dramatic ones fail. The practice of medicine is the per cent.) after the use of sulphuric acid only (25 study of life, and life is composed of little things, and per cent.), and 2 (10 per cent.) after counterstaining. these little things we cannot despise. It was a favorite Smears from the anterior urethra (fossa navicu- saying with the late Professor von Leyden: "For the laris) were made by Young and Churchman2 in 24 patient there are no small things." patients and smegma bacilli found in 11 (46 per cent.), 323 Geary Street. while of 6 patients, smegma bacilli were found in the urine of 5. The urine in the bladder at necropsy, or smears from the bladder wall, were negative in 50 THE SIGNIFICANCE OF TUBERCLE BACILLI cases. The posterior urethra was negative for smegma IN THE URINE bacilli in the 6 cases examined. This work led Young and Churchman2 to advise thorough cleansing of the LAWRASON BROWN, M.D. penis and rinsing with large quantities of water, as SARANAC LAKE, N. Y. well as careful irrigation of the anterior urethra. The The of tubercle bacilli in the urine urine they say should be passed in three glasses and significance may in or may not be grave. I shall consider it first, from the only the third used examination for tubercle bacilli. point of view of discovery of tubercle bacilli in the This technic, they believe, will fully exclude all routine examination of the urine of tuberculous smegma bacilli from the urine and acid- and alcohol- patients; and, secondly, from that of finding tubercle fast bacilli present can be considered tubercle bacilli. In catheterization of ureters bacilli in the urine of a with symptoms, more women, the must be prac¬ patient ticed. or less pronounced, referable to the urogenital tract. The differentiation of tubercle and smegma bacilli ACID-FAST BACILLI by methods of cultivation are said to be very unsatis¬ Before discussing these points, however, I would factory on account of the difficulty in getting smegma like to say a word about the acid-fast organisms and bacilli to grow. Brereton and Smith question whether their differentiation from tubercle bacilli. the true smegma bacilli have ever been successfully The cold blooded tubercle bacilli, while possibly cultivated. Mr. Petroff and I have found out that slightly infectious for man, and while it is possible that the so-called smegma bacilli, which grow luxuriantly, they might be excreted through the kidneys when cannot resist treatment with normal sodium hydroxid injected into the body or circulation in large quanti- (4 per cent.) solution for fifteen minutes, which pro¬ ties, can in most patients be disregarded. Lepra bacilli cedure affects tubercle bacilli little if at all. Of course and acid-fast streptothrices (actinomycosis) play here all differential methods, dependent on cultivation of a small part also. The milk and butter bacilli and the an organism, possess the inherent weakness that the timothy hay bacilli may possibly be excreted through organism may be dead. This argument was advanced the urine, for the work of Calmette and Ravenel has as the explanation of the inability of all observers ta shown that in dogs tubercle bacilli in a fatty emulsion grow tubercle bacilli directly from the feces, or, are readily absorbed from the intestine and pass indeed, to infect guinea pigs with the tubercle bacilli through the thoracic duct into the blood. These organ¬ contained in the feces. Since both these ends have isms, therefore, must be borne in mind, but their been accomplished, the foundation for such arguments occurrence in vesical urine must be rare. In all stain¬ has been materially weakened. Of course until a sat¬ ing methods the acid-fast organisms which can occur isfactory method for cultivating the true smegma in distilled water must be excluded. bacilli has been discovered, it is useless to base any methods on a which on SMEGMA BACILLI diagnostic procedure depends their growth; but Petroff's new Of all the most for "egg-meat-juice- organisms, however, important gentian-violet" medium will enable us to tubercle us in relation to differential is the grow diagnosis smegma bacilli readily. If at the end of ten or two weeks bacillus. Careful work has shown that no days staining no growth takes place in a tube which has been inocu¬ methods differentiate tubercle and smegma bacilli. lated with a sediment acid-fast we Recent work further reveals the fact that smegma containing bacilli, are almost justified in concluding that they are not bacilli are difficult to cultivate directly from the tubercle bacilli. patient. In fact, some hold that real smegma bacilli VALUE OF STERILE cannot be cultivated ; that smegma contains two varie¬ CULTURES* In ties of acid-fast organisms, only one of which can be 40 out of 42 cases of urogenital tuberculosis grown. It is of some importance to know the fre¬ Suter3 obtained no growth on inoculation into the quency with which smegma bacilli occur in nature. usual mediums of the carefully collected urine. The Brereton and Smith1 in 126 insane or uncleanly presence of symptoms of cystitis and the absence of patients found red staining bacilli in 85 (67.5 per growth on inoculation of catheterized urine into the cent.) after decolorization by 25 per cent, sulphuric ordinary mediums is, he holds, evidence of renal tuber¬ acid, while they occurred in only 19 (22 per cent.) culosis. Albarran looks on the absence of micro¬ of these patients after méthylène blue bad been used organisms in a "purulent" urine in the same light. as a counterstain after decolorization. were They FREQUENCY OF EXAMINATIONS AND COLLECTION in cent, when decolorized acid OF present 13 per by alco¬ SPECIMENS hol or Labarraque's solution (in 16 (13 per cent.) of 119 when decolorized by acid alcohol and in 16 (13 He who would base an opinion on the presence or absence of tubercle bacilli in on the per cent.) of 117 when decolorized by Labarraque's sputum examina¬ tion of one would be ridiculed. After think¬ solution). In a second series of 20 men of ordinary specimen it over we would all, I am sure, come to the same cleanly habits, smegma bacilli were present in 13 (65 ing conclusion in regard to the presence of tubercle bacilli Opening of a discussion at the mid-winter meeting of the American Sanatorium Association, Dec. 15, 1914. 2. Young and Churchman: Am. Jour. Med. Sc., 1905, cxxx, 52. 1. Brereton and Smith: Am. Jour. Med. Sc., 1914, cxlviii, 267. 3. Suter: Baumgarten's Jahresb., 1903, xix, 466. Downloaded From: http://jama.jamanetwork.com/ by a Georgetown University Medical Center User on 05/21/2015 in the urine. That they may occur for a while and then genito-urinary tract suggests much of interest. For disappear entirely, cannot be denied. The occurrence tubercle bacilli to be present in the uncontaminated of so-called "showers" of tubercle bacilli is common urine they must have, in some manner, gained entrance knowledge. Even good laboratory men, however, do into the body. It is to-day well established that they not always bear this in mind and do not hesitate, in can enter the body and leave no discoverable lesion at some instances, to deny the presence of tubercle bacilli the portal of entry. It would be but a step farther to in the urine after one or two examinations. The same go to picture that, if this can occur, their exit from care should be exercised in collecting specimens of the body without discoverable lesion can also take urine as of sputum. The patient should be warned place. Indeed, this would seem to occur through the that whenever any unusual symptoms supervene he liver, for Calmette has found tubercle bacilli in the should submit two or three specimens of urine. Such bile of experimental animals, which had, as far as I symptoms embrace increased diurnal frequency of recall, no discoverable lesion in the liver or gall tract. micturition, cloudiness of the urine when it is passed, If the liver permits the transmigration of tubercle and any unusual sensation connected with the genito¬ bacilli, it would appear from analogy that the kidney urinary system. might also. That this can take place in man appears now to be settled. A case has been Rist EXAMINATION OF THE URINE reported by PRACTICAL METHOD OF and Kindberg4 in which a patient with asystole of The most satisfactory method of finding tubercle aortic died of an intercurrent No that used Mr. Petroff origin erysipelas. bacilli in urine is probably by tubercle bacilli had been found in the sputum, even as follows: at the Adirondack Cottage Sanitarium, after animal inoculation, but on two separate occasions Add to the urine to be examined, which has been injection of urine had caused tuberculosis in guinea acetic 2 cent, of its acidified with 30 per cent, acid, per pigs. A necropsy revealed an apical tuberculous scar a acid. This volume of 5 per cent, solution of tannic in one lung, but in no other organ could any tubercu¬ ice-chest for urine is then put in the twenty-four losis be found. Many fragments of organs, including hours. The precipitate can then be centrifugalized, the kidneys, were introduced into guinea pigs without redissolved with dilute acetic acid, centrifugalized and producing tuberculosis. The explanation advanced on or the first by the sediment placed slides and stained, the authors is that the tubercle bacillemia was taken treated with normal sodium solu¬ precipitate hydroxid care of by the kidneys, which excreted or permitted tion and cultivated. the tubercle bacilli to pass.