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Pyonephrosis, Nephrolithiasis, Hematuria, Pyuria

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Pyonephrosis, Nephrolithiasis, Hematuria, Pyuria Lecture croscope, and we are led to make this search all the more thoroughly because the presence of blood corpus- cles in the urine has been emphasized, especially by my PYONEPHROSIS, NEPHROLITHIASIS, HEMATU- colleague Professor Ransohoff, as :i point of especial RIA, PYURIA; SUBSEQUENT NEPHROTOMY; value in the of stone in the You NEPHRECTOMY; RECOVERY. diagnosis kidney. can understand, however, that blood would be present A Clinical Lecture Delivered at the Good Sa- only when the pelves of the kidneys or ureters were maritan November 1898. Hospital, Cincinnati, 1, being fretted or torn by a rough stone. A perfectly BY JAMES T. WHITTAKER, M.D., smooth stoue, a Bacculated stone, or a stone embedded Professor of Theory and Practice of Medicine in the Medical Col- in pus would not scratch the kidney and would not lege of Ohio. show blood. The diagnosis in this case is manifest from the But whether there is a stoue present or not, there symptoms as given in the history. is pus in quantity and it is necessary to discover its History.— B. J. P., politician, age forty-two, en- source, that is, whether from the kidney or the blad- tered the hospital October 31, 1898. Family history- der. If the pus belonged to the urethra it would ap- good. Never had any serious sickness except his pear with the first discharge of urine, preceding the present trouble. When eighteen or twenty years of urine, almost, and could be expressed at any time ; if age he was struck with a club over the region of the from the prostate it could likewise he expressed, espe- kidneys. Since that time a slight strain from exertion cially with the finger in the rectum, where the large or catching cold would bring on attacks of pain in the mass of the prostate could be felt, usually with mani- kidneys, loins, testicles and ureter, followed by vesical festations of pain. The difficulty arises as between irritation and frequent urination with bloody urine. the bladder and the kidney. My old teacher, Oppol- Two years ago small calculi were found in the patient's zer, used to maintain that the reaction of the urine urine. Throe years ago the urine was found to con- would decide it, for if the pus came from the bladder tain pus. Last August he was seized with pain in the it would be alkaline, if from the kidney acid. This left kidney, radiating down the ureter to the testicle, view, however, is no longer tenable, as pyogenic micro- the bladder also being tender and sore and urination organisms may decompose the urine in the pelvis of very painful. During the night he passed a quart of the kidney and make it alkaline. Then it must not red blood ; on the second morning following a large be forgotten that pyelitis and cystitis may coincide ; amount of black blood clots was passed. On the they usually do in the course of time. third morning one-half gallon (?) of reddish-brown pus If from the kidney, which kidney? In a woman wo was passed. Since then his condition has been one of may catheterize the ureter to lind out. Bergmann, alternate improvement and relapse. He has gradually after washing out the bladder in man, makes pressure become very weak and is now subject to fainting spells, upon the diseased kidney, and finds that pus is emptied having lost twenty pounds. into the bladder and may be discharged from it quicker Present condition.— He is weak and emaciated. He than after pressure upon the sound kidney. We are lies in bed all the time, for the most, part on the right led to locate the source of the pus in the kidney in oui- side, with the legs Hexed on the abdomen. The face case because there is so much pain in this region. The is thin, the eyes deep sunken, surrounded with a dark patient spares this side in decubitus, and though wo halo. The voice is feeble and husky. The tempera- can discover no tumor there is considerable tenderness ture ranges from 99£° in the morning to 101° or 102° to pressure, both before and behind. in the evening. There is pain over the site of the loft The microscope reveals unmistakable pus cells in kidney, following the course of the ureter, and tender- great abundance. ness over the area of the bladder. Mention is made in the report of tailed cells. These The urine is turbid, muddy and gray with detritus. cells belong to the kidney and not to the bladder. The reaction is neutral or faintly acid. The following However, wo lay not too much stress upon the pres- is the report of the microscopical examination made by ence of these cells. We have not been helped much Dr. Malsbary : (1) Pus cells, large number; (2) pus by the presence or absenco of these cells. All the best casts; (3) small granular casts; (4) tailed cells, a modern authorities, especially Ebstein and Fiirbringer, few. No crystals found. declare emphatically that no cells are characteristic of this a The salient points in history are, first, contu- pyelitis and that in the majority of cases of pyelitis no sion of the abdomen. Just what importance to lay cells are to be found. The cells with tails aud multi- upon this accident it is difficult to Bay, but whether ple nuclei are anyhow not confined to the pelvis of the post hoc or propter hoc symptoms set in afterwards kidney, hut occur also in the bladder und in the ante- which were not present before. The blow may have rior portion of the urethra, as well as in the vagina and caused hemorrhage. The pain attending the passage cervical canal. The pain in the kidney, the tender- of kidney stones is so severe as to be unmistakable ness, the continuous fever, the previous attacks of kid- where there is no account to be taken of hysteria. ney-stone colic with hematuria, fix the disease in the But if there was any doubt about the pain, there could pelvis of the kidney, and in the left kidney. be littlo about the passage of blood, and none about the It is necessary always to eliminate tuberculosis. passage of the stones. It is always a matter of regret There is no evidence of tuberculosis elsewhere, and that the patient does not keep the stones aud bring Dr. Malsbary was not able to find the tubercle bacillus them to the physician, aud this fact is to be especially in the urine in a two hours' search. Ho did turn out lamented in this case because the examination of the some diplococci, a few of which seemed to be embedded urine shows no crystals. It has been a long time since in the cells, but there are so many diplococci as to any blood has been discharged, but pus flows now make the difierentiation of any particular species diffi- freely all the time. When the blood does not appear cult. But to make assurance doubly sure, 1 gave this to the naked eye it is sometimes evident uuder the mi- patient a test injection of tuberculin, which did not in The Boston Medical and Surgical Journal as published by The New England Journal of Medicine. Downloaded from nejm.org at THE CHINESE UNIVERSITY OF HONG KONG on February 22, 2015. For personal use only. No other uses without permission. From the NEJM Archive. Copyright © 2010 Massachusetts Medical Society. any way disturb the diurnal range of temperature. I constant in these conditions, and sometimes there is think, therefore, that we may consider the diagnosis to edema of the surface indicative of the suppuration be- be pretty clearly established as a pyelitis or a pyo- neath. nephrosis with neplnolithiasis. The disease began Where there is a tumor the question may he solved probably with a pyelitis, that particular kind of pyelitis by aspiration, though the presence of pus would not which results in the continuous formation of kidney necessarily differentiate a nephritis from an abscess in stones. These stones, or the cause which produces the vicinity of the kidney, as sometimes the kidney it- them, lead finally to suppuration, and this suppuration self is holiowed out to a mere shell or sac of pus. has in turn involved the substance of the kidney, so At the request of the patient an x-ray examination that the disease, beginning with a simple pyelitis, a was made by Dr. Taylor, a Bkilful skiagrapher of this pyelitis calculosa, has become a suppurative pyelitis, city. Such pictures are usually extremely unsatisfac- pyonephrosis or pyelonephritis. In the course of time tory, and this is no exception. It is difficult or impos- the flow of pus, with the bacteria which produced it, sible to secure penetration of the whole body to the has also irritated the ureter and finally the bladder. x-ray, but in this case penetration was easily secured The chief complaint which the patient now makes is on account of the emaciation, the body in the region the burning of the urine and the frequent desire to of the kidney being not as thick as the thigh of an or- Last for he was to man. Sometimes pass it. night, instance, compelled dinary these stones show as a light pass water twenty times — the tally was kept with spot in the picture. 1 pass the plate about. You may strokes — so that his night's sleep was broken up. make out without difficulty the arches of the iliac The pain is characteristic, but by no means pathog- bones and with difficulty a few of the lower ribs.
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