NEPHRECTOMY FOR TUBERCULOSIS.
DR. F. TILDEN BROWN presented three patients, saying that his main purpose in presenting them was to contribute towards the solution of the question raised at the last meeting in the dis cussion attending Dr. Murray's case of vesical tuberculosis, viz.. Shall such cases be treated surgically or climatically and with medicine? Two of his cases were operated on two years and the other sixteen months ago. Although tubercle bacilli are no longer found in the urine of any, still, in two of the cases the subjective symptom of frequent urination persists. He invited discussion in regard to what the present state of these patients would prob ably be had the operation been withheld and climatic with hy gienic measures employed. Although in these individual cases such a course was not possible. In view of the absence, to-day, of tubercle bacilli in the urine of these patients, he thought that suitable irrigation would benefit the vesical irritability in the two cases showing it. They have had no such treatment since the operations.
The first patient was a woman, thirty-five years of age, who came under his observation in October, 1898, suffering from symptoms supposed by her physician to indicate a renal calculus. For two years she had been troubled by aching in the left lumbar region and in the back after exercise. This she felt in some measure every day, and it was increasing in severity. In August, 1898, during a three days' trip at sea, she had experienced per sistent vomiting, preceded by a three hours' lasting severe pain in the left side. Since that time she had frequent repetitions of such paroxysms of pain, lasting from twenty minutes to three hours, sometimes accompanied by nausea, sometimes by vomiting. The pain always began at a point two inches to the left of the umbilicus and midway between the costal border and the iliac spine ; thence it radiated towards and below the last rib. In two months she lost twenty pounds in weight. There were no subjective urinary symptoms, but in the urine tubercle bacilli were found both by the reporter and by Dr. Sondern. Neither kidney was palpable, but pressure over the left kidney elicited some tenderness, not felt on the other side.
The result of Dr. Sondern's analysis of the two specimens of urine from the ureteral catheters, together with that of the mixed urines from the bladder, is as follows : One of the remarks made by the examiner is, " The presence in the bladder specimen of an amount of albumen in excess of what is seen in the specimen obtained from the left kidney is worthy of note and difficult to explain. While some of this difference is possibly due to nerve influence as the result of the catheterization, as observed in other elements of the urine, it is, however, so marked as to be seriously worthy of note." Right kidney, nothing abnormal ; bladder, except for un usual amount of albumen, no evidence of any lesions ; left kidney, tuberculous pyelonephritis, with suspicion of uric acid stone or gravel.
The diagnostic conclusion of Dr. Sondern's full analysis was, right kidney shows nothing abnormal, left kidney shows tubercu lous pyelonephritis plus a suspicion of uric acid stone or gravel.
The patient entered the Presbyterian Hospital, November 21, 1898, where, under observation for five (lays, her temperature ranged between normal and subnormal. The average daily ex cretion of urine was twenty-six ounces.
On November 26, 1898, under chloroform anaesthesia, Dr. Brown made a left extraperitoneal nephrectomy. After separate ligation of the vessels with chromic gut, the kidney was turned out with ureter attacker, and as much of this as the wound would permit (about six inches) was removed, where the ureter appeared to be of normal size and consistency. The wound was closed without drainage.
Since the operation she has never had any recurrence of the left side pain. In fact, she expresses herself as being now in excellent health.
The specimen showed a comparatively early stage, or but moderate degree of tuberculous disease. (See plate opposite page 228.) One small necrotic lesion was found involving the apex of one pyramid, and its particular calyx had numerous tubercles as well as some in the pelvis. And the ureter at its junction here was greatly thickened in the tissues surrounding the mucous mem brane, while the latter was well studded with tubercles. By this combination it was easy to believe that an cedematous obstruction to the outflow of urine might at times occur and give rise to the symptoms which had quite strikingly suggested stone to those who had seen her in attacks. For the first twenty-four hours after operation, twenty-five ounces of urine were passed, the daily average for ten days being thirty-four ounces. The highest tem perature recorded was me F. For thirty-six hours after opera tion vomiting was quite persistent, but relieved for brief periods by lavage. She was discharged in good condition at the end of four weeks. That winter she spent at Saranac, where for six weeks a small sinus, starting probably from a deep chromic suture, caused her some trouble.
The second patient was a man, thirty-two years of age, who came under observation in August, 1899. He had considered himself perfectly well until early in 1899, when he began to suffer from vesical irritability to such a degree that he entered a hospital and was subjected to bladder irrigation, and to salol and ichthyol by mouth, with much benefit. When seen by Dr. Brown, he had not lost weight, had never seen any blood in his urine, but he had a pretty severe and constant aching in the right lumbar region and back, with sometimes a little pain in the right testicle. If he delays responding to a call to urinate, he has pain in the bladder, and then in the urethra during micturition.
Examination of the urine revealed the presence of tubercle bacilli. The cystoscope showed moderate hyperemia over the central trigonum ; the mouth of the right ureter was high up and involved in a narrow zone of congestion upon catheterizing the ureters, ten cubic centimetres of very light urine came from the right catheter in twenty-five minutes ; from the left nine cubic centimetres collected in eighteen minutes. Analysis of the vari ous urines by Dr. Sondern gave the following results : Conclusions in Brief. Right kidney, tuberculous pyelitis and parenchymatous change ; bladder, cystitis probably tuberculous; left kidney, normal. Analysis of bladder urine, December. Isloo. Reaction, acid ; specific gravity, To24; albumen, trace; bile, negative ; urea, 2.34 per cent.; sugar, negative ; chlorides, I per cent.; blood, very small amount ; pus, moderate amount: mucus, small amount ; casts, very few hyaline casts ; bacteria, no tubercle bacilli found ; crystalline and amorphous matter, few crystals of uric acid. Other structures : few bladder-cells and few presumably from renal pelvis.
A painstaking and repeated search for tubercle bacilli re sulted negatively.
The conclusion of this analysis was that the left kidney was normal and that the right kidney harbored a tuberculous pyelitis, besides some more marked parenchymatous lesion. The patient accepted the proffered nephrectomy, as he said he could not tolerate life as it was. He was sent to the Presbyterian Hospital. Two days' observation showed fifty-eight ounces as the twenty four-hour quantity of urine. He had a slight afternoon tem perature. He was a stocky-built man, and looked robust except in color. Neither kidney was palpable, but pressure over the right caused some pain.
On August 29, 1899, under chloroform anmsthesia, Dr. Brown made outright extraperitoneal nephrectomy. Although the initial incision along the right semilunar line was with the intention of a transperitoneal removal, such persistent abdominal contractions were maintained, under even full anmsthesia, it was seen that difficulty would be met in managing the intestines. Consequently, a long plane of blunt dissection between the parietal peritoneum and transversalis fascia was followed to reach the kidney, then a lateral incision backward at right angles to the first was needed before enucleation and pedicle approach was possible. No space was afforded for getting at the ureter satisfactorily; practically all of this tube had to be left. Drain age was provided for at the posterior angle. All other planes closed in series. Temperature on day following operation was 105° F., receded gradually to toe on third day, and reached too° on the seventh. Vomiting was not a feature. In the first twenty-four hours eighteen ounces of urine passed. Average for the first twenty days after operation was fifty-eight ounces. He was discharged at end of six weeks with a fistula at the point of drainage, which persisted for nine months. The abdominal wall is strong, except at the site of a former appendicitis incision. He now lives by peddling in the elevated counties west of the Catskills. He is wholly free from the former right lumbar pain and the distress on urination, but frequency is still annoying.
Pathologist's report : Kidney weight, ten and one-half ounces; surfaces studded with many pearly cyst-like spots. At the junction of the lower and posterior surfaces is a cyst one and one-quarter inches in diameter. The pelvis of the kidney and ureter, intact, were much thickened and showed tuberculosis. (See plate opposite page 230.) The third patient was a woman, thirty-five years of age. who came under observation in October, 1898. She had tubercular family history, and she herself from the age of sixteen to twenty three was in poor health. After some years of improved health she began to be annoyed in 1895 with frequent urination, with pain often in the right lumbar region, and at times between the shoulders. For the past six months the lumbar pain had been almost constant. Some days and nights she has had to urinate every five minutes, and now the calls come every fifteen minutes. During the spring and autumn of 1898 she had chills and fever. After a severe chill six weeks ago, Dr. E. E. Smith found ma larial plasmodia in the blood, and also tubercle bacilli in the urine. During the last month she has lost ten pounds in weight. Through the cystoscope the entire trigonum is seen to be markedly congested. The mouth of the right ureter is hyper aemic and oedematous, the left is normal. Upon catheterizing the ureters, seventeen cubic centimetres of milky-hued urine is collected from the right catheter in three minutes, while from the left it took twenty-five minutes to collect six cubic centimetres of normal-looking urine. The analysis of these twines was as follows : If it could be assumed that at the time of ureter catheteri zation the kidneys excreted urine of the same gravity and chemical character as they did when the " bladder specimen" was ex creted, the following conclusions would be justified : A mixture of equal parts of the urines as drawn from the ureters would he equal to the bladder specimen in gravity and amount of urea. If so, the relative excretion of urea in a given time, taken as indicating excretory ability would be left, 23 ; right, t ; in other words, excretory work done, right kidney, 4 per cent.; left kidney, 95 per cent. Bladder : evidence of a vesical catarrh, possibly tuberculous cystitis.
The conclusions from this analysis were that the left kidney was normal, the right kidney was the seat of a tuberculous pyelo nephritis. The bladder presented some visible catarrh.
The patient was sent to the Presbyterian Hospital and ob served for six days, during which the temperature was normal or subnormal, and the daily urinary excretion averaged forty-one ounces.
On December 7, 1898, under ether, Dr. Brown did a right extraperitoneal nephrectomy, removing the gland with seven inches of its ureter, this being severed near the sacral brim. (See plate opposite page 232.) The ureter was greatly enlarged but not hard, the broad mucous surface was studded with tubercles. Undoubtedly the same condition affected the portion left. The kidney had good sized necrotic cavities in four of its pyramids, besides a number of smaller cortical foci. The rather large wound was closed in layers and provision made for two gutta-percha tissue drains.
For four days after operation vomiting was very persistent ; lavage gave temporary relief. For the first week urinary excre tion averaged twenty-nine ounces per diem, and for ten days the temperature did not exceed F. The first dressing was unintentionally postponed until the seventh day. The superficial appearances were perfect. On withdrawing the folded gutta percha tissue drains some drops of faulty material issued ; freer drainage was given at once, but the suppuration process was not controlled until all of the deep and superficial sections were removed. During these two weeks the afternoon tempera ture reached me. Healing of the cavity by granulation was slow and closure not complete until April 8, 1899 (121 days). Al though a heavy woman, she has no hernia, and requires no abdominal support. Since returning to her country home she has gained constantly in weight and strength, and is now able to do all her household work. She is wholly free from the lumbar distress and difficulty in urination, but urination is still so fre quent (every twenty minutes) as to be troublesome.
In many examinations of urine after operation tubercle bacilli were not found. An analysis made in December, 19oo, resulted as follows : Reaction, acid ; specific gravity, Imo; albumen, trace; bile, negative ; urea, 1.2 per cent.; sugar, negative; chlorides, 0.5 per cent.; blood, none; pus, very small amount ; mucus, small amount ; casts, none ; bacteria, no tubercle bacilli found; crys talline and amorphous matter, none ; other structures, few blad der and many vaginal cells.
These findings give no evidence of a lesion of kidney or renal pelvis. Indication of a moderate chronic cystitis. While speci men shows numerous what are believed to be smegma bacilli, a careful search fails to show tubercle bacilli in the specimens decolorized for twenty-four hours with absolute alcohol.
DR. F. LANGE called attention to the comparatively mild and favorable course pursued by many cases of renal tuberculosis and tuberculosis of the genito-urinary tract generally. In some such cases which have come under his observation, the patients have remained fairly comfortable for seven, eight, and even twelve years. In some instances, where one kidney was diseased to such an extent that its removal was imperative in order to pre serve life, and in spite of the presence of tuberculosis in the blad der and even of suspicious symptoms pointing to the opposite kidney, the nephrectomy was followed by apparent recovery in some cases, while in others the progress of the disease was ma terially checked.
In one case which came under Dr. Lange's observation, the patient had symptoms which pointed to tuberculous infection of one kidney. Subsequently, the opposite kidney became affected to such a degree that it had to be removed. Then, after several years, tuberculosis of the prostate developed. Later, a tubercu lous epididymitis which necessitated the removal of one testis. The opposite epididymis also became enlarged, but the swelling gradually subsided until it regained, apparently, its normal con dition, excepting that it is still somewhat resistant. This patient. Dr. Lange said, has been under his observation for ten years. He is a druggist, and perfectly able to attend to his duties.
The speaker referred to another patient, a woman, with far advanced tuberculosis of the urinary tract, who has been under his observation for seven years. In her case the disease was so far advanced that several surgeons refused to operate on her.
Both kidneys were apparently involved, and there was extensive tubercular ulceration of the bladder. After removal of the kid ney which was most seriously damaged, the woman apparently entirely recovered from the disease, and since then, under hygienic surroundings, she has been very comfortable. Tubercle bacilli have entirely disappeared from her urine.
Based on his experience, Dr. Lange said he was inclined to take rather a hopeful view of some cases of tuberculosis of the genito-urinary tract. Much importance should be attached to the constitutional treatment. The disease varied just as much in dignity and character as tuberculosis in other parts of the body.
DR. WILLY MEYER said that while the use of the cystoscope was lately often deprecated in cases of tuberculosis of the genito urinary tract, he thought the instrument ought to be employed in order to learn whether the tuberculosis is an ascending or a descending one. He had found and would venture to establish the pathognomonic fact, that in the descending form the mouth of the corresponding ureter is ulcerated, while in the ascending form it is comparatively healthy. In other words, if the mouth of the right ureter, for instance, is found to be ulcerated and the left healthy, we have to deal with a right primary descending renal tuberculosis. If there surely be tuberculosis of the urinary or genito-urinary system, and both ureteral mouths are not af fected, but urinary analysis points to renal affection, the case is one of ascending tuberculosis. If in the descending form the kidney which is primarily diseased be removed or in the ascend ing the same be done with the kidney mostly affected and sup purating, the condition of such patients can be very materially improved, especially if they can afford to go to a warmer climate.