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Treatment of Renal TuberculosisTHE treatment of renal tuberculosis has beenmodified but not revolutionised by antibiotics. Thesenew weapons, which are still being developed, are

likely to play an increasingly effective part in the waragainst tuberculosis ; but they have certainly notrendered obsolete the older weapons-constitutionaltreatment and surgery. They have indeed had theopposite effect by showing up the continuing need forconstitutional treatment and the advantages ofsurgery. As COSBIE Ross and his colleagues 1 remark,these three weapons are complementary, and surgery isonly an incident in the course of treatment. The crudedoctrine of Alberran, epitomised in the equationtuberculose rénale =néphrectomie immediate, is based ona false conception of the disease by which the tuber-culous process was regarded as starting as a solitaryfocus in one kidney and spreading from there to therest of the renal tract, including the opposite kidney.It is far more probable that the disease starts inscattered haematogenous foci in both kidneys and thatthe macroscopic

"

solitary " focus is merely one of

these lesions which has developed, the others havinghealed or become quiescent. In these circumstances

nephrectomy for tuberculosis cannot be viewed as aradical operation, and the concept of nephrectomieimmediate gives place to that of néphrectomie oppor-tune, in which the operation is delayed until constitu-tional measures and antibiotics have brought theinfection as far as possible under control.There is evidence that streptomycin can heal the

small closed parenchymatous focus, but not theestablished caseocavernous lesion.2 Fibrosis is a

feature of the untreated tuberculous lesion, making anavascular wall around the lesion which hinders theaccess of blood-borne therapeutic agents. Strepto-mycin, by increasing this fibrosis, impedes its ownaction. In urinary tuberculosis the contraction ofsuch fibrous tissue has other untoward effects, suchas ureteric obstruction and vesical contracture.

Altogether this action of streptomycin must bereckoned a serious defect, and it is encouraging to seethe results of histological studies of the effects ofisoniazid on tuberculous renal lesions, lately describedin these columns by Dr. DICK.3 One of the most

striking findings was the absence of fibrosis in themore recent lesions in cases treated with isoniazid

only. Even the old fibrotic lesions showed revasculari-sation, in striking contrast to cases treated with

streptomycin and to untreated cases. Moreoverisoniazid seemed to arrest caseation and even to

promote absorption of caseated material. Thusisoniazid put the tuberculous process, so to speak, intoreverse ; but unfortunately this improvement wasnot maintained after three months’ treatment incavities and in open lesions of the calyces and pelvis ;here there were signs of reactivation. These histo-

logical findings correspond with the clinical impressionthat the improvement brought about in. the first threeto six weeks of isoniazid treatment is not maintained.According to in-vitro bacteriological evidence tuberclebacilli resistant to isoniazid quickly appear ; but thiscomplication can be retarded by combining isoniazid

1. Ross, J. C., Gow, J. G., St. Hill, C. A. Brit. med. J. April 25,1953, p. 901.

2. Jacobs, A., Borthwick, W. M. Proc. R. Soc. Med. 1950, 43, 453.3. Dick, J. C. Lancet, April 25, 1953, p. 808.

with streptomycin. Moreover Dzc found evidencethat isoniazid reversed some of the fibrotic changeseven in chronic lesions previously treated with

streptomycin. Thus it seems that these two drugs areto some extent complementary.Nephrectomy is still the standard surgical treatment

of renal tuberculosis when the other kidney is freefrom infection or only slightly infected. This measureis based on the sound principle that a resistanttuberculous focus is best removed when this is ana-

tomically and physiologically feasible. At a conserva-tive estimate nephrectomy more than doubles thechance of cure ; and the antibiotics have not muchaltered this, for although they have improved theresults of non-surgical treatment they have also

greatly improved the results of nephrectomy, particu-larly by promoting smooth healing after operation.Nevertheless the limitations and disadvantages of

nephrectomy are obvious. The operation is at thesame time too radical and not radical enough : it istoo radical if the kidney contains healthy tissue, asis very commonly the case ; and it is not radical

enough because it leaves untouched the original extra-urinary focus, and possibly also small foci of diseasein the other kidney. On these grounds there is a clearprima-facie case for partial nephrectomy ; andSEMB,4 in an account of 87 cases treated by thismethod, shows that this is both feasible and successful.SEMB compares renal with pulmonary tuberculosis inregard to pathological anatomy and surgical treatment.In both conditions small parenchymatous foci mayheal, especially with the help of antibiotics ; butcavities (the ulcerocavernous or caseocavernous lesionsof renal disease) are much less likely to heal, especiallyin the kidney. Twenty years ago the surgical treatmentof a solitary cavity in the lung which resisted lessermeasures might have been total thoracoplasty ; now-adays it would probably be segmental resection. A

solitary caseocavernous lesion of a kidney is still

usually treated by total nephrectomy ; and SEMBconsiders this unjustifiable. The results of partialnephrectomy in his hands are, from the point of viewof cure, at least as good as those of total nephrectomy.There is one reservation : none of his cases has yetbeen followed for more than five years, but even sothe results are excellent. There have been no deaths,and the general condition of all the patients is satis-factory ; in nearly 90% the urine remains free fromevidence of tuberculous infection. In only 2 cases didthe function of the partially resected kidney fail ;and the series includes 13 cases in which part ofthe only remaining kidney was removed. Theseresults at least justify a thorough trial of thismethod. :’:

Partial nephrectomy is not a new operation It was:first performed as long ago as 1887 by CZERNY,(1"or,tumour), but until recently it was only rarely done;.In 1937 GOLDSTEIN and ABESHOUSE 5 collected a seriesof 290 reported cases and described 6 of their own.Only 41 of these operations were for tuberculosis, andthe results were poor ; of the 41 patients, 5 died,5 developed a urinary fistula, and 6 required a second-ary nephrectomy. The operation was much more oftenand more successfully done for stone ; and hithertoit has been practised mainly for this disorder. Of 155

4. Semb, C. J. Oslo City Hosp. 1953, 3, 45.5. Goldstein, A. E., Abeshouse, B. S. J. Urol. 1937, 38, 1.

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partial nephrectomies reviewed by HANLEY 6 in 1950,125 were for stone and only 8 for tuberculosis. Manypatients in this series were operated on before theadvent of streptomycin ; this antibiotic has widelyextended the field of partial nephrectomy, especiallyfor tuberculosis because of its effectiveness againsttuberculous infection of the wound. In total nephrec-tomy for tuberculosis the minimal requirements arethat one kidney is tuberculous and that the other isfree from infection and functioning adequately. For

partial nephrectomy, more precise information isessential. The details of renal anatomy are of primeimportance-particularly the arrangement of the

calyces, with its variations, and the blood-supply.SEMB adopts FoLGtREN’s scheme, according to whichthe kidney has seven pairs of pyramids, dorsal andventral. These pairs are grouped into three divisions ;the uppermost three pairs constitute the upper divi-sion, and the remaining four pairs are divided equallybetween the intermediate and lower divisions. Inaddition to this, there are six different ways in whichthe pelvis may branch to make the calyces of themiddle division. The ramification of the renal arteryand vein varies considerably, especially outside thekidney. SEMB’s scheme of pathological anatomydivides tuberculous renal disease into three groups.

In the first group there are small tubercles or tubercu-lous infiltrations which may lead to the excretion oftubercle bacilli in the urine, but in which there is nomacroscopic destruction and especially no open com-munication with pelvis or calyx. This he calls the" parenchymatous

"

group, and it is not a surgical prob-lem. For one thing this type of lesion may now oftenbe cured by medical treatment ; and for another it doesnot lend itself to pyelographic study, so that a detailedanatomical diagnosis cannot be made.The third group he terms the " total destructive," in

that all three divisions of the kidney are macroscopicallyaffected and often the ureter is also involved. Obviouslypartial nephrectomy has no place here.The second group, termed" local-destructive," is the

group for partial nephrectomy. Here the macroscopicdestruction may involve as little as one part of onepyramid or as much as two complete divisions of thekidney.This second group constitutes no less than 56% of allcases of renal tuberculosis in SEMB’s series-whichshows how important a part may be played by partialnephrectomy.

. By SEMB’s scheme, which he describes as selectivemedical-surgical treatment, the patient always under-goes preliminary sanatorium treatment, which maylast as long as six months if there are other activefoci or the general condition is poor. Antibiotics areused sparingly in this phase, streptomycin beingrestricted to a total amount of 15 g. In the post-operative phase a rather larger amount is allowed-up to 40 g. in uncomplicated cases. If operation onextra’-urinary lesions is necessary, this is done beforethe operation on the kidney. The renal lesions are

accurately charted by means of excretion and instru-mental pyelography. Aortography is also much used ;WEYDE,7 the radiologist associated with SEMB, hasdescribed the technique and results. He emphasisesthe importance of the " nephrographic

" effect, whichmaps out the areas of non-functioning parenchyma,in addition to the more obvious effect which delineatesthe individual vessels.

6. Hanley, H. G. Proc. R. Soc. Med. 1950, 43, 1027.7. Weyde, R. J. Oslo City Hosp. 1951, 1, 269.

Ample exposure is necessary for partial nephrec-tomy, and SEMB favours access through the bed ofthe eleventh or twelfth rib.A bloodless field may be obtained cither by clamping

the pedicle or by compressing the renal substance ; butSEMB found when operating on cases with a sole remainingkidney that the renal function took a harder knock whenthe pedicle itself was clamped. In his series the extentof the resection varied greatly from case to case, and in95 % of cases the lesion or lesions were removed in oneblock of tissue ; the upper division was involved morethan twice as often as the lower. The pelvis or neck ofthe calyx is sutured (in contrast to STEWART’S advicewhen operating for stone) ; and the vessels are dealt withmainly by ligature in the cut surface of the kidney, andmore rarely by securing individual vessels in the hilum.The cut surfaces are sutured with a double row of catgut,the outer row getting a hold on the capsule ; no fat ormuscle appears to be used as a further safeguard againsthaemorrhage.

Postoperative complications have been remarkablyfew, consisting in wound infection (3 cases) and failureof function of the remaining tissue (2 cases) ; therehas been no urinary fistula and no postoperativehaemorrhage.

These good results show that in the immediatepostoperative phase partial nephrectomy can beno less safe and satisfactory than total nephrectomy.It is reasonable to expect that the late results willalso be good, in view of the excellent showing atfive years ; for we know that after total nephrectomy75% of the deaths occur within five years. The leastthat can be said is that here is a method of surgicaltreatment which is based on sound principles, con.

serves functioning tissue, and gives promise of

improved results.

8. Stewart, H. H. Ann. R. Coll. Surg. Engl. 1952, 11, 32.9. Publ. Hlth, 1953, 66, 79.

Annotations

COMFORTABLE CHILDBIRTH

THE Government’s campaign to ensure that everymidwife shall know how to give gas-and-air analgesiafor the relief of pain in childbirth has eventually beenvery successful. By the end of 1951, 94% of all mid-wives in England and Wales had been trained in theuse of the method ; and the National Birthday TrustFund, as Mr. William Penman, the acting chairman,points out,9 have done much to ensure that enoughmachines be available. He has analysed the official

figures of domiciliary confinements attended by midwivesin 1951, to show how many of the mothers received

gas-and-air analgesia. The results show a wide varietyof practice throughout the country.

There were 253,069 domiciliary confinements attended bymidwives during the year ; in 192,529 of them the midwifeacted as midwife, and in 60,540 as maternity nurse. Analgesia_was given in 60% of the first of these two groups and 51%of the second. Of the 146 administrative units in the country,1 reported that confinements in which analgesia was givenamounted to only 8 % of the total, and in another 2 thefigure was only 16%. At the other end of the scale, 15 unitsreported figures of 80-90%, and 5 others over 90%. Themean for the country as a whole was 58%.

Clearly it is one thing to train a midwife in the useof this method, and another to get her to use it. Fromthe wide variation in the figures up and down the countryit seems that she may be influenced by somethingmore than the views of the mother-perhaps by the viewsof the medical officer of health. It would be convenientto know just how often relief in childbirth is’reallyneeded : medicine sorely lacks a handy little machine