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Successful Nephrectomy for Tuberculosis in which Bilateral Exploration was Necessary
530
TRANSACTIONS OF PHILADELPHIA BRANCH
the diagnosis of prolapsed right ureter or ureterocele was made. For four years he received no treatment except irregular bladder irrigations and urinary antiseptics. He was admitted to the Presbyterian Hospital June 9, 1926, where chromoureteroscopy demonstrated the elimination of a purulent urine from the right ureter, which appeared as a typical ureterocele at least 3 cm. in diameter. Indigocarmin was eliminated from the left ureter normally, no elimination appearing on the right side. On June 11th, a right-sided nephrectomy was performed. The kidney was found to be lobulated and enlarged, and associated with an enormous solitary cyst, from which during operation 3000 cc. of clear fluid were aspirated and after the operation 1000 cc., in all over 4000 cc. of fluid. The patient was considerably shocked from the operation, but eventually made a most satisfactory convalescence. SUCCESSFUL NEPHRECTOMY FOR TUBERCULOSIS IN WHICH BILATERAL EXPLORATION WAS NECESSARY B. A.
THOMAS
CASE REPORT
A. A., male, aged twenty-one, was admitted to my Service at the Polyclinic Hospital May 3, 1924, complaining of marked vesical irritability. His trouble began two years previously as a hematuria, but recently he has had only burning pain suprapubically, especially after urination. Has hematuria only occasionally during recent months. No tenderness on palpation of abdomen anteriorly or posteriorly, nor no fist percussion over either costo-vertebral angle. Cystoscopically, the bladder presented the appearance of advanced ulcerative tuberculosis, although neither ureteral orifice could be localized. Tubercle bacilli could not be demonstrated in the urine in three twenty-four-hour specimens, although t uberculosis was demonstrated by a guinea pig test subsequently. In spite of our best endeavors, it seemed to be impossible by repeated cystoscopies, under general and caudal anesthesia, also x-ray examinations, to determine the unilateral or bilateral renal source of the strongly suspected advanced urinary tuberculosis. Accordingly, on June 27, 1924, bilateral exploration operations of each kidney were performed, when the left kidney was found to be entirely normal in appearance, but the right one presented the appearance of a typical advanced case of cavernous tuberculosis, and was accordingly removed.
THE AMERICAN UROLOGICAL ASSOCIATION
531
The patient passed through a rapid and most satisfactory convalescence, and was discharged from the Hospital July 19, 1924.
Discussion Dr. MILLIKEN: I would like to discuss this subject from a different angle, I mean from the experimental standpoint, and I think that I can give you an explanation why, to my mind, indigo-carmine is as good or a better test of kidney function than phenolsulphonephthalein. There are two conditions in the kidney which can cause limited function: One is changes in the kidney tissues, and the other is vaso-constriction due to toxins or reflex causes. It can be shown experimentally that indigo-carmine in solution is much less diffusible than phenolsulphonephthalein and its excretion is therefore more influenced by structural change in the kidney. It has also been demonstrated that vaso-constriction in the kidney retards the elimination of indigo-carmine more than it does that of phenolsulphonephthalein; consequently indigo-carmine should be a much better test of kidney function in early tuberculosis where the lowered function is probably due to toxic vaso-constriction rather than to alteration of structure. I heard Dr. Herman report his case at the hospital and it was a beautiful example of what can be done with the pyelographic method of diagnosis. However, I feel sure that had he used indigo-carmine he would have had delayed elimination from the diseased kidney. Dr. HERMAN: I was surprised to hear that Dr. Thomas's case of tuberculosis could not be cystoscoped under caudal anesthesia, but, I take it that the failure was. not caused by the lack of analgesia but due to extensive disease. Caudal anesthesia should, I think, be used routinely in difficult cystoscopies. I question if the case of cystic disease of the kidney should be classified as an instance of solitary serous cyst inasmuch as there seems to have been multiple cysts present. The solitary cyst is an extremely rare disease and one that has been diagnosed in a very few instances before operation.
TRANSACTIONS OF PHILADELPHIA BRANCH
the diagnosis of prolapsed right ureter or ureterocele was made. For four years he received no treatment except irregular bladder irrigations and urinary antiseptics. He was admitted to the Presbyterian Hospital June 9, 1926, where chromoureteroscopy demonstrated the elimination of a purulent urine from the right ureter, which appeared as a typical ureterocele at least 3 cm. in diameter. Indigocarmin was eliminated from the left ureter normally, no elimination appearing on the right side. On June 11th, a right-sided nephrectomy was performed. The kidney was found to be lobulated and enlarged, and associated with an enormous solitary cyst, from which during operation 3000 cc. of clear fluid were aspirated and after the operation 1000 cc., in all over 4000 cc. of fluid. The patient was considerably shocked from the operation, but eventually made a most satisfactory convalescence. SUCCESSFUL NEPHRECTOMY FOR TUBERCULOSIS IN WHICH BILATERAL EXPLORATION WAS NECESSARY B. A.
THOMAS
CASE REPORT
A. A., male, aged twenty-one, was admitted to my Service at the Polyclinic Hospital May 3, 1924, complaining of marked vesical irritability. His trouble began two years previously as a hematuria, but recently he has had only burning pain suprapubically, especially after urination. Has hematuria only occasionally during recent months. No tenderness on palpation of abdomen anteriorly or posteriorly, nor no fist percussion over either costo-vertebral angle. Cystoscopically, the bladder presented the appearance of advanced ulcerative tuberculosis, although neither ureteral orifice could be localized. Tubercle bacilli could not be demonstrated in the urine in three twenty-four-hour specimens, although t uberculosis was demonstrated by a guinea pig test subsequently. In spite of our best endeavors, it seemed to be impossible by repeated cystoscopies, under general and caudal anesthesia, also x-ray examinations, to determine the unilateral or bilateral renal source of the strongly suspected advanced urinary tuberculosis. Accordingly, on June 27, 1924, bilateral exploration operations of each kidney were performed, when the left kidney was found to be entirely normal in appearance, but the right one presented the appearance of a typical advanced case of cavernous tuberculosis, and was accordingly removed.
THE AMERICAN UROLOGICAL ASSOCIATION
531
The patient passed through a rapid and most satisfactory convalescence, and was discharged from the Hospital July 19, 1924.
Discussion Dr. MILLIKEN: I would like to discuss this subject from a different angle, I mean from the experimental standpoint, and I think that I can give you an explanation why, to my mind, indigo-carmine is as good or a better test of kidney function than phenolsulphonephthalein. There are two conditions in the kidney which can cause limited function: One is changes in the kidney tissues, and the other is vaso-constriction due to toxins or reflex causes. It can be shown experimentally that indigo-carmine in solution is much less diffusible than phenolsulphonephthalein and its excretion is therefore more influenced by structural change in the kidney. It has also been demonstrated that vaso-constriction in the kidney retards the elimination of indigo-carmine more than it does that of phenolsulphonephthalein; consequently indigo-carmine should be a much better test of kidney function in early tuberculosis where the lowered function is probably due to toxic vaso-constriction rather than to alteration of structure. I heard Dr. Herman report his case at the hospital and it was a beautiful example of what can be done with the pyelographic method of diagnosis. However, I feel sure that had he used indigo-carmine he would have had delayed elimination from the diseased kidney. Dr. HERMAN: I was surprised to hear that Dr. Thomas's case of tuberculosis could not be cystoscoped under caudal anesthesia, but, I take it that the failure was. not caused by the lack of analgesia but due to extensive disease. Caudal anesthesia should, I think, be used routinely in difficult cystoscopies. I question if the case of cystic disease of the kidney should be classified as an instance of solitary serous cyst inasmuch as there seems to have been multiple cysts present. The solitary cyst is an extremely rare disease and one that has been diagnosed in a very few instances before operation.