fact in all the organs.) The well-known reaction of biliary coloring matter is very readily obtained from them. It is only necessary to treat a little piece of the affected tissue with liquor potassse (under a covering glass), then washing away the excess of the fluid with water, finally add nitric acid of the proper strength, in order to produce successive rings of green, blue, violet, and red extending from the periphery toward the centre. The bilirubine infarctions may be distinguished from those due to hsematoidine by the fact that the former occur very irregularly, and as a rule only upon single papillae, while the latter affect all the papillae equally .^ In adults, yellow, green, brown, and black granules of bile pigment occur, both in the convoluted tubules and in the straight ones, combined with chronic inflammation, in cases of icterus of long standing. (g.) Gouty nephritis also depends upon a deposition of crystalline masses, and is due to gout. Small, chalky, white spots or lines may be seen in the pyramids or (less frequently) in the cortical portion. Upon microscopic examination, they are found to be composed of masses of crystalline urate of soda, which appear not only in the form of very fine needles, as in the joints, but also in the form of large crystals 1 In distinguishing hsematoidine and bilirubine infarctions the question of the identity of the chemical composition of those two bodies is not considered ; their origin only is indicated by the name, hcematoidine originating from the effused blood by a direct local change, while bilirubine is excreted from the blood, where it is already present as biliary coloring matter. THE KIDNEYS. 219 (rhombic prisms). Chronic interstitial inflammation exists around them. Whenever these changes are found to exist in the kidney, the examination of a number of joints, especially that of the great toe, for gouty deposits, must never be omitted. 6. Tuberculosis occurs in two forms in the kidney ; sometimes as a disseminated, secondary affection, which has its favorite seat in the cortex, and again as a localized and primary tuberculosis, which takes its origin in the calices and apices of the papillae. In the first form submiliary and milary nodules are scattered through the cortex, especially on the surface. Upon the surface of the section the nodules often appear arranged in a narrow row following the direction of the vasa interlobularia ; as changes (fatty metamorphosis) in the neighboring tubules are usually connected with them, the appearances may be easily mistaken for small hemorrhagic infarctions. The presence of the minute gray nodules prevents any mistake. Leucemic and typhoid nodules, which are rare, resemble these tubercles. The second form, which has its principal seat upon the apices of the papillae, shows less plainly its origin from separate tubercles. A yellow, cheesy mass of variable size, softened and disintegrated upon the surface, and in which separate tubercles are no longer to be seen, takes the place of the apex of the papilla, and occupies the contiguous portion of the calyx. Isolated tubercles occur at the periphery, diminishing in size and number the more distant they are, and extend, in cases of long standing, to the outer surface of the kidney, where they may be recognized, but, of course, cannot be distinguished from those occurring in the disseminated form. Those lying next to the cheesy mass are yellow, and even cheesy ; those farther off are gray, translucent, in other words, perfectly fresh. Since the disintegration of the nodule continually extends from within outwards, larger and larger portions of the pyramidal substance, and, finally, the whole pyramid, and even a portion of the cortex, may be destroyed. As the superficial portions of the cheesy mass become de- 220 DIAGNOSIS IN PATHOLOGICAL ANATOMY. tached, the calyx, which was at first narrowed, now becomes widened (^phthisis renalis tuberculosa). This affection is frequently associated with a similar one of the urinary tract (bladder) and sexual apparatus. <Callout type="important" title="Important">Always examine joints for gouty deposits when suspecting kidney tuberculosis.</Callout> 7. Gummata are seldom met with. They appear when recent, in the form of nodules, which vary in size from that of a millet-grain to that of a pea, are of a uniform yellow color, have a firm, elastic consistency, and are situated within a fibrous tissue, produced by chronic interstitial inflammation, upon microscopic examination one finds the usual granulation-like tissue rich in cells, with fatty degeneration of the latter. 8. The new formations which occur here, include adeno- mata, carcinomata, and sarcomata (both primary and second- ary), fibromata, and, more rarely, others, such as lipomata, angiomata, etc. Adenomata appear in the form of yellowish nodules, the size of which varies from that of a millet-grain to that of a bean. They frequently contain numerous small cysts, and are surrounded by a connective-tissue capsule. Upon micro- scopic examination the urinary tubules are found to be wid- ened and furnished with offshoots, their cells frequently fatty ; hemorrhages are often situated within the canals, giving rise at times to a brownish-red color. Carcinomata and sarcomata are to be recognized here by the rules already laid down ; still it ought to be mentioned, that a mixed form of the two (carcinoma sarcomatosum) occurs in the kidney, the diagnosis of which is extremely difficult, and can only be made by a very careful examination of hardened specimens. The growth of malignant tumors of the kidney into the renal veins, and through these into the inferior cava, etc., has already been referred to. 4. Examination of the Calices, Pelves, and Ureters. Certain affections of the calices and pelves, which occur in connection with diseases of the kidney, have already been considered. (Edematous swelling of the mucous membrane with haemorrhage occurs in many varieties of renal inflammation. Hemorrhage occurs here, especially in hemorrhagic small-pox, etc. ; purulent and diphtheritic inflammation^ as elsewhere. It is worthy of mention, that while diphtheritis is present, both in the bladder and pelves of the kidneys, it is replaced by a simple, generally hemorrhagic inflammation of the ureters, so that it is possible to recognize a continuity of the inflammation, but not of the diphtheritis. Tuberculous inflammation is usually combined with phthisis renalis, and possesses similar appearances ; a thickening of the whole wall, cheesy degeneration of the surface, and gray tubercles in the mucous membrane about the cheesy places and at remote points in the more advanced cases. Cheesy ulcerations begin both in the pelvis of the kidney and in the ureter as lenticular ulcers, which are small, round, and either isolated or arranged in groups. These will be more minutely described in connection with the affections of the bladder. Chronic inflammation of the calices, which is frequently combined with a reticulated or linear thickening of the mucous membrane, is most frequently met with as a result of an irritation caused by concretions., either in the form of small brittle masses (gravel) or larger compact stones. Cases occur in which the whole cavity of the pelvis and calices is filled with one continuous mass of concretion. The character of the stones varies greatly according to their composition. Very compact ones of a dark brownish-yellow, or grayish color with a mulberry-like surface, are composed of the salts of oxalic acid, oxalate of lime calculi. Urate calculi., composed principally of uric acid salts, are usually smooth or but slightly uneven, of a clear brownish-yellow color, frequently streaked and of medium consistency ; finally, those composed of phosphates and carbonates are very soft, white, and chalky. As the latter are usually produced as a result of catarrh, or the decomposition of urine accompanying it, a layer of phosphates is frequently met with covering other stones. The excretion of oxalates and urates, apparently depends upon changes in the blood, and they may alternate in layers, so that under proper conditions all possible forms 222 DIAGNOSIS IN PATHOLOGICAL ANATOMY. of precipitates may be found upon one stone. It has already been mentioned that purulent inflammation of the urinary tract and kidneys (nephritis calculosa) may be produced by urinary calculi. It is necessary to add that they often produce dilatation of the tract, concerning which a detailed description will be directly given. It may be first mentioned that in rare cases a multiple cystic formation is found connected with chronic inflammation of the mucous membrane of the pelvis and ureter. The little cysts are often present in large numbers, their average size varying from that of a pin's head to that of a millet-grain. They project far above the mucous membrane, and usually contain a perfectly clear and often colloid material. Nothing definite is known in regard to their origin. One of the most important affections of the upper portion of the urinary tract is dilatation^ resulting from a retention of urine, caused by an obstruction to its discharge. According to the situation of the obstruction, which may be at a greater or less distance from the kidney, the ureter, pelvis, and calices, or only the two latter are involved, the kidney being affected in both instances (hydronephrosis^. The kidneys are converted in extreme cases into fluctuating sacks, in which only small portions of glandular substance are seen here and there, forming a part of the walls. The calices and pelvis form one large cavity, and the ureter, when the obstruction is situated near the bladder, is converted into a canal as large as the finger. A less degree of the affection is indicated by a slight fullness of the calices and pelvis, and also by more or less flattening of the otherwise pointed, wedge-shaped papillee. Between the two extremes all degrees of the affection occur. In all cases of hydronephrosis of any severity, the kidney is very ansemic, firm, tough, and in a state of chronic interstitial inflammation. The destruction of the parenchyma by atrophy begins in the papillsB, and passes from here outwards. The narrowing of the tract producing the hydronephrosis, is usually caused by external pressure upon the ureter, or by obstruction of the latter by a stone. In other cases no such cause exists, and it is then often found that the ureter leaves the renal pelvis at an acute angle, so that a valve-like projection from its wall becomes possible, which is sufficient to cause an obstruction at the beginning of the ureter. Unilateral hydronephrosis usually presents an extreme degree of degeneration, while the other kidney assumes a portion of its function by compensatory hypertrophy. The dilatation is bilateral in many diseases of the uterus, especially in carcinoma, in which affection the ureters are often included within the cancerous growth. When this condition of things is found, it is necessary to examine the size of the ureters by the rules already laid down, before removing the kidneys. Finally, a congenital anomaly of the kidneys and of the upper portion of the urinary tract sometimes occurs, which consists in a doubling of the parts, and sometimes affects the ureters alone, and again the pelvis and kidneys. In the latter case a wide glandular septum is usually seen upon making a section, separating the two ureters, but in such a way that it belongs more to the one than to the other. In rare cases a complete division of the kidney also occurs. <Callout type="risk" title="Risk">Hydronephrosis can lead to severe kidney damage if not treated promptly.</Callout> 5. THE PELVIC VISCERA. The examination of the bladder and urethra follows that of the kidneys, and as the former should only be removed in connection with the sexual apparatus and rectum, the pelvic viscera as a whole are now to be considered. After the relative position of the organs has been accurately determined, and especially the height of the uterus when that organ may happen to be enlarged, the examination begins with the consideration of the bladder^ its size, form, and degree of fullness. It is to be drawn somewhat away from the symphysis, and a longitudinal incision is made in its anterior wall that the character and quantity of its contents may be determined. 224 DIAGNOSIS IN PATHOLOGICAL ANATOMY. (a.) THE CONTENTS OF THE BLADDEE. The color of the urine varies, as is well known, from that of the clearest amber to a yellowish-red, brownish-red, or even perfectly black. If the latter shades are produced by drugs, as senna or rhubarb, the color disappears upon the addition of a mineral acid, otherwise it is due to an admixture of blood. When this is present in small quantity, and when the corpuscles have been so long soaked as to be deprived of their pigment, a cherry-red color results. A uniform discoloration indicates diffused coloring matter, while that which increases towards the bottom of the vessel by standing, points to a fresh admixture of blood. The point may be very easily and accurately determined by microscopic examination. The stroma of the soaked blood corpuscles may often be recognized as pale spheres possessing a delicate contour. Biliary coloring matter in the urine is easily recognized by the yellowish-red or brown color, and by the reaction with nitric acid. Granular or crystalline bile pigment adhering to cells or casts is occasionally met with, both in jaundiced children and in adults. Pus may be mixed with the urine in varying quantity. When only a very small amount is present the most superficial layers of the contents of the bladder may be perfectly clear, while a thick yellow pus is found at the fundus, when the body is in the usual dorsal position. When the bladder contains but little fluid, the latter has a more or less purulent quality. The pus corpuscles may be easily recognized with the microscope. A cloudy, dirty, grayish-yellow mass, which becomes brown when mixed with blood, may be present instead of pus, the ammoniacal odor of which indicates that it has already commenced to decompose. Yellow sand-like concretions are often to be found floating in this material. Large numbers of the different forms of micrococci and bacteria may be seen under the microscope. The different forms of hyaline casts may be briefly mentioned among the admixtures in the urine which change its gross appearances but slightly. These are sometimes perfectly transparent ; again, tinged with yellow and studded with blood corpuscles, fatty cells, bacteria, etc. ; also with small numbers of pus corpuscles, and in rare instances with cells from various tumors. The principal solid sediments consist of urate of soda, which appears in the form of small amorphous granules, and of pure uric acid in the form of whetstones or sheaves ; colorless triple phosphates in the form of a coffin-lid (ammoniaco- magnesian phosphates) are also met with, and finally, the envelope form of oxalate of lime. What has been said in regard to renal calculi applies in general to those of the bladder. In order to ascertain the above mentioned admixtures, the urine is to be allowed to stand for a while in a conical glass, the supernatant fluid is then to be poured off, and the remaining portion used for examination. (5.) GENERAL METHOD OF REMOVAL. After the urine has been removed the rectum is to be sep- arated from the colon, and the latter drawn somewhat up- wards (when the contents of the large intestine are thin and abundant a double ligature should be applied before the sep- aration is made). The rectum is then to be drawn forwards with a good deal of force, and a large knife is deeply inserted perpendicularly between the rectum and sacrum, to separate with a sawing motion the loose connective tissue from the latter along the linese arcuat« as far as the os pubis. The separation of the rectum from behind is to be continued by a few horizontal cuts extending to the anus. The rectum is now grasped with the last three fingers of the left hand, while the index finger of the same is placed in the opening in the bladder, then drawing firmly all the pelvic organs upwards and backwards, they may be removed by cutting through their attachments to the walls of the pelvis, keeping the knife close to the symphysis in front. By depressing the handle of the knife backwards and to the right when cutting, especially at the bottom of the symphysis of the male, the 15 ^26 DIAGNOSIS IN PATHOLOGICAL ANATOMY. whole prostate and even a portion of the urethra may be re- moved in connection with the bladder. In removing the penis, the abdominal incision may be extended as far as its middle, the posterior attachment of the corpora cavernosa separated, and the organ be then cut through subcutaneously as far forwards as one wishes. If it is desirable to preserve the attachment of the urethra to the bladder (strictures, false passages), the penis is cut through in the manner just mentioned, before the pelvic organs are removed. It is then to be separated from the attachments about it, especially to the pubes, and drawn backwards under the symphysis into the pelvis, from which it may be removed with the organs in the manner already described. The testes can be examined very easily without injury to the scrotum, by enlarging the spermatic canal somewhat from the inside and pressing them out from below. If it is desirable to allow them to remain attached to the pelvic organs, both are to be pressed out of the spermatic canal in this manner, and the vasa deferentia separated from the sides of the pelvis as far back as the bladder, before the pelvic viscera are removed. The female sexual organs, including the entire urethra, vagina and nymph«, rectum and anus, may be removed, as before, by detaching the rectum and drawing the organs forcibly backwards. When it
Key Takeaways
- Identify infarctions using biliary coloring matter reactions.
- Recognize gouty nephritis by crystalline urate deposits in the kidney.
- Distinguish between different forms of tuberculosis affecting the kidneys.
- Examine joints for gouty deposits when suspecting kidney tuberculosis.
- Understand the causes and symptoms of hydronephrosis.
Practical Tips
- Always check for signs of gout in patients with suspected kidney issues, as it can indicate underlying tuberculosis.
- Use microscopic examination to identify crystalline structures in urine samples, which may point to specific diseases like gout or urinary tract stones.
- Be cautious when removing organs during post-mortem examinations to avoid cross-contamination and infection.
Warnings & Risks
- Hydronephrosis can lead to severe kidney damage if not treated promptly. Always document the presence of hydronephrosis in your reports.
- Incorrect identification of urinary tract stones can result in misdiagnosis, so ensure thorough examination using appropriate techniques.
- Exposure to bodily fluids during post-mortem examinations poses a risk for infection; use proper protective equipment.
Modern Application
While the detailed methods described in this chapter are no longer used due to advancements in medical technology and practices, the principles of identifying infarctions, tuberculosis, and other kidney diseases remain relevant. Modern survival preparedness emphasizes rapid diagnosis and treatment to prevent complications like hydronephrosis, which can be life-threatening without prompt intervention.
Frequently Asked Questions
Q: How can one identify gouty nephritis in a patient?
Gouty nephritis can be identified by the presence of small, chalky white spots or lines in the kidney tissue, composed of crystalline urate of soda. These deposits are often found in the pyramids or cortical portion and may appear as fine needles or lar