Renal Tuberculosis.—Investigations by Braasch in the Mayo clinic have disproved the common opinion that renal tuberculosis is usually primarily unilateral. In seven out of 22 apparently unilateral cases, the urine from the supposed healthy kidney was proved to contain tubercle bacilli by animal inoculation, a fact which goes far to explain the comparatively heavy mortality in the first few years after nephrectomy. Continental writers estimate that in life the infection is bilateral in about 15% of cases, whereas in the post-mortem room it is as high as 65%. This fully bears out the experience that spontaneous cure is extremely rare and that the only rational treatment of unilateral tuberculosis is early nephrectomy. In bilateral infections, Ekehorn advocates and practises removal of that kidney which is found by inspection to be the most diseased, or is thought to be the cause of pyrexia and distressing bladder symptoms. In 20 cases reported by him the results were good enough to justify the operation. The treatment of the tuberculous ureter is still under discussion, most workers considering that it heals naturally after the diseased kidney has been removed, while others advocate a primary nephro-ureterec tomy to prevent infection of the lower urinary tract by the diseased ureter. All are now in favour of a post-operative course of tuberculin.
Movable Kidney.—Operations for nephroptosis are decreasing in number year by year, for surgeons have now realised that the condition is commonly associated with Glenard's disease and with such general symptoms as headache, gastric discomfort, neuras thenia and ptoses of various kinds, for which fixation of the kidney gives no relief whatever. Nephropexy is now reserved chiefly for cases of intermittent hydronephrosis, haematuria, casts and albuminuria, and for uncomplicated renal pain relieved absolutely by rest in the horizontal position.
Ureteral Calculus.—In the case of small stones impacted in the ureter most urologists favour removal by manipulative and other methods rather than by ureterolithotomy. The chief meth ods employed are : (i.) dilation of the ureter combined with instillation of sterile liquid paraffin, subcutaneous injection of atropine, and forced diuresis with Contrexeville water ; (ii.) intra ureteral instillation of 5 cu.cm. of a 2% solution of papaverine sulphate, selected for its analgesic and antispasmodic properties; (iii.) dilation of the ureter by diathermy, and (iv.) division of the ureteric meatus with scissors through a cystoscope.
Severe reactions after cystoscopic manipulations, and irregular stones greater than i cm. in diameter are indications for uretero lithotomy. The pelvic portion of the ureter is now always exposed extraperitoneally, either through a paramedian subumbilical incision or by Kidd's inguinal operation.
Bladder.—The ureter may be implanted into another part of the bladder, either for stricture of its extramural portion or after partial cystectomy for growths involving the ureteric orifice. For inoperable bladder growths and for extrophy of the bladder, Coffey has devised a method of simultaneous transplantation of both ureters into the pelvic colon, which does not obstruct the ureters or disturb kidney function.
The bacteriology of cystitis and pyelocystitis has received much attention from bacteriologists. The most important recent com munications on this subject are by Dudgeon, Wordley and Baw tree. These workers have isolated from different cases : (I) A special group of haemolytic bacilli, strongly resembling but not identical with the paratyphoid bacillus; (2) the colon bacillus; (3) Proteus.
Improvements in the cystoscope have led to earlier recognition of diverticula. Swift Joly reviews the whole subject and discusses the relative value of the different operations. He also points out that accompanying prostatic or urethral obstruction should be treated at the same time whenever possible.
Papilloma.—These tumours are now treated by fulguration through a cystoscope whenever possible, and in many instances can be destroyed completely at one sitting and under local anaes thesia. When the papilloma is sessile and diathermy can only be applied to the surface nearest the cystoscope, several treatments at intervals of a week or ten days may be required, a portion of the growth being destroyed at each sitting. Subsequently a cystoscopic examination should be made at intervals of three to six months for at least three years, so that fresh growths can be kept in check. Open operation by the suprapubic route is reserved for large growths, especially if sessile and for those involving the ureteric orifice. In some cases the tumour can be destroyed by diathermy with a large electrode, in others a partial cystectomy, with or without transplantation of the ureter, is necessary. At tention has been called to the danger of "graft-recurrences" in the abdominal wall after removal of papillomata by the suprapubic route, and Maybury and Dyke have reported a case in which three successive implants grew in the abdominal wall. The primary vesical growth was benign but the recurrent implants became pro gressively malignant. Carcinoma should be excised whenever possible, for as yet the results of treatment with imbedded radium is disappointing and uncertain. In the flat ulcerating form of car cinoma, peculiar to the aged, a fair measure of comfort and relief can be obtained from deep X-ray therapy.