THE
CYSTOSCOPIC
EXAMINATION
IN
RENAL
TUBERCULOSIS.
BY
BENJAMIN
S.
BARRINGER,
M.D.,
OF
NEW
YORL
THE
object
of
this
paper
is
two-fold.
First,
to
give
the
proper
diagnostic
value
to
the
cystoscopic
examination
in
renal
tuberculosis.
Second,
to
picture
as
accurately
as
pos-
sible
the
changes
in
the
ureteral
orifices
in
this
disease.
Walker
in
his
article,
"Tuberculosis
of
the
Bladder,"
ANNALS
OF
SURGERY,
Feb.,
Mar.,
Apr.,
I907,
indicates
the
importance
of
the
cystoscopic
examination
when
he
says:
"
There
is
no
sign
or
symptom,
nor
is
there
a
definite
symp-
tom-complex
which
indubitably
proves
the
presence
of
tu-
berculosis
of
the
bladder.
.
.
.
The
same
frequent
and
painful
micturition
and
the
general
bladder
distress
which
accom-
panies
tuberculosis
of
that
organ
are
also
produced
to
nearly
the
same
degree
of
intensity
by
tuberculosis
of
the
kidney,
and
almost
the
same
symptomatic
picture
is
presented
by
certain
cases
of
tuberculosis
of
the
prostate."
.-
I
can
add
to
this,
if
the
tuberculosis
be
renal
there
is
no
one
symptom
or
class
of
symptoms
which
can
unquestion-
ably
fix
the
tuberculosis
in
one
side
or
the
other.
Pain,
kidney
enlargement,
and
so
forth,
may
be
wholly
on
the
normal
side.
The
relative
frequency
of
primary
involvement
of
differ-
ent
portions
of
the
genito-urinary
tract
is
of
interest
and
should
be
kept
in
mind
when
a
diagnosis
is
being
made.
I
again
quote
from
Walker.
In
279
cases
"
the
kidney
seemed
to
be
first
implicated
in
I84;
the
epididymis
in
8o;
the
prostate
in
6;
the
Fallopian
tubes
in
6;
the
seminal
vesicles
*
Read
before
the
Genito-Urinary
Section,
Academy
of
Medicine,
Feb.
I7,
I9go;
and
before
the
New
York
Society,
American
Urological
Association,
May,
I9o9.
239
BENJAMIN
S.
BARRINGER.
in
2;
the
uterus
in
I."
That
is
in
about
two-thirds
of
all
cases
the
kidney
contains
the
primary
focus
as
far
as
the
genito-urinary
organs
are
concerned.
Also,
"clinically
primary
bladder
tuberculosis
has
been
reported
often,
but
as
the
pathology
is
being
more
carefully
studied
we
are
be-
coming
convinced
that
these
reports
are
erroneous."
"
while
primary
tuberculosis
of
the
bladder
is
a
possibility,
for
practical
surgical
considerations
its
existence
may
be
disregarded."
The
Pictures.-At
the
present
time
very
few
adequate
pictures
of
the
changes
in
the
ureteral
orifices
occurring
in
renal
tuberculosis
exist.
Fenwick,
in
his
classic
work,
"
Ureteric
Meatoscopy
in
Obscure
Diseases
of
the
Kidney,"
I903,
has
a
few
pictures
which
have
been
extensively
copied.
It
is
to
be
regretted
that
the
pictures
which
I
have
col-
lected
are
not
photographs.
The
present
photographic
cysto-
scopes
are,
however,
entirely
inadequate
to
produce
pictures
of
much
worth.
The
poor
illumination,
slow
lenses,
and
very
often
clouding
medium
all
contribute
to
the
production
of
poor
pictures.
All
of
the
pictures
I
have
made
are
from
sketches
made
at
the
time
or
after
the
cystoscopic
examination.
The
in-
direct
or
prismatic
cystoscope
of
either
the
Nitze
or
Otis
type
has
been
used
in
all
of
the
observations.
The
field
of
catheterizing
cystoscopes
is
too
small
to
allow
good
examina-
tion
of
the
ureteral
orifice.
Site
of
Involvement.-If
the
kidney
contains
the
primary
focus
of
the
disease
the
cystoscopic
examination
will
show
the
primary
involvement
of
the
bladder
around
that
ureter.
If
the
disease
comes
from
the
epididymis
and
prostate
the
lesions
are
first
around
the
vesical
neck
and
trigone.
The
cystoscopic
examination
may,
however,
be
very
misleading
as
is
shown
by
Case
VI.
In
this
case
the
cystoscopic
picture
was
typical
of
a
tuberculosis
ascending
through
the
prostate
to
the
bladder.
Yet
in
one
kidney
was
the
principal
if
not
the
primary
focus.
Rigid
Ureteral
Orifice.-In
most
cases
of
renal
tubercu-
240
CYSTOSCOPIC
EXAMINATION
IN
TUBERCULOSIS.
24I
losis,
whether
the
process
be
a
recent
or
an
old
one,
and
whether
the
bladder
be
involved
much
or
little,
the
ureteral
orifice
of
the
affected
side
is
rigid,
non-contracting.
"With
normal
ureters
the
contractions
of
the
ureteral
orifices
indicate
that
urine
is
flowing
through
them;
and
the
contracting
of
the
orifices
also
indicates
contractions
of
the
ureters
as
a
whole.
When
we
turn
from
normal
to
diseased
ureters
the
conditions
change.
When
the
ureter
itself
becomes
diseased
there
naturally
follows
grave
disturbance
of
the
ureteral
contractions."
1
In
probably
all
but
in
certainly
six
of
the
cases
the
ureteral
orifice
was
rigid.
In
four
of
these
cases
the
urine
from
either
kidney
was
obtained
by
the
use
of
the
Luys'
separator-
the
disturbance
to
the
ureteral
contractions
being
less
than
if
the
ureteral
catheter
had
been
used-and
the
flow
of
urine
from
the
diseased
side,
while
irregular,
was
always
inter-
rupted,
indicating
that
definite
ureteral
contractions
took
place.
This
disturbance
to
the
ureteral
function
is,
as
far
as
we
can
observe,
most
patent
in
that
portion
of
the
ureter
which
presents
itself
to
the
cystoscopic
view-the
ureteral
orifice
this
being
rigid
when
apparently
contractions
are
taking
place
in
other
pets
of
the
ureter.
"
This
might
suggest
that
the
vesical
portion
of
the
ureter
was
the
most
markedly
affected
of
any
portion
in
a
so-called
descending
tuberculosis
pf
the
urinary
tract.
And
this
would
be
natural,
as
the
ureter
is
constricted
for
a
considerable
dis-
tance
where
it
passes
through
the
bladder
wall,
and
this
con-
stricted
portion,
as
well
as
the
portion
just
above,
would
form
an
excellent
lodging
place
for
tubercle
-bacilli."
The
other
explanation
that
might
be
given
to
this
failure
of
the
ureteral
orifice
to
contract
at
the
same
time
that
peris-
taltic
contractions
in
the
ureter
as
a
whole
are
taking
place,
is
that
in
normal
contractions
of
the
ureters
the
part
of
most
vigorous
contraction
is
the
middle
third
of
the
ureter.
Lucas
says
"
.
.
.
the
middle
part
of
the
ureter
(comprising
at
'Barringer:
Observations
on
the
Physiology
and
Pathology
of
the
Ureteral
Function,
Folio
Urologica,
Band
ii,
i9o8.
9
BENJAMIN
S.
BARRINGER.
least
two-thirds)
shows
comparatively
large
contractions
The
uppermost
part
of
the
ureter
shows
contractions
of
another
type,
namely
small
oscillations
.
. .
The
contrac-
tions
of
the
lower
end
of
the
ureter
are
generally
more
frequent
and
not
nearly
so
large
as
those
.
.
.
at
the
middle
part."
"
So
if
the
entire
ureter
were
diseased
the
contractions
would
persist
longest
where,
under
normal
conditions,
they
were
largest
and
strongest."
2
The
former
explanation
is,
I
believe
the
correct
one.
Relation
between
the
Kidney,
Ureter
and
Bladder
Changes.
-There
are
two
conditions
so
frequently
seen
in
renal
tt-
berculosis
as
to
almost
make
them
peculiar
to
this
disease.
First:
When
there
is
entire
destruction
of
one
kidney
and
extensive
bladder
tuberculosis,
we
often
see
the
ureteral
orifice
of
the
other
kidney
entirely
normal,
and
obtain
entirely
normal
urine,
as
regards
pus
and
tubercle
bacilli,
from
this
kidney.
Such
a
condition
is
seen
in
Case
IV.
Second:
With
partial
or
complete
destruction
of
one
kid-
ney,
with
a
process
that
must
have
extended
over
a
period
of
years,
we
frequently
find
with
the
exception
of
the
ureteral
orifice
of
the
affected
kidney,
the
entire
bladder
normal.
Cases
I,
II,
and
III
illustrate
this.
With
these
two
classes
of
cases
the
tuberculosis
is
probably
primary
in
the
kidney
and
both
of
these
conditions
would
seem
in
a
measure
to
be
dependent
upon
the
frequency
of
urination
so
characteristic
of
renal
tuberculosis.
The
infective
material
from
one
kidney
does
not
stay
in
the
bladder
for
a
period
of
time
long
enough
to
affect
it.
This
frequency
seems
to
be
a
natural
prophylaxis
against
the
extension
of
the
tuberculous
process
both
to
the
bladder
and
to
the
other
kidney.
In
contrast
with
this
we
comparatively
often
see
bilateral
kidney
involvement
in
conditions
causing
retention
of
bladder
fluid-as
ureteral
stricture,
and
prostatic
enlarge-
ment.
The
course
of
a
kidney
involvement
arising
from
a
bladder
'
Barringer:
loc.
cit.
242
CYSTOSCOPIC
EXAMINATION
IN
TUBERCULOSIS.
243
infection,
is
probably
as
follows:
The
bladder
is
involved
and
with
it
the
bladder
portion
of
the
ureter.
The
bladder
portion
of
the
ureter
becomes
strictured,
so
causing
hindrance
to
the
excretion
of
urine
from
that
kidney.
This
causes
the
kidney
to
become
a
point
of
lowered
resistance,
a
fertile
field
for
the
growth
of
organisms
that
may
be
in
the
blood.
The
frequency
and
lack
of
bladder
retention
in
renal
tuberculosis
often
prevents,
I
believe,
this
affection
of
the
bladder
portion
of
the
ureter
and
so
the
kidney.
The
opposite
and
apparently
rarer
condition-slight
kidney
involvement
with
marked
bladder
changes,
as
seen
in
Case
V-would
be
perhaps
explained
by
the
fact
that
the
original
focus,
as
far
as
the
genito-urinary
organs
are
concerned,
starts
in
the
bladder
or
prostate,
and
there
is
secondary
in-
volvement
of
the
kidney.
It
is
possible,
also,
that
these
cases
have
a
certain
amount
of
bladder
retention.
The
cases
which
I
have
seen
shed
but
little
light
upon
this
question.
Relation
between
the
Extent
of
Kidney
Involvement
an-d
Cystoscopic
Changes
in
the
Ureteral
Orifice.-Fenwick
has
attempted
to
estimate
the
extent
of
kidney
involvement
by
the
ureteral
changes.
I
am
not
at
all
sure
that
this
can
be
done.
Cases
I
and
II
are
illustrative
of
this.
In
these
cases
there
is
no
marked
thickening
of
the
intravesical
portion
of
the
ureter,
no
marked
retraction,-yet
in
both
cases
the
kidneys
were
practically
destroyed.
I
can
conceive
that
a
ureter
that
is
markedly
thickened
and
retracted
might
point
to
an
advanced
process
in
the
kidney,
but
even
this
rule
might
be
fallible.
In
Case
VI
there
is
no
change
in
the
ureteral
orifice,
while
the
kidney
was
probably
wholly
destroyed,-
sclerotic,
not
excreting
anything
through
the
ureter.
I
believe
that
grave
errors
may
arise
if
the
cystoscopic
picture
is
alone
used
to
estimate
the
extent
of
the
kidney
lesion.
Clinical
Value
of
the
Cystoscopic
Examination.-If
a
cloudy
medium
or
a
badly
inflamed
bladder
does
not
interfere
with
the
cystoscopic
view
we
can
nearly
always
determine
which
kidney
is
involved.
An
example
of
this
is
shown
in
BENJAMIN
S.
BARRINGER
Case
VII
where
the
bladder
irritability
interfered
with
ureteral
catheterism
or
urinary
separation.
The
simple
cys-
toscopic
view
determined
which
kidney
was
involved
and
the
operation
confirmed
this.
If
on
careful
examination
one
ureteral
orifice
is
found
to
be
absolutely
normal,
contracting
and
excreting
urine,
I
be-
lieve
that
almost
always
the
kidney
corresponding
to
that
ureter
has
a
normal
functional
capacity
and
is
excreting
normal
urine-normal
as
regards
pus
and
tubercle
bacilli.
Notwith-
standing
this,
in
every
case
of
renal
tuberculosis
there
should
be
a
determined
attempt
to
either
catheterize
the
ureters
or
perform
urinary
separation.
If
ureteral
catheterism
is
per-
formed
it
is
probably
better
to
catheterize
the
normal
ureter
and
obtain
the
urine
from
the
diseased
kidney
by
means
of
a
catheter
in
the
bladder.
There
are
two
reasons
for
this:
First,
we
wish
to
find
if
the
presumably
well
kidney
is
ex-
creting
normal
urine.
Second,
I
think
that,
contrary
to
what
is
generally
believed,
there
is
less
danger
of
renal
infection
from
the
ureteral
catheter
when
a
normal
ureter
is
catheterized
than
when
a
diseased
one
is.
If
both
ureters
are
diseased
urinary
separation
or
double
ureteral
catheterism
should
be
performed.
The
Cases.-The
eight
cases
3
which
I
have
chosen
show
all
of
the
ureteral
changes
which
are
described
as
belonging
peculiarly
to
renal
tuberculosis.
In
most
of
the
cases
both
ureters
are
pictured,
so
allowing
a
comparison
between
the
diseased
and
healthy
ureteral
orifices.
In
examining
the
ureters
which
I
have
called
normal,
a
number
of
different
types
will
be
seen.
They
all
correspond,
however,
to
one
general
type.
They
are
not
ulcerated,
they
are
neither
swollen
lor
puffy;
ssome
of
them
show
slight
congestion
which
is
not
enough
of
a
departure
from
the
strictly
normal
to
be
of
any
diagnostic
significance;
some
are
larger
than
others
but-
all
'A
majority
of
the
cases
here
reported
are
cases
of
Drs.
C.
H.
Chetwood
and
E.
L.
Keyes,
Jr.,
to
whom
I
am
indebted
for
the
use
of
this
valuable
material.
244
FIG.
2.
Case
I.-Right
ureteral
o4ifice
of
tuberculous
1ddney,
before
nephrectomy.
FIG.
3.
Case
I.-Right
ureteral
orifice,
two
months
after
nephrectomy.
'FIG.
4.
Case
II.-Left
normal
ureteral
orifice.
Case
II.-Right
ureteral
orifice.
FIG.
5.
Case
III.-Right
ureteral
orifice
of
tuber-
culous
kidney,
before
nephrectomy.
FIG.
7.
Case
III.-Left
normal
ureteral
orifice,
be.
fore
nephrectomy.
FIG.
8.
Case
IV.-Right
ureteral
orifice
of
tuberculous
kidney.
Case
IV.-Left
normal
ureteral
orifice.
FFr.
IO.
Case
V.-Right
ureter.
Ureter
itself
ap-
parently
normal,
contracting.
FI(;.
I
I.
Case
VI.-Intravesical
portion
of
prostate;
nodular,
covered
with
pink
tubercles.
Case
V.-Left
diseased
ureter.
tRigid,
ulcerated,
golfjhole.
FIG.
12.
Case
VI.-Left
ureter.
Kidney
normal;
pink
tubercles
around
trigone.
FIG.
9.
FIG.
I4.
Case
VII.-Left
ureter,
before
nephrectomy.
Kidney
showed
caseous
areas.
Bullous
cedema
around
ureter.
FIG.
15.
Case
VIII.-Right
ureteral
orifice.
Nor-
mal,
contracting.
Case
VII.-Left
ureter,
one
month
after
nephrectomy.
BullJ
entirely
gone.
FIG.
I6.
Case
VIII.-Left
ureteral
orifice.
Ap-
parently
rigid;
otherwise
normal.
Kidney
was
tuberculous.
FIcG.
13.
CYSTOSCOPIC
EXAMINATION
IN
TUBERCULOSIS.
245
within
the
bounds
of
the
normal.
After
the
study
of
a
series
of
cases
with
an
adequate
cystoscope
(I
have
used
exclusively
the
prismatic)
it
is
not
difficult
to
recognize
and
classify
the
variations
of
a
normal
ureter.
Cases
I,
II,
III
and
IV
show
changes
in
the
ureter
which
are
practically
only
seen
in
renal
tuberculosis.
Case
VI
showed
no
ureter
changes
but
a
bladder
tuberculosis,
while
the
main
lesion
was
in
one
kidney.
Cases
VII
and
VIII
showed
changes
which
may
occur
in
conditions
other
than
renal
tuberculosis.
All
of
the
cases,
with
one
exception
(Case
VI),
have
been
proved
either
by
operation
or
the
finding
of
tubercle
bacilli
in
the
urine
to
be
tuberculous.
Six
of
the
cases
have
been
operated
upon.
In
five
cases
the
urine
from
either
kidney
has
been
obtained
by
ureteral
catheterism
or
urinary
separation.
All
of
the
cases
have
been
cystoscoped
before
operation
and
two
after
operation,-Case
I
two
months
after
nephrectomy,
Case
VII
one
month
after
nephrectomy.
REPORT
OF
CASES.
CASE
I.-Miss
O'H.,
26
years
of
age,
single,
History
of
frequent
and
burning
urination
for
the
past
four
months.
Urine
has
been
thick
and
turbid
for
the
past
week.
Has
lost
no
weight.
Right
kidney
palpable,
enlarged
and
tender.
Cystoscopic
Examination.-Bladder
capacity,
I75
c.c.
Bladder
urine
cloudy,
but
bladder
washings
returned
clear
after
two
irrigations.
Right
ureteral
orifice
(Fig.
I)
surrounded
by
red
granulations,
with
a
few
submucous
hemorrhages,
noncontracting;
no
ulcerations.
Left
ureteral
orifice
normal,
contracting
regularly,
clear
urine
issuing.
The
rest
of
the
bladder
entirely
normal.
ANALYSIS.
Separation
of
the
Urines
with
the
Luys'
Separator.
Right
urine.
Left
urine.
Quantity
.
3
c.c.
in
i5
min.
8
c.c.
in
IS
min.
Color
.Colorless
Yellow.
Reaction
.
Neutral.
Acid.
Appearance
.
Turbid.
Clear.
Albumin
.
Trace.
Marked
trace.
Urea
......
I
gram
to
litre.
25
grams
to
litre.
BENJAMIN
S.
BARRINGER.
MICROSCOPICAL.
Blood
..Moderate
No.
fresh.
Pus
.Many
pus-cells.
Rare
leucocyte.
Bacteria
.
Tubercle
bacilli.
None.
The
urinary
separation
was
exact,
even
the
reaction
of
the
two
sides
being
different.
The
total
urea
excreted
by
either
side
indicated
that
the
right
kidney
was
practically
non-functionating.
At
operation
I
found
the
right
kidney
to
be
composed
of
large
abscess
cavities,
practically
destroyed;
it
was
removed.
Two
months
after
nephrectomy
the
cystoscopic
examination
of
the
right
ureteral
orifice
(Fig.
2)
showed
that
the
red
granu-
lations
had
entirely
disappeared,
and
normal
mucous
membrane
surrounded
the
closed,
rigid
ureteral
mouth,
indicating
involution
of
the
tuberculous
process
in
the
urinary
system.
Remarks.-These
red
granulations
surrounding
a
ureteral
orifice
are
seen
only
in
renal
tuberculosis.
From
neither
the
history,
the
physical
signs
nor
the
cystoscopic
examination
could
any
idea
of
the extent
of
the
process
be
gained.
Ex-
amination
of
the
urine
from
either
kidney
gave
the
only
accurate
knowledge
of
the
extent
of
the
process.
CASE
II.-Case
of
Dr.
Beck,
New
Haven.
History:
Patient
diagnosed
as
having
hip
disease
(some
months
before
seen).
Had
pain
in
right
lumbar
and
inguinal
regions.
Has
a
large
cold
abscess
over
right
iliac
crest.
Urine
contained
pus
and
tubercle
bacilli.
Cystoscopy.-Bladder
capacity
150
c.c.
Urine
cloudy.
Right
ureteral
orifice
(Fig.
3):
Retracted
to
right;
much
thickened.
Orifice
small,
irregular;
surrounded
by
an
area
of
pink
granulations
with
a
few
conglomerate
tubercles.
Left
ureteral
orifice
(Fig.
4):
Normally
placed
and
normal
in
appearance.
The
rest
of
the
bladder
entirely
normal.
Ureteral
catheterism
was
not
performed
because
of
lack
of
time.
Operation.-Dr.
Beck
and
I
removed
a
right
tuberculous
kidney,
almost
completely
destroyed.
The
patient
is
convalescing,
now
some
weeks
post-nephrectomy.
246
CYSTOSCOPIC
EXAMINATION
IN
TUBERCULOSIS.
247
Remarks.-This
picture
could
not
be
mistaken
for
any-
thing
else
than
renal
tuberculosis.
The
diagnosis
could
be
made
without
finding
tubercle
bacilli
in
the
urine.
As
a
rule
this
cystoscopic
picture
is
seen
with
an
old
process
with
ex-
tensive
kidney
destruction.
CASE
III.-Mr.
J.
C.,
35
years,
married.
Gonorrhoea
four
years
ago.
One
and
a
half
months
later
could
not
urinate;
catheterized.
Since
then
bladder
irritation.
Weakness
of
back;
no
especial
pain
in
kidney
regions.
Has
lost
I5
to
20
pounds
in
last
year.
Night
sweats.
Now
urinates
daily
every
2
to
3
hours;
at
night
seven
or
eight
times.
Cystoscopic
Examination.-Bladder
urine
very
cloudy;
bladder
washed
clean
after
eight
to
ten
irrigations.
Moderate
congestion
and
cystitis
of
base
of
the
bladder.
Right
ureteral
orifice
(Fig.
5):
Open;
rigid;
sur-
rounded
by
slight
congestion.
Small
ulceration
at
one
angle.
Left
ureteral
orifice
(Fig.
6):
Slightly
congested,
contracting
regularly
every
ten
to
twelve
seconds.
Urine
issuing.
Ureteral
Catheterism.-Urine
ran
irregularly
from
right
catheter
and
regularly
from
left.
ANALYSIS.
Right
urine.
Left
urine.
Quantity
..
4
c.c.
in
IO
min.
5
2
c.c.
in
IO
min.
Color
..
Light
yellow.
Amber.
Appearance
Cloudy.
Slightly
cloudy.
Precipitate
..
Moderate.
Slight.
Reaction
.......
Faintly
acid.
Acid.
Albumin
.......
Heavy
trace.
Slight
trace.
Urea
..
I
gram
to
litre.
i6
grams
to
litre.
MICROSCOPICAL.
Red
blood-cells..
Rare.
Rare.
Pus-cells
.
Many.
None;
rare
leucocyte.
Bacteria
.
Tubercle
bacilli.
None.
The
"total
urea"
of
the
normal
kidney
was
twenty-two
times
as
much
as
that
of
the
diseased,
indicating
practically
an
entire
lack
of
kidney
function
of
the
diseased
kidney.
One
year
later
the
patient
returned
with
a
left
tuberculous
epididymitis.
Separation
of
the
urines
at
that
time
with
the
BENJAMIN
S.
BARRINGER
Luys'
separator
gave
practically
the
same
results
as
the
ureteral
catheterism
with
the
exception
that
the
process
in
the
right
kidney
had
extended,
the
fluid
excreted
from
the
right
kidney
contain-
ing
not
even
a
trace
of
urea.
Examination
of
the
nephrectomized
kidney
showed
complete
destruction
of
kidney
tissue,
with
large
cavity
formation.
The
patient
died
on
the
second
day
after
nephrectomy
from
heart
failure.
He
passed
a
sufficient
amount
of
urine
up
to
time
of
his
death.
Remarks.-Again
the
cystoscopic
picture
gave
no
index
of
the
extent
of
kidney
involvement.
The
cystoscopic
picture
of
the
diseased
ureter
is
but
very
rarely
seen
witn
conditions
other
than
renal
tuberculosis.
CASE
IV.-Hazel
T.,
I4
years
old.
History
of
increased
frequency
of
urination
and
cloudy
urine
for
the
past
eighteen
months.
Right
kidney
tender
on
deep
pressure.
Cystoscopic
Examination.-Bladder
capacity
50
c.c.
Urine
cloudy.
Right
ureteral
orifice
(Fig.
7):
Enlarged,
thickened
and
rigid;
ulcerated
in
places.
Left
ureteral
orifice
(Fig.
8):
Normal
and
contracting.
Base
of
bladder
congested
and
the
site
of
chronic
cystitis
in
places.
ANALYSIS.
Separation
of
the
Urines
with
the
Luys'
Separator.
Right
urine.
Left
urine.
Quantity
.
4
c.c.
in
12
min.
20
C.C.
in
I2
min.
Color
.Yellow.
Yellow.
Appearance
....
Cloudy.
Clear.
Albumin
aild
urea
Not
taken.
Not
taken.
MICROSCOPICAL.
Blood
.Few
red
blood-cells.
Many
red
blood-cells,
(traumatic).
Pus
.Many
blood
shadows.
No
pus;
few
leucocytes.
Epithelium
.
Much
pus.
Oc.
renal;
oc.
vesical.
Casts
.Much
renal.
I
epithelial;
2hyaline.
Oc.
hyaline
and
granular.
Bacteria
.
Many
tubercle
bacilli.
No
tubercle
bacilli.
Remarks.--Renal
tuberculosis
is
the
only
condition
which
gives
this
cystoscopic
picture.
Enlarged,
thickened,
rigid,
ulcerated
ureteral
orifice.
The
left
kidney
excreted
practically
normal
urine
and
the
left
ureteral
orifice
was
normal
not-
withstanding
the
surrounding
cystitis
of
the
bladder.
248
CYSTOSCOPIC
EXAMINATION
IN
TUBERCULOSIS.
249
CASE
V.-William
A.,
33
years,
married.
Case
of
Dr.
C.
H.
Chetwood.
Chief
complaint
at
present,
pain
in
right
kidney
re-
gion,
and
frequent
day
(I5
times)
and
night
(20
times)
urination.
Cystoscopic
Examination.-Bladder
capacity
30
c.c.
Urine
cloudy;
bladder
irrigations
returned
clear
after
6
to
7 washings,
but
rapidly
reclouded.
Bladder
ulcerated;
many
submucous
hemorrhages.
Ureters
not
seen.
Urinary
separation
failed.
The
separator
could
not
be
in-
troduced
into
the
bladder
because
of
the
rigid
bladder
neck.
Phloridzin
test:
Fifteen
minims
of
a
i
per
cent.
phloridzin
solution
(in
33
per
cent.
alcohol)
injected
in
arm.
Suggestion
of
sugar
at
40
minims
post-injection;
strongly
positive
at
50
minims.
Second
Cystoscopic
Examination
(Two
days
after
first
failure).-
Right
ureter
(Fig.
9):
Small,
normally
placed,
contracting;
surrounded
by
submucous
hemorrhages.
Apparently
fairly
normal.
Left
ureter
(Fig.
Io):
Golf
hole,
rigid;
surrounded
by
ulcerations.
Entire
base
of
bladder
covered
with
small
submucous
hemorrhages
and
ulcerated
areas.
Nephrectomy.-Left,
by
Dr.
Chetwood.
Specimen
showed
tuber-
culous
kidney
with
abscesses.
Much
normal
kidney
tissue
in
specimen.
Phloridzin
test
two
weeks
after
operation:
Suggestion
of
sugar
25
minims
post-injection;
positive
at
30
minims.
Some
months
after
operation
the
patient
died,
probably
from
a
general
tuberculosis.
Remarks.-The
right
ureteral
orifice
did
not
look
entirely
normal.
The
left
ureter
was,
however,
so
markedly
diseased
that
it
was
deemed
advisable
to
explore
the
left
kidney.
Find-
ing
abscesses
in
this
it
was
removed.
Unfortunately
the
case
was
not
cystoscoped
after
the
operation.
The
better
excretion
of
phloridzin
after
operation
would
seem
to
indicate
that
the
remaining
kidney
was
not
diseased.
CASE
VI
(Case
of
Dr.
C.
H.
Chetwood).-T.
F.
B.,
aged
46.
Haematuria
four,
three,
and
two
years
ago.
Patient
is
said
to
have
passed
a
calculus
two
years
ago.
In
I894
left
testicle
and
epididymis
removed
for
alleged
tuberculosis.
Chief
conplaint
is
pain
in
right
side
which
is
aggravated
by
movements
of
the
body;
and
marked
urgency
and
frequency,
but
no
pain.
Cystoscopic
Examination.-Bladder
capacity
200
c.c.
Urine
cloudy.
Bladder
fluid
returned
clear
after
six
to
seven
washings
and
remained
clear.
All
over
the
base
of
the
bladder
and
especially
marked
near
the
left
ureteral
orifice
are
irregular
patches
of
small
pink
tubercles
between
BENJAMIN
S.
BARRINGER.
which
is
normal
mucous
membrane.
Right
ureteral
orifice:
Normal.
Left
ureteral
orifice:
Normal
contracting
(see
Fig.
12).
Prostate:
The
intravesical
portion
of
the
prostate
is
nodular
and
covered
with
the
same
pink
tubercles
(Fig.
II).
Urinary
separation
(with
the
Luys'
separator):
The
separator
was
introduced
without
pain
and
remained
in
place
thirty-six
minutes.
In
that
time
three-fourth
c.c.
flowed
from
right
side
and
2o
c.c.
from
the
left.
ANALYSIS.
Right
urine.
Left
urine.
Quantity
......
Three-fourths
c.c.
20
c.c.
Color.......
White.
Bluish
(from
ind.-carmin)
Appearance....
Clear.
Slightly
flocculent.
Albumin.......
Negative.
Trace.
Sugar.......
Negative.
Negative.
Urea
......
Negative.
i8
grams
to
litre.
Indigo
Carmin
Test:
Some
minutes
before
the
introduction
of
sepa-
rator,
4
c.c.
of
a
three
per
cent.
solution
of
indigo
carmin
injected
into
buttock
with
following
results:
Right
side.-No
blue
up
to
4I
minutes.
Left
side.-Blue
in
I3
to
I4
minutes
post-injection.
Remarks.-Notwithstanding
the
fact
that
no
tubercle
bacilli
were
found
in
the
urine,
the
diagnosis
of
urinary
tuber-
culosis
was
unquestioned
because of
the
history
and
the
cys-
toscopic
picture.
Both
ureters
were
normal;
but,
as
the
affected
right
kidney
was
excreting
nothing
into
the
bladder,
this
is
natural.
This
case
well
demonstrates
the
danger
of
making
a
diagnosis
by
means
of
the
cystoscopic
examination
alone
as
suggested
by
Fenwick.
CASE
VII.-H.
P.
E.,
36
years
old.
(Case
of
Dr.
C.
H.
Chet-
wood.)
Haematuria,
once
many
years
ago.
Swollen
right
tes-
ticle
ii
years
ago;
left
epididymitis
six
weeks
ago,
which
left
the
epididymis
swollen
and
hard.
Principal
complaint,
pain
in
left
lumbocostal
region.
Urination
normal.
Cystoscopic
Examination.-Urine
cloudy;
bladder
fluid
returned
clear
after
five
to
six
irrigations
but
rapidly
reclouded.
Right
ureteral
orifice:
Normal,
contracting
regularly.
Left
ureteral
orifice
(Fig.
13):
Sur-
rounded
by
small
pink
nodules,
either
bullae
or
tubercles;
rigid
non-
contracting.
There
were
a
few
small
patches
of
cystitis
of
the
bladder
base.
250
CYSTOSCOPIC
EXAMINATION
IN
TUBERCULOSIS.
25I
Ureteral
catheterism
or
urinary
separation
was
not
attempted
because
of
the
extreme
irritability
of
the
bladder.
The
urinary
examination
showed
pus;
slight
trace
of
albumin,
but
no
tubercle
bacilli
on
two
examinations.
Diagnosis.-Pyuria
of
left
kidney
origin,
probably
tuberculous.
Operation
by
Dr.
Chetwood.
The
kidney
was
found
to
have
a
number
of
abscess
and
large
caseous
foci
in
the
lower
pole.
Cystoscopic
Examination
(One
month
after
nephrectomy).-Bladder
urine
slightly
cloudy;
bladder
washed
clear
in
two
to
three
irrigations.
Right
ureter
normal,
contracting.
Left
ureter
(Fig.
I4),
rigid,
closed;
bullae
around
the
orifice
have
entirely
disappeared.
Bladder
otherwise
normal.
Remarks.-The
changes
around
the
ureter
were
probably
not
due
to
the
formation
of
tubercles,
as
these
would
probably
not
disappear
in
one
month.
Rather
they
were
bullous
cedema.
This
bullous
cedema
is
not
all
characteristic
of
tuberculosis.
I
have
seen
it
with
stone
in
the
lower
portion
of
the
ureter,
cystitis,
pyogenic
infections
of
the
kidney,
etc.
Again
we
have
slight
bladder
change
with
marked
kidney
destruction.
CASE
VIII
(Case
of
Dr.
E.
L.
Keyes,
Jr.).-A.
G.,
male,
34
years
old.-
Seven
years
ago
frequent
and
painful
urination.
Four
years
ago
pain
in
left
kidney.
One
year
later
abscess
in
right
kidney
region;
opened.
Cystoscopic
Examination.-Urine
cloudy.
Bladder
irrigations
re-
turned
clear
after
four
to
five
washings
and
slowly
reclouded.
Right
ureteral
orifice
(Fig.
I5),
contracting
regularly
and
frequently;
appar-
ently
clear
urine
coming
forth.
Left
ureteral
orifice
(Fig.
i6)
apparently
rigid,
and
pus
coming
forth.
No
ulcerations,
no
changes
in
the
mucous
membrane.
ANALYSIS.
Ureteral
Catheterism.
Right
urine.
Left
urine.
Quantity
..
4
c.c.
5
c.c.
Color
.
.
Red.
Whitish.
Appearance
....
Slightly
cloudy.
More
cloudy.
Albumin
......
Marked
trace.
More
marked
trace.
Urea
.
.
26
Gm.
to
litre.
2o
Gm.
to
litre.
MIC:ROSCOPICAL.
Red
blood-cells
.
Number
(traumatic).
Rare.
Pus
..
None,
few
leucocytes.
Much
pus.
Epithelium
.
Rare
renal.
Kidney
cells.
Bacteria
.
No
tubercle
bacilli.
No
tubercle
bacilli.
BENJAMIN
S.
BARRINGER.
Nephrectomy
(by
Dr.
Keyes).-A
kidney
was
removed
with
a
tuberculous
focus
at
the
upper
pole
which
was
connected
with
the
pelvis
by
a
very
small
sinus.
Remarks.-It
is
rather
unusual
to
see
such
slight
ureteral
changes
when
the
kidney
process
has
extended
over
a
number
of
years.
SUMMARY.
i.
By
means
of
the
cystoscopic
examination
we
can
almost
always
tell
which
kidney
is
affected
in
renal
tuberculosis.
The
exception
to
this
is
when
the
tuberculous
process
is
shut
off
from
the
kidney
pelvis,
or
when
the
kidney
excretes
nothing
at
all
through
the
ureter.
2.
The
extent
of
the
lesion
cannot
be
accurately
deter-
mined
by
the
cystoscopic
examination,
which
must
in
all
cases
be
supplemented
by
ureteral
catheterism
or
urinary
separation.
3.
Aside
from
its
rigidity
the
most
typical
changes
in
the
ureteral
orifice
are,
(a)
tubercles
around
the
orifice;
(b)
red
granulations;
(c)
enlarged,
thickened
and
ulcerated
orifice.
4.
A
ureter
which
looks
normal
and
which
is
contracting
and
excreting
urine,
indicates
in
the
large
majority
of
cases
a
kidney
which
is
excreting
normal
urine
as
regards
pus
and
tubercle
bacilli,
and
has
a
normal
functional
capacity.
5.
In
some
cases
the
diagnosis
of
tuberculosis
can
be
made
by
means
of
the
cystoscopy
alone.
This
is
of
considerable
value
when
tubercle
bacilli
are
not
found
in
the
urine.
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