IMAGE EVALUATION
TEST TARGET (MT-3)

1.0

I.I

1.25

l^|2B |2.5

|}o '*'^= Ml^H

^ MS Hio

o>.

Photographic

Sciences

Corporation

as WIST MAIN STRUT

WUSTIR.N.Y MSIO

(716) 173-4503

s:<p

CIHM/ICMH

Microfiche

Series.

CIHIVI/ICMH
Collection de
microfiches.

Canadian Institute for Historical Microreproductions / Institut Canadian de microreproductions historiques

Technical and Bibliographic Notes/Notes techniques et bibliographiques

The Institute has attempted to obtain the best
original copy available for filming. Features of this
copy which may be bibliographically unique,
which may alter any of the images in the
reproduction, or which may significantly change
the usual method of filming, are checked below.

D
D

Coloured covers/
Couverture de couleur

I I Covers damaged/

Couverture endommag^e

Covers restored and/or laminated/
Couverture restaurie et/ou pelliculie

I I Cover title missing/

Le titre de couverture manque

I I Coloured maps/

Cartes giographiques en couleur

Coloured ink (i.e. other than blue or black)/
Encre de couleur (i.e. autre que bleue ou noire)

Coloured plates and/or illustrations/
Planches et/ou illustrations en couleur

. Bound with other material/
)LJ ReliA avec d'autres documents

Tight binding may cruse shadows or distortion
along interior margin/

La re liure serrie peut causer de I'ombre ou de la
distortion le long de la marge intirieure

Blank leaves added during restoration may
appear within the text. Whenever possible, these
have been omitted from filming/
II se peut que certainas pages blanches ajoutAes
lors d'une restauration apparaissent dans le texte,
mais, lorsque cela 4tait possible, ces pages n'ont
pas 4t* filmies.

Additional comments:/
Commentairos supplAmentaires;

L'Institut a microfilm^ le meilleur exemplaire
qu'il lui a 6t6 possible de se procurer. Les details
de cet exemplaire qui sont peut-dtre uniques du
point de vue bibliographique, qui peuvent modifier
une image reproduite, ou qui peuvent exiger una
modification dans la mithode normale de filmage
sont indiqu6s ci-dessous.

□ Coloured pages/
Pages de couleur

□ Pages damaged/
Pages endommagies

□ Pages restored and/or laminated/
Pages restaur^es et/ou pellicul6es

r~~| Pages discoloured, stained or foxed/

Pages ddcolor^es, tachetdes ou piqudes

Pages detached/
Pages ditachies

Showthrough/
Transparence

Quality of prir

Qualiti inigale de I'impression

Includes supplementary materii
Comprend du materiel suppl^mentaire

Only edition available/
Seule Edition disponible

I I Pages detached/

I I Showthrough/

I I Quality of print varies/

r~~| Includes supplementary material/

I I Only edition available/

Pages wholly or partially obscured by errata
slips, tissues, etc., have been refilmed to
ensure the best possible image/
Les pages totalement ou partiellement
obscurcies par un feuillet d'errata, une pelure.
etc.. ont M filmies A nouveau de fapon A
obtenir la meilleure image possible.

This item is filmed at the reduction ratio checked below/

Ce document est iWmt au taux da reduction indiqu* ci-dossoui.

10X

14X

18X

22X

26X

30X

12X

16X

20X

24X

28X

32X

The copy filmad hare has b««n r«produc«d thanks
to ths gensrosity of:

Medical Library
IMcGiii University
(Montreal

Ths imagss appsaring hara ara tha boat quality
possibia eonsidaring tha condition and lagibility
of tha originai copy and in Icaaping with tha
filming contract spacificationa.

Original copiaa in printad papar eovars ara filmad
beginning with tha front covar and ending on
tha iaat page with a printad or illuatrated imprea-
sion, or tha bacic cover when appropriate. All
other original copies ara filmad beginning on the
first page with a printed or illuatrated imprea-
sion. and ending on the last page with a printed
or illustrated impreasion.

L'exemplaira filmi fut reproduit grAce i la
ginirosit* da:

Medical Library
McGill University
Montreal

Lea images suivantas ont M reproduites avac la
plus grand soin, compta tenu de la condition at
de la nettett de l'exemplaira film*, at an
conformiti avac las conditions du contrat de
filmage.

Les exemplairaa originaux dont la couverture en
papier eet imprim^e son^ rilmte en commen^ant
par la premier plat at Bn terminant soit par ia
darnlAre page qui comporte une empreinte
d'Impreaaion ou d'illuatration, soit par la second
plat, salon la caa. Tous las autrea exemplairaa
originaux sont filmte en commen^ant par la
premiAre pege qui comporte une empreinte
d'impreasion ou d'illustratlon at an terminant par
la darniAre page qui comporte une telle
empreinte.

The Iaat recorded frame on each microfiche
shall contain the symbol — ^ (meaning "CON-
TilMUED "), or the symbol y (meaning "END"),
whichever eppilea.

Un dee symbolae suivants apparattra sur ia
damlAre image de cheque microfiche, selon le
caa: le symbols -^ signifie "A SUIVRE", ie
symbols ▼ signifie "FIN".

IMapa, platee, charta, etc., may be filmed at
different reduction ratioa. Thoae too large to be
entirely included in one expoaura ara filmad
beginning in the upper left hand corner, left to
right and top to bottom, aa many framea aa
required. The following diagrama llluatrate the
method:

Lee cartea. planchaa. tableaux, etc.. peuvent Atre
fllmia i dee taux da rMuction diffirents.
Lorsque le document est trop grand pour Atra
reproduit en un seul cliche, 11 eet film* A partir
de I'angle supArieur gauche, de gauche A droite,
et de haut en baa, an prenant le nombre
d'imagea n4caasaira. Lea diagrammea suivants
illustrent la mAthoda.

'W^'

RE-PBINTED FROM THE

'CANADA MEDICAL A SURGICAL JOURNAL,"
FEBRUARY, 1887.

EXPLORATION OF THE KIDNEY IN A CASE OF
TUBERCULOUS PYELITIS.

By Francis J. Shbphkbd, M.D.

The following case is of interest, as showing the difficulty of
diagnosis in the early stage of tuberculous disease of the kidney.
All the symptoms at first were referable to the bladder, and the
amount of pus in the urine was small. In many such cases the
prominent early symptom is frequent micturition, and this may
or may not be accompanied by pain, which, when excessive,
may be due to tuberculous deposits in the bladder itself. When
the man first came under my notice I considered that the disease
was one of the kidneys and not of the bladder, because of the
small amount of urea excreted daily and the absence of mucus
from the urine. The personal and family history of the patient
did not point to .uberculous disease, and the amount of pus was
so small that it might easily have originated in the bladder.
Careful examination revealed no tumor in the region of the
kidney, but there was always discomfort and pain in the left
lumbar region. Later on, when pus became more abundant
and the amount of urine less, it was evident that there was some
destructive disease of the kidney going on, due either to the
presence of stone or tubercle. The sudden diminution of the
flow of urine showed that both kidneys were inefficient, and
it was decided to cut down on the tumor which was now
present in the region of the left kidney in the hope of finding a
stone which was preventing the onflow of urine. When the
operation was performed the man was in an uraemic condition,
and evidently had not long to live.

The operation is instructive, and this lesson is to be learned
from it, viz., that no mere external examination of the kidney

R '

can satisfactorily determine its condition, and that in every case
an incision should be made into the organ and the parts explored
with the probe or finger. The aspirator failed to evacuate the
contained pus, because it was so thick and tenacious, although
a previous exploration had revealed its presence in small amount.
In cases of tuberculous pyelitis the disease is often symmetrical,
and it would be folly to perform a nephrectomy without a know-
ledge of the condition of the opposite kidney. Such cases de-
mand a nephrotomy with subsequent drainage until the condition
of the other kidney is ascertained. If it is found to be healthy,
nephrectomy may be afterwards performed with the object of
removing a suppurating organ and ridding the patient of foci of
disease. The condition of the other kidney is easily ascertained
after a nephrotomy, for all the urine from the incised and drained
kidney would come out of the lumbar wound, and that which
was passed through the ordinary channel would necessarily come
from the other kidney. If the urine is large in amqunt and of
a healthy character, this is partly good proof that the other
kidney is performing its functions properly.

For the report of the following case I am indebted to my late
house surgeon, Dr. H. S. Birkett : —

S. B., aged 38, was admitted into the Montreal General
Hospital on the 13th of July, 1886, complaining of frequent
and painful micturition. These symptoms first appeared three
months before, and he had been treated by several physicians
for catarrh of the bladder. Had always been healthy up to
three months ago, and was formerly stout, but had lost con-
siderable flesh lately. He made water every few minutes,
night and day, and each time the pain was severe. It com-
menced in the small of the back, on the left side, and extended
down the groin, along the urethra to the point of the penis.
He complained of continuous dull, aching pain in the left
lumbar region. Had never passed any blood ; urine contained
a small amount of pus, but no mucus, specific gravity 1.005,
contained albumen, and only two grains of urea to the ounce.
Quantity passed daily, 60 to 70 ounces. No tumor could be
made out in the lumbar regions. Bladder sounded for stone,

1 every case
rts explored
vacuate the
IS, although
lall amount,
ymmetrical,
out a know-
ch cases de-
;he condition
) be healthy,
the object of
jnt of foci of
ascertained
and drained
i that which
issarily come
nqunt and of
at the other

pd to my late

real General
; of frequent
>peared three
al physicians
lealthy up to
lad lost con-
few minutes,
re. It com-
and extended
of the penis,
n in the left
ine contained
gravity 1.005,
to the ounce,
imor could be
ded for stone,

with negative result. No cough or expectoration, and lungs
and heart perfectly normal. From the condition of the urine
and general symptoms, Dr. Shepherd concluded that he was
suffering from some affection of the kidney. He remained in
the hospital some weeks, but left no better than he entered,
treatment having no effect whatever.

Dr. Shepherd afterwards attended the man at his own house,
and the symptoms still continued as before, viz., frequent and
painful micturition, with pus in urine. The quantity of pus in
urine now rapidly increased and the urine diminished. He
passed 20 to 30 ounces of urine daily, 30 per cent, of which
was pus. He also became rapidly emaciated, and there was
occasionally an elevation of temperature in the evening. The
patient went to some mineral springs in the neighborhood, and
was not seen for several weeks, not, in fact, till the latter end
of September. He was then much emaciated, and seemed to
be in a stupid, drowsy condition. He was passing only 20
ounces of urine daily, and of that 50 per cent, was pus. A
tumor could now be distinctly made out in the left lumbar region.
It was aspirated, and at first only a little thick pus was drawn
off and then thin bloody serum.

He was again admitted into hospital Oct. 11th, 1886, and
the day after admission passed only six ounces of urine, from
which all pus had disappeared. His condition was serious ; he
had well marked uraemia, and Dr. Shepherd, thinking that the
arrest of urine might be due to a stone blocking the ureter, deter-
mined to cut down and explore the kidney, a proceeding which
he thought could do no harm and might do good. The horizontal
lumbar incision was practiced, beginning posteriorly at the edge
of the erector spinse muscles and extending downwards and out-
wards below the 12th rib. The kidney was soon reached and found
to be enormously enlarged and non-fluctuating. The finger easily
went through some tissue to the depth of one inch at the upper
end. A large aspirating needle was thrust in several directions
iiito the kidney, but failed to reach either a stone or pus. From
the great enlargement and general appearance it was thought
a neoplasm existed, and considering that the man was secreting

only six ounces of urine daily, the conclusion was arrived at that
the other kidney was also diseased, so a drainage-tube was intro-
duced and the wound sewed up. The man recovered from the
immediate effects of the operation, but died comatose that night.
No post-mortem examination was allowed, but after death the
wound in the lumbar region was reopened and the kidney taken
out. At the same time the kidney of the other side was searched
for, but could not be found ; it had probably been affected by a
similar disease and had undergone atrophy. On cutting through
the greatly enlarged kidney numerous pockets of pus were found
and some large cysts distended with serum. The cortical sub-
stance was studded with small suppurating points, and was much
thickened. Dr. Wyatt Johnston examined the case, and came
to the conclusion that it was a tuberculous kidney ; tubercle
bacilli were found in large numbers.