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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    the hospital, where he can be most carefully watched for periods of two or three days, as the diagnosis is not easy, save as one follows a definite line of thought and action, and after obtaining clinical evidence combines all his findings into one conclusion. Of course, the finding of the tubercle bacillus itself con- clusively proves the disease, but in the aver- age every-day hurry of the physician he is not in a position to carry out the necessary clinical observations, and this is best done by those best accustomed to these methods, or under his direction. (e) Then comes the local examination, which should not be resorted to, save as the previous suggestions have been more or less negated from the standpoint of a positive tuberculosis. (f) Palpation over the abdominal wall, and percussion, give many times clues as to the condition, by reason of the extreme soreness of the pericystic tissue when it has become in- vaded with the bacilli. By all means, and in every case, should it be regarded that the physician has not been true to the patient, un- less he makes a (g) thorough rectal examina- tion, especially regarding the condition of the rectum, prostate and seminal vesicles. (h) Also is he neglectful if he does not examine carefully the spermatic cord, in so far as he is able, with its epididymis, comparing both sides, and if necessary and in doubt, making an immediate comparison between the patient’s genital organs and a normal set, in order that the differences may be quickly noted and dwelt upon. (i) Finally, and as a last resort, if all the others have proved negative thus far, we may turn to the use of the cystoscope or segre- gator, or both. Personally, I am in favor of utilizing the cystoscope first, but for this purpose there must be a fixed technique and a certain adroitness which comes with practice, as well as a quick- ness of the eye in recognizing abnormal con- ditions present within the bladder, also to be only gained by practice. So far as the use of the cystoscope is concerned in a tubercular bladder, I do not believe that with proper pre- cautions any damage to the organ is done, where it is capable of holding four ounces or more of urine: for I have frequently seen where dilation by water or by air has caused extreme pain in a patient suffering from a cystitis, tubercular or otherwise, that the careful use of oxygen gas will allow one to search the bladder perfectly, without one iota of pain to the patient. Having satisfied oneself as to the condition of the bladder, and if one is sus- picious of a tuberculosis of the kidney by rea- son of the difference in the pictures presented, it is an easy matter to catheterize one or both ureters, as occasion seems to demand, or to use the segregator. For the beginner there will probably be much anguish in attempting to differentiate with the eye a tuberculous urine flowing down into a rather early infected bladder; but as he becomes adept in the use of the instrument, and more skilled in his sight and differentiation, I believe it is only right that he should ab- stain, in so far as he is able, from running the risk of infecting a good kidney by utilizing a ureteral catheter. If the bladder presents a surface and contour sufficiently satisfactory, far better is it, I think, for one to use the segregator in order to draw the urine from either kidney. But it must be remembered that the use of the segregator has its draw- backs, unless a thorough understanding of the location of the ureters and the conformation of the trigone is present beforehand. In gen- eral the use of instruments within a known tubercular bladder is one to be decried, inso- much as there is a prolonged spasm, as a rule, which is extremely painful to the patient. (j) Last of all, we may try the tuber- culin test, but this I believe to be inaccurate, except in the very early stages where the sec- ondary infection has not presented itself. For the differential diagnosis, we have first to notice those cases of simple cystitis, in which there is usually the sudden onset fol- lowing the infection of the urethra, and where the pus is in quite considerable abund- ance. From the inception of the disease there is usually less irritability in this condition than in tuberculosis, and the hemorrhage is decidedly less. The condition is helped ma- terially by the use of nitrate of silver injec- tions, while the tuberculous bladder is aggra- vated to an extreme degree. The temperature is higher and more continuously so, while the pulse is much more aggravated. Again, the histories of the two conditions are not to be compared, for in one, namely, in the tuber- colous condition, there seems to be for the time a resistance to secondary infection, while in the other, the simple cystitis, the secondary in- fection is almost immediately presented; and finally there is the discovery of the bacillus in the urine or a tuberculosis in some other ]iart of the body. From stone, which can only resemble it because of the pain, the blood and frequency of urination, we have but to re- member that the use of the cystoscope or of the searcher speedily clears up the condition, while if we have not these at hand we can easily remember that in stone a change of position, and especially where one rides over a rough road or on horseback, greatly aggra- vates the condition, while the dorsal decubitus alleviates the pain which is present. Also the pain of vesical calculus is mostly located deep in behind the pubis, radiating down to the groins, backward to the anus and forward to the end of the penis, being especially present at the end of urination. This condition of