PRIMARY CHRONIC TUBERCULOSIS OF THE KIDNEY.
It will be noted that primary chronic tuberculosis only is dealt with in this group, the reason being that ascending tuberculosis in vading the kidney secondarily from a source in the testicle, prostate, ' or vesicular seminales is apparent and diagnosable by touch. Inva sion from these sources induces pain and distress in the bladder in the larger number of cases prior to implication of the kidney. The attention of the practitioner, therefore, is directed to the bladder, and this particular region is considered later on. Occasionally the invasion of the kidney from the testicle is by the roundabout route of the lymph paths which lie alongside the venous channels of the testis, ascending to their termination in the left renal vein and inferior versa earn; these not only mix with the ureteral vessels but also not infrequently receive trunklets which drain the perirenal fat and the capsule of the kidney.
Miliary tubercles irrupt from beneath the mucous membrane of the renal pelvis, or colonize in the glomerular zone of the cortex. As our knowledge increases, we may be able perhaps to group sepa rately the symptoms evoked by the deposit in each of these differ ently constructed areas. At present this cannot be done with accu racy, and I can only express my belief that, in the pelvic form of the disease, the initial symptoms are as follows : Blood and pus appear in small amounts in the urine, either coincidently with renal pain or very soon after it commences ; the stages of the disease are passed through more quickly, and the bladder—our index to the progress and the severity of urinary tuberculosis—is affected earlier. When the deposit is, however, situated in the cortex, it has to break into the renal pelvis before it can give rise to characteristic symptoms. Polyuria, from the irritation of its presence, is perhaps the symptom first noticed or complained of, even before the aching in the kidney. The urine is murky, of low specific gravity, and contains albumin over and above that due to the trace of pus. The hemorrhage from these two positions also varies, hence perhaps the divergence in the opinions of writers ou the subject. In the early stage of pelvic ulceration the bleeding is usually slight and intermittent; when, however, a cortical deposit sloughs out suddenly into the pelvis, there may be profuse and dark but transient hwmaturia.
But I would again remark that the hrematuria in primary chronic tuberculosis of the kidney is, I believe, only a feature of the early stages ; it passes away more or less rapidly, and gives place to the passage of pus and clumps of caseous &Iris, and, when the bladder is fully attacked, to vesical bleeding.
Difficult as is the proper allotment of the symptoms induced by tuberculosis of the kidney and the bladder to their respective organs when both are implicated, I am probably right in assuming that hemorrhage from the tubercular bladder is much more abundant and much more easily evoked by cold than is that from the kidney.
Tubercular Deposit on the Mucous Membrane of the Renal Pelvis.— Mr. Knowsley Thornton" records the following case : "All the symptoms were those of calculus—pain over the kidney and down the ureter, with attacks of colic—then hemorrhage, and finally profuse suppuration and enlargement of the kidney. When I opened the pelvis I found its lining membrane covered with little seed-like tubercles and there was no stone. The patient was imme diately relieved of all her symptoms, but the fistula persisted, and the other kidney becoming affected, she died of uremia seven months after the operation. The post-mortem revealed extensive tubercu losis of the kidney operated upon and of the rest of the urinary organs—the other kidney having evidently been more recently at tacked, and probably by extension up the ureter. In neither kidney was there ulceration or caseous deposit. The patient was, at the time I operated upon her, a stout, rosy woman, so much so that I should have doubted her statements as to the pains she suffered had I not seen her actually in great agony." Chronic Tuberculosis Commencing Probably in the Cortex of the Kidney and Invading Bladder, Prostate, and Testicle Secondarily.— D. J., 33 years of age (under Dr. Hilliard.) Up to four and a half years previous to seeing me this patient was in perfect health. He had, at that time, an attack of pain in the right side, which was called by his doctor renal colic. The character was as follows : Blood appeared in the urine from two to seven days before the onset of the attack; it came in clots, and often the bloody urine was very red with much bright blood. The hematuria ceased, and the pain then seized him across the back, and coursed down the right ureter into the right testicle. He vomited, rolled about the bed in the acuteness of the agony, and passed water very frequently, the character of the secretion being normal to the eye. These symp toms lasted for twenty-four hours. He never passed a calculus.