These attacks of renal colic continued to recur at intervals of two or three months, becoming latterly more frequent and more severe until eight months before he saw me, when suddenly all symptoms ceased in the kidney. He had neither kidney-ache nor severe hema turia, but the bladder became troublesome.
Five months after the cessation of the renal pain, he had to get up at night to pass water, and he was forced to empty his bladder more often than usual in the day. The vesical irritability increased, pain at the end of the penis after micturitiou set in, and in this state and with this history he came under my care, requesting to have the stone which he had been told was in the bladder removed as soon as possible.
His symptoms were as follows : " He passes water, about a teacupful at a time, every half-hour, day and night; has much glans pain after micturition. If blood is seen, it is intimately mixed. There are no testicular deposits; no prostatic deposit, but the right side of the bladder base feels shotty. No renal tumor, but there is a tenderness over the right kidney. Urine con tains pus; tubercle bacilli have been found; specific gravity is 1.010." Electric Cystoscopy.—" Bladder only holds three ounces. There is no stone. The mucous membrane of the base is turgid, dark red, and spongy, like that of an exposed rectum. The rest of the bladder is either coated over with adherent patches of dull whitish pus, situated on an inflamed, purple, succulent mucous membrane, or is ulcerated. These white patches seem to be the boundaries of large superficial erosions of the surface. They have a fleecy base, and evidently rest on the submucous tissue. The ureteral orifices are puffy, more especially the right. There is much pain on instru mentation. Even when deeply under chloroform he flinches and moans on any slight over-distention, i.e., anything over three ounces." The diagnosis of descending tuberculosis was made, and Dr. Hilliard was warned of the probable implication of the right testis and right lobe of the prostate, which took place three months after, this exam ination. Since then I have had this patient under close observation
for eighteen months; the left epididymis is now affected. Several collections of pus (chronic abscesses) have formed under the skin of the forearm and thigh. The testicular deposit on the right side came to the scrotal surface and was opened, as were the other ab scesses, and scraped, iodoform being packed into the suppurating cavities. He now passes water every half-hour in the day and every three-quarters of an hour at night; his legs are cedematous, his sufferings great, and I doubt if he will live much longer. It is now six years since the onset of the symptoms.
Differential Diagnosis between Stone and Tubercle of the Kidney.— Our capacity for differential diagnosis here, as in other and similar problems in urinary surgery, will depend much upon our skill in cross-examining as to the initial symptoms, and upon our due ciation of the nature and intensity of the irritation which has pro duced them. We recognize that in stone we are dealing with a for eign body confined more or less loosely in a sensitive space, and dependent, therefore, for its power of inflicting injury (as evidenced by the blood and pus in the urine) upon the exercise which the pa tient takes. On the other hand, we realize that in tubercle we are grappling with one or more foci of short-lived tendencies, and there fore prone to produce puriform urine; that these foci possess caustic and continuous irritative properties, which place them beyond the calmative control of posture or of bodily rest. I believe that the best indications for the diagnosis of renal tubercle are to be found in the family history of the patient; in the appearance of pus in the urine very soon after if not coincidently with the renal pain; in the lessness of absolute rest to affect or subdue the symptoms, and in the causeless elevation of the evening temperature.
Other differences, however, exist, and an attempt may be made to tabulate them thus: