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to the high venous pressure. These organs sometimesbecome covered by a layer of fibrin and fibrous tissue.This icy coating is not produced by infection, as wasformerly believed. Venous stasis without infection canproduce it. The ascites may be marked and may bethe most conspicuous feature of chronic cardiac compression. The heart is quiet, showing little if any

precordial activity. Thereduction in

diastolic-systolicexcursion of the heart is best demonstrated by fluoroscopic examination. There are no murmurs. Thesounds are distant and faint. The heart itself is smallerthan normal, but one must not confuse the cardiacsilhouette with the cardiopericardial silhouette. If theheart is compressed by fluid over a long period of time,the pericardium stretches and the cardiopericardial silhouette is enormously enlarged but the heart per seis small and shrunken. A compressed heart cannothypertrophy nor can it dilate.

-Chronic cardiac compression triad.

The various lesions producing chronic cardiac compression have been presented in a previous publication.-

TREATMENT

Cardiac compression should be regarded as diametrically opposite to cardiac dilatation. Not only are thetriads of acute and chronic compression useful in diagnosis but, emphasizing as they do the mechanical

aspects of two large groups of disorders, they shouldbe useful in determining the nature of the treatmentthat should be given. The treatment of such mechanical disturbances obviously is surgical. Many of thesecompression syndromes, like those produced by stabwounds of the heart, tumors, scar, effusion, abscess orgeneralized pericardial infection, are recognized as surgical lesions. The question arises as to whether ornot some of the lesions in the nonsurgical group canbe placed in the surgical group. Perhaps some of thecases of spontaneous rupture of ventricles and auriclescould be saved by operation. In a study of cardiaccontusions, Dr. Ernest Bright and 12 found that 20

per cent of those that went on to rupture seemed tobe amenable to surgical repair, whereas operation wasnot carried out in a single case. The time is probablyclose at hand when the patient with a myocardial infarctor a myocardial contusion will be closely observed forthe development of cardiac rupture, just as a patientwith typhoid is watched for perforation of the bowel.

Should rupture occur, the attempt to suture the bleeding point would be carried out immediately. Perhapsthe time is not far distant when a prophylactic operationwill be carried out for the purpose of strengtheningthe ventricle or the auricle so that the strain of intracardiac pressure can be tolerated. This could be done

by placing a graft of pericardium over the weakenedarea in the heart. Undoubtedly the cases of acute andchronic compression of the heart offer opportunitiesfor surgical intervention, and diagnosis is imperative.When the diagnosis is in doubt, exploratory pericardi-otomy should be regarded as a justifiable procedure.

2. Beck, C. S., and Cushing, E. H.: Circulatory Stasis of Intra-

pericardialOrigin: The Clinical and Surgical Aspects of the Pick

Syn-drome, J. A. M. A . 102: 1543-1548 (May 12) 1934.3. Bright, E. F., and Beck, C. S.: Nonpenetrating Wounds of the

Heart: A Clinical and Experimental Study, Am. Heart J., to bepublished.

IS NEPHRECTOMY ALWAYS INDICATEDFOLLOWING A DIAGNOSIS OF UNI-LATERAL RENAL TUBERCULOSIS?

STANLEY R. WOODRUFF, M.D.JERSEY CITY, N. J.

AND

HERMON C. BUMPUS Jr., M.D.PASADENA, CALIF.

The possibility that renal tuberculosis, once it hasreached the point at which diagnosis is beyond question,ever heals has received considerable discussion duringthe last fifteen years. In 1920 Chute 1 reviewed threecases that occurred in his

practice; he considered that

there were indications in occasional cases that tuber-culous processes of the kidney healed. He pointed outhow such a belief is necessary if one is to accept thehypothesis of the hematogenous route of the infection.He says:

I believe we must assume that tubercle bacilli are broughtin approximately equal numbers to both kidneys, that smallcortical tuberculous infections are common and that far fromgoing on to complete destruction of every kidney that isinfected they are probably promptly stamped out in the greatermajority of instances. The generous blood supply of the kid-ney allows it to overcome perhaps the greater number of infec-tions while yet they are incipient.

After most careful

experimental study,Lieberthal

and von Huth 2 confirmed this observation and in thesummary of their work state :

The kidney has a peculiar immunity to hematogenous infection with tubercle bacilli because of its copious blood supplyand the comparatively large caliber of its blood vessels.Tubercle bacilli which are circulating in the blood tend to passthrough the circulation of the kidney to lodge in other organs.Infection of the kidney occurs only if local disturbances in thecirculation or the presence of the tubercle bacilli in largemasses which cause embolism (suspended in fat droplets,adherent to dbris or agglutinated masses of bacilli) allow theorganism to lodge in the renal tissue.

Read before the Section on Urology at the Eighty-Fifth AnnualSession of the American Medical Association, Cleveland, June 14, 1934.

1. Chute, A. L.: Some Hypotheses Regarding Renal Tuberculosis,J. Urol. 5: 431-438 (May) 1921.2. Lieberthal, Frederick, and von Huth, Theodore: TuberculousBacilluria and Excretion Tuberculosis: Experimental Study, Surg.,Gynec. & Obst. 55: 440-448 (Oct.) 1932.

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If such emboli do become lodged, the work of Medlar 3 would indicate that even then healing may occurif the original infection is not too extensive, a findingthat has abundant clinical and experimental proof in astudy by Harris 4 of forty-three adults and sixty-sevenchildren having tuberculous lesions outside the urinarytract. In 37 per cent of the adults and in 13.8 per centof the children a tuberculous bacilluria

occurred,and

yet in the majority of cases there were no urinarysymptoms. Harris was interested to see whether hecould demonstrate that any of the unexpected incidencesof symptomless tuberculous bacilluria were of the secretory type. He collected urine daily for ten days fromthree patients who were free of symptoms referableto the urinary tract but who had tuberculosis elsewhere.He wrote :

Each of these daily specimens produced tuberculosis wheninoculated into guinea-pigs. In other words, tubercle bacilliwere present in the urine every day though the patients werefree from symptoms. Were their presence due to excretionfrom the blood stream by the kidney, an equally constanttuberculous septicemia must have been present. A tuberculous

septicemiaso constant and severe could

hardlyexist without

the occurrence of miliary tuberculosis. None of the patientshad at that time nor have they at the present any evidence ofmiliary tuberculosis. Blood cultures taken during the periodswhen urine was collected were free of tubercle bacilli. Itseems certain, therefore, that the tubercle bacilli came fromfoci of renal tuberculosis.

In the majority of his cases, as stated, urinary symptoms were not present. The frequency with whichurinary tuberculosis occurs without symptoms is notgenerally appreciated. In reviewing 345 cases in whichstained smears of urine contained acid-fast bacilli atthe Mayo Clinic, one of us (Bumpus) working withThompson5 found that twenty-eight patients (8 percent) had no complaint referable to the urinary tract;

from twenty-three of these patients tuberculous kidneyswere removed. The other five also had renal tuberculosis but operation was thought inadvisable.

Bugbee,0 in reporting similar cases, has observedthat: "they lead one to believe that tuberculosis of thekidney probably exists much more frequently than isgenerally conceded, that a correct diagnosis of thistype of case is often overlooked and that such a lowgrade tuberculous renal infection is self limiting in somecases."

Since a goodly proportion of Harris's patients without symptoms, but with bacilli of tuberculosis in theurine, ultimately became free of the organisms, as indicated both by examination of the stained smears andby the results of inoculation of guinea-pigs, it is notstrange that in his conclusions he stated that "the initialrenal lesions frequently heal, less frequently theysteadily progress to complete destruction of the kidneyand death of the patient."

In such symptomless cases, once the diagnosis of renaltuberculosis is made, the question arises as to the justification of nephrectomy. Henline 7 answers this by stat-which tubercle bacilli have been repeatedly recovereding "We believe that the removal of a kidney from

without other clinical evidence is an error of judgment,"and he goes on to say that "until further convincingproof to the contrary is forthcoming we feel that sometypes of tuberculosis of the kidney will heal undercertain circumstances." Braaschs in a recent articleobserves that "the possibility of spontaneous recoveryfrom renal tuberculosis must be recognized," whileThomas and Kinsella conclude an article on the sub

ject by stating, "We cannot understand why tuberclebacilli behave differently in the kidney than in othertissue in that a renal lesion is not supposed to heal."

With such an apparent unity of belief relative tothe possibility of renal tuberculosis becoming arrested,the question naturally presents itself : When is nephrec-tomy indicated ? Certainly the keynote of whateverform of treatment is adopted must place emphasis onthe fact that there should be no hurry about operativeremoval of a tuberculous kidney. It is never an emergency procedure, and there can be no excuse for neglecting the most painstaking examination to be certain thatthe remaining kidney is not involved. For, if oneaccepts the hypothesis that renal tuberculosis in its pre-clinical stage is frequently bilateral, then the earlier oneis able to discover its presence in one kidney the morechance there will be for it to be present in the oppositekidney, although undiagnosed. Certainly to performa nephrectomy on a kidney from which the only evidenceof tuberculous infection is the presence of organisms,with possibly a few red blood cells and an occasionalleukocyte, and a few months later have the diseaseappear in the remaining kidney is, as Henline has stated,poor judgment. It would certainly seem probable, withthe increase in accuracy of diagnosis and the frequentdiscovery of the disease in symptomless cases, that thisunfortunate outcome should be assiduously avoided.

If one could follow all the patients with renal tuber

culosis for a certain length of time, and particularlythose in whom a proper hygienic regimen could beestablished, the incidence of healed lesions in the kidneys would probably be somewhat astonishing. Webelieve that the process of prolonged watchful waitingshould, however, be insisted on in behalf of thosepatients in the adolescent period, as it has been agreedthat younger patients are more prone to bilateralinvolvement than those of more advanced age and that

nephrectomy should be performed only when definitecavitation exists. We believe that the coexistence of

genital and renal tuberculosis gives preference to theformer when operative procedure is indicated.

We have found that the result of the renal functional

test is a most excellent guide in determining the timefor operation. If this remains normal, or nearly so, thedisease has probably not advanced to any great degree ;but a marked decrease in the amount of dye excretion,which can be demonstrated by the intravenous urogramas well as by the color dyes, would appear to show thenecessity of surgical intervention.

There is little danger of the infection of one kidneyby the other except through a deposit of the tuberclebacilli into the blood stream. Lymphatic connectionbetween the two is not constant, and since the lymphatics of the kidney are practically all of the efferenttype, such a contingency may usually be dismissed.

3. Medlar, E. M.: The Pathogenesis of Renal Tuberculosis, Am. J.Surg. 7: 605-606 (Nov.) 1929.

4. Harris, R. I.: Tuberculous Bacilluria: Its Incidence and Signifi-cance Amongst Patients Suffering from Surgical Tuberculosis, Brit. J.Surg. 16:464-484 (Jan.) 1929.

5. Bumpus, H. C. Jr., and Thompson, G. J.: Renal Tuberculosis;Changing Conceptions in the Decade 1920-1930, Am. J. Surg. 9: 545-551(Sept.) 1930.

6. Bugbee, H. G.: Two Cases Representing Unusual Types of RenalTuberculosis, Tr. Am. A. Genito-Urinary Surg. 17: 95-106, 1924.7. Henline, R. B.: Renal Tuberculosis, Surg., Gynec. & Obst. 57:

231-241 (Aug.) 1933.

8. Braasch, W. F., and de la Pena. Alfonso: Renal Tuberculosis,Pennsylvania M. J. 34: 769 (Aug.) 1931.9. Thomas, G. J., and Kinsella, T. J.: Renal Tuberculosis: Prelimi-nary Report of a Clinical Research Problem, J. Urol. 17: 395-405 (April)1927.


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The clinical experience of finding in the majority ofcases far advanced renal tuberculosis in the removed

kidney, while the disease is absent in the remainingkidney, would indicate that not until late in the diseasedoes the infection again become bilateral.

If there is vesical irritation or other evidence ofbeginning tuberculous cystitis, the question of the

advisabilityof

nephrectomyno

longer exists.It

ismandatory and it seems almost superfluous to add that,in cases in which the disease has advanced sufficientlyto show unmistakable roentgenographic changes in thepyelogram, no question of the desirability of nephrectomy can be entertained.

The case, however, that gives questionable roentgenographic evidence of the disease and in which thetuberculous infection has caused so little damage as toproduce but a few pus cells in the urine together withthe organisms seems to us to deserve sanatorium careand observation rather than immediate nephrectomy.

This advice was given to such a patient when firstseen by one of us (Bumpus) at the Mayo Clinic:

Case 1.A man, aged 26, seen in October 1926, had beenmarried six weeks before, shortly after which he noted anenlargement of the left testicle, followed in a week or two bya smaller swelling of the right. At first the enlargementswere associated with considerable pain, but during the nextthree weeks this had subsided, although the swellings hadincreased. His general examination was negative except foran acute vesiculitis, prostatitis and bilateral epididymitis. Theleft epididymis, being fluctuant, was operated on a.nd drained.

He was seen next two months later when a cystoscopicexamination showed normal renal function from both kidneys,as determined by a phenolsulphonphthalein test. The urinefrom the right kidney was normal, while that from the leftshowed an occasional pus cell. A diagnosis of bilateral tuberculous epididymitis and prostatitis was made and guinea-pigswere inoculated with urine from both

kidneys.The test with

the urine from the right kidney was negative, and the onewith the urine from the left was a failure. The patient wasplaced on heliotherapy with marked improvement. Jan. 16,1927, after a month's interval, cystoscopy was again done andthis time the stained specimen of urine from the left kidneyshowed acid-fast organisms to be present. The right kidneyurine was normal. The patient being dissatisfied with hisprogress, and at his urgent solicitation, a bilateral epididymec-tomy was done February 18, and the diagnosis of tuberculousepididymitis was confirmed. There wa s n o involvement ofeither testicle.

He was seen again in May 1927, and stated that a sinus hadpersisted on the left side following epididymectomy and thatrecently one had developed on the right side. Cystoscopicexamination showed the renal function to be unchanged. The

urine from the right kidney was normal, that from the left hadan occasional pus cell. Two guinea-pigs were inoculated withurine from each kidney ; those inoculated with urine from theleft were failures ; one of those inoculated with urine from theright kidney gave positive results and the other negative. Aleft pyelogram made at this time suggested evidence of cortical necrosis of the middle calix.

In July, approximately a month later, cystoscopic examination was repeated and a right pyelogram was made because ofthe finding of a positive reaction at the previous examination.The pyelogram, although blurred, seemed normal. Pigs wereagain inoculated with urine from each kidney ; those inoculatedwith urine from the right kidney gave negative results andboth pigs inoculated with urine from the left kidney gavepositive results. Seven weeks later two more pigs were inoculated with urine from the left side; the test in one pig wasa failure and in the other gave positive results.

The patient was not seen again for three years, duringwhich time he spent a considerable period in Arizona under

heliotherapy. When examined in July 1930, six pus cells tothe field were found in the urine from the left kidney, andstained smears showed acid-fast organisms ; guinea-pigs inoculated with the urine were positive. A pyelogram of the leftkidney showed the calices normal with the exception of oneof the minor upper calices, which appeared to be missing. Thepelvis was normal and there was no dilatation of the ureter.

The pyelogram on the right side was negative, the urine wasnormal, and the two guinea-pigs inoculated with urine fromthis side gave negative results. The bladder urine containedtubercle bacilli.

His next examination was made nearly four years later,Jan. 15, 1934. He had no urinary complaints and his generalexamination was negative, although a roentgenogram of thechest showed a healed lesion in the left apex. The one takenat his first visit was negative. The bladder urine containedonly an occasional pus cell and was negative for tubercle bacilli.The bladder was entirely normal on cystoscopic examination.The urine from the right kidney contained an occasional puscell and that from the left three in the high power field.Cultures of both proved sterile and stains were negative.Guinea-pigs inoculated with urine from the left kidney onJanuary 22 were examined on February 26 and both gave positive reactions for tuberculosis ; those inoculated with urinefrom the right kidney gave negative reactions.

The left pyelogram showed a normal pelvis but still someapparent abbreviation of the upper minor calix.

The action of three patients observed by one of us(Woodruff) is interesting:

Case 2.A woman, aged 32, complained on admission ofsevere hematuria of three weeks' duration. The appearance ofthe blood was sudden, and the amount has been about thesame since the beginning. There were no premonitory symptoms and no particular frequency except since the appearanceof the hematuria. Cystoscopic examination revealed bloodcoming from the left ureteral orifice. A very decided stricture was found in the left ureter about 5 cm. beyond its orificethat resisted catheterization. With the aid of the terminal eyecatheter, a successful ureteropyelogram was accomplished. Thelatter revealed no particular alteration in the pelvic outline

except a slight fuzziness in the superior calix. Following thepyelogram the hematuria immediately ceased, and the subsequent cystoscopy showed an equal and normal function fromeach kidney. The tubercle bacillus was demonstrated in thebladder urine. The history of this patient repeated itselfyearly over a period of nearly five years. After each cystoscopy and pyelogram the hematuria would immediately ceaseand not appear again until the lapse of from six to eightmonths. In the meantime, the stricture of the ureter hadbeen successfully dilated, and at each cystoscopy the renalfunctional test appeared normal, the pyelogram showing thesame fuzzy appearance in the upper portion of the superiorcalix. The tubercle bacillus was demonstrated in the urinefrom the left kidney at each examination. After four andthree-fourth years of this type of observation, the patientappeared with a hematuria after a lapse of six months. The

pyelogram still showed no difference in appearance from theone taken at the beginning, but the functional test was nowgrade 1 instead of grade 4, as formerly. The patient alsostated that she has lost some weight. Nephrectomy wasadvised at this time but was refused. Four months later thepatient returned, but without hematuria, and consented to anoperation because she felt herself that she was going downhill. Removal of the kidney revealed a typical tuberculousinfection in its upper pole. There were, however, no abscess

.cavities of any demonstrable size. The patient is alive andapparently well at this time, which is six years after theoperation.

Case 3.A man, aged 34, presented a most desperate tuberculous condition. Examination revealed evident tuberculosisof the left epididymis, the right epididymis and testicle, anda frank cavernous pyonephrosis of the right kidney. Thereare many tubercular organisms in the urine, these organismscoming mostly from the right kidney. There are a few organisms demonstrated in the urine from the left kidnev. The


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right kidney was evidently practically destroyed by caseo-cavernous infiltration of its substance. This patient urgedthat heroic measures be taken in an endeavor to effect a cure;and, rather against the author's will, a right nephrectomy, aright epididymo-orchidectomy, and a left epididymectomy wereperformed. The patient was sent to the Loomis Sanitariumfor treatment. After a stormy year there he purchased a housein Liberty and has lived there ever since. He has madeseveral visits for observation during the past ten years, andin the last six of these no tubercle bacilli have been found inthe urine.

Case 4.A woman, a nurse on whom bilateral renal tuberculosis had been clearly diagnosed, was given sanatorium treatment for one year, when it was found necessary to removeone kidney because of its evident destruction. Subsequentlyshe was given sanatorium and rest treatment for a period oftwo years. At the end of that time no tubercle bacilli couldbe demonstrated in the urine. Four years after this she wasfound to have tuberculosis of the lumbar spine, and an operation was performed, a bone from her shin being transplantedto the diseased portion. This was followed by recovery, andat this time, which is ten years after the nephrectomy, she isapparently well, and there are no tubercle bacilli in the urine.

Droegemueller 10 has reported his observations on a

tuberculous kidney in which the disease was so earlythat its only clinical manifestation was the appearanceof tuberculosis in guinea-pigs after inoculation withurine from the kidney. He discovered practically noevidence of healing in the pelvic mucosa, while in theparenchymatous portion of the kidney signs that heinterpreted as reparative processes were frequent. Inconclusion he states :

In considering healing of renal tuberculosis a distinctionshould be made between lesions inolving the pelvis or in communication with the pelvis and circumscribed parenchymallesions not in communication with the pelvis. Circumscribedtuberculous parenchymal lesions not involving the pelvis mayheal at times. It is questionable whether true healing everoccurs in lesions that involve the pelvis.

In contrast to Droegemueller's case, case 1 at no timeshowed any evidence of pelvic or ureteral involvement.Advice against nephrectomy until evidence of a moreextensive lesion in the kidney became manifest seemed

justified. Had the ureter or pelvis given evidence ofinvolvement by inflammatory dilatation, a nephrectomywould have been urged. From a clinical standpoint,the disease seems arrested ; only time of course canprove it permanently healed. In similar cases the keeping of the patient under observation rather than urgingimmediate nephrectomy would seem indicated, for everyphysician has observed how the clinical manifestationof diseases are undoubtedly changing. Glandular tuberculosis, common in our

youth,is

rarelyseen

today.The

resistance of renal tissue to the tuberculosis bacilli maybe undergoing a change ; certainly its reaction in variousparts of this continent appears different. For in theNorthwest one sees many cases of calcification in theinvolved areas, not alone in the late cases but occasionally so early as to make the differential diagnosis fromcalculus difficult. Yet, in the Eastern clinics, calcifiedtuberculous kidneys are rarely seen, while in the Southern sections of the country the incidence of the diseaseappears so slow that at the last meeting of the Pan-American Medical Association held in Dallas theSouthern urologists present all attested their surpriseat the amount of interest manifested in the North abouta pathologic process which they encountered so seldom.

SUMMARY

We believe there is sufficient laboratory evidence thattuberculous infection of the kidney actually heals. Webelieve there is great clinical evidence of this. Neitherof these facts, however, prohibits reinfection.

We believe in adequate hygienic treatment of renaltuberculosis in its early stage, preferably in a

sanatorium.We believe that nephrectomy should be performedonly when evidence of extension of the disease exists,when caseocavernous conditions can be demonstrated,or when the renal functional test has become markedlydiminished.

16 Enos Place1160 South Orange Grove Avenue.

ABSTRACT OF DISCUSSIONDr. R. M. LeComte, Washington, D. C. : A clear distinc

tion should be made between healing in renal tuberculosis andcure of the disease in the entire organ. Some evidence ofhealing may be found in practically every tuberculous kidney,but the occurrence of a complete cure may well be questioned.Renal tuberculosis,

pathologically,may mean

anythingfrom a

minute, solitary tubercle to an extensive process that hasdestroyed the whole parenchyma of the organ. In its surgicalform it consists of an ulcerating or caseating lesion, characterized clinically by the presence of grouped pus and clumpedbacilli in the urine and by evidence of destruction of theparenchyma, shown either by diminished function or by characteristic pyelographic changes in the suspected kidney.Unfortunately, not all the stages of this pathologic process aredistinguishable clinically and there are certain errors necessarily associated with the manipulations required to make abactriologie diagnosis of the disease. These are soiling ofthe ureteral catheter specimens by the bladder contents, eitherby material carried up on the catheter or from an unsuspectedvesico-ureteral reflux or by tuberculosis of the lower segmentof a ureter the kidney of which is quite normal. Each of thesepossible errors makes it more likely that diagnosis of tuber

culosis will be made in a normal kidney than that it will bemissed in a diseased one. To established a cure in a surgicalform, it would be necessary to show that the previously diseased kidney was capable of secreting a urine free from pusand bacilli and was negative both on roentgen study and onurography. I do not consider the pathologic studies of Dr.Medlar absolutely conclusive, because they were done on kidneys of people who died of pulmonary tuberculosis and thelesions studied differ materially from those encountered in theliving operable subject. None of the clinical references describein sufficient detail a case that would answer the criteria of cure

just noted, and all the apparent cures might easily be explainedon the basis of more or less prolonged remissions or possibletechnical errors in the diagnosis. As Dr. Thomas's work hasbeen reported, it can be subjected to criticism, for no matterhow skilful and careful a cystoscopist may be, he is in constant

danger of having the ureteral catheter soiledin one

wayor

another. There is considerable question in my mind as towhether Dr. Bumpus's patient might not have been benefitedmore by a left nephrectomy in 1927 than by the years of generaltreatment that he received, and whether he might not be benefited by it now or eventually come to it. I believe that Dr.Woodruff cured his three cases by removing a unilateral tuberculous kidney, although the clinical examination gave ratherconfusing data as to the freedom from infection of the remaining kidney in the second and third cases. I rather deplore thetendency to get away from surgery in the early unilateral cases,because it is in them that the best results are obtained.

Dr. J. C. Pennington, Nashville, Tenn. : I have beenurologist to the Davidson County Tuberculosis Hospital foreight years. It has a capacity of 300 beds and is always full.The interns have many times demonstrated tubercle bacilli inthe urine of patients free from urinary symptoms. We havehad only one case in the eight years which required surgeryfor tuberculosis of any part of the genito-urinary tract. Thispatient was a man who had tuberculosis of each epididymis

10. Droegemueller, E. H.: Renal Tuberculosis: A Detailed StudyMade Early in the Disease, S. Clin. North America 13:1007-1016(Aug.) 1933.


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and each seminal vesicle. It has been remarkable how fewtuberculous lesions of the genito-urinary tract were found incases of pulmonary tuberculosis. Whether or not the findingof bacilli in symptomless cases means that there is active tuberculosis in the urinary tract, I am unable to say. It has beenour policy to leave such cases alone and let them continue withtheir treatment of pulmonary tuberculosis.

Dr. Hugh H. Young, Baltimore : This is a subject of suchgreat importance that we should consider it thoroughly beforegiving forth to the medical world that the Section on Urologyeven considers the advisability of not carrying out nephrectomyin the presence of an early tuberculous lesion on one side. Thediagnosis is difficult. Tubercle bacilli are not always to befound in the urine, nor do guinea-pigs always die from urineinjections from a definite renal tuberculosis. I remember thecase of a young man in whom tubercule bacilli were foundelsewhere in the urine from the right kidney. When seen byme and my associates two months later, the urine was absolutely negative. Numerous studies and animal inoculationsshowed no tubercle bacilli, and ureteral catheterization wasalso negative. Inoculated guinea-pigs were killed from two tothree months later and were negative. About six months laterthe patient came down with a right epididymitis, the rightseminal vesicle was involved, and the diagnosis of tuberculosiswas positive. I carried out right epididymectomy, vasectomy

and seminal vesiculectomy, but as the prostate seemed not tobe involved, and the right epididymis and vesicle appearednormal, I did not remove them. Seven years later the patientreturned with cloudy urine, and tubercle bacilli were obtainedfrom the right kidney. Nephrectomy and partial ureterectomywere performed. For five years thereafter the patient wasapparently well. The urine was normal. In February 1926(twelve years after the first partial seminal tract operation)the patient returned with tuberculosis of the right epididymis.It was not possible to recognize tuberculosis of the prostate orremaining vesicle. He lived in Colorado and insisted on takingheliotherapy. Five years later he died of pulmonary tuberculosis, complicated by pneumonia, eighteen years after theinitial lesion in the kidney had been discovered. This casedemonstrates conclusively that it is often difficult to find tuberclebacilli in an early renal lesion. (After eight years the tuberculous area in the kidney removed by me was still small.)This case also shows the importance of removing both vesicles,both vasa deferentia and epididymides, and also the lateral lobesof the prostate when the radical operation is carried out. Theserious error was in failing to recognize the very early tuberculosis in the right kidney. Now intravenous and retrogradepyelography would have prevented such a mistake. The caseis an argument against the nonoperative treatment of evenslight renal tuberculosis. After a careful recent study of allour cases of tuberculosis of the genito-urinary tract, I amabsolutely convinced not only that early nephrectomy and partial ureterectomy are desirable but that wherever tuberculosishas involved an epididymis there is practically absolute certainty that the vasa, vesicles and prostate are also involved,and that an early bilateral radical operation on the seminaltract is indicated as soon as the patient has recovered from thenephrectomy.

Dr. H. C. Bumpus Jr., Pasadena, Calif. : Dr. Woodruffand I wished to emphasize the point that with the diagnosis ofrenal tuberculosis being made increasingly early one must beabsolutely certain that only one kidney is infected. I have seenmany nephrectomies performed when the microscopic study ofthe urine from the remaining kidney was negative only to havethe guinea-pig reported positive a few- weeks later. Suchpatients develop, or had one better say continue with, the infection in the only remaining kidney. That is why we assertedthat nephrectomy for tuberculosis is never an emergency procedure. Dr. LeComte referred to the case I reported. Anephrectomy was done last week. The patient's urine was freefrom pus, he had no roentgenographic evidence of tuberculosisand was free from symptoms, and only the guinea-pigs werepositive. After eight years the kidney showed, as in Dr.Young's case, a very limited single lesion a few millimeters

in diameter, a finding that further emphasizes, I believe, thatnephrectomy for tuberculosis can safely await the most exactingexamination. It is never an emergency procedure.

QUARTZ LIGHT THERAPY IN URO-GENITAL TUBERCULOSIS

STANLEY L. WANG, M.D.NEW YORK

Quartz light therapy has been included in the treat-ment of

urogenitaltuberculosis for the

past eight years.It is not used alone but is a part of the general planof treatment. The general plan is to remove the activelesions by surgery, so far as this may be done advan-tageously, and then to follow the surgery by a longcourse of after care. The after care, as is also thetreatment of inoperable patients, is based on the tradi-tional method of treating tuberculosis; namely, rest,fresh air and proper diet. To these are added othermeasures and procedures that have been found usefuland that seem indicated in the various kinds of patients.Among the useful measures is quartz light therapy.

The air cooled mercury vapor quartz lamps of boththe older and the newer types have been employed forthe local irradiation of sinuses and for general irradi-

ations over the regions of the kidneys and bladder.Formerly water cooled mercury vapor quartz lamps

Table 1.Irradiation of Wounds and Sinuses

Postnephrectomy..

Number Number of Months Treatedo

Patients

Inoperable epididymal.Postorehidectomy.

Inoperable testicle.

Postinguinal adeneetomy..

Postseminal vesiculeetomy.

with Quartz LampsBefore Healing

Postepididymeetorny. 18

3, 4, 2, 1, 10, 1, 4, 7, 9, 61, 1, 4, 6, 6, 2, %, %, 6, ;18, 4, %, 12, 7, %, 9, 1,6, iy2> 5, 8, 2, 8

8, 4, 1, 2, 2, 1, 3, 1, 7, 5VA, 2, 8, 14, 2, %, 3

2, 4, 18, 2, 2, 8, 6, 18, i

1

30

Average,Months

3.7

7.1

Total.

were used to some extent for local treatment. More

recently, about a year and a half ago, irradiation ofthe interior of the bladder of patients suffering frombladder tuberculosis was begun with a lamp that issomewhat of a variant from the usual mercury vaporquartz lamp.

The air cooled lamps have been very useful in thetreatment of wounds and sinuses. Sinuses followingthe surgery of urogenital tuberculosis are of considerable importance, for they occur in a more or less certain percentage of patients. The sinuses usually ensue

within a few weeks after the operative treatment, whenas a result of abscess formation the incision line breaksopen partially or completely. When the entire incisionor a large part is involved, a deep wound is formed,which discharges pus profusely. The postoperativerecovery is delayed and there is a long period of inconvenience as the result of the frequent dressing of thewound. Previous to the advent of quartz light therapypostoperative sinuses, particularly following nephrectomy for tuberculosis, had a long standing reputationfor persistence, and there were numerous reports thatdrainage often continued for three years and occa-sionallv longer. Besides the patients with sinusesfollowing surgen- there were other patients with sinuses

From the Department of Urology (James Buchanan Brady Founda-tion) New York Hospital.Read before the Section on Urology at the Eighty-Fifth Annual Session

of the American Medical Association, Cleveland, June 14, 1934.


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