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.