CLINICAL REPORT.

A Case of Large Pus Kidney, with Exhibition of

Specimen.1

BY HENRY T. WILLIAMS, M. D., Rochester, N. Y.

Surgeon to Rochester City Hospital and Saint Mary's Hospital.

MRS. A. A. F

F— -, widow; age 75 years. Always has been in usually good health except occasional colds and indigestion, but no serious illness. I first saw her April 6, 1906. She had been ill for several days suffering from a hard cold in her head and pain in the bowels, mostly in right side of abdomen, and some vomiting. When she came under my observa

tion her temperature under the tongue was 102° F.; had been able to take but little nourishment on account of pain in abdomen and nausea and occasional vomiting. The abdomen was sore and very tender upon pressure, especially over the McBurney point area where a large mass could be felt extending slightly beyond the median line and into the loins on the right side. Dulness on percussion and elastic and fluctuating were marked, more so over the McBurney point. The next day, April 7, dulness and tenderness had extended over a larger area and was more elastic and fluctuating. The urine, 1022 sp. gr., contained a trace of albumin, but no casts and no pus. Temperature 101 4-5; bowels had moved freely; nausea and vomiting increased.

1. Specimen exhibited at a meeting of the Hospital Medical Society of Rochester, N. Y.

I operated upon her that night. While under the anesthetic a large irregular shaped mass could be felt extending below the liver down to the lower part of the abdomen, into the right loins and back and beyond the median line of the abdomen, the most prominent part over McBurney point. The diagnosis was, tumor of the right kidney. A large median incision was made extending from three inches above pubes to three inches above the navel. The capsule was found to be very vascular, and several ligatures and hemostats were applied to stop the hemorrhage. It was noticed that the vessels were very much enlarged and sclerotic, (even calcareous), breaking frequently under the for

FIG. 2. WILLIAMS: LARGE PUS KIDNEY-SECTION VIEW.

Note the straws inserted into ureter and renal vessels.

ceps and ligatures. The ureter was quite large and was tied with two ligatures and cut between them.

After the capsule had been divided the kidney was easily drawn out and the renal vessels exposed. These were tied with catgut ligatures but the vessels were so hard and brittle that they several times broke off, and finally were tied in mass after clamping them together with some of the surrounding tissue. While carefully lifting out the large kidney there was a sudden gush of dark blood. Dr. Boddy, who was assisting me, put his hand under the tumor and grasped the venacava which stopped the hemorrhage. The kidney was then rapidly cut off at its pedicle (where the ligature had been applied to the vessels) and removed. It was found that the renal vein had torn off from the vena cava ;

both venacava and aorta were felt to be very hard and inelastic and seemed to be studded with calcarious deposits.

The tear in the venacava was grasped with forceps, but owing to its brittle condition, tore open again. A compress of sterile gauze was placed against the opening and other gauze compresses against that and strong strips of oxide of zinc plaster across the upper part of the abdomen holding them in place, whereupon the hemorrhage ceased. The rest of the abdominal incision was brought together with silkworm gut sutures. The patient rallied from the operation. Pulsation of the arteries of the feet could be plainly felt and the feet and lower extremities were normal in color, showing that the circulation was not interfered with. Owing to the condition of the venacava the left kidney was not examined.

A

The patient died from uremia 48 hours after the operation, only two ounces of urine passing per catheter after the operation. The kidney weighed twelve pounds. Upon opening the kidney it was found to be filled with a thick creamy pus, sacculated in places on outer part of kidney where the pus was gelatinous and in some places caked. The outer shell of the kidney as it may be termed, or pus sac, was only about 1-40 of an inch thick. straw carried through the ureter and one through the renal artery passed directly into the pus sac. No evidence of any normal kidney substance remained. The case is interesting from the size of the kidney and from the amount of pus which it contained, and because of the thinning of its walls, the age of the patient and the fact that no serious symptoms or pain or high temperature existed until so short a time before operation. It also demonstrates what grave condition a kidney may reach without causing, for a long time, serious symptoms.

274 ALEXANDER STREET.

PROGRESS IN MEDICAL SCIENCE.

Pediatrics

Conducted by MAUD J. FRYE, M.D., Buffalo, N. Y.

LEUCOCYTOSIS IN WHOOPING COUGH.

CHURCHILL (Jour. A. M. A., May 19, 1906) reviews the literature on this subject and adds the results of his own investigations, 36 cases having been studied. The patients ranged from 6 mos. to 17 yrs. The total leucocyte count was made in 29 cases. A general leucocytosis was found in all but one. The counts range from 10,000 to 112,000. Differential counts were made in

all cases, 30 showing a lymphocytosis; 15 out of 16 patients examined in the catarrhal stage had a lymphocytosis. The percentages ranged from 34.3, in a 5 year old child, to 93 in a 4 year old. The latter was the one with a total of 112,000, was a severe case, and came to the clinic at the height of the disease. A count made 16 days later showed a total of 32,600 with 64 per cent. of lymphocytes, and great improvement in all the symptoms. The total number of cases studied upon which the author bases his deductions was 100. The following conclusions summarize the paper:

1.

A general leucocytosis is present in almost all cases of whooping-cough.

2. A lymphocytosis, i. e., an increase in the number of lymphocytes is found in about 85 per cent. of cases at some time during the course of the disease.

3. A lymphocytosis is found even more constantly during the early or catarrhal stage, over 90 per cent. showing the phenomenon at this time.

4. A lymphocytosis is found usually in those conditions difficult to distinguish from whooping-cough.

5. Therefore, the presence of a lymphocytosis in a child with a hard persistent cough is a factor of great diagnostic value. It is also of prophylactic importance inasmuch as it can be utilised to prevent the spread of the disease by leading to the prompt isolation of the patient.

6. The child's age must be taken into account in estimating the importance of the lymphocyte percentage.

MELENA NEONATORUM.

BLOUNT AND GARDNER (Am. Jour. of Obstetrics, Feb., 1906) report a case of melena neonatorum developing four days after birth in a male child weighing 104 lbs. Hemorrhage began from the roof of the mouth followed by bloody stools. The hemorrhages from the bowels were repeated every two to six hours for 56 hours. It was estimated that one pint of blood was

lost in all.

The treatment first consisted of gelatine solution by mouth, an ounce of a two per cent. solution every two hours. At the same time an ounce was given every four hours by rectum.

Later the

gelatine by mouth was discontinued on account of its being promptly followed by griping and bloody stools. The gelatine per rectum was continued for 36 hours. Adrenalin solution (11,000) M. I. every hour was also given. Morphine was given to control restlessness. On the morning of the third day the breath, bowel movements and gases were very foul, the temperature was 101.6°. the child's condition grave, the stools containing more blood than at any previous time. All former treatment was sus

pended and the bowel was irrigated every 4 hours with lime-water and salt solution in equal parts, half an ounce of fluid being allowed to remain in the bowel. One ounce of lime-water was given by mouth three times daily. There were no further hemorrhages after this time, the temperature fell to subnormal and recovery was rapid. The birth weight was regained in four weeks.

GLANDULAR FEVER.

VIPOND (Archives of Pediatrics, January, 1906) writes of this disease and reports twelve cases from his own practice. He describes the disease as follows:

teen.

Glandular fever is a disease which presents distinct signs and symptoms, and, as a rule, is not difficult to diagnose when developed. It is a disease of childhood and is rarely seen after sixChildren between four and twelve years are most frequently attacked. It occurs in narrowly limited epidemics, but if one child in a family contracts the disease the rest are liable to be affected. Neuman claims that the disease is most likely due to streptococcus infection, the streptococcus entering by way of the tonsil without producing any local lesion. Dr. Koplik suggests that infection may be by way of the thoracic duct. It attacks both sexes in equal proportions. Most cases are found during the damp, cold months.

The incubation is from five to seven days. The onset is sudden, the child complaining of headache, pains in the limbs, vomiting, pain in abdomen, chills and loss of appetite. The bowels are constipated, but rarely there is diarrhoea. The tongue is coated, the face flushed. The evening temperature is 102° to 104° F., while the morning temperature is about one degree and a half lower; pulse 110 to 130. So far there is nothing characteristic about the symptoms-they may point to influenza, or to one of the acute exanthemata. In twenty-four to forty-eight hours' time the patient complains of stiffness and pain in the neck, the pain being aggravated by movement. On making an examination of the neck we find that the lymph nodes are enlarged, but on inspecting the throat we find it to be quite free from any signs of diphtheria or other inflammatory condition, and at the most some redness of the tonsils is found. In only one of my 12 cases did I detect any sign of pharyngitis; the condition of the lymph nodes is quite characteristic, and when it develops any doubt about the diagnosis is set at rest. Usually the lymph nodes on the left side. of the neck are first involved, the nodes at the posterior border of the sternomastoid being first affected. They are hard, intensely tender when handled, and freely movable, about the size of a large bean, and form a regular chain down the neck. Soon the lymph