BY HOWARD S. JECK, PH.B., M.D.,
New York, N. Y.
Renal tuberculosis occupies a pre-eminent place in the list of those
diseases whose initial symptoms are apparently so insignificant and
whose onset is so insidious that the true state of affairs is either
entirely overlooked or else recognized only after it is too late to
accomplish the most good.
[Footnote A: To the courtesy and generosity of Dr. Edward L. Keyes, Jr.,
with whom I am now associated, I owe the privilege of employing the
above cases, which have been selected from his wonderful storehouse of
instructive case histories.]
A large number of the cases that come under our observation, exhibit
symptoms which are referable solely to the bladder in the guise of a
mild cystitis, the patients perhaps complaining only of a slightly
increased frequency of micturition by day, not even being disturbed once
at night to empty his bladder. Here the temptation on the part of many
physicians at once arises to treat such cases lightly—doubtless to
dismiss the patient with assurances that his condition is one of a mild
inflammation of the bladder which, in all probability, will soon right
itself after an irrigation or two, plus a few tablets of urotropin.
On the other hand, the onset may be so stormy or symptoms so terrifying,
that we at once think of all the horrible conditions to which the
genito-urinary tract is heir. But once our suspicion is aroused as to
the possibility of tuberculosis of the kidney, the question of an exact
diagnosis, the question of which kidney is involved, and the condition
of the other kidney (on which naturally depend the course to pursue) are
matters not always easy to decide.
To this end, cystoscopy, ureteral catheterism, renal function tests and
the X-ray, lend themselves as invaluable aids. But we must remember that
even with so much assistance at hand, the pitfalls are many and it is
with the hope of pointing out a few of the former as well as emphasizing
the more certain means of diagnosis, that I feel justified in this
presentation.
_Case I_,—E. P. was first seen in September, 1907. He then complained of
an ulcer on the penis and frequent and painful urination. One brother
had died of pulmonary tuberculosis. The ulcer had appeared a year
previously, beginning with a redness of the meatus, which persisted,
with superficial ulceration. No history of exposure. In April, 1907, the
dysuria began, and at the time he first consulted Dr. Keyes, he was
urinating every two hours, day and night. He had also experienced a
chill three weeks before this time.
The patient had never noticed any blood in his urine. His weight had
dropped from 170 to 149. Physical examination showed his kidneys to be
insensitive, and his prostate and seminal vesicles were negative.
The urine was acid, showed a fair amount of pus and albumin, but no
casts. No. T. B. bacilli found.
A month later the patient was seen again. In the interim he had suffered
an attack of fever (T. 105), and also an intense pain in the right
testicle and right side, lasting four days. The urine suddenly showed a
great increase in pus after which relief followed. All this time the
prostate remained unchanged, but the right kidney was now tender on
palpation.
During the next couple of months the patient showed a quite perceptible
general improvement on anti-tubercular treatment, but had at times
passed some blood in his urine.
However, in January, 1908, he began to have pain all over the abdomen.
Cystoscopy having been unsuccessfully attempted two months previously,
separate urines from the right and left kidney were now obtained by
means of the Luys’ urine separator and showed the following: From the
right kidney, 14 cc. of urine, containing 2.4% urea, and a slight amount
of pus; from the left kidney ¾ cc. of urine, a very little urea and a
large amount of pus. A nephrectomy of the left kidney a few days later
revealed a small tubercular pyonephrotic kidney, with an apparently
normal ureter.
In April, 1910, this patient was heard from directly for the last time.
By virtue of his social status he was forced to lead a life which was
not in conformity with his personal welfare, doing hard manual labor
most of the time. And while he has suffered various setbacks, he always
managed to readily recuperate under enforced rest and anything like
proper hygienic conditions. He had even gained considerable weight when,
another setback occurring, due to over-exertion, he went to the
Adirondacks, immediately contracted pneumonia, and died within a week of
its beginning.
While the above case does not serve especially well to illustrate a
pre-operative diagnosis of renal tuberculosis, inasmuch as there was no
X-ray and no T. B. bacilli were ever found in his urine, it does bring
out a certain fairly infrequent symptom which would be extremely—I might
almost say—fatally, misleading in the diagnosis of surgical conditions
of the genito-urinary tract but for other aids in diagnosis. I refer to
the phenomenon of crossed renal pain. That this was renal involvement of
a kind requiring surgical interference was well evidenced by the blood
and pus in his urine, together with his history of pain at various
times. But had we gone strictly by the pain, whose location was chiefly
in his right testicle and right side, the patient would have been the
victim of a nephrotomy, at least of his right kidney. However, the
presence of 2.4% urea with a slight amount of pus (probably pus from the
bladder as the Luys’ separator does not always preclude this
possibility) from the right ureter as against a very slight amount of
urea and a large amount of pus from the left ureter, dispelled all
question of doubt as to which kidney should be explored.
_Case II, E. B._—Male, gave the following history: A father and two
brothers died of pulmonary tuberculosis. Others in the family had lived
to ripe ages.
At the age of 31, the patient passed blood in his urine. Three years
later he experienced right renal colics and slight irritability of the
bladder. The colics continued every few weeks for seven years. Then,
because of an attack of intense bladder symptoms, and profuse hematuria,
Dr. Charles McBurney diagnosed the condition as renal calculus (this was
in 1900—the pre-radiographic days), explored the kidney, and found
nothing.
The operation relieved the renal colics. But the bladder still caused
him untold agony, the patient urinating blood every two or three hours.
On January 16, 1908, eighteen years after the first symptoms of his
disease, the patient consulted Dr. Keyes, having in the interval
suffered three vain searches for stone and two cystoscopies, and having
developed double tubercular epididymitis.
Physical examination revealed nothing except ridgy seminal vesicles. The
urine was cloudy and contained a small amount of albumin, pus, red blood
cells, a few hyaline casts and many T. B. bacilli.
The X-ray revealed an irregular shadow in the right kidney region, which
the radiographer reported as “consistent with a diagnosis of renal
tuberculosis.”
Cystoscopy was now tried again, but failed on account of the extreme
pain attending it. Recourse was then had to the experimental polyuria
test, which showed fairly good, though deficient renal function. The
diagnosis of tuberculosis of the right kidney being now fairly certain,
the kidney was removed in April, 1909. Though the pelvis was uninvolved,
the parenchyma was riddled with abscesses, the latter confirming the
diagnosis.
I had the pleasure of seeing this case as recently as February 2d of
this year. While the function of his remaining kidney is evidently quite
poor, as shown by an output of only 16% of phenolsulphonephthalein
(injected intravenously) in the first half hour and 10% during the
second half hour, he says he feels fine and has suffered only moderate
inconvenience due to frequency. His weight is now 178 and has remained
so for quite a time. While his urine still contains pus, a careful
search failed to reveal the presence of T. B. bacilli. Could Dr.
McBurney have availed himself of the use of the X-ray and our present
renal functional tests, he doubtless would not have been satisfied with
a mere exploratory operation. And, finally, eighteen years later, when
the X-ray, together with the patient’s symptoms and urinary findings,
did point out the true diagnosis, and the kidney which was involved, or
most involved, it remained for the polyuria test to decide the question
of operating at all. For, while the right kidney was tubercular without
a doubt, who could offer any prognosis as to the outcome in the event of
a nephrectomy, without some knowledge of the condition of the other
kidney? That the X-ray showed nothing definite on that side, told us
nothing of the kidney’s functional power.
Since cystoscopy, or the passage of any instrument of any size into the
bladder could no longer be endured, reliance had to be placed on the
experimental polyuria test. This showed fairly good renal function
_somewhere_, and inasmuch as the X-ray had shown what was probably a
considerable involvement of the right kidney, it was inferred that the
“fairly good renal function” belonged chiefly to the left kidney. The
case, also well emphasizes, the fact that renal tuberculosis may exist
for a long time and then respond to proper treatment.
_Case III, G. S._—In October, 1904, this patient then nineteen years of
age, consulted a physician in Albany N. Y., because of moderate
frequency of micturition by day and night, attended by much terminal
pain and blood on a few occasions. T. B. bacilli were found in his urine
at that time, which gave a positive guinea-pig test. Cystoscopy was
performed and as a result the patient had chills, a rise in temperature
to 104, and some pain over his left kidney. A diagnosis of tuberculosis
of the prostate was made and the patient put on treatment which resulted
in an amelioration of his symptoms for some time.
In January, 1909, Mr. S., first came to Dr. Keyes on account of frequent
urination, incontinence, and a swollen testicle. There was no family
history of tuberculosis, and his previous history was that given above.
A twenty-four hour specimen of urine gave the following analysis: Amount
2070 cc., sp. gr., 1014, acid, urea 1.2%, a trace of albumin, no sugar,
white blood cells, red blood cells, but _no tubercle bacilli_. On
physical examination it was found that he had a lump in the left lobe of
his prostate and also in the tail of his right epididymis. There was in
addition, a dense stricture extending from the peno-scrotal angle to the
triangular ligament.
During the next few days, the stricture was dilated sufficiently to
permit a cystoscopy which showed the bladder to be much ulcerated. The
right ureteral orifice was considerably congested, and the left
resembled an irregularly-shaped volcanic crater. It was impossible to
catheterize either ureter.
The X-ray report was pyonephrosis of the left kidney. After an injection
of 2 cc. of phloridzin, no sugar appeared in the urine until two hours
and fifteen minutes had elapsed. A month later, on account of his
stricture having recontracted, internal and external urethrotomy were
done, and it is of interest to note that in place of prostate, there was
a cavity as big as a plum, with hard tubercular walls. Six days later,
another attempt was made to catheterize the patient’s ureters without
success. His bladder picture was the same as before. Likewise
unsuccessful was an attempt to pass a Luy’s urine separator. At this
time, another phloridzin test gave no sugar at the end of four hours.
Two experimental polyuria tests made a week apart, showed rather poor
functionating power of the kidneys. Although it was impossible to obtain
separate urines from the kidneys, in view of the functional tests all
pointing to an involvement of one or both of these organs, it was
decided to perform an exploratory nephrotomy especially since the
patient was apparently getting worse in spite of all treatment.
The location of the pain in his early history and the X-ray report
certainly indicated the left kidney as the more probable one to be
affected. Therefore, on March 13, 1909, a nephrotomy of the left kidney
was done. The kidney was low and lay almost transversely. The pelvis and
ureter were entirely uninflamed but much dilated, the ureter being
larger than a lead pencil. An incision into the ureter allowed about 100
cc. of apparently clean urine to escape. A soft rubber catheter was
introduced into the ureter and stitched into the lumbar wound. Now comes
the startling feature of the whole story. Immediately after the
operation, _all urine stopped coming from the urethra and perineal
wound_ and in its stead came only pus, while apparently normal urine
flowed from the tube in the loin. This continuing to be the case, forced
the conclusion that the right kidney was either absent or practically
destroyed; the latter view was substantiated by an excellent X-ray,
subsequently made, showing a small atrophied kidney on the right side.
The patient made an uninterrupted recovery from his kidney operation,
but his perineal fistula never completely healed.
Three years after his nephrotomy he was re-operated upon in order to
close his perineal fistula and died as a result of shock. In the
meantime, however, he had gained much in weight, had improved generally
and returned to his work. No T. B. bacilli could be found in his urine
at the time of his last operation.
Here, then, is an instance in which the X-ray, which had rendered so
valuable a service in the preceding case, deceived the surgeon and then
later redeemed itself, to some extent, by demonstrating the size of the
right kidney. For the radiograph of the left kidney showed a rather
typical picture of pyonephrosis. Hence, obviously, the lesson to be
learned from this is that under certain conditions, water may throw a
shadow similar to that of pus, so that it is not always possible to
differentiate a pyonephrosis from a hydronephrosis by such means.
The crater-like appearance of the right ureteral orifice, though quite
suggestive, was hardly evidence enough to warrant a diagnosis of
tuberculosis of the right kidney, but had it been possible to
catheterize both ureters or even only one (either one), the question of
the involved kidney, the approximate amount of involvement, and the
condition of the opposite kidney, could have been readily cleared up.
_Case IV_,—J. L., age 30, was admitted to Dr. Keyes’ service in Bellevue
Hospital in May, 1912, with the simple, but all-important, history of
hematuria and frequency of urination for one year. A physical
examination of the lungs revealed probable tubercular lesions.
Cystoscopy with catheterization of the ureters was performed at once,
showing pus from the right ureter whose orifice was swollen, with
deficient function of the right kidney. A microscopical examination of
the urine from this kidney showed the presence of Gram negative cocci
(which could not be grown, however,) and later a culture of the bladder
urine showed Gram negative cocci which were positively identified as
gonococci.
Finally, T. B. Bacilli were found in the bladder urine. Suspecting the
right kidney of being tuberculous, 25% argyrol was injected into the
right renal pelvis, and the right loin X-rayed. An excellent radiograph
showed small round shadows throughout the kidney, and a mouse-eaten
appearance of some of the papillae, a typical tuberculous picture. This
diagnosis was subsequently confirmed by the finding of T. B. bacilli in
the urine from the right kidney. The right kidney was accordingly
removed, and found to be rotten throughout. It was likewise full of
argyrol. When last heard from (February, 1915), the patient had gained
considerable weight despite his lung condition.
The above case was selected mainly to show what was doubtless a
gonococcus infection engrafted on to a tubercular kidney, as it is only
reasonable to suppose that the Gram negative cocci obtained from the
right ureter were the same as those in the bladder which was
subsequently found to be gonococci.
Aside from the readiness with which the diagnosis of tuberculosis of the
right kidney was made (by virtue of the T. B. bacilli in the urine) the
swollen right ureteral orifice, pus from the same, and deficient
function of the right kidney by the phenolsulphonephthalein test, the
case is of further interest because of the corroboration of this
diagnosis by pyelography after the injection of an organic silver
preparation.
_Case V_,—P. B., 27. Entered St. Vincent’s Hospital in February, 1911.
Family history of no importance; was a heavy drinker; denied venereal
disease. Pneumonia two years before admission. On his neck was a scar
from a gland which suppurated at that time. Hematuria was his chief
urinary symptom. Six years before he had had profuse, spontaneous and
painless passage of blood in his urine, which stopped after a few days.
When he was admitted to the hospital he had been bleeding again, but
there were no other symptoms referable to his urinary tract. He had lost
no weight. Immediately after entering the hospital he had delirium
tremens, which lasted two weeks. At the end of this time, physical
examination showed a very large low kidney on the right side and a
slight pulmonary dulness at the base of his left lung. Cystoscopy
revealed a normal bladder and normal ureteral orifices. The ureters were
readily catheterized, the result of functional tests made being as
follows:
_Right kidney._—5 cc. of urine (in eight minutes) containing numerous
casts, a few w. b. c., but no pus; 1.3% urea.
_Left kidney._—3 cc. of urine (in eight minutes), containing no casts,
no pus; 0.3% urea.
One cc. of phenolsulphonephthalein was now injected intravenously. It
appeared in eight minutes from the right side and in nine minutes from
the left. During the next thirty minutes, the right kidney excreted 3%
of the drug, while only a trace was obtained from the left side; in the
following thirty minutes, the right side excreted 5.6% while the left
showed only 1.7%.
The above findings hardly seemed to jibe with the patient’s symptoms,
and physical examination which suggested tumor of the right side.
However, the amounts of urea and phenolsulphonephthalein excreted from
the right side were so much greater than the amounts from the left side,
that this fact certainly pointed to at least a greater involvement of
some kind of the left kidney, irrespective of the condition of the
right.
Accordingly the left kidney was exposed and its upper third found to be
a cheesy mass, obviously an old tubercular process. The patient was then
turned over and an exploratory incision revealed a low-lying right
kidney which was hypertrophied to twice its size, but otherwise
apparently normal. The patient was now turned back and his left kidney
removed. Both wounds healed by primary union, the patient making an
uneventful recovery.
In later reviewing the case Dr. Keyes states that he would have been
warned of tuberculosis on the left side had he but seen some pus in the
urine from that side, for, as he further says, “casts on one side and
deficient function with pus and without marked enlargement of the kidney
upon the other side, is very suggestive of unilateral tuberculosis.” The
case is of further interest on account of the greatly hypertrophied
right kidney. Aside from demonstrating the capability of one organ to
take over the work of its impaired mate, it should emphasize the
necessity of keeping in mind such possibilities in making a diagnosis.