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.