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The diagnosis and indications for treatment of renal tuberculosis
THE DIAGNOSIS AND INDICATIONS FOR TREATMENT RENAL TUBERCULOSIS GILBERT J. THOMAS, M.D., F.A.c.s.,
THEODORE
Attending Urologist, Glen Lake Sanatorium, Oak Terrace, Minnesota; Eitel I Iospital, hlinneapolis; Associate Clinical Professor of Urology, Medical and Graduate Schools, University of Minnesota AND CHARLES
K.
L.
STEBBINS,
OF
M.D.,
Nicollet Clinic, Minneapolis, and Glen Lake Sanatorium, Oak Terrace, Minnesota
PETTER,
M.D.
GIcn Lake Sanatorium, Oak T errace, hlinnesota, and the Department of Surgery, University of Minnesota MINNEAPOLIS,
UCH has been accomplished during the past twelve years, not onIy by physicians and surgeons but by the genera1 pubhc, in the diagnosis and treatment of tubercuIosis. Lay workers have learned how to apply measures directed at the prevention of this disease. They now understand the necessity of isoIation of active cases and frequentIy report patients who have signs or symptoms usuaIIy associated with advancing phthisis. MedicaI officers have successfuIIy practiced prevention and prophyIaxis so that now they have to examine we11 persons if the contro1 of tubercuIosis may continue to advance. The use of tubercuIin skin tests and Roentgen ray examinations of the chest may demonstrate incipient puImonary Iesions in apparentIy we11 persons when the ordinary physica examination reveals no diagnostic signs of this condition. By the use of similar methods we can now discover earIy lesions of renaI tubercuIosis before the patient has urinary symptoms. During the last twenty years there has been a change, at Ieast apparent, in the character of extrapuImonary Iesions of tubercuIosis. This is particuIarIy true with the lesions that require surgica1 treatment. The resistance of individuaIs has been increased so that spread of tubercuIosis from the chest cavity occurs with greater difhculty, and surgeons find these Iesions more amenabIe to surgica1 treatment.
MINNESOTA
Today a history of genitourinary disease is not of much value in the diagnosis of the first or early Iesions of renaI tuberculosis. FormerIy, the kidneys were not suspected unti1 the patient began to compIain of bIadder irritabiIity, frequency, hematuria, etc. Today we fee1 that if we wait unti1 these symptoms appear, the kidney Iesions are usuaIIy far advanced so that they may not be amenabIe to treatment. A history of previous puImonary tubercuIosis is important. A history of bone, joint or intestina1 Iesions is sign&cant because this indicates that baciIIi of tubercuIosis have entered the bIood stream from a focus in the chest. When this occurs, the kidneys should be suspected because with their profuse brood suppIy there is a good chance that emboIi may be fiItered out and renaI lesions deveIop subsequentIy. There may be no symptoms of a renaI tubercuIosis in its earIy stages. Hematuria occurs infrequentIy with earIy Iesions. We beIieve that every patient with tuberculosis shouId be examined for renaI infection before urinary symptoms are present. If a11 patients are subjected to a routine method of diagnosis and treatment, a11 Iesions of renaI tuberculosis may be discovered early and the majority may be arrested. If arrest is not possibIe by conservative methods, appropriate surgica1 treatment may be instituted before the Iower urinary tract
M
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becomes invoived nentIy crippled.
ol’Surgcry
Thomas
et al.-Renal
and other organs perma-
The frequently repeated examination of a sterile specimen of urine for tubercle bacilli is the only method of examination which will reveal positive findings that clinch the diagnosis of renal invasion. The norma
kidney wiI1 not transmit baciIIi of tubercuIosis. Repeated intervaI examinations of the urine must be made because infected kidneys wiI1 transmit baciIIi of tuberculosis, pus celIs and bIood ceIIs into the urine at one time and not at another. The urinalysis practiced at Glen Lake Sanatorium, Oak Terrace, Minnesota, is as foIIows. AI1 patients have routine studies of the urine every three months no matter where the tubercuIous Iesion may be Iocated or its extent. If ceIIuIar eIements are found in the urine, the sediment is stained by the ZiehI Nielson method. If no baciIIi of tubercuIosis are found, four weekIy specimens, two of which are twenty-four hour coIIections, are centrifuged and the sediment is injected once each week into the peritonea1 cavity of the same guinea pig. If more than occasiona1 bacilli of tubercuIosis are present, these shouId produce tissue reaction in the anima1, and after six or eight weeks typica Iesions may be observed in the glands and organs. In some instances the number of organisms may be smaI1; the resistance of the anima1 may be greater than usual; or the organisms may have a Iow virulence so that Iesions may not be produced. Subsequent injection of the sediment of additiona1 specimens of urine may produce the disease. The culture method of isoIation of the baciIIi of tubercuIosis from the urine, which is Iess expensive, may be used instead of the inocuIation of guinea pigs. However, this method requires several years of experience on the part of the Iaboratory worker in order to perfect technique. The resuIts obtained by an experienced worker who uses the cuIture method are as good as, or better than, the anima1 method. A few positives may be picked up with the cuhure method that are missed with the guinea pig method
Tuberculosis
oCloUclc. IOJ,
and vice versa. Dr. McNabb of the Ontario ProvinciaI Laboratories (who has done the most extensive cuItura1 work to date) found more positives with the cuItura1 method aIone than with the guinea pig method aIone in thousands of examinations. Petragini’s cuIture media which consists of whoIe eggs combined with dye and bIood media have been found to be the most successful. At the Division of PreventabIe Diseases of the Minnesota Department of HeaIth in Minneapolis, the cuIture method is used with all voided specimens of urine, as we11 as sputum. When catheterized specimens of urine are examined, part of the sediment is inocuIated into one guinea pig and the remainder inocuIated into cuIture media. In five years, the bacterioIogists of the Minnesota Department of HeaIth have found only one instance in which organisms isoIated in cuItures were non-virulent for guinea pigs. Any patient with tubercutosis in any form who shows cellular elements in the urine shouId have a complete urological examination, incIuding cystoscopy, whether or not baciIIi of tubercuIosis are found in the urine. After compIete examination of the urine, functiona tests shouId be done before cystoscopy is considered. Kidney function tests do not furnish a positive or negative diagnosis of earIy renaI tubercuIosis but they do give information as to the abiIity of the patient to withstand complete urological examinations, incIuding biIatera1 retrograde pyeIograms. These functional tests teI1 us when cystoscopy can best be done. The tests we most commonIy use are the phenosuIphonphthaIein excretion test and bIood chemistry studies, which incIude bIood urea nitrogen, nonprotein nitrogen and bIood creatinin. At the same time we obtain kidney, ureter and bIadder roentgenograms. These films are not of great vaIue in the diagnosis of early renaI Iesions of tuberculosis but they do revea1 the oId calcified type. They may also suggest the presence of psoas abscess. When cystoscopy is attemped, it shouId be carefuIIy performed. The reflux test
NEW SERIES VOL. XXXVIII,
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Thomas
et aI.-Rena1
should be done to determine the possibility of contamination of the uretera specimens of urine. This test is done by overdistend-
FIG. I. Series of pyeloureterograms
demonstrating
ing the bIadder with a soIution of methylene bIue after the ureteral catheters are in pIace and before the cystoscope is removed. The urine that flows through the uretera catheters is watched carefuIIy for evidence of return of the methyIene bIue. If this is obtained, we know that reflux has occurred from the bIadder up the uretera lumen to the renaI peIvis and back through the ureteral catheter. RefIux has been demonstrated inr4.0 per cent of our cystoscopies. This has occurred with a11 types of pathoIogy and anesthesia. When the reflux test is negative, indigo carmine may be given intravenously. This reveaIs a comparison of the gross function of the separate kidneys. We know that minor differences in the return of the indigo carmine do not necessariIy indicate renal Frequently kidneys with Iarge damage. destroyed areas of tubercuIosis have no diminution of function. However, these findings are of vaIue when considered in combination with other findings. 10-20 C.C. of urine are SubsequentIy colIected from each kidney peIvis. These specimens are taken to the laboratory at
TubercuIosis
American Journal of Surgery
39
once, where a cell count of each is made. They are then centrifuged, the sediment divided and injected into two guinea pigs.
parenchymal
abscess type of renal tuberculosis.
These pigs are sacrificed at the end of six weeks. If the autopsy of the first pig is negative for Iesions of tubercuIosis, the second pig is aIIowed to Iive a second six weeks’ period and then sacrificed. We beIieve that bilateral pyelography is necessary before a compIete diagnosis of the presence and extent of earIy destructive lesions of tubercuIosis can be made. The practice of making repeated biIatera1 pyeIoureterograms in renaI tubercuIosis has been criticised. We have made hundreds of bilateral pyeIograms over a period of many years without evidence of spread of tuberculosis from the kidney. We have not observed miIiary infection or meningitis as sequeIIae of retrograde pyeIography. Uretera1 catheters shouId be inserted so that their eyes are in the kidney peIves and not in separate calices or in the ureters. This arrangement permits withdrawal of the sodium iodide or whatever radio-opaque soIution has been used as soon as the films are exposed. Two syringes are necessary to prevent cross-contamination of the specimens of urine obtained from the kidney peIves. We try to aspirate from each renaI
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pelvis the same amount of radio-opaque soIution injected before pyeIoureterograms were made.
FIG. 2. Pyeloureterograms showing uIcerative type of renaltubercu1osi.s involving the right kidney.
We know of no method of examination that wiII revea1 the tiny macroscopic uIcerative or destructive Iesions of tubercuIosis in the kidney parenchyma as constantIy as the pyeIogram. By this method we have been abIe to demonstrate smaI1 uIcerative Iesions and parenchyma1 abscesses when a specimen of urine from the same kidney did not reveal baciIIi of tubercuIosis. Repeated biIatera1 pyelograms are necessary because if only one kidney is examined, the surgeon may overIook an unsuspected Iesion in the other. The pyeIogram has heIped to estimate the reIative amount of IocaI defense against baciIIi of tubercuIosis as manifested by the kidney. If a patient has a good IocaI and genera1 resistance, a destructive tubercuIous Iesion may be held in abeyance or progress sIowIy. When the Iocal defense and the genera1 resistance are sIight, the kidney may be destroyed quickIy. These changes may be accurateIy foIIowed onIy by pyeIography.
TubercuIosis
oc-lOsEl<. 1<,)1-
There is aiwnys plenty of time available for careful study of the patient’s urinary tract before surgica1 treatment is undertaken.
FIG.
2. <
PveIoureteroarams Ious pyoneph&is,
showing tuberculeft kidney.
”
Repeated pyeIograms revea1 that a patient may have a destructive renaI Iesion of tubercuIosis for months and years without demonstrable symptoms. The intravenous method of urography has not been vaIuabIe in the diagnosis of the earIy or small destructive Iesions of renal tuberculosis. However, this method of urography may furnish a positive but not a negative diagnosis of renaI tuberculosis. It may not visuaIize the minor fiIIing defects which may be observed with the retrograde method. Intravenous urography is most usefu1 when it is impossibIe to cystoscope a patient or to catheterize both ureters. In these instances pyeIography might be impossibIe without this method. The Iesions of renaI tubercuIosis that may be demonstrated in a weII-hIled retrograde pyeIogram are the ulcerative lesions, parenchymal
nephrosis.
abscess,
These
by well-filled
and tuberculous
can be diflerentiated
retrograde
pyelograms,
pyoonly
which
~~~ sEHIEs var. XXXVIII,NCA I Thomas
et aI.-Renal
wiIl visuahze any deformity of the kidney peIvis or parenchyma. The Ieast destructive of these Iesions, or the ulcerative type,
FIG. 4~. Pyeloureterograms showing biIatera1 renal disease (1924). Guinea pigs positive.
appears in the pyeIogram as a small irregularity or moth-eaten area in the border of a caIyx. This projects sIightIy, if any, into the parenchyma. This defect may be so sIight that a positive diagnosis may depend on its constant appearance in repeated retrograde pyeIograms associated with the presence of pus ceIIs and baciIIi of tubercuIosis in the urine. The second type of Iesion is the parenchymal abscess. In this, more destruction of renal tissue has occurred so that it is recognized in the weII-HIed pyeIogram as a definite fiIIing defect, projecting from the border of a caIyx into the parenchyma of the kidney. Depending on the size of these lesions and the IocaI efrorts at heaIing, there may or may not be urinary symptoms. These Iesions may be muItipIe and tissue destruction may progress rapidly to pyonephrosis. In most instances the IocaI and genera1 resistance is sufficient to hoId an area of this type in check for many years. SmaII or moderate-sized abscesses or
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phthisica1 areas may be surrounded by sufficient connective tissue so that they cannot, temporariIy at least, connect with
FIG. 413. PyeIoureterograms, same patient as 4A, eleven years later, showing normal pelvic outin the upper Iine on the left and calcification poIe of the right kidney. Guinea pigs negative.
the calices or peIvis, preventing pus ceIIs and baciIIi of tuberculosis from reaching the urine from this source. They may not compIeteIy hea1; however, one has been observed that did not progress for thirteen years and others have remained quiescent for shorter periods of time. The third type of destructive Iesion of renaI tubercuIosis we recognize is tuberculous pyonephrosis. This is the termina1 stage of renaI infection. It consists of muItipIe, extensive, parenchyma1 abscesses associated with widespread tubercuIosis of the kidney peIvis. This type of Iesion is the end-resuIt of the two previousIy described. It foIIows undiagnosed and untreated renaI tubercuIosis occurring in a patient with IittIe IocaI or genera1 resistance against the disease and extending over a considerabIe may be period of time. The pyeIogram required in the diagnosis of this type of Iesion but the destruction of the kidney is often so great that it is unnecessary. (Figs. 1, 2, 3 and 4.)
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INDICATIONS
FOR
Thomas
et aI.-Rena1
TREATMENT
We are making a study of the autopsy findings of individuaIs who died in Hennepin County with some Iesion of genitourinary tuberculosis. These reports are obtained from the Department of PathoIogy of the University of Minnesota. We are trying to determine how effective genera1 and IocaI resistance of patients can be in the arrest and contro1 of Iesions of tubercuIosis in the kidney or kidneys. Can the IocaI or genera1 resistance become effective so that Iesions of genito-urinary tubercuIosis remain under control? And do we have to consider this defense a factor or the naajor factor when considering indications for treatment? Our study is incompIete; however, certain encouraging information is obtained. We examined I 7,777 consecutive autopsy reports and found 1,283 cases with some finding of tuberculosis. Of these 202 or 15.74 per cent had evidence of genitourinary tubercuIosis. There were fifty-five cases of uniIatera1 renaI tuberculosis. This was 4.28 per cent of the total number of cases examined and is the same figure obtained during a cIinica1 study of the prevaIence of renaI tubercuIosis in association with genera1 tuberculosis. We found one case with a report of biIatera1 heaIed scars of renaI tuberculosis. There were seventeen cases that showed evidence of tuberculosis of the prostate or epididymis, or both, without any gross evidence of renaI tubercuIosis. Unfortunately, there was no microscopic study of the kidneys in these cases so we cannot say positiveIy whether a renal Iesion existed. WhiIe tubercuIosis can be carried to the prostate by the bIood stream, we fee1 that in the majority of cases the spread of the infection is via the urine from the kidneys. Our incompIete study of autopsy data and our cIinica1 experience teach us that the first consideration in the determination of the treatment to be given any patient with renaI tubercuIosis is the estimation of his genera1 condition and his or her ability to
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contro1 Iesions of tuberculosis. This defense against the baciIIus tuberculosis must be manifested before any surgica1 treatment is recommended. We never forget that renaI tuberculosis is a Iocal manifestation of a genera1 disease. It is rareIy possibIe to extirpate a11 of a given individuaI’s tubercuIosis, so in genera1 it may be stated that surgical treatment does not cure but is an aid in obtaining a good cIinica1 resuIt. It is dangerous to attempt surgica1 treatment for renaI tubercuIosis in the presence of acute or recent puImonary disease with the exudative types of Iesions. Such radical treatment may cause an exacerbation of the disease and Ieave the patient in worse condition than before surgica1 treatment was attempted. The chronic fibrotic stages of the disease offer the surgeon a safer fieId for surgica1 treatment. However, there is always the possibiIity that any trauma which Iowers the IocaI or genera1 resistance of the patient may be foIIowed by a Iighting up of a quiescent lesion IocaIIy or in some other organ. We h ave had one case of tubercuIous meningitis two months foIIowing nephrectomy for renaI tuberculosis. Dr. J. HaroIde Turner reported a case of tubercuIous meningitis foIIowing nephrectomy in the Journal of Urology for September, 1935. The time of operation as we11 as the patient must be carefuIIy seIected. The avoidance of anesthetic trauma is necessary to prevent reactivation of a quiescent puImonary lesion. When a diagnosis of uniIatera1 destructive progressive renaI tuberculosis is made, the treatment indicated is usuaIIy nephrectomy. The small destructive lesions of the uIcerative group may, with safety, be watched temporariiy. SurgicaI treatment is indicated when pus ceIIs and baciIIi of tuberculosis are constantly present in the urine and the pyeIogram reveaIs that the Repeated tests must Iesion is increasing. revea1 no Iesion or baciIIi in the urine obtained from the contra-Iateral kidney before nephrectomy is attempted. The patient must have no other active IocaI or genera1 Iesion of tubercuIosis. With these
NEWSERIESVOL.XXXVIII. NO.I Thomas
et aI.-Renal
conditions present, the treatment of uniIateraI tubercuIous parenchyma1 abscess and pyonephrosis is aIways nephrectomy. In the presence of uniIatera1 or biIatera1 non-destructive renaI tuberculosis, surgical treatment is not indicated. The patient shouId receive constitutiona treatment and the IocaI and genera1 condition shouId be frequentIy checked to revea1 evidence of a destructive process. With the appearance on the pyeIogram of evidence of some sIight destruction nephrectomy shouId not be done immediateIy but the Iesion shouId be watched for a time. A possibIe undiscovered Iesion in the other kidney and the presence of much good functioning kidney tissue in the affected kidney may postpone nephrectomy unti1 it is apparent that the Iesion being watched wiI1 not be controIIed. With proper constitutiona treatment smaI1 Iesions may be heId in abeyance for a Iong time. When the patient has biIatera1 destructive lesions of renaI tubercuIosis, constitutiona1 therapy and heIiotherapy become the first considerations. In the event that one kidney is destroyed and the other kidney shows evidence of good function, and the tuberculous lesion is non-destructive, nephrectomy may be indicated provided that the patient has shown a good resistance against other Iesions of tubercuIosis. OccasionaIIy nephrectomy may be indicated or justified when a patient with biIatera1 destructive Iesions of tubercuIosis has severe pain, uncontroIIed hemorrhage or obstruction of the ureter with pain and toxemia. The span of life, in the patient with biIatera1 destructive Iesions, is governed by the amount of good functioning renaI tissue that he possesses. In the presence of biIatera1 non-destructive renal tubercuIosis the treatment is medica1. About 65 per cent of the early Iesions of renaI tubercuIosis are biIatera1. is Nephrectomy in renal tuberculosis practically never an emergency procedure. There is plenty of time for all factors to be considered bejore surgical treatment is attempted.
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If a perinephritic abscess, whether tuberculous or non-tubercuIous, shouId deveIop in association with uniIatera1 or biIatera1 renal invoIvement, the treatment indicated is immediate surgica1 drainage. If the patient is in poor genera1 condition, onIy drainage of the abscess shouId be done. With the comphcation of perinephritic abscess, nephrectomy shouId not be attempted since then it is a procedure attended by considerabIe extra risk. The kidney associated with a tubercuIous perinephritic abscess may be compIeteIy destroyed and a11 renaI tissue extruded through the drainage opening. The drainage of this puruIent materia1 may resuIt in aImost miracuIous improvement in the condition of the patient. H’eliotberapy is indicated in a11 cases of extrapulmonary tubercuIosis. The use of uItra-vioIet therapy is indicated onIy in certain instances. The beneficia1 effect of actinotherapy on tubercuIous Iesions, particuIarIy extrapuImonary ones, has been known for a Iong time. However, at times it is used unwiseIy. We cannot be sure whether the beneficia1 effect of the uItravioIet therapy comes from a IocaI antiseptic action of the actinic Iight or whether it is due to a stimuIating action on granuIating tissue by drying or heating. There can be no question that improved heaIing results in seIected cases. Overdosage must be avoided. In a patient who has to trave1 some distance daiIy to receive treatment, better resuIts may be obtained by keeping him or her at home with rest than with the use of actinic therapy. SurgicaI patients should have very carefu1 preoperative and post-operative treatment. When the usual carefu1 diagnostic routine is foIlowed, the patient wiII have had considerabIe constitutiona treatment, rest and heIiotherapy before operation. The recuperative powers of tubercuIous patients are decreased; consequentIy a patient who submits to any surgica1 procedure shouId be required to remain in bed, at rest, with heliotherapy when possibIe, from one to six months folIowing the surgica1 treat-
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ment. This Iength of time required for bed rest can be decided when the resistance, temperature and genera1 condition of the patient are known. The treatment of renal
tuberculosis should be directed at the patient as a whole and not alone at the local lesion. CONCLUSIONS I. AI1 patients with tubercuIosis shouId have routine urinaIyses every three months. 2. Patients showing ceIIuIar eIements in the urine should have a compIete uroIogica1 study. 3. The destructive Iesions of renal tubercuIosis can be differentiated onIy by weII-fiIIed retrograde pyeIograms. 4. The successfu1 surgica1 treatment of urogenita1 tubercuIosis depends primarily upon an accurate diagnosis. This may be accompIished onIy after repeated compIete uroIogica1 examinations. 5. There is an earIy or “invasion” stage of renaI tubercuIosis just as there is with any other type of this infection. This period may be symptomIess but a carefu1 search wiI1 revea1 cIinica1 findings that are sufficient for a diagnosis. 6. The diagnosis and earIy treatment of the earIy lesion of renai tubercuIosis may prevent the deveIopment of renaI phthisis. 7. Surgical treatment for any type of except in an emergency, tubercuIosis, should not be undertaken unti1 the patient has deveIoped a sufficient defense mechanism. 8. The progress of lesions of tubercuIosis may be sIow. 9. The surgica1 treatment of urogenita1 tubercuIosis is rarely an emergency. IO. SurgicaI or medica treatment of tubercuIosis shouId aim at the patient as a whoIe, not aIone at the local Iesion. I I. Rena1 tubercuIosis or other urogenita1 Iesions are IocaI manifestations of a constitutiona disease. I 2. Non-destructive renaI tubercuIosis, uniIatera1 or biIatera1, is a non-surgica1 condition and shouId be treated intensively by medica methods,
OC.L.OBEH, 193-
TubercuIosis
13. BaciIIi of tubercuIosis in one speciment of urine obtained from the kidney peIvis do not alone give an indication for nephrectomy. 14. In earIy renal tuberculosis, surgeons shouId be more conservative in advising the remova of a kidney which eIiminates baciIIi of tubercuIosis unIess the pyeIogram reveaIs definite evidence of erosion and the urine from the second kidney is repeatedIy negative when injected into animaIs. I 5. UniIateraI sIightIy destructive tubercuIosis shouId be treated conservativeIy under carefu1 observation. Nephrectomy is indicated onIy when progressive disease is present. 16. Extensive uniIatera1 destructive Iesions shouId be treated by surgica1 methods. I 7. BiIateraI destructive renaI tubercuIosis is not a surgica1 condition except to stop hemorrhage or to reIieve pain and sepsis, the resuIt of an obstructed ureter. 18. TubercuIous patients shouId have careful pre-operative treatment. 19. Heliotherapy is beneficia1 but uItravioIet Iight should be given only in seIected instances. REFERENCES
ALCOCK, NATHANIEL G. One hundred forty-five cases of renal tuberculosis. Trans. Am. Assn. of G. U. .%geOnS, 17: 1924. F. OccIuded renal tuberculosis. BRAASCH, W. J. A. hf. A., 75: 1307-1309 (Nov. 13) 1920. BRAASCH,W. F. and SCHOLL, A. J. PossibIe errors in the diagnosis of renal tuberculosis. J. A. M. A., 82: 688-692 (March I) 1924. MCDANIEL, ORIANNAand HEATHMAN,LUCY S. Personal communication. Minnesota Dept. of Health, Division of Preventable Diseases, Minneapolis, Minn. MEDLAR, E. M. and SASANO,K. T. Experimental renal tubercuIosis. Am. Rev. Tuberculosis, IO: 370-391 (December) 1924. MEDLAR, E. M. Cases of renal infection in pulmonary tuberculosis; evidence of healed tuberculous Icsions. Am. J. Patbol., 2: 401-414, 1926. MEDLAR, E. M. Significance of tuber& bacilli in the urine. urol. and Cutan. Rev., 36: 71-75, 1932. SPITZER, W. H. The indications and contraindications for surgicat intervention in genitaI tuberculosis. urol. and Cutan. Rev., 36: 88-90, 1932. THOMAS,G. J. Renal tubercutosis. J. A. M. A., 94: za2359 ‘93”.
THOMAS, G. J. The diagnosis of renal tuberculosis. Minn. Med., 1: 22-28, 1932.
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SERIES VOL. XXXVIII.
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THOMAS, G. J. and KINSELLA, T. J. Some data conccrning the cIinica1 course of renaI tuberculosis. J. Ural., 19: No. 2, 1928. THOMAS, G. J. and KINSELLA, T. J. Inflammatory obstruction of the ureter caused by psoas abscess, secondary to tubercuIosis of the spine. Am. J. Surg., ns., 13: 72-74, ‘931. THOMAS, G. J. and KINSELLA, T. J. Modern aspects of the surgical treatment of genitourinary tuberculosis. Minn. Med., 14: 821-827, 1932. THOMAS, G. J., KINSELLA, T. J. and VAN WINKLE, C. C. Cgstoscopic technique necessary for the
NONDESCENT of both testicIes
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at other periods .
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Hopkins
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is usually
into the circulation From-“Urology M.D.
associated
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is seen in littIe girls and in aged women;
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.
.
test, originated
whoIIy
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in the urine
.
.
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in 1910 by Rountree
kidneys;
from 60 to 83 per cent of the entire
its appearance
Kirwin,
.
takes
and Geraghty
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in the bases that this drug is that amount
the
normal
within
kidney
wiI1
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or the muscles. for Nurses”
65
diagnosis of genitourinary tubercuIosis. Trans. Am. Assn., G.U. Surgeons, pp. 65-70, 1934. THOMAS, G. J. and KINSELLA, T. J. Modern concepts of gcnitourinary tuberculosis. Am. J. Surg., n.s., 23: I I r-128 (January) 1934. WHITE, S. M. Tuberculous glomerulitis. Trans. Chicago Patbol. SW., 3: 277-283, r8g7-1899. WILDHOLZ, HANS. Ueber die Moglichkeit einer Spontanheilung der Nierentuberkulose. Ztscbr. J. uroI. Cbtr. u. Gyntik., 42: 257-267, 1936. WYLER, J. ExperimentelIar Beitrag zur Frage der tuberkulosen Bacillurie, Vorlautige Mitterlung. Ztscbr. J. urol. Cbir. u. Gyniik., 42: I 57-163, 1936.
of life.
University,
aImost
American ~~~~~~~~ or surgery
tract.
PROLAPSE of the urethra
rarely
TubercuIosis
by Oswald S. LowsIey, M.D. and Thomas
J.
THEODORE
Attending Urologist, Glen Lake Sanatorium, Oak Terrace, Minnesota; Eitel I Iospital, hlinneapolis; Associate Clinical Professor of Urology, Medical and Graduate Schools, University of Minnesota AND CHARLES
K.
L.
STEBBINS,
OF
M.D.,
Nicollet Clinic, Minneapolis, and Glen Lake Sanatorium, Oak Terrace, Minnesota
PETTER,
M.D.
GIcn Lake Sanatorium, Oak T errace, hlinnesota, and the Department of Surgery, University of Minnesota MINNEAPOLIS,
UCH has been accomplished during the past twelve years, not onIy by physicians and surgeons but by the genera1 pubhc, in the diagnosis and treatment of tubercuIosis. Lay workers have learned how to apply measures directed at the prevention of this disease. They now understand the necessity of isoIation of active cases and frequentIy report patients who have signs or symptoms usuaIIy associated with advancing phthisis. MedicaI officers have successfuIIy practiced prevention and prophyIaxis so that now they have to examine we11 persons if the contro1 of tubercuIosis may continue to advance. The use of tubercuIin skin tests and Roentgen ray examinations of the chest may demonstrate incipient puImonary Iesions in apparentIy we11 persons when the ordinary physica examination reveals no diagnostic signs of this condition. By the use of similar methods we can now discover earIy lesions of renaI tubercuIosis before the patient has urinary symptoms. During the last twenty years there has been a change, at Ieast apparent, in the character of extrapuImonary Iesions of tubercuIosis. This is particuIarIy true with the lesions that require surgica1 treatment. The resistance of individuaIs has been increased so that spread of tubercuIosis from the chest cavity occurs with greater difhculty, and surgeons find these Iesions more amenabIe to surgica1 treatment.
MINNESOTA
Today a history of genitourinary disease is not of much value in the diagnosis of the first or early Iesions of renaI tuberculosis. FormerIy, the kidneys were not suspected unti1 the patient began to compIain of bIadder irritabiIity, frequency, hematuria, etc. Today we fee1 that if we wait unti1 these symptoms appear, the kidney Iesions are usuaIIy far advanced so that they may not be amenabIe to treatment. A history of previous puImonary tubercuIosis is important. A history of bone, joint or intestina1 Iesions is sign&cant because this indicates that baciIIi of tubercuIosis have entered the bIood stream from a focus in the chest. When this occurs, the kidneys should be suspected because with their profuse brood suppIy there is a good chance that emboIi may be fiItered out and renaI lesions deveIop subsequentIy. There may be no symptoms of a renaI tubercuIosis in its earIy stages. Hematuria occurs infrequentIy with earIy Iesions. We beIieve that every patient with tuberculosis shouId be examined for renaI infection before urinary symptoms are present. If a11 patients are subjected to a routine method of diagnosis and treatment, a11 Iesions of renaI tuberculosis may be discovered early and the majority may be arrested. If arrest is not possibIe by conservative methods, appropriate surgica1 treatment may be instituted before the Iower urinary tract
M
57
58
AmericanJournal
becomes invoived nentIy crippled.
ol’Surgcry
Thomas
et al.-Renal
and other organs perma-
The frequently repeated examination of a sterile specimen of urine for tubercle bacilli is the only method of examination which will reveal positive findings that clinch the diagnosis of renal invasion. The norma
kidney wiI1 not transmit baciIIi of tubercuIosis. Repeated intervaI examinations of the urine must be made because infected kidneys wiI1 transmit baciIIi of tuberculosis, pus celIs and bIood ceIIs into the urine at one time and not at another. The urinalysis practiced at Glen Lake Sanatorium, Oak Terrace, Minnesota, is as foIIows. AI1 patients have routine studies of the urine every three months no matter where the tubercuIous Iesion may be Iocated or its extent. If ceIIuIar eIements are found in the urine, the sediment is stained by the ZiehI Nielson method. If no baciIIi of tubercuIosis are found, four weekIy specimens, two of which are twenty-four hour coIIections, are centrifuged and the sediment is injected once each week into the peritonea1 cavity of the same guinea pig. If more than occasiona1 bacilli of tubercuIosis are present, these shouId produce tissue reaction in the anima1, and after six or eight weeks typica Iesions may be observed in the glands and organs. In some instances the number of organisms may be smaI1; the resistance of the anima1 may be greater than usual; or the organisms may have a Iow virulence so that Iesions may not be produced. Subsequent injection of the sediment of additiona1 specimens of urine may produce the disease. The culture method of isoIation of the baciIIi of tubercuIosis from the urine, which is Iess expensive, may be used instead of the inocuIation of guinea pigs. However, this method requires several years of experience on the part of the Iaboratory worker in order to perfect technique. The resuIts obtained by an experienced worker who uses the cuIture method are as good as, or better than, the anima1 method. A few positives may be picked up with the cuhure method that are missed with the guinea pig method
Tuberculosis
oCloUclc. IOJ,
and vice versa. Dr. McNabb of the Ontario ProvinciaI Laboratories (who has done the most extensive cuItura1 work to date) found more positives with the cuItura1 method aIone than with the guinea pig method aIone in thousands of examinations. Petragini’s cuIture media which consists of whoIe eggs combined with dye and bIood media have been found to be the most successful. At the Division of PreventabIe Diseases of the Minnesota Department of HeaIth in Minneapolis, the cuIture method is used with all voided specimens of urine, as we11 as sputum. When catheterized specimens of urine are examined, part of the sediment is inocuIated into one guinea pig and the remainder inocuIated into cuIture media. In five years, the bacterioIogists of the Minnesota Department of HeaIth have found only one instance in which organisms isoIated in cuItures were non-virulent for guinea pigs. Any patient with tubercutosis in any form who shows cellular elements in the urine shouId have a complete urological examination, incIuding cystoscopy, whether or not baciIIi of tubercuIosis are found in the urine. After compIete examination of the urine, functiona tests shouId be done before cystoscopy is considered. Kidney function tests do not furnish a positive or negative diagnosis of earIy renaI tubercuIosis but they do give information as to the abiIity of the patient to withstand complete urological examinations, incIuding biIatera1 retrograde pyeIograms. These functional tests teI1 us when cystoscopy can best be done. The tests we most commonIy use are the phenosuIphonphthaIein excretion test and bIood chemistry studies, which incIude bIood urea nitrogen, nonprotein nitrogen and bIood creatinin. At the same time we obtain kidney, ureter and bIadder roentgenograms. These films are not of great vaIue in the diagnosis of early renaI Iesions of tuberculosis but they do revea1 the oId calcified type. They may also suggest the presence of psoas abscess. When cystoscopy is attemped, it shouId be carefuIIy performed. The reflux test
NEW SERIES VOL. XXXVIII,
No. I
Thomas
et aI.-Rena1
should be done to determine the possibility of contamination of the uretera specimens of urine. This test is done by overdistend-
FIG. I. Series of pyeloureterograms
demonstrating
ing the bIadder with a soIution of methylene bIue after the ureteral catheters are in pIace and before the cystoscope is removed. The urine that flows through the uretera catheters is watched carefuIIy for evidence of return of the methyIene bIue. If this is obtained, we know that reflux has occurred from the bIadder up the uretera lumen to the renaI peIvis and back through the ureteral catheter. RefIux has been demonstrated inr4.0 per cent of our cystoscopies. This has occurred with a11 types of pathoIogy and anesthesia. When the reflux test is negative, indigo carmine may be given intravenously. This reveaIs a comparison of the gross function of the separate kidneys. We know that minor differences in the return of the indigo carmine do not necessariIy indicate renal Frequently kidneys with Iarge damage. destroyed areas of tubercuIosis have no diminution of function. However, these findings are of vaIue when considered in combination with other findings. 10-20 C.C. of urine are SubsequentIy colIected from each kidney peIvis. These specimens are taken to the laboratory at
TubercuIosis
American Journal of Surgery
39
once, where a cell count of each is made. They are then centrifuged, the sediment divided and injected into two guinea pigs.
parenchymal
abscess type of renal tuberculosis.
These pigs are sacrificed at the end of six weeks. If the autopsy of the first pig is negative for Iesions of tubercuIosis, the second pig is aIIowed to Iive a second six weeks’ period and then sacrificed. We beIieve that bilateral pyelography is necessary before a compIete diagnosis of the presence and extent of earIy destructive lesions of tubercuIosis can be made. The practice of making repeated biIatera1 pyeIoureterograms in renaI tubercuIosis has been criticised. We have made hundreds of bilateral pyeIograms over a period of many years without evidence of spread of tuberculosis from the kidney. We have not observed miIiary infection or meningitis as sequeIIae of retrograde pyeIography. Uretera1 catheters shouId be inserted so that their eyes are in the kidney peIves and not in separate calices or in the ureters. This arrangement permits withdrawal of the sodium iodide or whatever radio-opaque soIution has been used as soon as the films are exposed. Two syringes are necessary to prevent cross-contamination of the specimens of urine obtained from the kidney peIves. We try to aspirate from each renaI
60
American
Journal
d Surgrry
Thomas
et al.PRenaI
pelvis the same amount of radio-opaque soIution injected before pyeIoureterograms were made.
FIG. 2. Pyeloureterograms showing uIcerative type of renaltubercu1osi.s involving the right kidney.
We know of no method of examination that wiII revea1 the tiny macroscopic uIcerative or destructive Iesions of tubercuIosis in the kidney parenchyma as constantIy as the pyeIogram. By this method we have been abIe to demonstrate smaI1 uIcerative Iesions and parenchyma1 abscesses when a specimen of urine from the same kidney did not reveal baciIIi of tubercuIosis. Repeated biIatera1 pyelograms are necessary because if only one kidney is examined, the surgeon may overIook an unsuspected Iesion in the other. The pyeIogram has heIped to estimate the reIative amount of IocaI defense against baciIIi of tubercuIosis as manifested by the kidney. If a patient has a good IocaI and genera1 resistance, a destructive tubercuIous Iesion may be held in abeyance or progress sIowIy. When the Iocal defense and the genera1 resistance are sIight, the kidney may be destroyed quickIy. These changes may be accurateIy foIIowed onIy by pyeIography.
TubercuIosis
oc-lOsEl<. 1<,)1-
There is aiwnys plenty of time available for careful study of the patient’s urinary tract before surgica1 treatment is undertaken.
FIG.
2. <
PveIoureteroarams Ious pyoneph&is,
showing tuberculeft kidney.
”
Repeated pyeIograms revea1 that a patient may have a destructive renaI Iesion of tubercuIosis for months and years without demonstrable symptoms. The intravenous method of urography has not been vaIuabIe in the diagnosis of the earIy or small destructive Iesions of renal tuberculosis. However, this method of urography may furnish a positive but not a negative diagnosis of renaI tuberculosis. It may not visuaIize the minor fiIIing defects which may be observed with the retrograde method. Intravenous urography is most usefu1 when it is impossibIe to cystoscope a patient or to catheterize both ureters. In these instances pyeIography might be impossibIe without this method. The Iesions of renaI tubercuIosis that may be demonstrated in a weII-hIled retrograde pyeIogram are the ulcerative lesions, parenchymal
nephrosis.
abscess,
These
by well-filled
and tuberculous
can be diflerentiated
retrograde
pyelograms,
pyoonly
which
~~~ sEHIEs var. XXXVIII,NCA I Thomas
et aI.-Renal
wiIl visuahze any deformity of the kidney peIvis or parenchyma. The Ieast destructive of these Iesions, or the ulcerative type,
FIG. 4~. Pyeloureterograms showing biIatera1 renal disease (1924). Guinea pigs positive.
appears in the pyeIogram as a small irregularity or moth-eaten area in the border of a caIyx. This projects sIightIy, if any, into the parenchyma. This defect may be so sIight that a positive diagnosis may depend on its constant appearance in repeated retrograde pyeIograms associated with the presence of pus ceIIs and baciIIi of tubercuIosis in the urine. The second type of Iesion is the parenchymal abscess. In this, more destruction of renal tissue has occurred so that it is recognized in the weII-HIed pyeIogram as a definite fiIIing defect, projecting from the border of a caIyx into the parenchyma of the kidney. Depending on the size of these lesions and the IocaI efrorts at heaIing, there may or may not be urinary symptoms. These Iesions may be muItipIe and tissue destruction may progress rapidly to pyonephrosis. In most instances the IocaI and genera1 resistance is sufficient to hoId an area of this type in check for many years. SmaII or moderate-sized abscesses or
TubercuIosis
American Journal of Surgery
61
phthisica1 areas may be surrounded by sufficient connective tissue so that they cannot, temporariIy at least, connect with
FIG. 413. PyeIoureterograms, same patient as 4A, eleven years later, showing normal pelvic outin the upper Iine on the left and calcification poIe of the right kidney. Guinea pigs negative.
the calices or peIvis, preventing pus ceIIs and baciIIi of tuberculosis from reaching the urine from this source. They may not compIeteIy hea1; however, one has been observed that did not progress for thirteen years and others have remained quiescent for shorter periods of time. The third type of destructive Iesion of renaI tubercuIosis we recognize is tuberculous pyonephrosis. This is the termina1 stage of renaI infection. It consists of muItipIe, extensive, parenchyma1 abscesses associated with widespread tubercuIosis of the kidney peIvis. This type of Iesion is the end-resuIt of the two previousIy described. It foIIows undiagnosed and untreated renaI tubercuIosis occurring in a patient with IittIe IocaI or genera1 resistance against the disease and extending over a considerabIe may be period of time. The pyeIogram required in the diagnosis of this type of Iesion but the destruction of the kidney is often so great that it is unnecessary. (Figs. 1, 2, 3 and 4.)
62
A me&an
Journal of Surgery
INDICATIONS
FOR
Thomas
et aI.-Rena1
TREATMENT
We are making a study of the autopsy findings of individuaIs who died in Hennepin County with some Iesion of genitourinary tuberculosis. These reports are obtained from the Department of PathoIogy of the University of Minnesota. We are trying to determine how effective genera1 and IocaI resistance of patients can be in the arrest and contro1 of Iesions of tubercuIosis in the kidney or kidneys. Can the IocaI or genera1 resistance become effective so that Iesions of genito-urinary tubercuIosis remain under control? And do we have to consider this defense a factor or the naajor factor when considering indications for treatment? Our study is incompIete; however, certain encouraging information is obtained. We examined I 7,777 consecutive autopsy reports and found 1,283 cases with some finding of tuberculosis. Of these 202 or 15.74 per cent had evidence of genitourinary tubercuIosis. There were fifty-five cases of uniIatera1 renaI tuberculosis. This was 4.28 per cent of the total number of cases examined and is the same figure obtained during a cIinica1 study of the prevaIence of renaI tubercuIosis in association with genera1 tuberculosis. We found one case with a report of biIatera1 heaIed scars of renaI tuberculosis. There were seventeen cases that showed evidence of tuberculosis of the prostate or epididymis, or both, without any gross evidence of renaI tubercuIosis. Unfortunately, there was no microscopic study of the kidneys in these cases so we cannot say positiveIy whether a renal Iesion existed. WhiIe tubercuIosis can be carried to the prostate by the bIood stream, we fee1 that in the majority of cases the spread of the infection is via the urine from the kidneys. Our incompIete study of autopsy data and our cIinica1 experience teach us that the first consideration in the determination of the treatment to be given any patient with renaI tubercuIosis is the estimation of his genera1 condition and his or her ability to
TubercuIosis
OcrooEl<, 193-
contro1 Iesions of tuberculosis. This defense against the baciIIus tuberculosis must be manifested before any surgica1 treatment is recommended. We never forget that renaI tuberculosis is a Iocal manifestation of a genera1 disease. It is rareIy possibIe to extirpate a11 of a given individuaI’s tubercuIosis, so in genera1 it may be stated that surgical treatment does not cure but is an aid in obtaining a good cIinica1 resuIt. It is dangerous to attempt surgica1 treatment for renaI tubercuIosis in the presence of acute or recent puImonary disease with the exudative types of Iesions. Such radical treatment may cause an exacerbation of the disease and Ieave the patient in worse condition than before surgica1 treatment was attempted. The chronic fibrotic stages of the disease offer the surgeon a safer fieId for surgica1 treatment. However, there is always the possibiIity that any trauma which Iowers the IocaI or genera1 resistance of the patient may be foIIowed by a Iighting up of a quiescent lesion IocaIIy or in some other organ. We h ave had one case of tubercuIous meningitis two months foIIowing nephrectomy for renaI tuberculosis. Dr. J. HaroIde Turner reported a case of tubercuIous meningitis foIIowing nephrectomy in the Journal of Urology for September, 1935. The time of operation as we11 as the patient must be carefuIIy seIected. The avoidance of anesthetic trauma is necessary to prevent reactivation of a quiescent puImonary lesion. When a diagnosis of uniIatera1 destructive progressive renaI tuberculosis is made, the treatment indicated is usuaIIy nephrectomy. The small destructive lesions of the uIcerative group may, with safety, be watched temporariiy. SurgicaI treatment is indicated when pus ceIIs and baciIIi of tuberculosis are constantly present in the urine and the pyeIogram reveaIs that the Repeated tests must Iesion is increasing. revea1 no Iesion or baciIIi in the urine obtained from the contra-Iateral kidney before nephrectomy is attempted. The patient must have no other active IocaI or genera1 Iesion of tubercuIosis. With these
NEWSERIESVOL.XXXVIII. NO.I Thomas
et aI.-Renal
conditions present, the treatment of uniIateraI tubercuIous parenchyma1 abscess and pyonephrosis is aIways nephrectomy. In the presence of uniIatera1 or biIatera1 non-destructive renaI tuberculosis, surgical treatment is not indicated. The patient shouId receive constitutiona treatment and the IocaI and genera1 condition shouId be frequentIy checked to revea1 evidence of a destructive process. With the appearance on the pyeIogram of evidence of some sIight destruction nephrectomy shouId not be done immediateIy but the Iesion shouId be watched for a time. A possibIe undiscovered Iesion in the other kidney and the presence of much good functioning kidney tissue in the affected kidney may postpone nephrectomy unti1 it is apparent that the Iesion being watched wiI1 not be controIIed. With proper constitutiona treatment smaI1 Iesions may be heId in abeyance for a Iong time. When the patient has biIatera1 destructive lesions of renaI tubercuIosis, constitutiona1 therapy and heIiotherapy become the first considerations. In the event that one kidney is destroyed and the other kidney shows evidence of good function, and the tuberculous lesion is non-destructive, nephrectomy may be indicated provided that the patient has shown a good resistance against other Iesions of tubercuIosis. OccasionaIIy nephrectomy may be indicated or justified when a patient with biIatera1 destructive Iesions of tubercuIosis has severe pain, uncontroIIed hemorrhage or obstruction of the ureter with pain and toxemia. The span of life, in the patient with biIatera1 destructive Iesions, is governed by the amount of good functioning renaI tissue that he possesses. In the presence of biIatera1 non-destructive renal tubercuIosis the treatment is medica1. About 65 per cent of the early Iesions of renaI tubercuIosis are biIatera1. is Nephrectomy in renal tuberculosis practically never an emergency procedure. There is plenty of time for all factors to be considered bejore surgical treatment is attempted.
TubercuIosis
American
Journal
of surgery
63
If a perinephritic abscess, whether tuberculous or non-tubercuIous, shouId deveIop in association with uniIatera1 or biIatera1 renal invoIvement, the treatment indicated is immediate surgica1 drainage. If the patient is in poor genera1 condition, onIy drainage of the abscess shouId be done. With the comphcation of perinephritic abscess, nephrectomy shouId not be attempted since then it is a procedure attended by considerabIe extra risk. The kidney associated with a tubercuIous perinephritic abscess may be compIeteIy destroyed and a11 renaI tissue extruded through the drainage opening. The drainage of this puruIent materia1 may resuIt in aImost miracuIous improvement in the condition of the patient. H’eliotberapy is indicated in a11 cases of extrapulmonary tubercuIosis. The use of uItra-vioIet therapy is indicated onIy in certain instances. The beneficia1 effect of actinotherapy on tubercuIous Iesions, particuIarIy extrapuImonary ones, has been known for a Iong time. However, at times it is used unwiseIy. We cannot be sure whether the beneficia1 effect of the uItravioIet therapy comes from a IocaI antiseptic action of the actinic Iight or whether it is due to a stimuIating action on granuIating tissue by drying or heating. There can be no question that improved heaIing results in seIected cases. Overdosage must be avoided. In a patient who has to trave1 some distance daiIy to receive treatment, better resuIts may be obtained by keeping him or her at home with rest than with the use of actinic therapy. SurgicaI patients should have very carefu1 preoperative and post-operative treatment. When the usual carefu1 diagnostic routine is foIlowed, the patient wiII have had considerabIe constitutiona treatment, rest and heIiotherapy before operation. The recuperative powers of tubercuIous patients are decreased; consequentIy a patient who submits to any surgica1 procedure shouId be required to remain in bed, at rest, with heliotherapy when possibIe, from one to six months folIowing the surgica1 treat-
64
American Jourd
of Surgery
Thomas
et al.-Renal
ment. This Iength of time required for bed rest can be decided when the resistance, temperature and genera1 condition of the patient are known. The treatment of renal
tuberculosis should be directed at the patient as a whole and not alone at the local lesion. CONCLUSIONS I. AI1 patients with tubercuIosis shouId have routine urinaIyses every three months. 2. Patients showing ceIIuIar eIements in the urine should have a compIete uroIogica1 study. 3. The destructive Iesions of renal tubercuIosis can be differentiated onIy by weII-fiIIed retrograde pyeIograms. 4. The successfu1 surgica1 treatment of urogenita1 tubercuIosis depends primarily upon an accurate diagnosis. This may be accompIished onIy after repeated compIete uroIogica1 examinations. 5. There is an earIy or “invasion” stage of renaI tubercuIosis just as there is with any other type of this infection. This period may be symptomIess but a carefu1 search wiI1 revea1 cIinica1 findings that are sufficient for a diagnosis. 6. The diagnosis and earIy treatment of the earIy lesion of renai tubercuIosis may prevent the deveIopment of renaI phthisis. 7. Surgical treatment for any type of except in an emergency, tubercuIosis, should not be undertaken unti1 the patient has deveIoped a sufficient defense mechanism. 8. The progress of lesions of tubercuIosis may be sIow. 9. The surgica1 treatment of urogenita1 tubercuIosis is rarely an emergency. IO. SurgicaI or medica treatment of tubercuIosis shouId aim at the patient as a whoIe, not aIone at the local Iesion. I I. Rena1 tubercuIosis or other urogenita1 Iesions are IocaI manifestations of a constitutiona disease. I 2. Non-destructive renaI tubercuIosis, uniIatera1 or biIatera1, is a non-surgica1 condition and shouId be treated intensively by medica methods,
OC.L.OBEH, 193-
TubercuIosis
13. BaciIIi of tubercuIosis in one speciment of urine obtained from the kidney peIvis do not alone give an indication for nephrectomy. 14. In earIy renal tuberculosis, surgeons shouId be more conservative in advising the remova of a kidney which eIiminates baciIIi of tubercuIosis unIess the pyeIogram reveaIs definite evidence of erosion and the urine from the second kidney is repeatedIy negative when injected into animaIs. I 5. UniIateraI sIightIy destructive tubercuIosis shouId be treated conservativeIy under carefu1 observation. Nephrectomy is indicated onIy when progressive disease is present. 16. Extensive uniIatera1 destructive Iesions shouId be treated by surgica1 methods. I 7. BiIateraI destructive renaI tubercuIosis is not a surgica1 condition except to stop hemorrhage or to reIieve pain and sepsis, the resuIt of an obstructed ureter. 18. TubercuIous patients shouId have careful pre-operative treatment. 19. Heliotherapy is beneficia1 but uItravioIet Iight should be given only in seIected instances. REFERENCES
ALCOCK, NATHANIEL G. One hundred forty-five cases of renal tuberculosis. Trans. Am. Assn. of G. U. .%geOnS, 17: 1924. F. OccIuded renal tuberculosis. BRAASCH, W. J. A. hf. A., 75: 1307-1309 (Nov. 13) 1920. BRAASCH,W. F. and SCHOLL, A. J. PossibIe errors in the diagnosis of renal tuberculosis. J. A. M. A., 82: 688-692 (March I) 1924. MCDANIEL, ORIANNAand HEATHMAN,LUCY S. Personal communication. Minnesota Dept. of Health, Division of Preventable Diseases, Minneapolis, Minn. MEDLAR, E. M. and SASANO,K. T. Experimental renal tubercuIosis. Am. Rev. Tuberculosis, IO: 370-391 (December) 1924. MEDLAR, E. M. Cases of renal infection in pulmonary tuberculosis; evidence of healed tuberculous Icsions. Am. J. Patbol., 2: 401-414, 1926. MEDLAR, E. M. Significance of tuber& bacilli in the urine. urol. and Cutan. Rev., 36: 71-75, 1932. SPITZER, W. H. The indications and contraindications for surgicat intervention in genitaI tuberculosis. urol. and Cutan. Rev., 36: 88-90, 1932. THOMAS,G. J. Renal tubercutosis. J. A. M. A., 94: za2359 ‘93”.
THOMAS, G. J. The diagnosis of renal tuberculosis. Minn. Med., 1: 22-28, 1932.
NEW
SERIES VOL. XXXVIII.
No.
Thomas
I
et
al.-Rena1
THOMAS, G. J. and KINSELLA, T. J. Some data conccrning the cIinica1 course of renaI tuberculosis. J. Ural., 19: No. 2, 1928. THOMAS, G. J. and KINSELLA, T. J. Inflammatory obstruction of the ureter caused by psoas abscess, secondary to tubercuIosis of the spine. Am. J. Surg., ns., 13: 72-74, ‘931. THOMAS, G. J. and KINSELLA, T. J. Modern aspects of the surgical treatment of genitourinary tuberculosis. Minn. Med., 14: 821-827, 1932. THOMAS, G. J., KINSELLA, T. J. and VAN WINKLE, C. C. Cgstoscopic technique necessary for the
NONDESCENT of both testicIes
ment elsewhere
in the genital
at other periods .
THE phthaIein
Johns
Hopkins
eliminated excrete that
is usually
into the circulation From-“Urology M.D.
associated
with Iack of deveIop-
is seen in littIe girls and in aged women;
.
.
.
test, originated
whoIIy
.
.
.
. . . is eIaborated by the
in the urine
.
.
.
very
.
in 1910 by Rountree
kidneys;
from 60 to 83 per cent of the entire
its appearance
Kirwin,
.
takes
and Geraghty
of
in the bases that this drug is that amount
the
normal
within
kidney
wiI1
two hours, and
place very soon after
its injection
or the muscles. for Nurses”
65
diagnosis of genitourinary tubercuIosis. Trans. Am. Assn., G.U. Surgeons, pp. 65-70, 1934. THOMAS, G. J. and KINSELLA, T. J. Modern concepts of gcnitourinary tuberculosis. Am. J. Surg., n.s., 23: I I r-128 (January) 1934. WHITE, S. M. Tuberculous glomerulitis. Trans. Chicago Patbol. SW., 3: 277-283, r8g7-1899. WILDHOLZ, HANS. Ueber die Moglichkeit einer Spontanheilung der Nierentuberkulose. Ztscbr. J. uroI. Cbtr. u. Gyntik., 42: 257-267, 1936. WYLER, J. ExperimentelIar Beitrag zur Frage der tuberkulosen Bacillurie, Vorlautige Mitterlung. Ztscbr. J. urol. Cbir. u. Gyniik., 42: I 57-163, 1936.
of life.
University,
aImost
American ~~~~~~~~ or surgery
tract.
PROLAPSE of the urethra
rarely
TubercuIosis
by Oswald S. LowsIey, M.D. and Thomas
J.