CASE HISTORY

Patient was sent to outpatient 3-weeks before admission, complaining only of strangulated piles. On routine questioning he was found to have had the following urinary symptoms for 4 weeks: Frequency D2-3hrs/N 2-3hrs, pain on micturition, of stabbing nature, referred to the end of the urethra after micturition, also occasional pain in the right loin. The stream was good, intermittent at times, when stop occurs and causes severe pain at the end of the urethra. The urine was dark at times. He had had "lumbago" 5 years previously, without any urinary symptoms. Was otherwise healthy and had only lost one day’s work as a bricklayer until his admission to hospital. On examination, on 11.5.37, the right kidney was palpable. There was no tenderness and nothing else abnormal was found. Cystoscopy, after dilation of a stricture at the bulb of the urethra showed a small phosphate stone in the bladder and a sub-acute cystitis. There was no excretion of indigo carmine from the right kidney and very weak excretion from the left. The urine contained RBC and pus and many organisms. Blood urea was 85mg per 100cc. urea clearance test 33% of normal. X-ray showed bilateral multiple renal calculi. Operation was performed on 2.6.37 and the left kidney exposed and the stones removed through the incision in the kidney substance. There was much perinephritis and the kidney was drained. Until 3 days after the operation progress was good, but on 6.6.37 patient looked ill and shocked. He had had an attack of abdominal pain radiating to the left shoulder at 10 pm the night before. This was thought to be due to coronary thrombosis or peritonitis. The condition grew rapidly worse and patient died on 6.6.37

PATHOLOGY

The specimen consists of both kidneys with ureters and bladder, mounted in continuity. Both kidneys have been cut to show the pelvis, and the bladder has been opened from its anterior aspect. The bladder presents the appearances of subacute cystitis - no distinct hypertrophy and a rather congested, and in parts haemorrhagic mucosa. It contains an oval stone, about 3 x 2cm in diameter. The left kidney shows an operative incision in its posterior part, with some of the sutures left in situ. There is some haemorrhage into the kidney substance in this region. The rest of the kidney substance is pale and greatly reduced in thickness, particularly in the upper half, and the demarcation of cortex and medulla is very poor. The capsule was thickened and stripped with some difficulty. The kidney pelvis and the ureter are dilated the pelvis mucosa is thickened and shows some haemorrhage. The right kidney is grossly enlarged, about 18cm from pole to pole, the capsule was very thick and adherent. The enlargement is due to extreme distension of the kidney pelvis and calyces, causing reduction of the kidney substance to a thin shell, which shows a good deal of fibrosis. Very little renal tissue can be distinguished, the pelvis and calyces contain a number of large coralline stones, these are mixed containing largely phosphates. The mucosa of the pelvis is thickened. The ureter shows some dilatation. The stone mounted at the side is one of those removed at operation.