VOL. XXIV.

ORIGINAL ARTICLES.

SOME GENERAL OBSERVATIONS ON THE SURGERY OF THE KIDNEYS.

By L. S. MCMURTRY, M.D., LOUISVILLE, KY., Professor of Gynecology, Hospital College of Medicine, etc., Louisville, Kentucky.

No. 1.

aggressive character of modern surgery has overestimated the necessity of operating upon simple movable kidney. When this operation is performed it is necessary to pursue the course in the operative technique that is observed in posterior nephrotomy or nephrectomy; to cut down upon the kidney with the patient in the prone position with a pad underneath the opposite side, so as to elevate the field of operation; cutting down im

surgery, and the surgery of the abdomen

has become established, the surgery of the kidneys has assumed conspicuous proportions. It It is important to observe that the right kidney is three-quarters of an inch lower than the left; that the kidney is behind the peritoneum, and that the ureter is entirely retro-peritoneal.

Among the most conspicuous symptoms that relate to the kidney, to which the attention of surgeons is called, is that of floating kidney; and it is more frequently on the right side than the left, I think, from the fact that I have mentioned, i. e., the anatomical relations of the right kidney.

Physicians who give special attention to physical diagnosis attach much importance to movable kidney. Severe paroxysms of pain are attributed to the twisting of the nerves which supply the kidney when the kidney is floating. I have met with very few cases of floating kidney associated with paroxysmal pain; I do not mean to say that such condition does not obtain, but I think it is more rare than we are prone to believe. When a person has a floating kidney, and it is more frequent in females than in males, any disturbance of the digestive functions or pelvic organs characterized by pain is apt to be attributed to the floating kidney.

Floating kidney results from loosening of the tissues surrounding the kidney. The kidney is held in place by the attachment of the peritoneum to the perinephric fat, and any wasting disease, by causing absorption of the fat, permits motion and elongation of the peritoneal folds. Traumatism may dislocate the kidney and render the organ mobile. This is, of course, very much increased by the abdominal muscles being distended so as to lose their tone, as from child-bearing or other causes which impair muscular support; consequently, we find this condition more frequently in females who have borne children.

Several operations have been devised for anchoring the kidney in its proper position. I remember in talking with Dr. Senn, of Chicago, two or three years ago, he invited me to be present at an operation (which I was unfortunately unable to do) where he proposed to wire the kidney to the twelfth rib. I believe that the * Read before the Louisville Surgical Society. Stenographically reported for this journal by C. C. Mapes.

renal fat; then by placing silver or silkworm gut sutures through the capsule of the kidney attach it to the muscles. This is the ost common method of suturing the kidney. The ultimate results of the operation, so far as I have been able to learn, are not encouraging.

A very common condition in renal pathology, in which modern surgery has achieved some brilliant results, is that of calculi. Salts of the urine deposited upon some colloid material become encysted, forming a calculus in the kidney itself. The painful passage of a small calculus along the ureter is a common clinical observation. A calculus may become engaged in the ureter and be. come lodged there, producing hydronephrosis; it may pass down into the ureter for a distance and after remaining for a time pass on into the bladder; or a calculus may be in the pelvis of the kidney, barely engaged in the ureter and too large to pass. Of course I will not take the time to discuss the symptoms, but will only give a general outline of the pathological process. When the symptoms are of a character which indicate such a pathological condition as this, the surgeon is justified in making an incision down to the kidney, introduce a needle, or, if necessary, make an incision and introduce the finger, to determine the existence of calculi. The damming up of the urine and the results which follow are quite familiar. The condition of hydronephrosis may become a pyonephrosis.

Injuries of the kidney are not very common ; they sometimes occur from stab and other wounds. The symptoms are usually very marked, hematuria being the most prominent. In this condition, drainage, and if necessary repair of the kidney, constitutes the only appropriate procedure.

Cysts of the kidney are among the rather common conditions of renal disease.

A year ago last July I operated upon a young German woman of this city that I am sure any physician or surgeon would have unhesitatingly pronounced the subject an ovarian cyst. The tumor occupied the pelvis and abdomen, pushing the uterus out of the normal position. It was as large as a half bushel. I opened the abdomen in the usual line for ovariotomy and in cutting through the peritoneum and introducing my fin

ger I found a double layer of peritoneum and supposed I was confronted with an intraligamentous ovarian cyst unfolding the broad ligaments. Passing my finger down and exploring, I found both ovaries and the uterus quite normal. I soon discovered that I was dealing with a cyst of the left kidney and proceeded to remove it. The cyst was filled with fluid as clear as spring water. The woman made an easy recovery and is in robust health now. Such a cyst as that is quite rare.

Hydatid cysts of the kidney are among the pathological conditions of these organs. The hooklets are usually to be found in the urine, and lead to the diagnosis.

Tumors of the kidney are very frequently malignant. Medullary cancer is very common; sarcoma is also of frequent occurrence, and these malignant tumors usually occur in the very young, or in the very aged.

Tuberculous kidney is another pathological condition which is not at all infrequent. The diagnosis can usually be determined by indications of tuberculous disease in other parts of the system. Operative treatment for this condition promises very little.

Abscess of the kidney, such as evidenced by the specimen I present this evening, is among the common lesions of the kidney; it is frequently due to the presence of calculi; sometimes due to the spread of suppurative infection along the ureter from the bladder from various causes, and the condition is very amenable in the early stages to surgical treatment. When it is one-sided an incision may be made by the posterior route. Nephrotomy in the early stages is the most successful operation. The kidney is incised, the abscess evacuated altogether extra-peritoneally, gauze drainage established. When the abscess extends to the extent that a nephrectomy is advisable, of course it is a more complicated and more difficult operation.

Hydronephrosis is invariably mechanical and obstructive; and in a large number of cases is congenital.

It is my purpose, in these remarks, in connections with the specimen I have exhibited, to simply outline the scope of renal surgery, and not to attempt an elaborate essay upon special conditions of disease.

Dr. Turner Anderson: I am particularly interested in the question of movable and floating kidney, and am disposed to attach more importance to the development of digestive disturbances, etc., than Dr. McMurtry has done. We all recognize that we have encountered this condition of movable or floating kidney much more frequently since attention has been more particularly directed to abdominal surgery, and in connection with tumors of the abdomen. In my examination of women I encounter a very much larger percentage of movable or floating kidney than I formerly did. I have been especially interested in an article written by Dr. Stewart, of Columbus, Ga., upon this subject. He has gone over the whole subject in a very exhaustive way, and presents it in a manner that coincides with my personal experience. He classifies the digestive disturbances, etc., into three or four classes.

He speaks of neurasthenic symptoms produced by movable or floating kidney; also very decided symptoms of hysteria in women; but the most prominent symptoms relate to digestive disturbances, such as dysentery, occasional diarrhoea, etc. I am sure that I have seeen decided digestive disturbances produced by movable kidney.

I did not notice that Dr. McMurtry made the distinction brought forward in Gregg Smith's work between floating and movable kidney. I will not discuss the paper by reporting cases, but I have seen several where permanent cures resulted when the cases were properly understood, the treatment being the ordinary treatment of rest and building up of the patient, together with a properly applied bandage.

I have never seen the operation of wiring the kidney performed, and do not know of many surgeons who are familiar with the procedure. It is frequently spoken of by Northern surgeons as a simple operation. Patients may come to us who have a floating kidney presenting all the typical symptoms described, and if we do not operate upon them, they go east, and surgeons there tell them that their whole trouble is referable to the kidney, which may easily be remedied by making an incision and tying the kidney to the muscles of the back. As a case in point, a prominent lady in this city, who has presented some curious symptoms for a long time, recently came under my care; the first thing I discovered in connection with the case was a movable or floating kidney. This patient went east, and was under the care of Dr. Goodell, who treated her by the usual non-operative methods, rest, etc., for six weeks, and told her if the kidney gave her any further trouble it would be a very simple operation to tie it to the muscles of the back. This patient presents a number of very annoying nervous phenomena, and I am quite convinced from what I have seen of the case that these disturbances are the result of the floating or movable kidney. She has a large kidney; it can be carried about; it is not necessarily a diseased kidney; in fact, the patient's general health is very good; it is sometimes lost and cannot be found again at a single examination; it can be made to descend quite low, almost to the crest of the ilium. She has had her uterus scraped; the cervix has been operated upon for laceration, that, too, after she had passed the climacteric period; she has had an operation performed upon the cervix for the relief of these disturbances, and all this time the kidney trouble was recognized, but no especial attention paid to it, and no effort has been made to restrain or confine its movements.

It is very important to remember certain anatomical points in connection with the kidney; that it is behind the peritoneum, and no doubt in many cases diagnosis has been made of abdominal tumors, when the trouble was demonstrated later to be connected with the kindey.

Dr. J. G. Cecil: Concerning movable kidney: I have in mind now a case which Dr. McMurtry saw with me-rather he saw the case for me at a time when I was unavoidably detained-in which

one of the very prominent symptoms was paroxysms of pain that the doctor in his remarks said was not regarded as very common, and which he had seldom seen. This case I am sure from the subsequent history must have been one of movable kidney. Nothing else would conform to the symptoms as far as we can judge, by such means of diagnosis as we have at hand, in making the diagnosis of abdominal tumors. It is the right kidney in a maiden lady, æt. thirty-six years; the kidney appears to be about normal in size, and can be readily felt in its abnormal situation. It is not accompanied by very much general constitutional disturbance, but rather with pain and more or less disturbance of the digestive organs, constipation, loss of appetite and loss of flesh. These paroxysms of pain are so severe that it requires opium to relieve her at times. The tumor rests very low in the abdomen, about two inches below the normal site of the kidney, which brings it just to the superior part of the crest of the ilium. It is not very tender, but answers every description of movable kidney. The woman has a very pronounced rheumatic history, and also indications of well-marked heart disease. She is being treated by rest in bed, opiates as necessary to relieve pain, and in addition to this such remedies as are called for to keep the bowels in proper condition.

In regard to abscess of the kidney: I was very much pleased to see Dr. Pozzi operate on a case in which he started out with the intention of removing the kidney, but, having cut down into a very fat subject, he found a small portion of the kidney involved, and, instead of removing the kidney, packed it all around with iodoform gauze, and used the Paquelin cautery a great deal in getting to and opening the abscess. He thought he was justified in leaving it, because he believed that part of the kidney left would be serviceable after the abscess cavity was properly drained. I believe the patient would have been better served by removing the entire kidney. The operation was done by the lumbar route, in Dr. Pozzi's private hospital in Paris.

I have under observation now an old gentleman who presents a line of kidney symptoms which are in some respects rather peculiar, and for a year I have been looking for something definite to develop. It is a case of pronounced hematuria without symptoms, which has existed for a year. This old gentleman, aged seventy-five years, a large, healthy looking man, has been passing blood almost every day, sometimes large quantities of urine passed are heavily loaded with blood, which has been diagnosed by chemical analysis to be from the kidney. Notwithstanding this he has gone on without any variation and apparently without much benefit, until lately he has begun to show decided emaciation and symptoms indicating simply loss of blood. One peculiar feature, which indicates that it must be kidney trouble and only one kidney, is that at times during the day he will pass perfectly clear urine, then perhaps after several hours he will pass a few clots, followed by bloody urine, indicating that one ureter is obstructed by blood

clots; then after passage of the clots the urine is freely mixed with blood. There is not, and has never been, the least pain, not the slightest sign of a tumor, and nothing else to indicate the cause -it is simply a case of hematuria without symptoms. I have ventured the diagnosis that there must be a small papillomatous growth in one kidney. I think had it been cancer, which might be suggested on account of his age, it would have terminated his life before this, or certainly he would have developed pain and a tumor, which are the most prominent symptoms of cancer of the kidney. I believe, also, had it been stone in the pelvis of the kidney, pain would have been one of the first symptoms.

Dr. A. M. Cartledge: So many points suggest themselves in connection with the paper read by Dr. McMurtry, that it would hardly be possible to discuss them in detail. First, as regards movable kidney: I think the classification of this affection might still be modified to advantage and make it more accurate, that would be (1) displaced kidney, (2) movable kidney, and (3) floating kidney. The fact is, we often have kidneys displaced and fixed, as I had occasion to observe a few weeks ago. The kidney was standing right on its end and absolutely fixed, being adherent to the lower margin of the liver. It was the right kidney, and its location was such that it had every appearance of being an enlarged gall bladder. An incision proved it to be the right kidney, which was fixed to such an extent that it was impossible, with the hand on it, without doing violence to the condition, to attempt to replace it in the normal position. Therefore I say there is a displaced kidney, which does not come under the head of movable or floating kidney. I believe a floating kidney is supposed to be one where it has a mesonephron.

In regard to the symptomatology of floating kidney: kidney I agree with Dr. Anderson that this condition often gives rise to very marked symptoms, gastric symptoms especially, and their occurrence is so universal in these cases that they can hardly be attributed to anything else.

Ás to the pathology of the gastric symptoms: It has usually been attributed to a twisting of the kidney pedicle. I have sometimes thought there is another explanation of the peculiar nausea, and that is retention. That, by the way, is a very important thing when suspecting floating or displaced kidney. These patients almost invariably complain of having periodical flooding of the urine, as it were; probably for twenty-four hours they will pass not to exceed twelve ounces of urine, then during the next twenty-four hours pass sixty or eighty ounces, and it is during the periods of retention that the gastric symptoms are

most marked.

As to operations for the relief of this condition, I would like to correct one impression that seems to have gained ground, concerning the operation of cutting down and anchoring the kidney to the muscles or the rib. Results in the hands of men, who have done a great many of these operations, prove that relapses of the condition are very frequent, that the anchoring may

fail to hold the kidney in its proper position, and simply stitching the capsule, as suggested by Dr. McMurtry, often results in failure; after a few months the kidney again begins to wander.

The best paper I ever heard upon this subject was one read before the last meeting of the Southern Surgical and Gynecological Society by Dr. Johnson, of Richmond, Va. He reported thirty-five cases upon which he had operated without a death, and reported them in detail. He suggested a little different technique from that ordinarily employed. He makes a free incision down to the kidney, carrying his suture quite deep into the substance of the kidney, suturing it to the deeper layer of muscles and fascia; he also suggests, by means of making an additional safeguard, to not close the wound, so as to get union by first intention in the strict sense of the word; he said he wanted to get a certain amount of plastic exudation, and his object was to so treat the case as to increase the amount of exudation and consequent adhesion, in order to prevent recurrences that so often occur after the ordinary operation of fastening.

In reference to the paper Dr. Anderson quotes: The author's deductions are entirely erroneous. I do not think any form of mechanical contrivance can be sufficient to hold the kidney in position. Owing to the conformation of the anterior abdominal wall, we are not able to produce direct pressure sufficient to support the kidney in its proper situation. I have treated one case by this method, but my success was not such as to encourage its further employment.

Abscess of the Kidney and Nephritis.-Unfortunately these cases do not promise very brilliant results from operative ir terference, from the fact that they are nearly always bilateral. We hope for the best results in those cases of suppurative pyelitis or abscess from calculus, but where we have suppurative pyelitis, the result of extention of septic infection from the bladder, as they are nearly all bilateral, operative procedures do not promise very brilliant results.

Dr. W. C. Dugan: The question of floating kidney is especially interesting to me, and I am surprised to find that so few of the surgeons present have operated upon such cases. I hardly I hardly believe the symptoms Dr. Cartledge speaks of can be due to retention of urine; I am of the opinion they are due to some nervous disturbances which I am unable to explain, brought about by the retention of urinary salts in the blood. I recently operated upon a patient for floating kidney, by making a posterior opening and stitching the kidney to the fascia. Instead of splitting the kidney proper, as Dr. Cartledge has mentioned, I simply split the capsule and stitched it to the fascia with a large curved needle, using silk worm gut as suture material, and to make it doubly sure, some three or four deep sutures were applied by going deep down into the kidney substance with the curved needle. The patient was passing only The patient was passing only ten ounces of urine daily before the operation; this was increased to twelve ounces the second day; and, strange to say, within a week after the operation she was passing more than double

the usual quantity of urine per diem; one day she voided as much as three quarts. I am unable to explain it. It could not have been due to twisting of the ureter, because she had no symptoms of that condition. The patient had no dilatation, or but little, of the pelvis of the kidney, so the trouble could not have been due to retention; therefore, I claim that the symptoms are due to some nervous disturbance, produced by the salts of the urine acting on the brain cells. As to the question of packing: This patient had disease of the pelvis (chronic pyelitis) of the kidney, and as a result there was a deposit of urinary salts; this was scraped out, and to right that condition of chronic pyelitis the wound was packed with gauze and left open. Patient was allowed to go home while the wound was filling up, and although she had improved some she was still in a bad state of health. wound continued to suppurate so profusely that I decided to remove the kidney, so she was brought back to the city, and then for the second time an incision was made at the same site by following the fistula, and we found that the adhesion of the kidney to the structures where sutured was very firm, so showing that the success of the primary operation was perfect, for it was with some force that it was dislodged from its new attachment. I have not had a failure so far.

The

Abscess of the Kidney.-I am sure that the best operation is by the posterior route. At any rate, at the primary operation it is best to make a posterior incision, open the kidney and secure drainage. When these patients come to us they are full of septic material, and so by doing the operation at two sittings we get rid of the septic material, which, if allowed to remain, will do much to endanger the life of our patient, if not cause the death. After getting rid of the septic material by drainage, the patient usually becomes markedly improved, and, too, his appetite comes to his rescue; then if it is necessary later to remove the kidney, the patient has sufficient vitality to withstand the operation, and then, if for any reason we prefer the laparo-nephrectomy, we can cut down upon the capsule from the front. I think, in selecting the anterior or anterior-lateral incision, especially in those cases where we are going to remove a suppurating kidney, we should cut down upon the peritoneum; and then, with the handle of the scalpel, carefully push the peritoneum up out of the way. Now, if we make a good, long incision, the kidney is exposed, and when carefully separated from the surrounding structures a ligature can be thrown around the kidney blood vessels and then securely tied and cut off, and all done without invading the peritoneal cavity. In operating for cyst of the kidney the same method might be selected, yet the same. reason does not prevail. In fact, I prefer laparonephrectomy for tumors of the kidney, for here, as a rule, we have to deal with a large mass, and then we subject our patient to the risk of sepsis, which is known to surround the simplest section and no more, which risk I consider less hazardous than operating to the disadvantage we experience doing the extra-peritoneal nephrectomy.

I remember a case I operated upon not long since; there was a very large tumor, which would hold at least three to five quarts of pus. The patient lived in the country, and was brought here on a cot for operation. Dr. Chenowith was present, and I do not know how much pus we drew off through a free incision, made in the lineasemilunaris; so went in behind the peritoneum, in fact did not see it at all; washed the pus out carefully, and then to be sure that none was left, the hand was introduced and each compartment was scraped out, and the wound packed with gauze. She went home on the tenth day after operation, much improved, having no fever and was eating some, and weighing not over sixtyfive pounds. I received a letter from her mother, a few days ago, stating that her daughter was in excellent health, and weighed 120 pounds. In this case there was an enormous abscess of long standing, yet there was no history of an injury or any of the infectious fevers that are thought to cause them generally. The disease was unilateral in this case. There has been no evidence of a recurrence. I have had a number of such cases, and am thoroughly satisfied that the best surgery here, as elsewhere, is that which saves the greatest per cent. of patients that are so operated upon. If I had made an attempt to take this kidney out, why, there is no doubt but the last part would have been a post mortem. Then there is another point against primary nephrectomy, and that is no one can say when a kidney is beyond Nature's ability to patch up. And there is still another reason against it, which is our patient may have but one kidney, or we may be operating on the best one. So open behind and drain, and then let results determine the future.

Dr. I. N. Bloom: One point of importance has occurred to me in connection with the paper read by Dr. McMurtry, and especially is this applicable to cases of abscess of the kidney, i. e., our ability to determine whether one or both kidneys are affected. It has been claimed recently, especially by eastern surgeons, that they have been able to catheterize the ureter by means of the cystoscope. When that can be done, in the male (and I suppose it is possible), we will have an unfailing method of determining which kidney is affected, and whether one or both. I take it that there may be men who could occasionally, at least, catheterize the ureters, but they undoubtedly have a skill which few of us possess. Among 100,000 doctors, we would probably find not more than one man who has the ability to carry out this procedure.

I believe a good suggestion would be to do a suprapubic operation, going into the bladder and catheterizing the ureters to determine which kidney is diseased, before performing the operation of nephrectomy. The dangers dangers of suprapubic of suprapubic cystotomy are not great, especially where the bladder itself is not extensively diseased.

In the later writings no distinction is made between movable and floating kidney, and the term floating kidney is entirely done away with. Morrow states, in his latest work, that the distinction is an unnecessary one. I have seen two cases, both of

which were under the care of Dr. Anderson, and both recovered. In these two cases very decided stomach and intestinal symptoms were present, but nausea and emesis were the principal symptoms manifested. The treatment was simply rest, and compression by means of a pad and bandage. In the first case the diagnosis of floating kidney was made, and the misplaced kidney could be felt. The patient has gone for four months without any symptoms, and the kidney has apparently remained in its normal situation. In the latter case the diagnosis was made purely by exclusion, by the location, etc. I saw the patient to-day, and she stated there had been no return of the trouble. In this case the patient told me that she did not pass over ten to twelve ounces of urine in the twenty-four hours. A sample was carefully examined and found to be normal.

Dr. A. M. Vance: Surgery of the kidney is one of the most difficult problems with which the surgeon comes in contact, not only in the diagnosis, but oftentimes in the operative procedure. One point that we must bear in mind is that surgeons are not usually called upon to treat these cases of abscess of the kidneys-pyelitis-until they have been treated for months, and often years, for disease of the bladder, etc. The physian often overlooks cases of pyelitis, for instance, until the golden opportunity has passed for doing the patient much good by any surgical operation.

One of the most important things to consider in operations upon the kidney is the choice of an anæsthetic. If any trouble about the kidney is suspected we should always use chloroform as the anæsthetic. Oftentimes, after abscess of the kidney is relieved by nephrotomy, we have the greatest difficulty in relieving the trouble consequent upon it.

Dr. James S. Chenoweth: At the June, 1894, meeting of this Society, I reported two cases of suppurative pyelitis upon which I had operated a short time before, and made a few remarks as to the diagnosis and treatment. A week after that meeting I operated upon the third case, and it might be of interest to refer to them briefly. showed one of the cases since recovery at one of our Society meetings several months ago.

I

The first case was a young man who had a displaced kidney, which seemed to be enlarged, but this proved not to be the case; it was normal in size, but was displaced downward, moved with respiration, and he suffered from every symptom of stone in the kidney; he had almost constant pain; the appearance of blood in the urine, occasionally some pus. For a time the tumor seemed to increase in size very perceptibly, and during this period no blood was observed in the urine; then blood would be voided in considerable quantities, and the tumor would decrease slightly in size. There was at all times great discomfort. The urine was examined repeatedly, and the indications were simple congestion of the kidney, with a little pyelitis-hardly enough to account for the trouble. An operation was advised and accepted. We cut down upon and incised the kidney, evacuating a small quantity of pus, introduced strips of gauze for drainage purposes,