Diagnosis of renal tuberculosis

Abstract

S EVERAL years ago, we reviewed the records of the Jefferson HospitaI of surgica1 renaI tubercuIosis to check the end-resuIt and to get data which wouId serve as a basis for an earIy diagnosis. The study was enIightening inasmuch as it faiIed to eIucidate either purpose. We then reviewed the Iiterature, oId and new, on the subject and found ardent support for most any view we cared to accept. The present study is an attempt to buiId up a safe working method for the earIy diagnosis of renaI tubercuIosis and to reIiabIy estimate indications for surgica1 intervention. To do this, we have drawn upon the experience and the methods of many workers in many fieIds as we11 as upon our own observations. TubercuIosis of the kidney is practicaIIy never the primary tubercuIous Iesion; it is aIways secondary to another one, most frequentIy phthisis. Notions regarding the avenues of tubercuIous renaI infection have changed considerabIy in the Iast decade. It was supposed that infection by the Iymphatics, by the urinary tract, ascending infection and the hematogenous route were of about equa1 importance. The bIood stream, as Huebschmann’ says, is the onIy avenue deserving serious consideration. Stoerch2 points out that if ascending infection were as common as it is supposed to be, one ought to be abIe to demonstrate more often the progressive nature of the Iesions from the Iower urinary tract to the kidney. The oIder pathoIogists formuIated the concept that 1uberc1e baciIIi were often excreted by a sound kidney without necessariIy producing a Iesion. If this be true any judgment formed of the presence of a renaI tubercuIosis by the discovery of the tubercIe baciIIus in the urine rests on very doubtfu1 premises. The very carefu1 and painstaking work of MedIar and Sasano,3 Liebertha and v. Huth,4,5 Menton, Dimtza and Schaffhauser? prove the error of this concept. If the renaI epitheIium permits the passage of tubercIe baciIIi through it, there is renaI damage and that damage is in the nature of a tubercuIous Iesion, be it ever so small. TubercIe baciIIi in the urine are indicative of a tubercuIous infection of the genitourinary tract. Once the presence of a Iesion has been estabIished, the confirmation of its tubercuIous nature depends upon the isoIation of the tubercIe baciIIus from the urine. The three methods, viz: direct microscopic examination of urinary sediment for tubercIe baciIIi, inocuIation of guinea pigs with suspected materia1 and cuIture for the recover! of the tubercle baciIIus are empIoyed. More discrimination in the use of these methods ought to be used; the reason for it deserves comment at this time. We must insist that the exclusive use of the first method is inadequate and dangerous. The finding of acid-fast baciIIi in smears made from urinary sediment is usuaIIy but not aIways indicative of tubercIe baciIIi. The oft recorded statement that B. tubercuIosis may be confused with B. smegmatis and other acid-fast