NOTES ON INTERESTING CASES 357

References ( A ) COLLINS, D. C. “ Congenital Unilateral Agenesis of the Kidney,” Ann&

(2) CARSON, W. S. ‘‘ Congenital Solitary Kidney,” Wisconein Medical Journscl,

(3) STEWART, A. B. ‘‘ Congenital Absence of one Kidney,” B.J. Urology, 5,

(4) SOUZA, J. DE. “ Congenital Absence of Right Kidney,” Bahia Med., 4,

(5) ROCHE, ALEX. “ Congenital Solitary Kidney,” Proc. R. SOC. Med., 26,

(6) MCNWY, A. “ Unilateral Agenesis,” J . Urology, 28, September, 1932.

of Surgery, 95, 1932.

29, 1933.

June, 1933.

March, 1933.

February, 1933.

REPORT OF A CASE OF TUBERCULOSIS OF THE URINARY TRACT WITH SOME EVIDENCE OF SPONTANEOUS HEALING

By J. GRAY, F.R.C.S., and 5. T. Hsm TEE LESTER INSTITUTE, SEANQEAI.

THIS case is recorded as it illustrates clearly some features in the etiology of the disease, and points to the possibility of a t least a degree of spontaneous healing.

HistorJr.-Tlie patient was a Chinese boy, aged nineteen, admitted to the wards with tuberculosis of the 0s calcis. This condition had been present for twenty-two months. He had experienced no previous illness of note. The trouble began as a swelling of the heel with some pain. Unfortunately .it had been inadequately operated on by a native herbalist with the resultant formation of chronic sinuses.

Physical Examination.-When. first he came under our care there were three chronic sinuses present, two below the internal malleolus, and one below the external. There was the usual wasting of the leg muscles and limitation of full extension of the foot, but the ankle movements were otherwise normal.

Chest.-There was impairment of resonance over the left apex. There were no other signs of note and the X-ray of the chest did not demonstrate any obvious lesion. There were no tubercle bacilli in the sputum.

Blood Examination.-There was nothing special about this. Lympho- cytes were 30 per cent. Monocytes, 8 per cent., and the Hb. 79 per cent.

Blood Culture for tubercle bacilli was negative. Urine.3pecific gravity 1010. Alkaline. No albumin, sugar or cells.

358 THE BRITISH JOURNAL OF UROLOGY

FIG. 1.-Showing tuberculosis disease limited to the 0s calcis with considerable amount of calcium deposition.

No tubercle bacilli were found by concentration methods after repeated examinations.

X-ray of the 0 s Ca1cis.-The films showed tuberculous disease limited to the 0s calcis. There was a considerable amount of calcium deposit around the infected area.

NOTES ON INTERESTING CASES 359

First Operation.-On account of the localisation of the condition and for social and economic reasons, i t was decided to excise the 0s calcis with its surrounding infected tissue, and at a later date to do a plastic operation if necessary. It was realised that amputation would have been theoretic- ally the better treatment.

On August 22nd, 1933, the operation was performed. The 0s calcis together with the surrounding infected tissue was excised as widely as possible, and the wound closed without drainage. A plaster cast was applied. This was removed in order to take out the stitches fourteen days later, and was then re-applied and retained for three months. The wound was practically healed after fourteen days, and soundly healed when the second plaster cast was removed.

A second blood culture for tubercle bacilli forty-eight hours after operation was negative.

18/10/33, or some six to seven weeks after the operation, haematuria was observed but was not very severe.

23110133. A few acid fast bacilli were discovered in the urine for the first time. Culture of the urine made at this time was reported a month later as positive. Tubercle bacilli began to be found clinically and regularly towards the middle of November.

First Cystoscopy, 26/10/33.-A bladder capacity of 6 ozs. was noted. Multiple tubercles and ulcerations were seen all over the base of the bladder, more especially around the left ureter.

Both ureteric orifices appeared to be normal and indigo blue (10 C.C. of 0.4 per cent. given intravenously) appeared in ten minutes from each side.

The urine from the right kidney contained 120 pus cells per cubic millimetre.

The urine from the left kidney contained no pus cells. Cultures for tubercle bacilli were negative. This threw a suspicion

on the right kidney, but as the lesions in the bladder were more marked in relation to the left ureteric orifice it was decided to repeat the observation in a month’s time. This was done.

Second Cystoscopy, 7/12/33.-The ulcerations were now completely healed. Both ureteric orifices were normal and blue appeared from both sides in seven and a half minutes.

Both ureters were catheterised and the specimen from the right side now contained 88 pus cells per cubic Ipillimetre.

No tubercle bacilli were obtained. Third Cystoscopy was carried out on 1012133 for the purpose of

further exthnat ion and guinea-pig inoculation. The bladder was. perfectly normal with a capacity of 8 oz. Indigo blue appeared from the right side in five minutes, from the left in eight. The culture obtained

J.U. 0 0

360 THE BRITISH JOURNAL OF UROLOGY

from the right kidney was now positive, from the left negative. A guinea-pig inoculated from the right specimen showed definite, though

FIU. 2 . S a m e case after excision of 0s calcis. Disease healed locally.

slight signs of tuberculous infection after two months, that from the left was negative.

NOTES ON INTERESTING CASES 36 1

Intravenous Pyelogaphy indicated a possible cavity in a calyx of the kidney.

It must be pointed out that the patient had no symptoms of any sort during this period of observation. Pulse and temperature were normal. There was no frequency, and there were few if any pus cells in the urine, the pH of which was 6.0. The patient was putting on weight

FIG. 3.-Intravenous pyelogram showing cavity in cortex of right kidney.

all the time. It was, therefore, somewhat difficult to obtain consent for the operation.

24/4/34. Right nephrectomy was carried out. The kidney looked normal on the outside and the ureter was not thickened. The wound was closed without drainage. A large section of the kidney made for us by Mr. Henderson demonstrates the condition found, namely, a tuber- culous cavity with a fibrous wall, corresponding with the appearance noted in the pyelogram.

The patient made an uneventful recovery and tubercle bacilli disappeared from the urine after about one month. There are no symp- toms and no pus cells in the urine.

0 0 2

362 THE BRITISH JOURNAL OF UROLOGY

Discussion I n this case a visible focus of tuberculosis was present in bone

instead of the usual possible or hypothetical one in the lung. Organisms must clearly have been released into the blood stream, most probably from this focus, although blood cultures were unsuccessful. The operation on the 0s calcis may or may not have been a precipitating factor. If i t were, there was a latent period of pix weeks between infection and obvious open manifestation of involvement of the urinary tract. It may be

FIG. 4.-Specimen of kidney removed blood vessels injected with carmine gelatin solution.

reiterated that there were no signs of infection of the urinary tract prior to the operation.

The first cystoscopy seemed to suggest that organisms were being excreted from both sides although they were not obtainable from either. Indeed i t was thought a t the time that, judging from the cystoscopic appearance alone, the left side would prove to be the one involved.

The general clinical improvement of the patient as well as the resolu- tion of the bladder condition, and the obvious appearance of healing in the kidney specimen, seem to suggest that this might well have healed spontaneously had i t been possible, for economic reasons, to keep the patient sufficiently long under observation.

NOTES ON INTERESTING CASES 36 3

The other point of interest is the possibility of an operation on a tuberculous focus releasing organisms into the blood stream with a consequent renal infection. Had the patient not been watched systematic- ally from the beginning i t is very probable that the urinary tract lesion might have been missed completely and either progressed or healed spontaneously without being observed. Except for a very mild and transient hzematuria there were no symptoms of urinary disease at any stage and the only positive finding was tubercle bacilli in the urine. It raises the question as to whether a similar blood stream release of organisms may not occur more frequently than we realise in tuberculous disease and transient involvement of the urinary tract take place with spontaneous healing.

FATAL GONOCOCCAL PYEMIA FOLLOWING INTERNAL URETHROTOMY

BY GEOFFREY E. PARKER, F.R.C.S.

ASSIPTAST SCRGEON TO OUT-PATIENTS AT THE FRENCH HOSPITAL. SURGICAL REQISTRAR AT THE XATIOSAL TEMPERANCE HOSPITAL.

THE operation of internal urethrotomy while not devoid of potential complications, both local, such as primary or secondary haemorrhage and epididymitis, and general such as suppression of urine and uraemia, is not commonly a direct cause of death, and still more rarely death from the specific infection introduced thirty years previously. The following case, therefore, is not without interest.

A man, aged 61 years, was admitted to the French Hospital in March of this year complaining of gradually increasing difficulty with micturition during the last eighteen months ; during the last three months there had been nocturnal frequency.

There was a definite history of one isolated attack of gonorrhea thirty years before, but no further re-infection since that date, nor further urinary symptoms after the original acute attack until the present time.

On examination the urinary stream was tortuous, the prostate not enlarged and there was no lesion of the central nervous system. Under a general anaesthetic it was not possible to pass any instrument down to a No. 8 Charridre gum elastic bougie.

After Xashing out the anterior urethra, therefore, and lubricating with paraffin in the usual way, an internal urethrotomy was per-. formed.

The operation presented no special difficulty and after passing a