Secondary vesical tuberculosis / by James N. Vander Veer.

  • Vander Veer, James N., 1877-1937.
Date:
1909
Catalogue details

Licence: In copyright

Credit: Secondary vesical tuberculosis / by James N. Vander Veer. Source: Wellcome Collection.

Provider: This material has been provided by The Royal College of Surgeons of England. The original may be consulted at The Royal College of Surgeons of England.

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    be taken from the inception of the disease or when the symptoms were first noted, going especially into the family history and into the residence history of the patient, regarding the liability to infection and the susceptibility of the patient to the disease, noting carefully any evidence of tuberculosis in the testicle, pros- tate, seminal vesicles or in the lungs or other organs, and- taking into consideration any tubercular aspect which the patient may present. Extremely minute notes should be made of the resistance of the apparent cystitis to treatment at the hands of physicians, for it is the tuberculous case which travels from one to the other in its primary stage, vainly seeking an accurate diagnosis. (b) The patient should be asked to void in one’s presence, when the bladder is sup- posedly filled to its greatest capacity, and this voiding should be by means of the three-glass test, in vessels suitably gauged, so that the total amount can be quickly added together. (c) Examination of the urine at this time shows it to be, if in the early stage of normal or lowered specific gravity, while in the later stage it will be of normal or raised specific gravity, depending upon the amount of sedi- ment present. The urine is invariably acid, save where there has been retention and in- fection due to an intercurrent trouble, and a quality of acidity as will lead one to remark about the same. Albumin is usually present in the early stages in small quantities and is invariably present in the later stages in large quantities when secondary infection has oc- curred. The amount of indican is increased, insomuch as the patients bowels are usually somewhat constipated, due to the disinclination of the patient to move his bowels because of the pain and pressure caused in the perineal legion. Microscopically, we usually find, to our surprise, at this time, the red blood cells, due to the unseen hemorrhage in very early stages, with perhaps a very few epithelia, while as the disease progresses the secondary infection creeps in and we find also an in- crease in the pus cells and epithelia, together with at times kidney epithelia and casts. The latter should lead us always to suspect and search for the primary cause as being in one or the other kidney, rather than in the blad- der itself. Next we return to the examina- tion of the urine from another standpoint; namely, the withdrawal of the sterile speci- men of urine, avoiding contamination with the smegma bacillus and especially taking care to collect the first and the last portions in sufficient amounts to allow of centrifuging, and thereby collecting the bacilli in concen- trated quantities. Usually it is found that the urine is not centrifuged sufficientlv long enough to throw down the tubercle bacillus, and many cases are allowed to go undiagnosed by reason of this fact. Each tube should be twirled for at least 20 minutes at a high speed, the supernatant fluid drawn off and the concentrated parts at the bottom placed in one test tube and again centrifuged. In this manner it will be al- most impossible for one to miss collecting at least a few of the bacilli, if they are at all abundant in the urine. But it is by reason of the fact that at first the bacilli are so few that they are overlooked. It has been sug- gested that the use of a small amount of al- bumin intermixed with the urine collects and entangles the bacilli more readily and carries them to the bottom, and I believe this to be of great value where they are exceedingly few' in number. This sterile concentrated specimen should then be divided into two parts, and from the first there should be made at least four or five slides for staining. Probably the best method is that of Papen- heim, wdiich causes the smegmao bacilli to be decolorized and counter-stains the tubercle bacilli in the usual way. It may involve the search of several slides before one can find one or two of the tubercle bacilli. The smegma bacillus is found to be more slender; it is not granular, and the groupings of the tubercle bacilli are more characteristic, while the smegma bacillus decolorizes wdth hydro- chloric acid and alcohol, whereas the tubercle retains its stain. The second portion of the centrifuged amount should be employed in animal experimentation. This should be washed repeatedly and then rubbed up with normal saline solution, and from one to two cc. of the solution injected into the peritoneal cavity of a guinea pig which has been pre- viously weighed and properly marked. Should the pig survive, at the end of about four weeks, or according to his loss in weight, he should be killed and examination made of the abdominal organs, where it is found that the bacilli, thrive the best. Better is it to make injections into several animals, by reason of the fact that quite often an animal will die of another infection, usually streptococcic, and the experiment has then been rendered null and void. Foster suggests that it is best to heat the saline mixture for ten minutes at 60° C.. thus killing, as he claims, all of the in- flammatory organisms except the tubercle it- self. (d) Having cultured out as best we may, and made the smear of the urine, we next pro- ceed to the examination of the patient in gen- eral, carefully noting the time at which the examination is made and the temperature and the pulse. Better is it that w'e take the tem- perature and the pulse for a period of 24 to 36 hours, in two-hour periods, for by this means we are enabled to note the variations. For this purpose it is usually wdsest to send a patient to