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. nomonic, as just as severe attacks of colic occur in a There is something of a smirch or smudge which simple pyelitis without stones or blood clot. A marked might be interpreted as a foreign body, but I would increase in the acidity or alkalinity of the urine is not be willing to accept it as the picture of a kidney enough of itself to produce pain as severe as that stone. Neither does the skiagrapher in this case. caused by like conditions iu the stomach. The fever As to the prognosis, it is plain to see. The patient is more characteristic of pyuria ; but it must not be for- has postponed an operation to the last possible mo- gotten that many cases of chronic pyelitis, even though ment. All the remedies of medicine have long since attended with suppuration, run a course without fever. been exhausted. The indication now is to make an It is not so much the pyelitis as the pyonephrosis which exploratory incision and drain the pus sac, wherever it is responsible for the fever. Fever, more or less con- is. The operation may be a success, or it may be too tinuous or remittent, interrupted by chills, and profuse late already. We cannot tell exactly what is the con- sweats, are signs of great value in the diagnosis in pyo- dition of the other kidney, but the quantity of the urine nephrosis. The picture is, then, one of sepsis, and the voided, notwithstanding the weak action of the heart, patient succumbs to marasmus with the symptoms of would indicate a pretty sound kidney on the other side. hectic fever, as in the course of advanced tuberculosis. The patient having finally consented, two weeks These symptoms are seen more especially after per- after the clinic, my colleague, Dr. Ransohoff, with his foration of the kidney substauce with tho formation of assistant, Dr. FVeiberg, and with the assistance of the a peri- or para-nephritic abscess. internes, in my presence, opened the abdomen in the show this loins The urine does not always purulent ap- posteriorly, and soon came upon a kidney en- pearance. It may be perfectly normal at times. larged to three times its natural size, whose pelvis was Thus it may be heavily loaded with pus at one time distended with pus, of exceedingly offensive nature, aud perfectly normal aud clear at another. This con- which was evacuated to the amount of perhaps six dition occurs with especial frequency in pyelitis of cal- ounces by incision. It was now seen that the kidney culou8 origin, and finds explanation in occlusion of one substance had suffered injury. The cavity of the ureter. pelvis extended in anfractuosities in every direction. What we want to know now is the condition of the The kidney itself was found so deeply congested and other kiduoy. Where suppuration exists for any dark that it was deemed advisable to remove it. It length of time it is liable to induce a parenchymatous had the appearance of the small lobe of tho liver nephritis in the second kidney, and, in any event, lobulated. The entire mass was accordingly with-— a long-continued suppuration may lead to amyloid drawn from the abdominal cavity, ligated at the pel- change. This amyloid degeneration, when of long vis, clamped and exsected, after the manner of treat- duration, may be appreciated by enlargement of the ing an ovarian tumor. On section of the kidney it spleen and liver. We find nothing of this kind here, was seen that the parenchyma was greatly riddled by but an obstinate diarrhea has set in of late which suppuration and reduced. In one of the anfractuosi- might speak for an amyloid degeneration of the ties a stone was found about the size of and twice as mucous membrane of the intestinal canal. thick as an ordinary coat button. It was perfectly Having eliminated tuberculosis, the diagnosis rests smooth. Near it was found a smaller stoue of the between a pure pyelitis or a nephritis or the coinci- size of a small pea. This stone was also smooth. It dence of both. It is by no means always easy to set- was apparent that neither of these stones had done the tle this question. The implication of the kidney usu- mischief. ally imparts the graver signs of sepsis, and the profuse Tho patient passed urine freely on the night of the pyuria, tho emaciation and the great prostration speak same day. The urine was still turbid, but the quantity for suppurative nephritis in this case. The fact that of pus was notably lessened and decomposition did not there is more albumin in the urine than the pus would set in so rapidly. Urotropin, seven and one-half account for would indicate also involvement of the grains every four hours, was now prescribed, where- kidney. The presence of granulated casts lends addi- upon the urine became perfectly sweet and free from tional testimony. A peri- or para-nephritis usually pus in the course of twenty-four hours. There was shows a high temperature. The pain is also more no fever after the operation, and the patient partook

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. of food and drink so soon as he had recovered from They are, as mathematicians would say, functions of the effects of the anesthetic, aud íb now, ten days after one another. They are, however, none the less real the operation, doing so well in every way that we may when we come to deal with given species, races or predict, a restoration to perfect health in two weeks. types of individuals whom the tubercle bacillus may Dr. Raii8ohoff promises to detail the particulars of infect. It takes a long time to modify bacteria, and the operation in this case in a report including a num- for the short space of life of the individual their char- ber of similar successful cases. The great amount of acters are practically fixed. We need here a certain effort neceBBary to deliver tho kidney, that is, to with- sense of perspective to enable us to appreciate the draw it bodily through the wound to the outside of the slow change during long periods of time and the tem- body, was a surprise to me. I have since seen a com- porary fixity. The evolution of new characters is going ment to this effect made by Dr. Ben JoIiubou in his re- on in all living organisms, but all our information con- port on the Surgery of the Kidney at the recent ses- cerning them is anchored, ¡ib it were, to their tempo- sion of the Mississippi Valley Medical Society. rary stability. In the laboratory we are able to modify experimen- tally both the virulence of certain bacteria and the resistance of the host. By passing these bacteria through Original Articles a long series of susceptible animals of the same Bpecies a greatly increased potency of the bacteria, with reference to that species, is noticed at the end. By treat- VARIATIONS IN PATHOGENIC ACTIVITY animals with certain bacterial AMONG TUBERCLE BACILLI.1 ing susceptible products or cultures killed by heat or chloroform, the resistance BY THEOBALD SMITH, M.D., BOSTON. may be increased. Different degrees of induced resistance lead to different clinical of In the production of states of disease due to infec- and pathological types the same inoculation so that the tion we should two main factors disease, etiological recognize modifying between them would be surmised the pathogenic activity or virulence of the infecting relationship hardly —organism, and the resistance2 of the infected indi- without a definite knowledge of the experimental de- vidual. tails.8 Variations in the have been Variations in the pathogenic power of bacteria are pathogenic activity the result of sojourn in demonstrated for a considerable number of diseaBe- probably prolonged slightly In it seems to be the rule to different environments. If, for instance, a tu- producing species. fact, given encounter variations in the of series of bercle bacillus had successfully invaded a slight study vigorous cultures of the same obtained from different adult, and had passed from this person to organism successfully sources. I cite illustrations in of a second, a third, or a long series of vigorous adults, might, many support these but I shall limit to one of aud had then after this prolonged coutact with tissues statements, myself interest. The which is so of a certain vitality invaded the body of a child, we general diphtheria bacillus, well characterized the of a are justified in assuming that the virulence of this ba- by production specific toxin, cillus with reference to the child has been increased by may vary in the power to produce this toxin from case case. Thus bacilli from one source have its successful invasion of naturally more re- to produced vigorous, for three times the amount of toxin sistant adults. if a tubercle bacillus, years just produced Again, vegetat- bacilli from another when cultivated in in a tuberculous lesion of the skin, through a by source, ing of the same numerical favorable combination of accidents had a bouillon composition. Other produced relations in the of toxin be series of infections of the skin, we may assume that power production may cited, differences, however betweeu this bacillus and but the fact I wish to emphasize is the constancy of slight, the variation under identical conditions. one infecting a series of lungs would become eventu- established. A continuation of such series, through In their coulact with infectious diseases physicians ally have laid the now on now on re- fortuitous circumstances, might finally produce two va- emphasis virulence, rieties of tubercle bacilli, each incapable of taking the sistance. With diseases having a rapid course, like the and the relative resist- other's successfully. It is probably in some such cholera, plague diphtheria, place ance of individuals is in the and the viru- way as this that varieties are produced which become background, lence of the receives more attention. restricted as to the are capable of in- iufecting agent territory they With diseases of slow like while at the same time they become especially progress, tuberculosis, at- fecting, tention is centred the of the adapted to infect this restricted territory. The bacil- upon resisting capacity lus of bovine tuberculosis illustrates another phase of individual as expressed by heredity, bodily conforma- tion aud environment—the in other of the same Does it its continued passage soil, words, problem. by which wo so the bovine become more virulent to hu- have heard much. It may be that the through body instinct of the is correct man or does it lose its power experienced physician quite beings, thereby largely in to the of the individ- to itself upon the human system ? Either alter- attributing resisting capacity graft ual in the more chronic infections a more native be true, but neither is proven. prolonged may influence than in the acute be- 1 cite these illustrations to emphasize the relativity conspicuous infections, cause in the former the latent forces of resistance have of the term virulence and its depeudeuce on the char- had time to in the course of the disease. Of acter of the host, as well as the of the term develop relativity these two virulence and 1 shall resistance, as it depends more or less on the bacterium. conceptions, resistance, confine remarks the most one not TheBe two virulence aud bo my to neglected terms, resistance, may — compared to the two opposite sides of the same shield. a I havo expressed this relationship between the typo of dlseaso on tho one rosistanoe on other tho 1 by the of hand aud tho virulence and tho by Presented, invitation, at meeting the American Clima- v tological Association, September 1, 1898. simple equation d= whorov=: virulence, r=;resistance. Increas- 1 in medical writings chiotly as immunity, al- ThiH term figures ing v or r wo augment tho of the disease (d). though tho term is merely relative, since there is no absolute im- diminishing severity munity. Increasing r or diminishing v wo diminish its severity.