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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 ' 
 
 i 
 
 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, 
 
 h 
 
8 
 
 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.