furnished with the following pathological report, by Dr. Stephen Rogers, of New York city, upon a small portion of the kidneys sent him; dated March 25th. "I find that the portion of the large kidney sent shows that it has been invaded by both interstitial and tubular inflammation. " The result of the latter is seen in the fact that both the tubes and the malphigian bulbs, still recognizable, are stuffed to repletion with exfoliated renal epithelial scales, exudation corpuscles, and a great amount and confused admixture of granular, oily, and imperfectly crystallized material. In many regions, the connective, or intra-tubular tissue is found to present a laminated appearance, and is greatly thickened. "Judging, therefore, from both the history given, and the condition of this piece of the kidney, it appears to have been the seat of a most destructive pyelo-nephritis. " The portions of the other kidney sent are very firm, indeed almost leathery, and are found to present that condition known as renal cirrhosis; that is to say, the 12 former fibrous exudation into the intertubular, or inter- stitial tissue has so contracted as firmly to compass the contents of the tubes and malphigian bulbs, which have been in part removed by degeneration and absorp- tion, leaving great numbers of microscopic cysts and sections of empty tubes. "The greater part of these fragments of kidney, there- fore, consists of the former tube walls, surrounded by laminated and contracted organized lymph, all appear- ance of healthy kidney structure having disappeared.” While I was in Albany, Dr. Edward R. Hun, very kindly made a microscopic examination of the entire pathological specimens, and has since furnished me the following report, dated April 6th: — "The left hidney presents all the characteristics of fatty degeneration, with destruction of the epi- thelium lining the tubules. The intertubular connec- tive tissue is infiltrated with a number of small nu- cleated cells and free nuclei, which are especially abundant in the neighborhood of an abscess. At some points these cells are collected in little masses, forming distinct deposits, and many of these deposits have undergone granular and calcareous degeneration. " The right hidney (that is, the one which appeared to be divided in two) was in a condition of cirrhosis. The tubules had lost their epithelial lining, and were pressed upon, and in a great measure obliterated, by dense fibrous tissue. " The small cells, which were so abundant in the in- tertubular spaces of the left kidney, did not appear to exist in the right one. There were, however, a num- ber of granular and some calcareous deposits. " From the above examination, and the history of the case, I am of the opinion that there was tubercular 13 deposit in both kidneys, and that this deposit subse- quently softened and resulted in abscess. The abscess in the right kidney became very large, and yon opened it. After the operation the walls of the abscess col- lapsed, and its cavity became obliterated, thus dividing the organ into two parts, and at the same time a chronic inflammation was excited, which resulted in cirrhosis and destroyed the kidney as a secreting organ. " Thanking you for the opportunity of seeing so in- teresting a case, the whole of which is so complicated in its nature, " Yery truly yours, " Edward R. Hun.” Journal of the Gynecological Society of Boston. Recommendations of the Press. EDTTED T5Y WINSLOW LEWIS, 31.B. HORATIO R. SLORER, 31. D. GEO. H. BIX BY, 31. B. •‘Since the first appearance of the Journal it has met with marked success, and the reports of cases which it contains, contributed by various members of the Society, make it a very valuable addition to our medical litera- ture, while the distinguished names of its three editors would alone entitle it to the respectful consideration of the medical world.”—American Literary Gazette, March, 1870. “ It is ably edited, and must hold a high position in the estimation of every intelligent physician.”—Cin- cinnati Medical Repository. “The Gynecological Journal is supplying a need long felt in this country, and meets with a welcome at every phvsieian’s table. We predict that, ere ten years elapse, it will have the largest circulation of any medical periodi- cal in the world.”—Northwestern Medical and Surgical Journal. “This Journal is alike creditable to the Society, under whose auspices it is published, and to the distinguished physicians who edit it, and it has taken a foremost place in the literature of the profession.”—Boston Post, June 8th, 1S70. “A useful addition to the physician’s library.”— Boston Journal of Chemistry. “We have the first volume of this most interesting and valuable Journal, intrinsically valuable because pre- eminently practical.”— Eclectic Medical Journal, May, 1S70. “ Gives much practical experience in treating diseases of women, which should always be acceptable to stu- dents and practitioners.”— Philadelphia University Journal of Medicine and Surgery. “ The Journal contains a large amount of valuable original matter.”— N. Y. Medical Record, April, 1870. “ It ir making effective war upon quackery and ignorant practice in a field where both have flourished quite too much. . . . It exhibits the vigor and intrepidity which are characteristic of this publication.”—The Com- monwealth, February ig, 1870. “This is an ably conducted periodical, and merits the patronage of educated physicians of all schools.”— Hall’s Journal of Health, February, 1S70. “ Its contributions are by pure-minded and able physicians, on the most delicate and difficult of medical ques- tions.”—The Index, February, 1870. “ It is well edited and handsomely printed, and it deserves liberal patronage.”—Philadelphia Medical and Surgical Reporter. “ It discusses, with vigor and intrepidity, topics of the utmost importance to the welfare of society.”—Port- land Tr anscript. “ It is a practical work. Its editors are men of experience,— connected as they are witb.twohospitals fordis* eases peculiar to women, — eminently qualified for their task.”—Newport Express, March 15, 1870. “ The extensive experience and high scientific attainments of the editors and conductors is a sufficient guaran- tee that the Journal will be an important addition to American Medical Literature.”—Boston Journal op Chemistry. “ Is certainly creditable to the editors, to the Society, and to the publisher.”—Dominion Medical Journal. “Whatever differences of opinion there may exist as to the expediency of specialties in the practice of medi- cine, we think that all must admit the benefits of special labor in its study, and the advancement of the science. . . . . We have no doubt that this Journal, devoted to the advancement of the knowledge of the Diseases of Women, will be most acceptable, not only to those practising in this specialty, but to the general practitioner.’’— The Medical Bulletin. “This new Journal of a new Society appears in the arena, armed alike for science or for fray. ... This first number is exceedingly interesting.”—California Medical Gazette. “ We hail it as the first Gynaecological Periodical in the United States — indeed, if our memory is right, the first in its branch anywhere. . . . The Journal starts under favorable auspices, and will be a success; and, we trust, a credit to American medicine.”—St. Louis Medical and Surgical Journal. “ It is devoted to a specialty upon which much light is needed, and we fee! confident that the editors are fully competent to meet the demand.”—Nashville Journal of Medicine and Surgery. “ It has a double excellency as the organ of the Boston Society, and as particularly devoted to this specialty.” — Cincinnati Lancet and Observer. “ It is neatly printed, and its contents will be highly appreciated by every practitioner who is ever called to treat Diseases of Women. We hope it will be liberally sustained by the profession.”—Western Journal of Medicine. “ It is printed in large type, on fine paper, in a manner reflecting credit upon the publisher, while its contents are of a character that cannot fail to interest all engaged in studying Diseases of Women.”— Detroit Review of Medicine and Pharmacy. " It is, in appearance, the most attractive of all its contemporaries, being printed upon fine paper, with large type.”—Philadelphia University Journal of Medicine and Surgery. “ It will fill a void long felt in this particular branch of Medical Science.”—American Journal of Homoeo- pathic Materia Medica. “ Like the Society of which it is the exponent and representative, it covers a field in medicine that has not* herc.iifore, in this country, been regularly oocupied. ... It contains mue’’ valuable matter.”—Hahneman- nian Monthly. “The Journal, notwithstanding its medical character, contains much interesting to the general reader.”— Christian Register. ' “Treating upon a most important branch of diseases.it cannot fail to receive that encouragement which it merits.”—American Literary Gazette. TERMS: To Subscribers, Fve Dollars a year, payable in advance, or Fifty Cents per Number.