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favorable prognosis in another, tedious and prolonged bladder treatment in a third, and in all, a more or less prolonged and unnecessary disability before a final cure was obtained.
Why continue to treat cystitis without proper investigation, when it is safe to assume that where painful bladder symptoms persist, renal tuberculosis is present. It is also worthy of note that occasionally, early in the disease, increasing frequency, especially at night, and a painless hematuria will occur, associated with pain over the kidney on percussion. But, as a rule, renal tuberculosis is a silent disease, voicing its first subjective symptoms as a cystitis, a causeless cystitis apparently, where the patient cannot definitely name a starting period and the only objective symptom may be a slightly turbid urine.
Examination of the urine should always be made according to the method described by Crabtree (1). His technique is described as follows: “If the urine contains much pus, centrifuge for one or two minutes at the lowest speed. The bulk of the pus and detritus will be thrown down in a heavy sediment, leaving a somewhat cloudy urine above, containing a few pus cells and the majority of the bacilli. Tubercle bacilli are almost of the same density as urine and only those bacilli that are entangled in the pus cells are thrown down and the rest float above. Decant the urine into a clean tube, discard the sediment and centrifuge the urine at a high speed until it is clear. This step requires 15 to 30 minutes. The urine may then be decanted and the tube containing the sediment refilled with partly clarified urine and replaced in the centrifuge. In this way the contents of two or more tubes of urine may be concentrated into a small, single sediment. Pour off the urine, invert the centrifuge tube on a towel and drain off the last drops. A fairly dry, small sediment will be obtained which can be removed with a loop, and a cover glass preparation may be made or cultures planted.
“In urines containing but little pus, the important step is to centrifuge until clear to insure deposit of bacilli. The centrifuge tubes should be above suspicion of containing acid fast organisms. Thoroughly cleanse the tube with water and cotton swab, rinse in concentrated sulphuric acid, then with water and dry with sterile sponge.
“In performing the Ziehl-Neilson Stain, the cover glass preparation should be decolorized by exposure for thirty seconds, to 30 per cent nitric acid followed by alcohol.”
A cystoscopic examination with ureter catheterization is the final, most thorough and satisfactory diagnostic procedure, affording often most conclusive evidence in many ways. To the skillful observer, the appearance of the bladder mucosa is
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often characteristic, and occasionally with the aid of the Buerger operating cystoscope, a small portion of the ureter lip may be removed by the punch forceps for subsequent microscopic diagnosis (2).
The urine from each kidney may not only be collected separately to localize the disease, but at the same sitting the individual functional capacity of the kidneys may be determined. A guinea pig inoculation should always be made unless previous evidence is absolutely conclusive. Occasionally this procedure is unreliable from the possible temporary exclusion of the affected kidney, though only a very small amount, 15 or 20 minims, of suspected urine is required for subcutaneous or introperitoneal inoculation into abdominal wall of the pig.
The long delay in diagnosis incidental to the development of tuberculosis in the inoculated pig, often extending from four to six weeks, can now be largely obviated by using Roentgenrayed guinea pigs, according to the experiments of Norton (3). The animal is subjected to a massive X-ray dose, either before or just shortly after inoculation, by placing the pig in a pasteboard box so that it could not move about and then rayed for a period of ten minutes with the Coolidge tube, the target being twelve inches from the base of the box. A five milliampere current was passed through the tube, backing up eight and one-half inches of spark between points. No filters were used, and after ten days the pigs were killed and examined. The X-ray treatment caused the normal white blood count of 12,000 to 15,000 cells per C Mm to drop to between 4,000 and 6,000, mainly in the lymphoid cells. This count remained depressed for about a week without apparent injury to the general health of the animal.
The prognosis and treatment of renal tuberculosis largely depends upon an early diagnosis. The prognosis is usually good in unilateral disease and good also perhaps in 90 per cent of advanced unilateral disease if subsequent climatic and hygienic treatment is obtained.
The treatment of renal tuberculosis is invariably operative. Nephrectomy offers the only hope for permanent cure.
Tuberculin with climatic and hygienic measure preliminary to operation in early and slightly infected cases may offer some hope of localizing the destructive process or immunizing the patient against a post-operative dissemination, but the diseased kidney will always be a source of possible subsequent infection.
Some points should be especially emphasized in performing nephrectomy for renal tuberculosis: the posture of the patient should be such that the largest possible space be obtained between the lowest rib and the crest of the ilium; the incision should be at once quite ample to give free access, beginning over the 12th rib slightly anterior to the sacrospinalis muscle, extending downward and outward to the crest of the ilium, and then forward as required. Separation of the muscles as done for a suspension or exploration should not be tried, but cut through without injury to important nerves if possible. Freedom of space insures thorough mobilzation of the kidney, which is quite necessary if one desires the greatest factor of safety in dealing with the pedicle. In securing mobility, special care should be observed in separating adhesions on the anterior surface of the kidney to prevent injury to the peritoneum or intestines, especially on the right side.
In dealing with the pedicle one should decide according to accessibility. I prefer, if possible, to tie off the ureter first as the vascular pedicle is then usually more easily reached.
In the management of the ureter one is up against all kinds of advice—from complete exsection to simply cutting off and dropping into the wound untied. I believe, however, the safest plan is to tie off very securely, cut apart under rigid asepsis and treat each stump thoroughly with carbolic acid, paying no attention to the amount of ureter excised except as seems most expedient to secure a rapid and clean division. In the treatment of the fatty capsule the same variance of opinion is found, but it seems to me the less interference the better the result.
In the ten cases quoted the perirenal fat was left in place. In all, the kidney lesion was very destructive, and in one, the fatty capsule was decidedly infiltrated, yet the fistulae remaining after the small drains were removed, quickly healed. It seems to be a generally accepted idea that after a successful nephrectomy the patients should be turned loose to shift for themselves very much as one would do after, say, a herniotomy; such, I believe, is a grevious error in many of these cases, as a properly conducted after treatment will often obviate serious and prolonged invalidism. The climate, hy. gienic and general physical life of each should be as carefully studied as in pulmonary phthisis. The factor of safety has been eliminated in the kidney and with the very great possibility of tubercular foci in some other region of the body; the precautions against future exacerabation should be wisely considered and outlined to each patient. With men, particularly, and sometimes with women, it is necessary to regulate very rigorously the sexual life, for it seems to me these tubercular subjects have rather a predilection toward undue excesses.
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If there is any value in tuberculin as a curative immunizing agent, then why not apply it after operation?
The bladder after nephrectomy is frequently neglected, and while the tendency is to recover after removal of the offending kidney, such is not always the result. An irritable ulcerated bladder is not only slow to heal spontaneously but will often unnecessarily prolong convalescence.
The most commonly advocated solution for local application is that recommended by Rovsing, a 5 per cent solution of carbolic acid, but the treatment is so intensely painful that one application only is accomplished as a usual thing. Frequent irrigations with } to 2 per cent carbolic solutions will show a decided benefit. Very hot irrigations with weak solutions of cynide of mercury and borate of soda often succeed where the carbolic application fails. After the irrigation allay the acute tenderness, it is wise to gradually distend the bladder at each sitting up to the point of utmost tolerence as the capacity of these bladders to retain urine is much lessened, even where the tubercular invasion is comparatively slight; gradual dilation seems to materially increase not only the actual capacity, but the ability to retain without irritation or subsequent pain after urination. When dilation with solution causes after pains it should be stopped and the bladder should be injected with some gomenol or iodoform in oil.
In conclusion, I would urge a more careful clinical and scientific observation of all bladder symptoms, and while the surgical treatment of each case largely depends upon the operative ability and personal equation of the surgeon, the after management should not be left entirely to mother nature, and the hopeful optimism of a convalescent.
1. Surgery Gyn. and Obs. 1916, Vol. 22, p. 221. 2. Buerger-American Journal of Surgery, February, 1913. 3. Journal of Experimental Medicine, 1916, Vol. 24, p. 419.
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H. Welland Howard,. M.D., Urologist
of urine back pre urinary of weigh
(Read before the Portland City and County Medical Society, Nov. 21, 1917)
The mortality in prostatectomy was once very high, in excess of 50 per cent, but this has been greatly reduced by improvement in the technic of the operation, selection of risks, etc., until now it stands less than 20 per cent. This is still too high and is certain to be greatly reduced by a more comprehensive understanding of the patient and a better application of the measures for his relief.
Functional study and restoration is pertinent because in a large part of patients suffering from prostate hypertrophy or adenomatosis there is an all but insuperable obstruction to the issue of urine and consequent damage to the organs engaged therein by back pressure, and intoxicating of the entire system with the various urinary constituents. This is not only apparent clinically by loss of weight and strength, but is accurately demonstrable in the excessive retention within the blood of urea, creatinin, etc., and by the low output of test substances, such as phthalein, and indigocarmine, and the solid constituents of urine. In the ordinary case this lack of elimination has been present for a considerable period of time and obviously has increased operative risk. It is therefore properly urged that this situation should be remedied by temporary means before the shock of prostatectomy is superadded.
A very constant characteristic of the urine in serious prostatic obstruction is a diminution in the daily output of total solids. As this fall of total solids in the urine and the consequent rise of the same in the blood occurs, there is noticed a disposition on the part of the body to force elimination by increasing demand for water, becoming at times a notable thirst. This makes for a large amount of urine of low specific gravity. Consequently, a careful study of the 24-hour urine should be made, and when the output of total solids is low, the surgeon should not be content to operate until nearly normal urine had been obtained.
The phthalein output will be slow and smaller than normal; but I doubt if this as an indicator is as reliable as the notation of the total solids.
Blood urea is necessarily high when urine urea is low. Its determination is of value before cystotomy to corroborate urine findings, but is of greatest value after cystotomy when it is not possible to collect the urine accurately.
Creatinin, of all the urinary constituents in the blood, is