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1^ 
 
 .'■Wi ' " - lo-'Vl Jl f^ l ^ Tr. 
 
 O.C 
 
 A Successful Case of Nephrectomy 
 for Calculous Pyelitis." 
 
 By FRANCIS J. SHEPHERD, M.D., 
 
 PROFESSOR OF ANATOMY IN m'gILL UNIVBRSITV, SURGEON TO THE MONTREAL 
 
 GENERAL HOSPITAL, 
 
 Reprinted from The Medical Record. Decemb r 12, 1885. 
 
 Extirpation of the kidney, though now an operation of 
 comparative frequency, is of such recent origin that sur- 
 geons are not yet agreed, either as to the cases in which 
 It IS justifiable or as to the proper method of its perform- 
 ance. Most of the advocates of the abdominal opera- 
 tion are specialists in abdominal surgery, while the ' ver- 
 dict of the general surgeons is largely in favor of the 
 lumbar operation. As, in the large majority of cases 
 the surgeon is unable to say till the kidney is reached,' 
 whether nephrotomy or nephrectmy should be per- 
 formed, and even abdominal surgeons admit that the 
 lumbar incision is the most suitable for nephrotomy, it 
 seems to me that this reason alone should strongly influ- 
 ence us as to the choice of operation. The lumbar 
 operation is, without doubt, the safest operation in the 
 hands of surgeons who are not specialists in abdominal 
 surgery, notwithstanding all that is now said about the 
 "traditional fear" of opening the peritoneal cavity, 
 being a ghost of the dark ages of surgery which has been 
 effectually slain. 
 
 1 
 
 » Read before the Montreal Medico-Chirurgical Society, October 23, 1885. 
 
 ii'tiiiiMiiHi. 
 
 mIKk 
 
Extirpation of the kidney for calculous pyelitis has 
 been a particularly fatal operation, especially when un- 
 dertaken in advanced cases of the disease. The mor- 
 tality has been so great that it has been advised by many 
 that a preliminary nephrotomy should, in all cases, be 
 performed ; others, again, strongly recommend drainage 
 of the kidney alone, in cases where the organ is in an 
 advanced stage of suppuration, and when it is surrounded 
 by such an amount of cicatricial tissue as would render 
 its removal a hazardous procedure. 
 
 The following case of nephrectomy for advanced cal- 
 culous disease is, I trust, not withoat interest, and adds 
 one more case to the list from which the rules govern- 
 ing renal surgery will, in the future, be formulated. 
 
 I am indebted to Dr. Gustin, my house-surgeon, for 
 the history of the case. 
 
 Eliza T , aged twenty-four, married, was admitted 
 
 into the General Hospital under Dr. VVilkins, on August 
 ID, 1885, suffering from a painful swelling in the left side 
 of the abdomen. Family history throws no light on the 
 case ; no consumption. Has had two children and one 
 miscarriage. She recovered rapidly from her first con- 
 finement, but convalescence was tedious after the second. 
 Up to two years ago was always a very healthy woman. 
 She dates the commencement of her illness from nine 
 months ago, when she began to lose flesh and to suffer pain 
 in the left lumbar region, pain occasionally reached as 
 far as the thigh. She attributed these pains to the press- 
 ure of the pregnant uterus. She first noticed a *' lump " 
 in the left side of her abdomen two years ago, after the 
 birth of the first child ; it was movable, tender on press- 
 ure, but not painful. It gradually increased in size, and 
 became painful. Five months ago she noticed that her 
 urine was milky, and that if it stood for a short time a 
 considerable deposit appeared. Occasionally the urine 
 would be quite clear for two or three days, and then 
 there would be a large amount of deposit. She never 
 had anything resembling blood in the urine, nor had she 
 
 T 
 
 1 
 
 £' 
 
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 f\l 
 
 ever had any attack at all like renal colic ; never had 
 had any chills or sweatings. 
 
 On admission into hospital, the following note was 
 made concerning her condition : " Patient extremely 
 
 emaciated and anaemic, with 
 
 an anxious expression of 
 a sallow hue, and hangs 
 
 countenance ; skin dry, of 
 
 loosely over the tissues ; tongue red and flabby ; bowels 
 regular ; no cough ; lungs on examination are found 
 perfectly healthy. Patient is very weak ; has a pulse of 
 14c, and temperature, 101° F, 
 
 " Has painful and frequent micturition, and complains 
 of pain in the lumbar region which shoots occasionally 
 down as far as the thigh. 
 
 ''Abdomen. — On examining the abdomen, the superfi- 
 cial veins are seen to be much enlarged on both sides, as 
 if there were some deep-seated obstruction. A distinct 
 fulness is seen in left lumbar and iliac regions. Palpa- 
 tion reveals a large tumor extending across to within 
 an inch of the umbilicus, continuous with the splenic dul- 
 ness above, and below reaching as far as the brim of the 
 true pelvis. By bimanual palpation the tumor can be 
 grasped between the hands and moved slightly. No 
 fluctuation made out, but tumor feels very elastic, and 
 on pressure it is very tv. nder. Urine has a specific grav- 
 ity of 1.020, is slightly acid, and after standing a few 
 minutes deposits a large amount of pus. On microscopic 
 examination no casts are found, but pus-globules and ox- 
 alate and phosphate crystals are seen in abundance." 
 
 In the last week of August, Dr. VVilkins transferred 
 the patient to the surgical wards, where she came under 
 my care. At that time her condition was somewhat im- 
 proved, she had gained flesh, but was still greatly emaci- 
 ated. Her pulse, however, was still rapid (140), and her 
 temperature ranged from 99° to 101.5°. The tumor had 
 not increased in size since her entrance. 
 
 The diagnosis of the case rested between tuberculous 
 and calculous pyelitis. The history of the case pointed, 
 however, rather to the latter affection, on account of the 
 
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 wm 
 
•*' 
 
 pain, occasional absence of pus in urine, and the absence 
 of any jjlithisical history ; on the other hand, there had 
 never been any blood in the urine. 
 
 The condition of the patient not improving, the pulse 
 remaining at 140, and the temperature sometimes running 
 up as high as 103" at night, after consultation with my 
 colleagues 1 decided to explore the left kidney through 
 a lumbar incision, and to perform nephrotomy or neph- 
 rectomy, as would be determined by the condition of af- 
 fairs found on reaching the kidney. 
 
 Operation.— 0\\ September 17, 1885, the patient hav- 
 ing been etherized, the right kidney was first examined 
 by palpation, and easily made out to be normal in size 
 and apparently healthy. It was freely movable. The 
 woman was now placed on her right side, in the colotomy 
 position, with a pillow under her right loin. An incision 
 was made, a little nearer the rib than the iliac crest, from 
 the edge of the erector spinal muscle, downward and for- 
 ward for nearly six inches. There was plenty of room 
 between the last rib and crest of the ilium, the distance 
 being somewhat greater than usual. 
 
 After dividing the various structures, the quadiatus 
 lumboruni muscle was reached, and its most external 
 fibres were divided transversely, so as to give more room 
 posteriorly. During the dissection there was pretty free 
 venous hemorrhage, owing to the distended state of the 
 veins. 
 
 The kidney tumor now came into view ; it was dis- 
 tinctly fluctuating, and on aspirating it, stinking pus was 
 drawn* ofif ; passing the hand around the kidney in the 
 direction of the pelvis, a hard substance was f^lt, which 
 by needle exploration was found to be a calculus. An 
 incision was now made into the most prominent part of 
 the tumor, and nearly a pint of very fetid pus evacuated. 
 Through this incision the kidney was explored with the 
 finger, and a large calculus was felt filling up the pelvis 
 and calyces of the kidney and extending down into the 
 ureter. The kidney was converted into a large saccu- 
 
 Ml 
 
 <*■ 
 
 \ 
 

 5 
 
 lated pus-containing bag as large as a fretal head, with 
 numerous outlying cysts with thin walls. Seeing the 
 extent of the disease and the impossibility of removing 
 Uie calculus, I forthwith decided to remove the kidney 
 The incision already made was found too small to satis- 
 factorily free the kidney from the surrounding structures 
 so it was enlarged by incisions at right angles to the 
 original one, about its middle. In this way plenty of 
 room was obtained, and the whole hand could be intro- 
 duced for the purpose of freeing the kidney. 
 
 The upper end was freed without difficulty from the 
 capsule and suprarenal body, which was left behind. 
 1 he lower and posterior part was not so easily separated, 
 as there were many adhesions— in fact almost a cicatricial 
 condition of the surrounding structures. To give still 
 more room many of the projecting cysts were punctured 
 and the contained pus let out; in one of these cysts a 
 stone, the size and shape of a marble, was found. 
 
 The posterior surface of the lower end of the tumor, 
 which extended deep down in the iliac fossa, was the 
 most troublesome part to clear, and some hemorrhage 
 from the engorged veins occurred during the prodess. 
 The peritoneum, however, escaped uninjured. The ves- 
 sels entering the hilus were now tied with a strong car- 
 bohzed silk ligature, which was cut short. The vessels 
 were then divided, and the kidney delivered through the 
 wound with ease. The ureter was also tied, cut, and 
 brought out as near as possible to the edge of the 
 wound. It was of normal size, except near the kidney, 
 and was apparently healthy. After dividing a few bands 
 of cellular tissue about the hilus, the kidney was re- 
 moved. 
 
 During the freeing of the kidney there was consider- 
 able venous hemorrhage, and much oozing continued 
 after the removal of the organ ; several bleeding points 
 were secured and tied with catgut, and the oozing ar- 
 rested by sponge-pressure. The cavity left by the re- 
 moval of the tumor was almost immediately filled up by 
 
 VI 
 
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/ 
 
 it? 
 
 the intestines, which pushed forward the peritoneum. 
 The wound was now irrigated with bichloride i to 2,000, 
 and then brought together with catgut sutures, dusted 
 with iodoform, covered with a pad of sublimate jute, and 
 over all a broad gauze bandage. A large drainage-tube, 
 I omitted to mention, was inserted into the lower end of 
 
 the wound. _ . , , , ^ 1. 1 
 
 The patient, although suffermg considerably from shock, 
 rallied well. She had a little vomiting, which was con- 
 trolled by champagne, and, for the first four-and-twenty 
 hours, she was fed per rectum by brandy and beef-tea 
 
 enemata. 
 
 During the night after the operation there was con- 
 siderable oozing, and the dressings had to be changed on 
 the second day ; at this dressing the drainage-tube was 
 much shortened. About thirty ounces of urine was 
 passed in the twenty-four hours following the operation ; 
 it contained some blood and a small amount of pus; 
 after the third day neither blood nor pus were found in 
 the urine. Her pulse, which before the operation was 
 140, soon fell to 115, and the temperature after the first 
 day never reached 100° F. The patient made an un- 
 interrupted recovery, the wound healing by first intention 
 everywhere except at the point of drainage. In two 
 weeks she was sitting up, and in three wheeling herself 
 about the ward in a chair. Her appetite was now 
 enormous, and she rapidly gained flesh. By October 
 17th she was walking about, and looking quite healthy 
 and strong. The daily amount of urine passed was from 
 forty-five to fifty ounces, of a specific gravity of 1.020. 
 
 The calculus on examination proved to be composed 
 chiefly of oxalates. 
 
 There are several points of interest in this case : 
 
 Pirst. — The ease with which, in the patient's emaciated 
 condition, the right kidney could be felt and recognized 
 to be of normal size. 
 
 Second. — The large amount of room obtained by the 
 crucial method of incision. 
 
 ■ppp 
 
 i 
 

 Third.— The satisfactory way in which, notwithstand- 
 ing the advanced state of the disease and the number of 
 adhesions, the kidney was removed without wounding 
 the peritoneum or other important structure. 
 
 Fourth. — The rapidity with which the large cavity, 
 caused by the removal of the tumor, was obliterated by 
 the intestines pushing forward the peritoneum. 
 
 I feel certain that, in this case at least, the lumbar op- 
 eration was the more suitable; had an attempt been 
 made to remove the organ by abdominal section, it 
 would have been impossible to avoid breaking the thin- 
 walled cysts, and so allowing some of the fetid pus to 
 get into the peritoneal cavity. 
 
 P. S., November 23d. — When last seen, a day or two 
 ago, the patient was attending to her household duties, 
 and feeling strong and well. There was still a sinus, 
 large enough to admit a small probe, wherq the drainage- 
 tube had been. There was very little discharge from 
 the sinus. 
 
 Montreal, November 24, 1885. 
 
 
 f 
 
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