A Case of Renal Phthisis 
COMPLICATING PULMONARY 
Tuberculosis. 
BY 
HERBERT MAXON KING, M. D., 
GRAND BAPIDS, MICH. 
REPRINTED FROM THE 
Web Yorfc .pieTitcal journal 
for July 11, 1896. Reprinted from, the New York Medical Journal 
for July 11, 1896. 
A CASE OF RENAL PHTHISIS 
COMPLICATING PULMONARY TUBERCULOSIS.*- 
By HERBERT MAXON KING, M. D., 
GRAND RAPIDS, MICH., 
Mb. Peesident and Gentlemen: Transient albu- 
minuria intervening in the course of pulmonary tu- 
berculosis is a most frequent and trivial complica- 
tion which need neither occasion alarm nor ne- 
cessitate any change in the mode of treatment, since, as 
a rule, it is either simply an evidence of the impaired 
nutrition of the renal epithelium or the result of the 
periodic pyrexia. Even that degree of renal congestion 
marked by the presence in the urine of albumin, small 
hyaline casts, and cylindroids, appearing at intervals in 
the course of the disease, is not an alarming or infre- 
quent complication of phthisis and can not of itself indi- 
cate any serious disturbance of the integrity of the 
kidneys. 
But a persistent albuminuria appearing after the de- 
velopment of tuberculosis in the lungs, attended with an 
increased pyrexia and less marked remissions, rigor, poly- 
uria, dysuria, and especially pyuria to a greater or less 
degree, should always excite the keenest apprehension 
* Read before the Grand Rapids Academy of Medicine, March 9, 
1896. 
Copyright, 1896, by D. Appleton and Company. 2 
A CASE OF RENAL PHTHISIS 
and vigilance. For these are unmistakable signs of ne- 
phritis, a condition grave enough in itself, to be sure, 
but doubly so when occurring as a complication of pul- 
monary phthisis. 
Intervening in the later stages of pulmonary tuber- 
culosis, or in the course of an acute general tuberculosis, 
nephritis only hastens the inevitably fatal termination, 
and its recognition in such cases is a matter of little mo- 
ment to the patient and, aside fiom gratifying scientific 
zeal, of little practical value to the physician. 
But, appearing as it sometimes does early in the course 
of the pulmonary disease, when hut a small portion of 
the lung is involved, I can not but think that its recogni- 
tion is the means of occasionally saving life, or at least 
of prolonging it. 
Nephritis in a tuberculous patient whose kidneys 
have before been healthy must almost of necessity be 
either a renal phthisis due to direct infection through 
the lymph channels (or possibly the circulation?) 
or an interstitial nephritis due to prolonged dis- 
turbance with the nutrition of the kidney cells. The 
case which I desire to present to you this even- 
ing is a type of the former, one of unmistakable 
tuberculosis of the kidney; its interest lies mainly 
in the microscopical appearance of the urinary sediment, 
in which absolute proof of the nature of the existing 
lesion is demonstrable by the presence of the tubercle 
bacilli in characteristic arrangement. 
Tuberculosis of the kidney occurs in two distinct 
forms: (a) acute miliary tuberculosis, and (b) local 
caseating tuberculosis or scrofulous kidney (Purdy). 
The former is twice as frequently met with as the latter, 
according to the above-quoted authority, and hence renal COMPLICATING PULMONARY TUBERCULOSIS. 
3 
phthisis is not a condition often met with, especially in 
private practice. 
I find upon a careful resume of the last fifty cases of 
tuberculosis occurring in my own practice that I have 
seen three in which renal phthisis was a complication. 
I have been able to demonstrate the presence of tubercle 
bacilli in the urinary sediment in two of these, including 
the case which I present to you to-night. The third in- 
stance of this condition yielded to treatment * before 
there was breaking down of the involved tissues, and the 
specific bacillus has presumably not been present in the 
sediment, although the case is still under close observa- 
tion. Even when the bacilli do exist in the urine, as 
shown in the development of cultures inoculated from 
such urine, Purdy states that it is very difficult to demon- 
strate their presence from cover-glass preparations of 
urinary sediment. Yierordt, however, says it is as easy 
to demonstrate their presence in the urine as in the 
sputum. I have not found it so in my experience, and for 
obvious reasons I should think it would always be a much 
more difficult matter. 
The case which I wish to present is that of a woman, 
thirty years of age. In the family history it develops 
that one sister died from acute tuberculosis at eighteen 
years of age, and one brother has shown evidences of 
incipient disease at the apex of one lung. Parents and 
grandparents free from tuberculosis in any form. The 
patient has been married seven years, in which time she 
has borne five children, all apparently healthy, the last 
being, at the time of examination (February 17th), seven 
weeks old. Cough and emaciation date from about one 
year ago. She was, however, much better during preg- 
nancy, only to grow rapidly worse after parturition. 
* The hypodermic administration of nucleinic acid solution in doses 
averaging a hundred minims daily. 4 
A CASE OF RENAL PHTHISIS 
Subjectively, cough and expectoration, occasional 
night sweats, anorexia, and general loss of strength are 
the only distressing symptoms. It is worth remark that 
at no time in the history of the disease has pain, either 
in the region of the kidneys or upon micturition, been 
present. 
Physical Examination, 2 o’clock, p. m.—Pulse, 
125, regular and fairly strong. Temperature, 102° F. 
Inspection discovers marked emaciation, depressed infra- 
clavicular spaces on both sides, with considerable loss 
of expansion at right apex. Palpation discovers in- 
creased vocal fremitus at right apex. Percussion: Dull- 
ness marked at right apex; much less, though slight, 
dullness at left apex. Auscultation: Cavernous respira- 
tory sounds, moist and dry rales, and increased vocal 
resonance at right apex. “ Roughened ” respiration at 
left apex. Posteriorly, diminished vesicular murmur at 
base of right lung. Examination of the blood by Thoma- 
Zeiss cytometer gives an average of 3,975,000 red cor- 
puscles to the cubic millimetre; by von Fleischl’s has- 
mometer, fifty per cent, of normal haemoglobin. Micro- 
scopically, numerous poikilocytes present. (It is inter- 
esting to remark the discrepancy between the numerical 
value of the blood and the amount of haemoglobin pres- 
ent.) Examination of sputum: Profuse in quantity, 
watery, muco-purulent, containing a small number 
(comparatively) of bacilli tuberculosis and large colo- 
nies of streptococci and other bacteria. Examination 
of urine: The vagina having been cleansed by thorough 
douching, a single specimen of urine was obtained. It 
was acid in reaction. Specific gravity, 1.013; good color, 
slightly clouded. The chlorides and sulphates in nor- 
mal amount, phosphates somewhat diminished, and nine 
grains of urea to the ounce. Albumin present, one for- 
tieth per cent, by weight (Esbach’s albuminometer). 
Peptones. Sugar and bile absent. Microscopically, 
there were present numerous hyaline and granular casts, 
some coated with epithelium; a few red blood-corpus- 
cles were also found. There was abundance of pus and 
considerable kidney epithelium present, and colonies of COMPLICATING PULMONARY TUBRECULOSIS. 
5 
bacteria, but I was able to demonstrate no bacilli tuber- 
culosis. The unusual pyrexia and prostration in this 
case were not to be accounted for by the comparatively 
slight lesion in the lungs, nor even by any ordinary inter- 
stitial nephritic complication, such as might exist with- 
out active destructive changes. A provisional diagnosis 
of renal phthisis was therefore made pending further 
developments. The patient had been receiving one 
drachm of the improved yeast nuclein solution by the 
stomach once daily, and two hypodermic injections of 
about twenty minims each, besides the usual medication 
directed to the improvement of nutrition. She was now 
placed on tablespoonful doses of Basham’s mixture thrice 
daily; aquozone, about one pint daily; the usual doses 
of cod-liver oil, which I believe she was taking already, 
and from a hundred to three hundred minims of yeast 
nuclein solution were administered hypodermically in 
one dose daily. To control exacerbations of temperature, 
cool sponging was employed, and the diet was regulated 
with a view of avoiding as far as seemed feasible nitro- 
genous foods. For a few days the patient did well sub- 
jectively, but a glance at the clinical chart which I pre- 
sent to you will show practically no change in pulse or 
temperature, while repeated uranalyses demonstrated 
a rapid increase in the amount of pus present, together 
with other formed elements. Several times I have found 
what I think were pus casts in the urinary sediment, 
such as are described by Johnston, but which Purdy says 
“ have rarely been noted by other observers.” Up to 
March 6th, however, I was unable to demonstrate tuber- 
cle bacilli, and notwithstanding the condition now exist- 
ing in the kidney no ursemic symptoms appeared (accord- 
ing to Purdy, ursemic complications are extremely rare in 
renal phthisis, and this is probably due to the fact that 
usually but one kidney is affected, while the other acts 
vicariously and is aided by the profuse diaphoresis which 
is almost always present). On March 6th uranalysis 
resulted as follows: Quantity in twenty-four hours, thir- 
ty-six ounces; reaction, acid; specific gravity, 1.011; 
chlorides normal; sulphates and phosphates diminished. 6 
a case of renal phthisis 
Urea, six grains and a half to the ounce; two hundred 
and thirty-four grains in twenty-four hours; albumin 
present, six per cent, in bulk, after filtration (Purdy’s 
method with the centrifuge). 
Microscopical Examination.—Large and small 
hyaline, granular epithelium, and pus (?) casts abundant- 
ly present. A few red blood-corpuscles and a very large 
amount of pus present, much kidney epithelium 
in which degenerative changes were marked, and, final- 
ly, large colonies of tubercle bacilli were easily demon- 
strable in the urinary sediment. This discovery placed 
the diagnosis beyond all question of doubt as to the 
nature of the complication, and it only remained to estab- 
lish as far as possible the extent of the kidney lesion and 
the prognosis. On March 7th Dr. Eugene Boise and Dr. 
C. H. Johnston saw the case with me. On palpation, a 
rigidity of the abdominal muscles and tenderness upon 
pressure over the right kidney were noted; this, taken 
with the fact that the volume of urine and the amount 
of urea excreted in the twenty-four hours were in goodly 
proportion to the weight of the body, seemed to indi- 
cate that the disease was limited to the right kidney 
while the integrity of the left was unimpaired. Owing 
to the nature of the case, Dr. Boise and Dr. Johnston 
recommended disregard of the laws which govern the 
diet of ordinary nephritis, and as improved nutrition 
was an imperative essential to any degree of success in 
treatment, forced alimentation was advised, nitrogenous 
food included. No change in medication was suggested. 
Now, as to prognosis: Chance of convalescence or 
even delayed fatal termination seems almost hopeless 
when the circumstances surrounding this particular case 
are considered. The patient brought down to the lowest 
point of resistance by the rapid succession of pregnan- 
cies is in no condition to face the pulmonary disease, 
to say nothing of its more serious renal complication. 
The extreme danger of liver involvement (from its close COMPLICATING PULMONARY TUBERCULOSIS 
7 
proximity), before complete sacculation of the renal cap- 
sule can have rendered the liver safe, is pointed out by 
Purdy and others, and is especially to he feared in this 
case, provided death does not intervene from other 
causes. On the other hand, there is no danger of the 
other kidney becoming involved through hetero-infec- 
tion, which late observers agree is impossible, the ex- 
istence of tuberculous disease in the one kidney hav- 
ing little or no influence on the other, aside from increas- 
ing the exercise of its function; therefore, in time, pro- 
vided other complications did not arise, a condition of 
pyonephrosis might give place to complete obliteration 
of the affected organ, its functions being entirely sup- 
planted by the healthy kidney. 
I now beg to call your attention to the specimens 
under the microscopes. The first is a cover-glass prepara- 
tion made from the 
sputum, stained in the 
ordinary manner. 
There is nothing re- 
markable about it ex- 
cept as it shows the 
moderate extent of the 
tuberculous process in 
the lungs, by the small 
number of bacilli pres- 
ent, and the existence 
of a mixed infection, as 
shown by the presence 
of septic bacteria. The 
second specimen is one 
of the urine sediment unstained, as obtained by the 
centrifuge; the characteristic formed elements are very 
Fig. 1.—1, 1, 1, 1, Bacilli tuberculosis ; 2, 2, 
2, streptococci and other bacteria; 3, 
3, 3, pus cells. (Drawn with the aid of 
a camera lucida.) 8 
A CASE OF RENAL PHTHISIS 
prettily demonstrated. The third is a more rare and far 
more interesting specimen, one of the urine sediment, 
containing bacilli tuberculosis, and accordingly the 
pathognomonic sign of the existing condition. It is 
PULSE 
TEMP 
TEMPERATURE 
PULSE 
Fig. 2. 
stained by the same process as the sputum and demon- 
strates the bacilli, in several fields, in an arrangement 
similar to that met with in pure cultures, which, accord- 
ing to Vierordt, Purdy, and others, is characteristic of 
this condition, and it would be quite impossible to con- 
found them with the smegma bacilli of the healthy 
urethra. By aid of an improvised camera lucida I have COMPLICATING PULMONARY TUBERCULOSIS. 
9 
made a sketch of one field which after long search I 
found best illustrated this arrangement of the bacilli, 
and this I also beg to present as perhaps showing this 
peculiar arrangement better than the field now under 
the microscope (see Fig. 1). 
In conclusion, the lesson taught us by such a case 
may he worthy of note. In the first place, the urine from 
a phthisical patient should be subjected to frequent and 
PULSE 
TEMP. 
TEMPERATURE 
PULSE 
Fig. 3. 
rigid examinations, and more particularly in cases where 
the rigors, pyrexia, and prostration are out of proportion 10 
A CASE OF RENAL PHTHISIS.' 
to the extent of the apparent lesion. In this connection 
I would ask your attention to the two clinical charts. 
The first (Fig. 2) is that of a patient suffering from fully 
as great a pulmonary involvement as is the case reported, 
and the temperature and pulse I regard as typical of the 
generality of such cases. The second (Fig. 3) is a chart 
from the case reported. The departure from the rule in 
this would, of course, excite our most lively suspicions. 
Finally, vigilance should not be relaxed because of 
absence of subjective symptoms pointing to renal com- 
plications, which, as I have shown, may progress to an 
advanced stage without any symptoms which would 
indicate the nature of the complication. 
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