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.