Filling defect of the greater curvature due to retroperitoneal sarcoma, simulating the defect of carcinoma (Fig. 24)... Squamous-cell epithelioma, grew from size of five-cent piece to size of silver dollar during six months' course of X-ray treatment (Fig. 1) Same patient as Fig. 1, two years and eight months after operation (Fig. 2) Rodent ulcer of side of nose (Fig. 3) Same patient as Fig. 3, one year after operation (Fig. 4) Epitheliomatous degeneration in senile keratotic patch on nose (Fig. 5) Same patient as Fig. 5, ten months after operation (Fig. 6) Scar remaining after removal of rodent ulcer of lower lip. Three and onehalf years postoperative (Fig. 7) Scar remaining after removal of rodent ulcer of side of nose and cheek. One year postoperative (Fig. 8) Case of first-degree malignancy, cured by röntgenotherapy without cosmetic blemish (Fig. 1) ...... ..... Case of first-degree malignancy. Mycosis fungoides. Diagnosis confirmed by microscopical examination (Fig. 2) Case of first-degree malignancy. The growth had been cut out with resultant scar and deformity (Fig. 3) .... Case of third-degree malignancy. Lymphosarcoma. Diagnosis confirmed by microscopical section (Fig. 4) Case of third-degree malignancy. Sarcoma (infectious granuloma). Diagnosis based on microscopic section (Fig. 5) Case of third-degree malignancy. Epithelioma. Diagnosis confirmed by microscopical section (Fig. 6) Diagrammatic drawing of heating unit transformer for Coolidge tube for direct current (Fig. 7) .... Diagrammatic drawing of heating unit transformer for Coolidge tube for alternating current (Fig. 8) .... 96 Localization of cauterization or coagulation effects of the high-frequency currents in an albuminous fluid according to the size of the electrode used (Figs. 10, 11, and 12) 99 J. B. Murphy 170 Electric motor saw for bone surgery (Fig. 1) 184 Case I.-Double fracture and absorption of intervening fragment (Fig. 2) 186 Method of applying straps in Brady's frame (Figs. 2 and 4) 196 196 Diagnosis and Treatment REMARKS ON THE DIAGNOSIS OF POLYCYSTIC KIDNEY 1 BY SIR WILLIAM OSLER, Bt., M.D., F.R.S. POLYCYSTIC kidney in the adult is not often recognized. It is a rare disease, but, following the law of dual coincidence, there are two cases at present under observation. In the patient before you, a woman, aged 52, sent by Dr. Hayward, of Abingdon, the diagnosis has already been made by Dr. Thompson, the house physician. She is thin, semicomatose, with purpuric spots about the face, and there is a blood-stained fluid oozing from her mouth. She is very apathetic, and it is difficult to get her to reply to questions. Interesting and, in my experience, unique features are seen on inspection of the abdomen. It is enlarged, particularly in the flanks, which bulge. But what catches the eye at once, particularly on the right side, are large, hemispherical projections between the navel and the costal borders. On the right side there is a whole series—one as large as an orange above the level of the navel, while below, extending to Poupart's ligament, are half a dozen, ranging in size from a small marble to a large walnut. On the left side they are smaller, but very distinct, particularly as the tumors descend on inspiration. It is a very remarkable pattern of abdominal tumidity--the bilateral swelling, the marked prominence of the flanks, and the hemispherical projections seen beneath the thin abdominal wall. One could not go far wrong in making the diagnosis on inspection alone of bilateral cystic kidneys. On palpation large tumors can readily be felt passing posteriorly deep into the flank, and firm, resistant cysts of various sizes project from the surface. The heart does not appear to be much enlarged, the arteries are sclerotic; the urine is very scanty, with a low specific 1 Radcliffe Infirmary, Oxford, November 23, 1914. VOL. I. Ser. 25-1 1 gravity, and contains numerous hyaline tube casts. The history of the case is remarkable. At the fourteenth year she had the first attack of hæmaturia, with colic, and naturally the diagnosis was made of stone. These have occurred at intervals, sometimes of a few months, sometimes of a year or more, but she has had fairly good health, and has been able to work hard. About two years ago she had a uræmic attack. Last year, for the first time, the tumor on the right side was detected. She had felt the abdomen increasing in girth; she was at that time much stouter, and a well-known gynecological surgeon suggested that it might be an ovarian tumor. Within the past few weeks she has had constant vomiting, has been very drowsy; a purpuric rash has broken out, and there has been slight bleeding from the gums. She has grown progressively worse, and is in a very critical condition. [The patient died the next day, unfortunately, before a photograph was obtained of the abdomen. The post-mortem showed enormous bilateral cystic kidneys. The large cyst on the right side extended into the pelvis, and was in contact with a small pedunculated fibroid of the ovary-a very puzzling condition, I should think, for a gynæcologist. The colon was completely pushed aside and lay to the left of the kidney. As is often the case, the liver contained numerous cysts; one on the upper surface of the right lobe was larger than the fist, and was filled with a clear fluid. The heart was not enlarged, but the arteries were sclerotic.] The other patient, a woman, aged 39, has been admitted once or twice to the surgical side, where, too, the diagnosis has been made. She is, as you see, very healthy looking, not thin, and with a good color. About ten years ago, after an aching feeling in her right side, she passed two stones, with hæmaturia. Since then she has had several attacks of pain, associated with passage of blood, and twice she has passed small calculi. In the intervals the urine has always been clear, and it now has a specific gravity of about 1.014, and is without albumin. On inspection of the abdomen, the flanks bulge, more to the left than the right, but there is no special prominence in front. On the right side a large tumor occupies the flank, passes high beneath the costal border and into the epigastric region, and below reaches to the level of the anterior superior spine. The colon can be felt passing over the tumor, the surface of which presents numerous irregular bosses or projections. On deep palpation from behind the tumor mass can be moved forward, and lifts the skin. The left side is occupied by a smaller mass with similar characters. The liver is not enlarged. The superficial arteries are palpable, the blood-pressure is only 130 mm., the apex beat cannot be felt, the heart does not appear to be large, and the aortic second is not specially accentuated. There are no other special features on examination. Her eyes are normal. The X-ray picture shows, on the right, three or four small shadows, suggestive of stones, far away from the kidney position, but quite within the limits of the tumor mass. The pathology of polycystic kidneys has been much discussed. They are often congenital, and the tumors may be at birth of enormous size. They may be associated with other anomalies. They may be quite small at birth, as in a child with several congenital malformations, in whom both kidneys were slightly enlarged and uniformly occupied by small, just visible cysts, lined with epithelium. A very remarkable feature is the hereditary character. In 1902 I reported the case of a man, aged 39,2 whose mother died of the same disease. As the subsequent history of the case has never been given, I may state that between 1902, when I saw him, and 1906, when he died of uræmia, he had many attacks of hæmaturia, and the kidneys increased greatly in size. The right kidney weighed 4370 grammes, the left kidney 5270 grammes. Three cases have been reported in one family, and a woman has been known to give birth to five children in succession with the disease. The origin of the condition has been much discussed, but the view put forward by Koster is probably correct, that in an error of development there is failure in the union of the secretory and collecting tubules, which develop separately. Very strong confirmation of this view has been recently brought forward by Forssman, who, studying the problem by the method of reconstruction, arrives at the conclusion that there is a failure of the union of the collecting canals, which develop from the ureter section, with the tubules of the metanephric portion. His 2 American Medicine, vol. iii, p. 951. 3 |