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.