XXV. On a Dilatation of the Ureters, supposed to have been caused by a malformation of their Vesical Extremities. BY JOHN OKES, Esq. OF CAMBRidge. HONORARY MEMBER OF THE CAMBRIDGE PHILOSOPHICAL SOCIETY, [Read November 12, 1821.] ALTHOUGH extensive dilatation of the ureters consequent upon obstruction be by no means rare, yet it cannot be said to occur frequently, particularly to the degree remarked in the instance which forms the subject of this paper. It is not however the magnitude, so much as the cause of the derangement, which deserves our notice in the case about to be related. In those upon record, the causes of obstruction have been generally ascertained to be calculi and tumors compressing the tubes. Sabulous, purulent and mucous accumulations have been thought by some, sufficient to obstruct those passages. Of the first and most common kind Monro mentions an instance, in which "the lower aperture (of the ureter) being filled up by a stone, the kidney was distended to a monstrous size; and the ureter was so large, that, at first sight, he mistook it for a piece of intes tine*." A dilatation of equal extent was found by Morgagni, in a person who died from a large stone in the bladder. "Pure autem et urinâ pleni erant renes et ureteres; immò hi tam distenti ut Ilei intestini diametrum æquarentt." A still stronger instance of the extensibility of the ureters occurred to Ruysch‡. He precedes his history by a remark, in which he is by no means singular: that the unnatural distension which membranous tubes undergo, is accompanied by a proportional thickening of their substance. Malformations of the ureters, at their junction with the bladder, may be reckoned among the causes of their enlargement. But examples of this kind are of very rare occurrence, and may be easily confounded with the effects of disease upon these ducts. The least doubtful instance, next to that I am about to describe, is one that fell under the observation of Ruysch §. The obstructing cause consisted in a membranous + Morgagni opera, (Neapoli 1762.) tom. 3. p. 314. "Nil magis admiratione dignum crediderim quàm vasa membranacea, quò magis distenduntur, eo magis sæpe ab humore heterogeneo incrassari. Ureteres aliquando ita esse dilatatos, ut digitum admittant, rarum non est. Rarissimum tamen et inauditum, ureIn ureteris dextri infimâ parte supra terem pintam materiæ purulentæ continuisse; insertionem in vesicam calculus hærebat nucis avellanæ magnitudine. Pars media dicti ureteris ita erat extensa, ut pintam ad minimum contineret." Ruyschii Observatio XCIV. § "Vogelesangh, chirurgus diligentissimus, ad dissectionem duos nobis attulit renes ovillos, ita extensos et humore aquoso repletos, ut duas ferè pintas uterque contineret. Ureteres admodum tortuosi et tantæ erant capacitatis ut radicem majorem pastinacæ admitterent. Utraque renum tumentium extremitas substantiam naturalem glandulosam non amiserat, spatium verò intermedium constabat ex membrana. Intrinsecè tubuli pelvis cellulas magnas repræsentabant, tantæ capacitatis, ut nucem juglandem viridi cortice obductam admitterent. Urinam in vesicâ urinaria contentam facili negotio exprimebam versùs ureteres et renes, verumenimverò ab ureteribus et renibus versùs vesicam, non nisi vi adhibitâ idque parcissimè per exiguum foraminulum in medio cujusdam clausuræ membranaceæ, quam vesicam inter et ureteres inveniebam. Talis, inquam, erant constitutionis dicta foraminula, ut è vesicâ urinaria versùs ureteres et renes satis liber esset urinæ transitus, expansion stretched over their apertures into the bladder, and perforated in such a manner, that the urine passed through them out of that cavity, much more freely than into it. It may reasonably be doubted, whether such a membrane would be the product of inflammation falling upon a mucous surface. this point Ruysch has expressed no opinion. Upon The instance which came under my own inspection, occurred in a patient of mine at Addenbrooke's Hospital in Cambridge, a boy of eleven years old. About ten days after his admission, he complained when taking his usual exercise in the garden, of great pain in his body, numbness in his legs, and faintness. He was immediately conveyed to his bed, and, in a few minutes, expired. At the time of his admission into the house, it was thought that some of his symptoms resembled those of stone in the bladder, until an examination by the sound, induced a contrary opinion. Although not greatly emaciated, his appearance was far from healthy; he was of a diminutive stature, pale complexion, and very weak. The unnatural size of his abdomen, led to a frequent and careful examination of it, more particularly as he had complained of pain in that part: but it was always, even when most distended, so soft, as to yield freely to pressure. Sometimes during these examinations, I was inclined to think that a fluctuation was perceptible, yet the idea of a dropsical tendency was abandoned from its being somewhat irreconcileable with the abundant secretion of urine, that had for a long time existed. Again, the figure of the abdomen led to the supposition, that the intestines might be the seat of the enlargement; though this was at variance with the regularity and healthy state of his evacuations, and some cathartic medicine was situs, contraria verò compressio ab ureteribus et renibus versùs vesicam maximâ ex parte erat frustranea, unde dubio procul oborta fuit urinæ regurgitatio, et temporis progressu talis renum et ureterum expansio." Ruyschii Observatio XCIX. directed, but with no other result, than that of adding to his excessive debility; for the large and pendulous form of his body continued the same. His urine, when first passed, resembled water rendered turbid by a small quantity of milk, and after cooling, afforded a copious deposit of pus, entirely devoid of the ropy mucous sediment secreted by a bladder under the irritation of a stone. This had been the state of his urine since he was a year old; it had never been known to be tinged with blood, nor to contain any calculous matter; neither had he ever after that age less power of retaining it than the generality of children, but on the contrary, though the desire to discharge it was very frequent, the effort often proved unavailing. To this distressing circumstance his mother attributed his general unhealthy condition as an infant. It was among her observations as well as those of the Hospital nurse subsequently, that the inclination to make water was not so incessant during the night as in the day; and that he would pass many hours in the day-time upon his bed, and even upon the floor, as though he had discovered from experience, that the recumbent was the most efficacious posture for allaying that continual desire to make water by which, for hours together, he was tormented. So severe indeed was the distress which he usually endured, that it seemed scarcely probable his existence could have been so long protracted, without the discovery of some such means of temporary alleviation. He had, however, intervals of comparative ease; these he had occasionally enjoyed for two or three successive months, when he used to recover rapidly, to a certain degree, his strength and spirits. Such were the observations I had partly made and collected respecting this inexplicable case, when, the boy suddenly dying, an opportunity was afforded of investigating still further, its peculiarities. That the urinary apparatus was the seat of the derangement, there could be little doubt, but the train of symptoms was such, as could not be referred to any one of the known diseases, to which these organs are liable. DISSECTION. Nothing remarkable presented itself to notice, until the omentum and intestines were raised from their natural situations in order to obtain a view of the kidneys. It then seemed as if the intestines were adhering to the iliac regions instead of being easily moveable almost from one side of the body to the other, and, as there were no marks of inflammation to be seen, we were at first incapable of accounting for so unusual an appearance. Upon closer inspection I perceived that besides the intestines, I had also attempted to lift up the ureters, which, owing to their extreme enlargement, had been mistaken for intestine. Pursuing the examination, we found the two ureters of nearly equal dimensions, describing in their course convolutions not very unlike those of the intestines, and containing in their lowermost part a large quantity of urine, that flowed freely into the bladder, or back again into the ureters, according as the position of either was varied. The figure and external appearance of the bladder were perfectly natural, but the ureters, instead of taking an oblique direction through its coats, described a curve that placed their extremities almost at right angles to that organ*. The kidneys bore strong marks of disease; their collapsed sides consisting of little more than their own proper tunic, shewed the almost total destruction of their glandular substance, and thereby confirmed the only conjecture which so singular an assemblage of symptoms could • The transparency of the dried preparation affords a view of the apertures of the ureters into the bladder, which are large enough to admit a common sized goose-quill. These parts, as well as the bladder, exhibit no other proofs of deranged structure. The kidneys are almost entirely destroyed; there remains of glandular substance, in each, a portion equal to about of the whole gland, the other part consists of cells, perhaps thirty in number, which, if solid, would give it the appearance of the fœtal kidney. Z z Vol. I. Part II. |