Tuberculosis.
—At no age are the kidneys exempt from tuberculous lesions, although these are more frequent in the earlier years of life. Here as elsewhere they may assume the disseminated miliary type or occur as a solitary focus. The infection may proceed upward from the bladder, or it may be a local expression of a widely diffuse process. In the latter case it has passed beyond the control of the surgeon as such, and calls for general therapeutic measures, judiciously selected and actively maintained. Not a few cases of renal abscess, of pyelonephritis, and even of perinephritic abscess, are due to primary tuberculous lesions.
Symptoms.
—About the earliest symptoms that a patient may complain of are thamuria (frequency of urination), with blood or pus in the urine. Even at this early stage the condition is essentially surgical, so the diagnosis should be established. Cryoscopy alone is hardly sufficient, although if the freezing point be studied it should be regarded along with the amount of fluid ingested and the quantity of carbohydrates taken with the food. Ureteral catheterization is valuable, although until it came into vogue we were content to study the cystoscopic appearance and to judge by the ureteral orifices, assuming that if one appear healthy and the other not so operation is indicated.
The question of removal of a totally diseased kidney when the other is more or less affected is one demanding greatest judgment. Some of the more recent operators endeavor to determine this by the cryoscopic test of the urine from the less affected organ. If this stand the test they do not hesitate to remove the one which is totally diseased. Thus it would appear that the ideal method is one of careful study of the urine from each kidney, although it is acknowledged that when the question is still in doubt the associate kidney may be explored before deciding to remove the one most diseased.
Diagnosis of Renal Tuberculosis.
—The most frequent and significant symptoms of renal tuberculosis are pain, local and referred; hematuria, polyuria, and pyuria. In young adults suffering from bladder irritability, painless pyuria usually indicates tuberculosis of the bladder, secondary to that of the kidney, this being particularly true when the urine is hyperacid. This urine, if noted, will be found at first faintly cloudy or smoky, while later the admixture of pus becomes more evident. The frequency of micturition (thamuria, pollakiuria), which is frequently noted early, may be due mainly to polyuria; the final test is the discovery of bacilli in the urine. There is another form of thamuria which is associated with tenesmus, constituting the painful cystitis of Guyon, which depends on complications in the bladder itself. A search for bacilli is often disappointing, and tuberculin may be used in the endeavor to make a diagnosis, as well as animal inoculation. Tuberculin might, however, give rise to error were there tuberculous foci elsewhere about the body.
Fig. 634
Tuberculosis of kidney, nodular form. (Israel.)