IMAGE EVALUATION 
 TEST TARGET (MT-3) 
 
 
 Zi 
 
 1.0 
 
 I.I 
 
 11.25 
 
 If 1^ 1^ 
 
 Kt tji |22 
 
 £ us 12.0 
 
 us 
 
 1 1.8 
 
 \A. Ill 1.6 
 
 ' 
 
 
 y] 
 
 v: 
 
 "> .? 
 
 c^^ ^"".^ 
 
 * 
 
 %.>> 
 
 ^\ 
 
 '/ 
 
 /A 
 
 Photographic 
 
 Sdences 
 
 Corporation 
 
 23 WEST MAIN STREET 
 
 WEBSTER, N.Y. 14580 
 
 (716) 872-4503 
 
 f\ 
 
 ;v 
 
 •^ 
 
 \\ 
 
 fv 
 
 
 ■<^>. 
 
 c^ 
 
 U 
 
 'Sb^ 
 

 CIHM/ICMH 
 
 Microfiche 
 
 Series. 
 
 CIHIVI/ICMH 
 Collection de 
 microfiches. 
 
 Canadian Institute for Historical Microreproductions / Institut Canadian de microreproductions historiques 
 
Technical and Bibliographic Notaa/Notas tachniquaa at bibliographiquas 
 
 Tha Instituta haa attamptad to obtain tha baat 
 original copy available for filming. Faaturaa of thia 
 copy which may ba bibliographically unique, 
 which may altar any of tha imagaa in the 
 reproduction, or which may significantly change 
 the uaual method of filming, are chec'.ed below. 
 
 Coloured covers/ 
 Couverture de couleur 
 
 r~| Covers damaged/ 
 
 D 
 
 Couverture endommagte 
 
 Covers restored and/or laminated/ 
 Couverture reatauria at/ou peliiculAe 
 
 Cover title missing/ 
 
 Le titre de couverture manque 
 
 I I Coloured mapa/ 
 
 D 
 D 
 D 
 D 
 
 n 
 
 n 
 
 Cartas giographiquas 9n couleur 
 
 Coloured inic (i.e. other than blue or black)/ 
 Encre de couleur (i.e. autre que bleue ou noire) 
 
 Coloured plates and/or illustrations/ 
 Planchea at/ou illustrationa en couleur 
 
 Bound with other material/ 
 Reli* avec d'autres documents 
 
 Tight binding may cause shadows or distortion 
 along interior margin/ 
 
 La re liure serrAe peut causer de I'ombre ou de la 
 distorsion le long de la marge IntArieure 
 
 Blanic leaves added during restoration may 
 appear within the text. Whenever possible, these 
 have been omitted from filming/ 
 II se peut que certaines pages blanchea ajoutiaa 
 lore d'une restauration apparaissem dana le texte, 
 mais, lorsque cela Atait possible, ces pagea n'ont 
 pas 6tA filmtes. 
 
 Additional comments:/ 
 Commentairas supplimentaires: 
 
 L'Institut a microfilm* le meilleur exempiaira 
 qu'il lui a itA possible de se procurer. Las details 
 de cet exempiaira qui sent paut-Atre uniques du 
 point de vue bibliographique, qui peuvent modifier 
 une image reproduite, ou qui peuvent exiger una 
 modification dans la mithoda normale de filmage 
 sont indiquts ci-dessous. 
 
 r~~\ Coloured pages/ 
 
 D 
 
 This item is filmed at the reduction ratio checked below/ 
 
 Ce document est film* au taux de reduction indiqui ci-dessous. 
 
 Pagea de couleur 
 
 Pages damaged/ 
 Pagea endommagtea 
 
 Pages restored and/oi 
 
 Pagea rastaur^as at/ou pelliculies 
 
 Pagea discoloured, stained or foxei 
 Pages dicolories, tachetAes ou piqu6as 
 
 I — I Pages damaged/ 
 
 pn Pages restored and/or laminated/ 
 
 r~y] Pagea discoloured, stained or foxed/ 
 
 □Pages detached/ 
 Pages ditachias 
 
 0Showthrough/ 
 Transparence 
 
 Transparence 
 
 Quality of prir 
 
 Qualiti inigale de I'impression 
 
 Includes supplementary matarii 
 Comprend du materiel supplimentaire 
 
 Only edition avaibhle/ 
 Seule Edition disponible 
 
 pn Quality of print varies/ 
 
 I I Includes supplementary material/ 
 
 r~1 Only edition avaibhle/ 
 
 Pages wholly or partially obscured by errata 
 slips, tissues, etc., have been refilmod to 
 ensure the best possible image/ 
 Lea peges totaiement ou partiellement 
 obscurcies par un feuillet d'arrata. une pelure, 
 etc., ont M filmtes A nouvaau da fapon A ■ 
 obtenir la meilleure image possible. 
 
 10X 
 
 
 
 
 14X 
 
 
 
 
 18X 
 
 
 
 
 22X 
 
 
 
 
 26X 
 
 
 
 
 30X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 J 
 
 
 
 
 
 
 
 
 
 
 ■ 1 
 
 
 
 12X 
 
 
 
 
 16X 
 
 
 
 
 20X 
 
 III 
 
 
 
 24X 
 
 
 
 
 28X 
 
 
 
 
 32X 
 
 \ 
 
Th« copy filmad h«r« has b—n r«produc«d thanks 
 to tha ganarosity of: 
 
 Msdical Library 
 
 McQill University ^ ^ 
 
 IMontreal 
 
 Tha imagaa appaaring hara ara tha bast quality 
 possibia considaring tha condition and lagibiiity 
 of tha original copy and in icaaping with tha 
 filming contract spaciflcatlona. 
 
 L'axampiaira fiimi fut raproduit grAca i la 
 gAnArositi da: 
 
 ■Medical Library 
 McGill University 
 lyflontreal 
 
 Laa imagas auh/antaa ont 4tA raproduitas avac la 
 plua grand soln, compta tanu da la condition at 
 da la nattati da l'axampiaira film*, at an 
 conformit* avac las conditions du contrat da 
 filmaga. 
 
 Original eopiaa in printad papar covars ara filmad 
 baginning with tha front covar and anding on 
 tha last paga with a printad or illustratad impraa- 
 sion, or tha back covar whan appropriata. All 
 othar original copias ara filmad baginning on tha 
 first paga with a printad or illustratad impraa- 
 slon, and anding on tha last paga with a printad 
 or illuatratad imprasslon. 
 
 Las axamplalras originaux dont la eouvartura wi 
 papiar ast ImprimAa sont fllmAs an commanqant 
 par la pramlar plat at an tarminant soit par la 
 darnlAra paga qui comporta una amprainta 
 d'Impraasion ou d'lllustration. solt par la sacond 
 plat, salon la cas. Tous las autras axamplairaa 
 originaux sont filmte an commandant par la 
 pramlAra paga qui comporta una amprainta 
 d'imprassion ou d'lllustration at an tarminant par 
 la darniira paga qui comporta una talla 
 amprainta. 
 
 Tha laat racordad frama on aaeh microficha 
 shall contain tha symbol -^^ (moaning "CON* 
 TINUED"). or tha symbol V (moaning "END"), 
 whichavar appllas. 
 
 Un das symbolaa suh/ants apparattra sur la 
 darnlAra imaga da chaqua microficha, salon la 
 caa: la symbols -^ signifia "A SUIVRE", la 
 symbols ▼ signifia "FIN". 
 
 Mapa, piatas, charts, stc may ba filmad at 
 diffarant raductlon ratloa. Thoaa too larga to ba 
 antlraly includad in ona axposura ara filmad 
 baginning in tha uppar iaft hand comar, laft to 
 right and top to bottom, as many framaa aa 
 raquirad. Tha following diagrama illustrata tha 
 mathod: 
 
 Laa cartaa, planchaa, tablaaux, ate, pauvant Atra 
 filmAa i daa taux da reduction diff Arants. 
 Lorsqua la documant ast trop grond pour Atra 
 raproduit an un saul ciichA, II ast filmA A partir 
 da I'angla supAriaur gaucha, da gaucha A droita, 
 at da haut an bas, an pranant la nombra 
 d'Imagas nAcassaira. Las diagrammas suivants 
 illuatrant la mAthoda. 
 
 t 
 
 2 '^ 
 
 :■ 9 
 
 \ 
 
 1 
 
 ' 2 
 
 3 
 
 4 
 
 5 
 
 6 
 
r>. ■-e"'^^,. 
 
 
 
 ry," '. 
 
 r^>- 
 
 
 .V'' 
 
 -tf— w 
 
 A 0A8S OF DbflBUS NKPHBO- 
 
 JJAHBS BXKL, U.P., 
 geon'tS th« Montma 0«aer«| B<Mplt«l. ' 
 
 
 r9ii l««*MMR, ItM,. 
 
 
 ' 'Sm 
 
 J1 
 
 J t-''^' 
 
 
 •is 
 
 1- Via 
 
 't; 
 
 
 
 l-?^; 
 
 iU 
 
ill'**-- 
 
 
A CASE OP DOUBLE NEPHROLITHOTOMY. 
 
 BY 
 
 JAMES BELL, M.D., 
 
 AssiBtant Professor of Surgery and Clinical Surgery, McGill University, Montreal ; Sur- 
 geon to the Montreal General Hospital. 
 
 THE compjvratively rare occurrence of calculous disease in 
 both kidneys of the same subject, and the still rarer 
 occurrence of pyonephrosis or other symptoms which call 
 for operation upon both organs (for there can be no doubt that 
 many kidneys which contain one or more calculi perform their 
 functions throughout life without giving rise to serious symp- 
 toms), as well as the many risks attending double nephrolitho- 
 tomy, whether both kidneys be operated upon at the same time 
 or not, must be my apology for presenting a condensed report of 
 the following case : 
 
 E. B , a French Canadian, aged 36, was admitted to the 
 Montreal General Hospital on the 2d of February, 1892, with 
 right pyonephrosis and an old and light stricture of the urethra 
 six inches from the meatus. There was no family history of 
 tuberculosis, and the patient had always enjoyed good health 
 until eight years previous to admission, when he contracted 
 gonorrhoea, and within eight days was seized with a severe acute 
 left sciatica, for which he was treated for three months in one 
 hospital and eighteen months in another. One year after re- 
 covery he was treated for stricture by dilatation at one of the 
 aforesaid hospitals, and some months later he was treated for 
 stricture again in the Montreal General Hospital. He remained 
 well and never had any kidney symptoms until January, 1891, 
 when he was seized with a severe pain in the right side with 
 some swelling in the right hypochondrium and constipation. 
 He suffered for ten days, but was only away from his work for 
 three days. He continued his work, although at times he did 
 not feel well, and had more or less discomfort about the right 
 sideiintil Christmas, 1891, when he was again seized with a very 
 severe pain in the right lumbar region which lasted about three 
 days, and then suddenly left him. An attack of influenza (la 
 
 • Read at the 7th Annual Meeting of the American Association of Qenito-Urinary 
 Surgeons, at Harrogate, Tenn., June 20th and 2l8t, 1893. 
 
Okiqinal Communication. 
 
 grippe) followed, then chills and fever, vomiting und constipa- 
 tion. The pain returned about the 6th of January, and the 
 swelling became evident (to patient) a week later. On admis- 
 sion, February 2d, patient was fairly well nourished, but very 
 ill, with rapid uulse, septic temperature, constant nausea and 
 constipation. There was a firm but somewhat indefinitely out- 
 lined tumor about as large as a fcetal head in the right lumbar 
 region of the abdomen, slightly tender on |)ressure, and immov- 
 able. The urine contained a large quantity of pus and albu- 
 men. Under observation the tumor varied in size from time to 
 time, and I was enabled to diagnose a pyonephrosis of probably 
 calculous origin. I was in doubt as to whether I should 
 operate first upon the kidney or the stricture. On the one hand, 
 the kidney condition called urgently for relief. On the other, 
 I dreaded the consequences of possible retention of urine and 
 difficult catheterization after a nephrolithotomy, specially in the 
 septic condition of the patient, as above described. I did not 
 entertain the idea of operating upon both at the same time. I 
 finally decided to operate upon the stricture first, and did so on 
 the 27th of February. The operation was internal urethrotomy. 
 First making a section of the stricture on the roof of the urethra 
 with 'Guyoirs small Maisonneuve instrument, then making a 
 section of the floor of the urethra and dilating with Otis' s di- 
 vulsing urethrotome, and finally a perineal section for drain- 
 age. With the exception of some slight haemorrhage from the 
 perineal wound there was no further trouble with tne stricture, 
 and on the 12th of March I proceeded to operate upon the kid- 
 ney tumor, which had now become considerably reduced in size. 
 A large branched calculus weiging about 400 grains was re- 
 moved by section into the substance of the organ. There was 
 very little pus. The patient rallied well from the operation and 
 urine flowed freely from the wound. His general condition 
 rapidly improved, fever disappeared, appetite returned, and he 
 began to gain in weight. The urine still contained pus, though 
 in much smaller quantity than before operation. After a time 
 occasional attacks of pain in the right groin and bladder were 
 complained of with frequency of micturition. These symptoms 
 led to an exploration of the bladder in search of stone, but with 
 negative results. The wound was completely healed by the 
 25th of April, and the patient was discharged on the 28th of 
 May, 1892, well and free from pain, but with still some pus and 
 albumen in the urine. On the 18th of October, 1892, he re- 
 turned to hospital stating that he had attempted to resume his 
 work two or three times during the Summer, biit had been un- 
 able to continue it owing to weakness and pain in the left lum- 
 bar region. There was also a history of several attacks of left 
 renal colic. On examination the left kidney was found 
 to be enlarged and tender and the urine, which was small in 
 
 P 
 
 i 
 
 A 
 
 t 
 
A Case of Double Nephrolithotomy, 
 
 8 
 
 \\ 
 
 \ 
 
 quantity (about 20 ounces per day), contained a large quantity 
 of pus. Patient's general condition was poor and his temperature 
 ranged from 99*^ P. to lOl^* P. Operation was performed at one 
 o'clock P. M. on November 17th. On exposing the kidney a 
 thinned fluctuating spot of kidney substance was incised. About 
 eight or ten ounces of pus escaped and through this wound 
 were removed two branched and three small laceted calculi 
 with a quantity of fragments of stone— evidently the result of 
 spontaneous fracture. The operation was completed without 
 delay or accident and the wound loosely packed with iodoform 
 gauze, but the patient did not rally well. He remained weak 
 and pale, with rapid pulse and a tendency to vomit. During 
 the afternoon champagne and weak beef tea were ordered, but 
 he could not retain them on his stomach. Patient perspired 
 freely, but passed no urine nor was there any oozing from the 
 wound. The pulse continued small and rapid, 120, temperature 
 subnormal, 97.5" P. And the general condition was that of a 
 man suffering from the effects of an exhausting haemorrhage. 
 In a few hours the temperature become normal, although the 
 pulse still remained small and rapid, and the restlessness, vomit- 
 ing and prostration persisted until the iirst urine was passed at 
 11 A. M., November 20th, two days and twenty-two hours after 
 operation. During this time a catheter was passed regularly 
 night and morning, but there was no urine in the bladder. The 
 suppression of urine, to which I attribute the foregoing symp- 
 toms, was treated as follows: a mixture of infusion of digitalis 
 and liquor ammoniae acetatis was first given, but each dose was 
 rejected as soon as swallowed. Inhalations of nitrite of 
 amyl, (three drops every four hours) were next given, and 
 next morning a hot-air bath and a hypodermic injection of 
 tincture of digitalis ( 3 ss.) Twenty-four hours after operation the 
 dressings were renewed and eight ounces of nornal salt solution 
 injected into the subcutaneous tissues of eac' tJiigh. Patient's 
 condition seemed better after this infusion vi salt solution, 
 which was repeated in twenty-four hours. At 11 A.M. on the 
 25th 2 ounces of urine were passed and in the next twenty-four 
 hours 7 ounces. In the next twenty-four hours 19 ounces and 
 in the next 35 ounces. In the meantime the symptoms all im- 
 proved. After the first day the urine was perfectly clear and 
 free from blood or pus, the vomiting ceased and the further 
 progress of the case was uninterrupted. The urine has contin- 
 ued clear ever since, averaging from 40 to 70 ounces, and con- 
 taining only a trace of albumen. A sinus persists, from which 
 some fragments of stone have escaped at times, but as no urine 
 has ever escaped through it I believe it to be entirely perirenal. 
 Patient's general health is good and his only complaint is to 
 discharging sinus due probably to some fragments of stone 
 lodged in the perirenal tissues. 
 
4 Obioinal Gommunioation. 
 
 Up to the present time only four cases of double nepbrolith- 
 otomy has been put on record in surgical literature. Two of 
 them ended fatally soon after operation and two recovered. They 
 are as follows : 
 
 (1) In October, 1890, Dr. F. Lange presented (for the second 
 time) at a meeting of the New York Surgical Society, a male 
 patient on whom ne had about five or six years before done 
 nephrolithotomy on both sides. The operation on the right 
 side was done six or seven weeks after the first one (that on the 
 left), for complete retention of urine in the pelvis of the kidney, 
 and he was lucky in removing from the ureter an impacted clot 
 consisting of gravel and blood. There was also an abscess in 
 the substance of the kidney which was opened. The patient 
 had b'jen in fairly good condition ever since, especially about 
 the time when he had presented him to the society some three 
 or four years ago. The wound on the left side by which a large 
 quantity of stones had been removed had, however, never 
 healed entirely except for short periods. A fistula still per- 
 sisted and through it repeatedly small stones had been extracted. 
 Lately the urine had again become more cloudy. At the bot- 
 .tom of the sinus some stone could be felt. {New York Medical 
 Journal, vol. 1, 1891, p. 78.) 
 
 (2) On the 15th of December, 1886, Mr. H. W. Page 
 operated in St. Mary's Hospital, London, upon the left kidney 
 or a man aged twenty-two, from whose bladder stones had been 
 already removed on two different occasions by perineal litho- 
 tomy. A transverse incision was made in the loin, but the 
 kidney could neither be seen nor felt. A large cyst, however, 
 was found and freely incised, and gave exit to pus and two small 
 calculi. The kidney was found high up under the ribs, being 
 very shrunken and small, but containing no calculus. In the 
 latter part of January pain appeared. On the 18th of February 
 the quantity of urine dropped one half, and in the next few 
 days rose again with a vast increase of pus. There was also a 
 return of renal pain. On the 26th of February the right kidney 
 was exposed. It was found surrounded by stinking urinous 
 pus. The kidney was considerably hypertrophied. No stones 
 were found. Some collapse followed operation, but the patient 
 did well. The wound healed slowly and did not close until the 
 8th of May. Patient left hospital on the 26th of May, and a 
 week afterwards passed four small calculi after a slight attack 
 of pain. Since then he has been free from all pain and gained 
 steadily in health and strength. {Medico-Ckirugical Transac- 
 tions. London, 1888, vol. 71, p. 239.) 
 
 (3) In November, 1888, Mr. R. J. Uodler operated upon the 
 left kidney of a gentleman aged thirty- seven, removing a large 
 
A Case of Double Nephrolithotomy. 
 
 mass of uric acid and phosphate stone weighing 832 grains. The 
 patient made a rapid recovery, but the closure of the wound 
 was not permanent. During the next year the patient suffered 
 from a series of attacks of high fever, drowsiness, diminished 
 secretion of urine and once a stone was passed. Accumulation 
 of pus and urine occurred in the left kidney, and at onetime 
 the ureter became completely blocked and an operation was 
 undertaken to remove a stone which was supposed to be obstruct- 
 ing it. None was found, but the ureter became patent after 
 the operation and the state of the kidney very much improved. 
 A rubber plug was worn in the fistula to prevent these accum- 
 ulations. Symptoms pointing to stone in the right kidney, it 
 was operated upon on the 19th of November, 1890, and 480 
 grains of stone removed. Patient died suddenly an hour and a 
 half after the operation as a result of htemorrhage from the 
 kidney. {Medico-Chirugical Transactions. London, 1891, vol. 
 74, p. 141, and Lancet, Vol. 1, 1891, p. 144.) 
 
 (4) On the 23rd of July, 1890, Mr. G. R. Turner operated in 
 St. George's Hospital, London, upon both kidneys of an intem- 
 perate woman, aged 45, who had had symptoms of renal 
 calculi for about five years. At the time of the operation she 
 was suffering from anuria, vomiting and great prostration. 
 Operation was undertaken for the relief of the suppression of 
 urine. "The right kidney was found full of maladorous pus 
 with calculus formations weighing an ounce. The same condi- 
 tion was found on the other side. The woman recovered very 
 well indeed from the immediate effects of the operation and 
 lived for thirteen days. She eventually died, not from suppres- 
 sion of urine, but from asthenia." {La,ncetf\o\. 1, 1891, p. 146, 
 and Transactions of Clinical Society of London, 1891, vol. 24, 
 p. lf)7.) 
 
 In connection with the foregoing case Mr. Turner made the 
 following statement, at a meeting of the Royal Medico-Chirug- 
 ical Society, viz.: that in the post-mortem records of St. 
 George's Hospital for twenty-one years past he had found men- 
 tion of 43 cases of renal calculi, in only nine of which were 
 both sides affected. I know of no other statistics on this sub- 
 ject (not having looked for them), but this fact, together with 
 the fact that 160 cases of nephrolithotomy are now on record, 
 in only four of which have both sides been operated upon, goes 
 to show that double nephrolithotomy is an operation but rarely 
 called for. An analysis of the five cases here referred to shows 
 the net results to be three recoveries and two deaths. Of the 
 former at least two have sinuses persisting. In one (Dr. Lang's 
 case) the second operation does not seem to have been a very 
 
Ortoinal Communication. 
 
 severe one. In another (Mr. Page's case) no stones were re- 
 moved from either kidney by operation. (In the flrst the 
 stones lay in a cyst outside the kidney, and in the second the 
 stones were passed after recovery from the operation.) In this 
 case it is not stated whether sinuses persisted or not. In the 
 third case— the subject of this paper — the recovery seems to be 
 so far very satisfactory, and to promise well for the future, as 
 with the exception of a sinus which, I believe, for reasons 
 already stated, has no direct connection with the kidney, and 
 which I hope to be able to close by ordinary surgical measures, 
 there is practically nothing to be desired in the patient's con- 
 dition. The most interesting feature of this case is the sup- 
 pression of urine which followed the second operation. Of the 
 fatal cases the death from htemorrhage (Mr. Godler's case) has, 
 of oourse, no special bearing upon the double operation. In 
 Mr. Turner's case, the only one in which both kidneys were 
 operated upon at the same time, one may be pardoned for 
 thinking (although the operator states distinctly that death was 
 due to asthenia and not to suppression of urine) that if not due 
 to suppression of urine, at least deficient urinary secretion was 
 the main factor in causing death on the thirteenth day. This 
 case, however, and others, notably the case reported by Mr. Clem- 
 ent Lucas {Lancet^ vol. 1, 1891, p. 144), in which he performed 
 nephrolithotomy on the sole remaining kidney three months 
 after nephrectomy, and on the fifth day of complete anuria for 
 the relief of the latter symptom, with the most satisfactory re- 
 sult, prove that the operation may be performed with safety in 
 the most advanced stages of pyonephrosis, and under the most 
 unfavorable circumstances. Brought face to face, for the first 
 time, with such conditions as above described, the surgeon 
 may well be pardoned for hesitating to advise operation — and 
 yet he has no alternative. Fortunately, however, the records 
 of the double operation up to the present time offer a far more 
 hopeful prognosis than one would be led by a priori reasoning 
 to expect. 
 
 }]■