HX64064093 RD575 T39 The surgery of the k RECAP SURGBRY OF .THE KIDNEYS, J.KNOM/S-LEy THORNTON (jlolumbta Ittrnfrstty in tl)? (Ettg of Nnu Sork (EoUrgp of Phgairiana anb ^urgruna If ram tl^p ^Gibrary of (El|urrI|tU (Carmalt. M. i. ^rPBfntpft by ll]f Exlfrup (Illub of Nfto ^wr<:^w^ - >,'^Jv - ■•*•' 'Ji^^i'l^-fe/v V;.v >^■•*v^■'^.v.l■•- 5gt*.V''^-«-' ^■'^'.■r^, f,3r3-'in.,'-.- yr '^ ■■■■ I ' ^ "i '•i«: -f..' ' / Ji THE SURGERY OF THE KIDNEYS BEING THE HARVEIAi^ LECTURES, 1889. J. KNOWSLEY THORNTON, M.C., SURGEON TO THE SAMARITAN FREE HOSPITAL; CONSULTING SURGEON TO THE GROSVENOR HOSPITAL FOR WOMEN, AND TO THE NEW HOSPITAL FOR WOMEN, ETC., ETC. Wintteen Kllusttations. LONDON : CHAELES GEIFFIN AND COMPANY, EXETER STREET, STRAND. 1890. [^All rights reserved.'] 73') SIR JOSEPH LISTER, BART., F.R.S., F.R.C.S., D.C.L.OXOX., LL.D.CAXTAB., ETC., ETC., Professor of Surgery, King's College ; Surgeon Extraordinary to the Queen ; TO WHOSE TEACHING AND FRIENDSHIP I OWE WHATEVER SUCCESS I HAVE ATTAINED IN MY PROFESSION, g 5)e6icafe t6ts "^ooft, WITH EVERY SENTIMENT OF AFFECTION AND ESTEEM. J. KNOVVSLEY THORNTON. v> <■ 4 'J > 1 Digitized by tine Internet Arciiive in 2010 witii funding from Open Knowledge Commons http://www.archive.org/details/surgeryofkidneysOOthor TABLE OF CONTENTS. LECTURE I. Introductory remarks, difficulties in early diagnosis, as to whether cases are surgical or medical. Anatomical position, and relations of the kidneys, of the renal vessels, and of the ureters — Size, weight, and dimensions of the normal kidney — Importance of the adipose areolar capsule, and its liability to become involved in diseases affecting the contained organ. Absence of one kidney, fusion of the two, union by membrane, simple non-mobile displacements (congenital and acquired) — Floating kidney, and moveable kidney, differentiated — their etiology, pathology, symptoms, and treatment— Nephrorraphy — Hydro-nephrosis, its etiology, pathology, symptoms, diagnosis, and treatment : puncture, incision, and drainage, extirpation — Pyonephrosis, its etiology, pathology, symptoms, diagnosis, and treatment — Pyelitis — Pyelo-nephritis— Renal abscess, its etiology, pathology, symptoms, diagnosis, and treatment — Peri- nephric suppuration. Renal calculus — History of the operation for its removal— I-ec- turer's operations — Varieties of calculus, periods of life when most common, symptoms, all may be present with no stone, illustra- tive case — Transference of pain from the kidney which contains the stone to its fellow, illustrative case — Diagnosis — Needling— Renal Colic — Fixation of stone in ureter and its results, illustrative case — Calculous suppression of urine — Nephro-lithotomy — Lecturers combined operation, reasons which led to its suggestion, method of performance, cases, advantages claimed for the method, compared with the objections raised against it. Lumbar Nephrolitomy — Failures to find the kidney, to find the stone, risk of incising the healthy kidney, steps of the procedure and treatment of the wound. vi CONTENTS. LECTURE II. Simple cysts, single and multiple— Peri-nephric cysts, pathology, differential diagnosis and treatment— Conglomerate simple cysts- Etiology, pathology, and symptoms— Cases and specimen — Difficulties of diagnosis. Hydatids— Pathology, symptoms, and treatment— Scrofulous and tubercular kidney— The tubercle bacilli— Possibility of unilateral primary renal tuberculosis— Pathology, absence of early symptoms, illustrative cases— Deductions from these cases— Question of treat- ment— Primary chronic tuberculosis, or scrofulous kidney — Pathology, (Newman)— Etiology, symptoms, and diagnosis — Presence of bacilli in urine or pus, method of preparing specimens for their detec- tion — Catheterisation of ureters — The endoscope — Differential diagnosis of tubercle and calculus — Summary of diseases so far considered, and of the relative value of puncture, or of free incision and drainage through the loin in each — Dangers of punc- ture in tubercle — Unjustifiable ever to puncture through the abdomen — Discussion of the Lecturer's views as to the value of the carbolic spray in abdominal surgery — Chemical anti- septics versus so-called "Cleanly Surgery"— The past records of abdominal surgery and their teaching— Possible dangers in the use of antiseptics — The Lecturer's seventeen years' experience without change of method. Puncture of tfie kidney, its uses and method of performance — Nephrotomy by lumbar incision— Position of the patient— Position and extent of the incision — Other details of the procedure— Its uses and limitations— Illustrative cases — Objections to a preliminary nephrotomy in advanced renal suppurations, in which nephrectomy will probably be ultimately necessary — Cases in which there is perinephric suppura- tion also present — Illustrative cases — Summary of the uses of puncture and nephrotomy respectively. LECTURE III. Renal tumours, their classification — Fibromata, their varieties — Cystic and lipomatous degeneration — Note of some of the largest re- moved by operation — Fatty transformation of the kidney — The etiology, symptoms, diagnosis, and treatment of the simple tumours— Adenometa — Papillomata— Illustrative case and specimen— Sarcomata— Spindle cell, round cell, alveolar, myo and myx-omatous— Difference in type in chi'dren and adults— Greater malignancy in the former and often con- CONTENTS. Vll genital — Slow growth and less liability to recurrence in the adult — Lecturer's five nephrectomies for Sarcoma — Specimens — Notes of the cases — Summary of our knowledge as to Sarcoma — Differential diag- nosis — Lymphadenometa — Carcinomata, encephaloid, scirrhus, colloid, epithelial and cylindrical — Etiology, period of life when most common — Patholog)', symptoms, and treatment — Successful nephrectomy for — Case of — Early recurrence and death — Summary of the various renal diseases, which may be amenable to surgical treatment. Lumbar nephrectomy — Illustrative case — Disadvantages and dangers — Its statistics and their fallacy — Cases in which it may be advisable — Method of performance. Incision outside the co'.on suggested by author in 1SS3, its practical disadvantages. Abdominal nephrectomy, method, precautions, case illustrative of accidental omission — Ligature of vessels — Treatment of ureter, its im- portance — After treatment — Avoid opium — When to drain — Danger of uniting capsule to parietes, illustrative case — Advantages of the opera- tion — Statistics of ihe Lecturer compared with those of the lumbar operation. Question of the condition of the other kidney — How to decide — Its exact importance — Methods. Injuries of the Kidneys and of the Ureters. Bruise, contusion, shake causing mobility, crush, rupture, tear, in- cised wound, and shot or bullet wound — Injuries to the ureter during surgical operations and midwifery — Statistics — Results of bruises — Of crush, with case — Lacerations — Cases of injury to the ureter — Urine in cellular tissue and peritoneum — Symptoms of traumatic esions — Penetrating wounds — Treatment. THE SURGERY OF THE KIDNEYS. By J. Knowsley Thornton, M.C, Surgeon to the Samaritan Free Hospital, LECTURE I. TV /TR. PRESIDENT and Gentlemen,— My first duty to-night is to thank the Council of the Society for the great honour they have conferred upon me in asking me to dehver the Har- veian Lectures, and in doing so, I can only express the hope that they, and you, who kindly support their choice by your presence, may, when I have completed my pleasant task, not regret the appointment. I have selected '^' The Surgery of the Kidneys " as my subject, in preference to any of the others, with which my work in London has made me specially famiHar, because while the latter have all been largely written upon, both by myself, and others, with considerable experience in abdominal surgery, our subject to-night has been chiefly discussed by the general surgeon, and sometimes, with an evident bias against the abdominal methods of dealing with renal disease. It is always well to hear both sides of a question, and as we are already in possession of several able expositions of the views of those who advocate the lumbar methods in dealing with most of the surgical diseases of the kidneys, I shall offer no apology for devoting much of the time at my disposal, to an examination of the methods of treating these diseases by abdominal section. I shall take it for granted that we all possess a sufficient knowledge of the minute anatomy and physiology of the kidneys, and I shall only ask you to allow me to remind you very briefly, of the position and anatomical relations of these organs, and of the more common abnormalities which are met with, in their position, relations to one another, and to other organs, and of the I varieties in the distribution of their blood-vessels, and excretory ducts. In no department of surgery have greater advances been made within the last few years, than in the treatment of diseases of the kidneys ; indeed, it is only within these years, that many diseases have been recognised, as being more often in the province of the surgeon, than in that of the physician. It is in the early stages of renal disease, often exceedingly diffi- cult, to make a correct diagnosis, and yet upon this depends the decision, as to whether the case is one for the physician, or the surgeon to treat. Here, then, as in many other diseases, the surgeon who is to do his work thoroughly and well, must also be a competent physician. This fact was early impressed upon my mind by my old friend and master, Sir Joseph Lister, who said to me, when I asked for his house surgeoncy, " You should get a house physicianship first, before you are fit to do your work as a house surgeon thoroughly ; " and the more I see of surgery, the more I am convinced of the wisdom of his advice. The kidneys are deeply placed in the loins, behind the peri- toneum, in a bed of areolar tissue and fat, and on a level with the last dorsal and upper two or three lumbar vertebrse ; this adipose areolar tissue completely surrounds their true fibrous capsule, and upon its healthy condition, and normal amount, chiefly depends liieir fixity. When it is deficient they are apt to become abnormally mobile. The right kidney lies about half a rib's breadth lower in the abdomen, than the left ; both are in health nearly half covered by the ribs, so that they cannot be thoroughly palpated from the loin, but with a moderately lax abdominal wall, the healthy kidney can frequently be distinctly felt, and a great part of its surface examined, by deep pressure from the abdominal surface. The diagrams in the works of Morris and Bruce Clarke, show- ing the position of the kidneys from the front, both seem to me to place the kidneys too low as regards the ribs, making it appear that their upper borders are quite uncovered by the ribs. I show you two diagrams, modified from Tillaux and Quain respectively, in which I have given the position of the kidneys in dotted out- line, in the position in which I have commonly found them in the living subject. Very frequently they are even more covered by the ribs than in my diagrams (figs, i and i8). L h er — Right Kidney Vena cava. _' Aorta — I Cacum Slomazh Spleen Left Kidney Position of Umbilicus Ureter Si gin old Ftesiure Fig. I. Diagrarr, after Tillaux, to show Position and Relations of the Kidneys and Ureters, The other organs and structures in intimate relation with the kidneys are, on the right side, the diaphragm, the anterior layer of lumbar fascia, and the psoas muscle, the liver, the duodenum, and the ascending colon ; on the left side the same structures posteriorly, with the stomach, the spleen, the pancreas, and the de- scending colon. The left kidney, being less covered than the right by the colon, has a larger peritoneal covering. The fibrous tunic of the kidney is thin, and invests it closely, but can be readily stripped off in health. The renal arteries arise from the aorta, and are relatively large for the organs they supply ; the right is the longest, and passes behind the vena cava ; the left vein is the longest, and passes in front of the aorta, and into it the left spermatic and left inferior phrenic veins open. Variations in the arrangement and number of both arteries and veins are, however, not uncommon. On this figure, from Bruce Clarke's "Surgery of the Kidneys," are marked the more common varieties of arterial distribution ; f^M^ Fig. TA. Alnorrr.al Branches to Kidney (Eriice Clarke). — i, Suprarenal. 2, Lumbar. 3, Iliac. 4, Aortic. those of the veins are not so important. Both rcral arteries occasionally arise from a common trunk, on the anteiior surface ot the aorta ; additional arteries sometimes arise from the aorta, ihe supra-renal, the lumbar, and from either of the iliac arteries, also more rarely from the right hepatic and middle sacral. Some- times these extra branches enter at the hilum, but they may enter at any other point on the surface of the kidney. The normal renal arteries may give off abnormal branches to the supra-renal capsule, to the pancreas, or to the colon. It is obvious that such abnormal vessels may, when present, cause unexpected and troublesome haemorrhage, especially in operations undertaken through the confined space of a lumbar incision ; in the abdominal operation they can be readily seen and tied. Figs. 2 and 3. 2. Kidneys, Ureters, and Bladder from behind, after Henle. 3. Diagrammatic View of Kidney from behind, to show Relations of Pelvis, Ureter, and Vessels. The ureters pass out of the hilum, and lie immediately under the peritoneum, being very loosely connected to the parts on which they lie by areolar tissue. These are, on the right side, the psoas muscle, the genito-crural nerve, the external iliac vessels, and the side and base of the bladder ; on the left side, the common iliac vessels are in relation to the ureter, instead of the external. The ureters are two inches apart where they enter the wall of tlie bladder, pass through it obliquely for three-quarters of an inch, and emerge by slit-like openings only an inch apart, and about the same distance behind the urethra. In the female the ureter passes along the side of the neck of the uterus, and in the male is dose to the vas deferens, before entering the bladder. There may be two ureters passing to the bladder from one kidney, or only one for both, and other abnormalities are met with, which, however, do not much concern the surgeon. The normal kidney weighs about 4^ ozs. in the male, rather less in the female, and is 4 inches long, 2^ broad, and 1} thick. 4'' >■ t--!jLj>,u^^<'^c>l'^^- Va^it^a* Fig. 4. Sketch after Grcig Smith, showing the Relations ol the Ureters to the Neck ot the Uterus at their Entrance into the Bladder. — The position ot the Ureters is better in Greig Smith than in this sketch, in which they are too much curved, and hence too far from the neck of the uterus. — J. K. T. I think if we bear the above brief sketch of the anatomy and relations of the kidneys in mind, there will be no difficulty in following the various details of the operations we are about to consider. I will also ask you to remember, that the adipose areolar tissue in which the kidneys are bedded, is more or less implicated in all the diseases which affect these organs, and the ease or difficulty with which each operation can be performed, ia almost entirely determined, by the extent and nature of the implication of this surrounding tissue. I place before you drawings, illustrating some of the more common abnormalities in the position and relations of the kidneys, and of their excretory ducts, the ureters. The entire absence of one kidney,* or the complete fusion of two (the perfect horse-shoe), (figs. 5, 5A) need not detain us, as except in very rare possibilities, to which I shall briefly refer later, these conditions are, if known to exist, a complete contra-indi- cation to operation. The imperfect horseshoe (fig. 6), in which the two organs are merely joined together by a web or membrane, is a much more im- portant abnormality, as it has recently been shown to be no bar to successful surgery. In perfect fusion disease affecting one part will be pretty certain to involve the whole, but when there is a well- defined web, the one organ may be as free from disease affecting the other, as if they were entirely separate, and in their normal position. This is well shown in a specimen in Middlesex Hospital Museum, in which the one half of a horse-shoe is hydro- nephrotic, and the other normal (fig. 6a). Professor Socin, of Bale, during last year, aspirated a swelling in the right hypochrondrium of a woman aged forty-seven. Ob- taining urine, he performed lumbar nephrotomy, and found that it was a case of hydronephrosis; the result of this operation was parenchymatous nephritis and pyelitis. He then performed abdo- minal nephrectomy, and after separating the kidney from the vessels and ureter, he found that it was united to the left kidney by a thin band of renal tissue, passing over the aorta and vena cava ; this he divided with the thermo-cautery ; he also applied some ligatures, and sutured the edges of the capsule over the raw sur- face, and the patient was in good health four months after the operation. Braun, of Heidelberg, operating for pyonephrosis, found an * Case, Path. Trans., vol. x., p. 190, man, 45, single, right, usual situa- tion, double S'ze, gk oz., 5 J inches by 3^ ; no trace of left kidney or ureter (Murchison). isthmus uniting the two kidneys and very firmly adherent to the cava, and in separating this, had such profuse venous haemorrhage that the patient died at the close of the operation.* Simple Non-.moeile Displacemext (figs. 7, 8 and 9).t Marked displacement of a kidney may be of the utmost im- portance, not only as predisposing it to certain kinds of disease, but also in relation to its differential diagnosis from disease of some other organ, which its abnormal situation may cause it to simulate, and when its position, and pathological state, have been clearly made out, its changed relations will entirely alter the plan of any surgical operation for its relief. I fear, however, the small space at my disposal will not allow me to enter at any length into such rare conditions. The left kidney is most often permanently dis- placed. The displacement is generally downwards into the iliac ossa, or on to the sacro-iliac synchondrosis, or the promontory of the sacrum. The supra-renal capsule may be displaced with the kidney, but more often maintains its usual position, and is cjuite independent of the kidney. Floatixg and Moveable Kidnev. Floating kidney is essentially a congenital condition, the organ having a true mesentery, so that it becomes practically an intra- peritoneal, instead of an extra-peritoneal organ. The chief surgical importance of this condition, lies in the fact, that it may be alto- gether impossible to reach such an organ by lumbar incision, or, at any rate, the keenest advocate of the lumbar operation, as opposed to the abdominal, must admit that in this particular abnormality, the latter operation is the easiest and safest. Move- able kidney is not such a well-defined condition, because there are several varieties ; thus the kidney with its true capsule and areolar adipose capsule may slip about under the peritoneum, or the kidney with its true capsule may be mobile inside its areolar * ViJv B. RL Jouri-.al, July 131b, iSfQ, p. £9. t Case similar to Canton's, also left kidney, but placed just above the bifur- cation of the aorla (Path. Trans., vol. xi., p. 143). adipose capsule, generally from deficiency of fat in this latter covering ; or again, there may be no anterior peritoneal covering, and the kidney may slip about between processes of the peri- toneum. I would recommend those who wish thoroughly to understand the varieties which may be met with to read the exhaustive chapter on this subject in Dr. Newman's lectures to practitioners, on "S.irgical Diseases of the Kidneys." Fig. 5- Horse-shoe Kidnev, after Bruce Clarke. Etiologv. — A deficiency in the adipose tissue is the chief pre- disposing cause. Sometimes this is a normal condition ; sometimes it is acquired. My own observations lead me to conclude that the kidney may be shaken from its place by a series of severe jolts and jars, as in rough riding, and also by constant action of the feet and legs when the person is bending forward, as in working a sewing-machine. I have seen several cases in which the first dis- placement seemed distinctly to be traced, to one or other of these causes. Of course, in a thin and weak person such a cause will act more decidedly and quickly, than in a strong one, and in the relaxed condition of the abdomen after pregnancy the kidney is very 10 likely to slip from its normal position, and become unduly mobile. The views of various observers as to the cause of moveable kidney differ greatly, but there is probably some truth in most of the theories advanced. It is an undoubted fact that the right kidney is much more often unduly mobile than the left, that women are more subject to the disease than men, and that it is more common Fig. 5A. Horse-shoe Kidney Misplaced (H. Morris). in the former sex in those who have borne children. The greater length and freedom of the vessels on the right side, and the down- ward pressure of the liver, have been tnought to account for the greater frequency of the condition on this side, the vessels on the left side being not only shorter, but more fixed by their connections wnth the pancreas ; others dwell upon the looser attachments of the colon on the right side. The increase and decrease in the size of the pregnant uterus, with the consequent changes in abdominal pressure, the greater vascularity of the kidney during gestation and menstruation, and the drag on the ureters from displacements of the uterus and ovaries, are again, thought to account for the greater frequency of the condition in women. Pathology. — The displaced kidney may be but little affected, structurally for along time, but it is generally abnormally sensitive. and the patient has a constant sense of some weakness, which makes walking and standing difficult ; and in time the escape of the urine is interfered with, and hydronephrosis, to be considered later, may be produced. Torsion, either of the ureter or of the A'^essels, may cause urcemia. Symptoms. — These are the sense of weakness, weight, and dis- comfort, chiefly in the loin on the affected side, the presence of a moveable lump in the abdomen, which can be felt to descend from Fig. 6. Horse-shoe Kidney with Membranous Union (after Bruce Clarke). under the ribs when the patient stands up, or turns on to the opposite side in bed, and to slip up again on pressure, or on assuming the dorsal recumbent position. There are also frequently present severe gastric and neurotic symptoms. Women with mobile kidney are usually excitable, hysterical, and easily depressed. When the patient stands up, or lies completely over on the face, the dull area in the back will be absent in marked cases. Treatment. — I have found a truss which is made by Mr. Hawks- ley, a great comfort in some cases. Others derive more benefit from a simple spiral elastic bandage, and in one case a half-moon- 12 shaped pad, worn inside an ordinary abdominal belt, gave great relief. As in other surgicil procedures, opinio.is differ greatly, as to whether it is proper to operate in these cases. I think there can Fig. 6a. Hydronephrosis in Horse-shoe Kidney (H. Morris). Middlesex Hospital Museum. Specimen in be no doubt that the removal of a kidney simply because it floats, or is miobile, is quite unjustifiable, but I think that the suturing of the kidney (nephrorraphy) into its proper position is in extreme cases quite a proper proceeding, and it has been attended in my own hands, as in those of many others, with marked benefit, and I am not aware that the operation has ever had a fatal result. The recent debate on Renal Surgery at the Leeds meeting, as reported in the British Medical Journal \z.%\. week (November i6th), brings out the difference in opinion strongly. Morris says, " Nephrorraphy in the treatment of moveable kidney has proved 13 very successful in its ultimate results, as well as in th" .diness of recovery from the operation." Newman : " In all the cases in which I have operated the result has been most satisfactory. There are some writers who deny the efficiency of this operation, but this most surely arises either from want of experience or from prejudice." Tait : " I have been persuaded to perform three of these useless Fig. 7. Single Misplaced Kidney (Canton). and unscientific operations, with the result that not one of the patients have been benefited in the least, and one of them has died under such circumstances that I think the operation might fairly be blamed for it. I shall have nothing more to do with fixing kidneys." Bruce Clarke advocates " its judicious application in those instances where severe pain was suffered on account of moveable kidney. The balance of opinion and good results are clearly both in favour of the operation, when carefully performed, in suitable cases." Nephrorraphy is an operation for causing adhesions between the kidney and the structures surrounding it, this end being, as the name indicates, generally secured by suturing the kidney, or its capsule, to the tissues incised in exposing it. The operation is simple enough, and if aseptically performed should be free from all risk, but unfortunately in these aseptic cases the sutures do not set up enough irritation to permanently fix the kidney. This difficulty has, however, been successfully combated by Gould, who employs kangaroo tendon for the sutures, leaving them in per- manently.* I found the ordinary silk sutures, deeply passed into the substance of the kidney, and left in for a fortnight, answer admirably in one case, but I must confess to some anxiety as to the after-result of the procedure, on those portions of the secretmg tissue of the kidney included in the three loops I used. I think it is a good plan to thoroughly stir up the areolar adipose tissue over a considerable surface, and put in several thick red rubber drainage-tubes, so as to obtain the maximum of aseptic irritation. I have under my care a lady who has both kidneys moveable, and both as a result hydro-nephrotic. One I opened, and drained through the loin with great relief to her suffering, and complete restoration of general health, but a fistula persists, and all attempts to close it cause a return of serious symptoms. The other kidney has ceased to be troublesome, as the result of improved general health, and increase of flesh, but it was undoubtedly kept in place, to the great comfort of the patient, by one of Hawksley's trusses, while its natural packing was being formed. The oblique incision usual in lumbar colotomy, only rather higher up, answers well for exposing the kidney in this operation. Some operators incise the capsule and stitch the two cut edges to different parts of the external wound, but I do not think this is either necessary, or advisable. In some exceptional cases it might be well to open the abdomen, in order to get a more perfect com- mand of the kidney, and a more exact application of the fixing sutures, but in the majority of cases this is certainly one of the renal operations which may be as well performed from the loin, and probably more safely, as the abdominal section would have to be supplemented by some amount of lumbar section, for the introduction of the fixing sutures. * Lancet, Oct 6lh, iSS8, p. 674. 15 Hydro-nephrosis. Distension of the kidney with its own secretion, from some obstruction to the escape ot the urine, is, as I have said, an occa- sional result of undue mobility of the organ, and we may there- fore conveniently pass on to the consideration of this condition. Etiology. — Obstruction to the escape of the urine may occur at any point between the renal opening of the ureter and the meatus urinarius. It is most commonly somewhere in the ureter. Many cases are congenital, the ureter being abnormal in structure, or in anatomical relation to the kidney. I show you here a kidney which I removed from a girl aged seven, in which no trace of the ureter could be found. It was my first nephrectomy, and the child rapidly improved in health, and remains well. In other cases it is an acquired condition, due to some congenital abnor- mality in neighbouring parts, which in time interfere with the passage of the urine. Bands and adhesions, displacements of the kidney, or of other abdominal organs, and the presence of abdominal and pelvic tumours are among the causes, but calculus is the most common cause of the unilateral variety, with which surgery is chiefly concerned. Cancer in the pelvis, and affections of the bladder and prostate, most often cause bilateral disease, and do not often afford opportunity for surgical aid. Pathology. — The whole kidney may be affected, or only some portion of it ; usually the pelvis is first dilated, then the calyces, and finally the secreting structure. The fluid in an advanced stage, frequently contains neither urea nor uric acid, but is watery, with a little salt, and a trace of albumen ; later it may contain blood, or become pyoid, producing one variety of pyo-nephrosis, the next disease to be described.* The internal pressure of the accumulating urine, as pointed out by Newman, acts both as a cause of more watery secretion, and also by stopping the circu- lation in the blood-vessels. The cases in which large abdominal tumours are formed, are those in which there is some escape of urine, the secreting structure being then irritated by the alternate expansion and contraction of the organ. In the more * Note Path, Trans., vol, xiii., Goodfellow. i6 permanent cases the secreting structure is paralysed, and the fluid may be reabsorbed, and atrophy of the kidney take place.'* Symptoms. — Often there are no symptoms till a tumour is dis- covered, or the patients suffer from an indefinite ache or pain which is not traced to the kidney ; but in bad cases there may be uraemic symptoms, or colic, which will be more especially con- Fig. 8. Fusion ot two Kidneys (Virchow). sidered when we come to renal calculus. When a tumour appears the case has probably been long progressing, with proportionate damage to the secreting structure. The tumour may be round, or lobulated, or oval, and will fluctuate, though this latter symptom is often very difficult to make out. Perhaps the most certain symptom is the occasional disappearance of the tumour, with in- creased flow of urine. Diagnosis. — This is not always easy ; retro-peritoneal, omental, and mesenteric cysts are especially difficult to differentiate from hydro-nephrosis, and it has been a common error to mistake an * Cases, Path. Trans., vol. viii., p. 280, Sidney Jores ; vcl. x., p 209, Quain ; vol, xiii., p. 145, Goodfellow, 17 ovarian cyst for a hydro-nephrosis, or vue versa. It is also in some cases difficult to distinguish between hydro- and pyo- nephrosis. The position of the colon, curving across the tumour, is one of the best diagnostic points in renal tumours, giving a clear note on percussion over their inner border. Sometimes this is lost through the intestine being contracted and empty, but even then it can often be defined as a raised cord, which varies in shape under pressure. In very large tumours the bowel sometimes gets Fig. 9. Misplaced Kidney (Bruce Clarke). behind, and this sign is altogether lost. I have seen some retro- peritoneal cysts, which it was quite impossible to distinguish from hydro-nephrosis, till the abdomen was opened, and in one case I did not discover what the tumour was, till I had enucleated a con- siderable portion of it, so exactly did it simulate a distended adherent kidney. There should, however, be no difficulty in differentiating a hydro-nephrosis from an ovarian cyst, and yet they are frequently mistaken for one another. In the former there is the position of the colon, the dulness going far back into the loin and under the ribs, and nearly always a clear line between the lower edge of the tumour and the iliac crest. In the ovarian cyst the dulness and i8 fluctuation rarely go so high, and so far back, and though its upper margin is often overlaid by clear intestine, there is not the same fixed curve of clear note, and the dulness extends down to the iliac crest and pubes. The ovarian cyst has usually more lateral mobility than the renal cyst. The pelvic examination alone will usually distinguish the one disease from the other. The hydro-nephrosis rarely becomes pelvic ; the ovarian tumour is nearly always more or less so. If the lower part of the hydro-nephrosis does enter the pelvis, its close connection with the bladder can be traced, Yig. lo. Hydronephrosis and Double Ureter (Bruce Clarke). while pressing up its abdominal portion does not affect the uterus, the exact reverse being the case for the ovarian cyst. Careful aseptic puncture far back in the loin, and examination of the fluid removed are, however, the only certain means of diagnosis, at any rate in many of the cases. Treatment. — I have alluded to puncture as a means of diagno- sis ; it may also be tried as a means of treatment, before proceed ing to any more serious operation. I have never cured a case by puncture, and I do not find in the literature of the subject, any good evidence that cures are often so effected. Of course 19 all congenital cases, and others in which the obstruction is com- plete, are out of court, and it is only in some few cases in which a stone may pass after the pressure behind it is relieved, or some other temporary obstruction is removed, that puncture can be curative. Puncture should be performed with the aspirator, the needle being introduced far back in the loin, to avoid risk of puncturing the colon or peritoneum, or of allowing extravasation of urine into the latter cavity. The skin round the point of puncture, and the needle and trocar, should be carefully purified by a watery solution of corrosive sublimate, or other powerful antiseptic, and great care should be taken to avoid the entrance of air, as the trocar is withdrawn from the empty cyst. If sufficient relief is obtained by puncture to warrant the hope that the obstruction may be relieved, the operation may be re- peated from time to time, especially if the intervals during which the kidney remains contracted lengthen with each puncture. If, on the other hand, as is usually the case, the fluid rapidly reaccumulates, some more radical operation must be undertaken. Incision and drainage have been so warmly advocated that I have tried them in t.vo cases, which seemed to me suitable, but in both they have completely failed, and the patients are exposed to the misery of wearing a tube constantly in the sinus, and a receptacle for collecting the urine. Whenever the tube is blocked, or removed, distension recurs, with pain, and constitutional disturbance ; both patients are, however, in decidedly better health than before the operation. Nephrectomy is the other alternative, and I believe that it is the proper treatment in all cases which do not improve after one or at most two tappmgs. Very large tumours I would not attempt to cure by tapping, but would perform nephrectomy by abdominal section at once. I shall not now describe this operation, as I think it will save time to consider the various diseases for which the operation may be necessary, and then discuss the operation, and the best methods of performing it for each disease, all at the same time. Morris, who was till recently an advocate for repeated tappings, has now changed his opinion. In the debate above referred to he says, " The results of this treatment have, however, been disap- pointing, for the tapping has had to be again and again repeated, and nephrotomy has been frcr^uently followed by a urinary fistula in the loin.'' Fig. II. Kidney, with Stone in Pelvis and another in Cortex at lower end Pelvis dilated ; Cortex thinned. PyO-NEPHROSIS is a similar distension of the kidney, with purulent urine, or pus alone. Etiology. — It commonly results from suppuration in an old hydro-nephrosis, also from tubercle, calculus, or injury. It can only occur from the introduction of pyogenic organisms into the kidney, and is most commonly the result of careless catheterism. It must not be forgotten, however, that the kidneys are the great excretors of septic organisms, hence suppuration may occur in them, without direct external agency. Pathology. — It is obvious that when pus formation is added to simple dilatation, the pathological results will be proportionately severe. Thus we get inflammation and suppuration spreading into the secreting structure, and involving also the capsule, and 21 circum-renal tissues. This involves not only destruction of the secreting tissue, but cicatricial changes in the surrounding adi- pose tissue, which add greatly to the difficulties to be encountered in giving surgical relief. Symptoms. — These are those which are common to all suppura- tions, fever, anorexia, and chills or rigors, together with the appearance of pus in the urine, and the presence of a tender loin- swelling, varying in size. Frequently there is rapid enlargement of a pre-existing loin tumour, and disturbance of the peritoneum. To these maybe added at any moment the symptoms of septicaemia, or of uraemia, from sympathetic suppression of the secreting func- tion in the opposite kidney. Diagnosis. — This is easier than in hydro-nephrosis, because the symptoms are more severe, and more localised to the affected organ, but in a chronic case in which the pus only passes occa- sionally, the differential diagnosis between the two is by no means easy. Treatment. — This will vary according to the cause and extent of the pyo-nephrosis. Simple pyo-nephrosis, resulting from injury, from the transformation of hydro-nephrosis, from the earlier stages of tubercle and scrofula, and from the presence of calculus, may all be successfully treated by incision and drainage, combined in the latter variety with the removal of the stone. This operation may be more conveniently dealt with when I describe the opera- tion of nephrotomy and its various applications. I may, however, give bdef notes of a case which well illustrates pyo-nephrosis due to injury, and its cure by incision and drainage. In July, 1887, I was called to Dublin, and saw, in consultation with my friends Dr. Little, and Professor Thornley Stoker, a gentleman about forty-five years of age, a member of our own profession, who had served in India, and suffered from fever and enlarged spleen. In 1886, while at home on sick leave, sailing in a small yacht, he was struck by the boom on the left side, his arm was fractured, and the elbow was driven violently against his side. Pain in the abdomen and rigors followed, and pus appeared in the urine. Shortly before I saw him a considerable tumour had formed in the left loin j the pus amounted to fully a third of the urine passed, and was occasionally mixed with blood ; he had emaciated much, was very weak, and had a sallow, earthy colour, quick pulse, and irregular temperature. I found a large fixed and fluctuating tumour, in the situation of the left kidney. The examination of the tumour, and his general condition, made me advise lumbar incision and drainage, in preference to abdominal section with aview to nephrectomy, which had been suggested. This operation was performed, a large quantity of pus evacuated, and I satisfied myself that the pelvis of the kidney had been opened. Rubber tubes were introduced, and the wound treated antisepti- cally, and thanks to the care bestowed upon the patient, after my departure, by Professor Stoker, he made an excellent recovery. I examined him six months later, and found that the kidney had regained its proper size, and that the urine merely contained a trace of albumen, and an excess of renal epithelium. This is, however, a favourable result, upon which we cannot often reckon. In advanced cases, w^hen there has been much destruction of the secreting structure of the kidney, and extensive inflammatory changes in the tissues around the organ, nephrotomy and drainage are very likely to end in prolonged suppuration and a urinary fistula. Morris, who was at one time a strong advocate for incision and drainage, now advises against their employmenl " in cases in which it is probable that nephrectomy will, in the long run, be requisite or desirable." Pyelitis is suppuration in the pelvis of the kidney. It is included in pyo- nephrosis, and may be best discussed under the calculous, the tuber- cular, and the scrofulous conditions which most frequently pro- duce it. PVELO-NEPHRITIS is an inflammatory suppuration involving the whole kidney, and is a result of some disease of the pelvic urinar\^ organs, and com- monly known as "surgical kidney.'' It nearly always involves both kidneys, and is not susceptible of surgical relief, so that it need not detain tig. 23 Renal Abscess is a collection of matter in the tissue of kidney. Etiology. — It may arise from injury, calcalus, spread of suppura- tion from neighbouring parts, or from the administration of some drug specially obnoxious to the kidney. Pathology, — It is limited in extent, usually occurs in only one organ, and arises from some of the above-named causes, so lower- ing the vitality of a portion of the renal tissue that the pyogenic cocci, which are probably always present, are enabled to develop. Symptoms. — Those of acute suppuration, with renal pain, and possibly renal tumour, though this may not be, at any rate in the early stages, easy to detect. Diagnosis. — This must depend on the presence of a known cause, the severity of the constitutional symptoms, and their coincidence with renal pain, or other sympathetic renal disturb- ance. If the matter does not find its way into the pelvis of the kidney, and down the ureter, and the physical signs are obscure, explora- tory puncture may be employed, to be followed by free incision and drainage, when the exact situation of the abscess is made out. Such incision should of course always be made in the loin, and its exact method of performance will be described under Nephro- tomy. Perinephric Abscess is a collection of matter in the tissues immediately surrounding the kidney. It is very often diffuse, spreading in the sub- peritoneal cellular tissue and the sheaths of abdominal and retro- peritoneal muscles. Etiology. — It is most commonly caused by extension of suppura- tion from within the kidney, in advanced tubercle or very old cases of calculus. It may also arise from direct external injuries, and is, I regret to say, in these days not uncommonly the result of the improper use of the exploring needle and trocar. I shall have to refer to this subject again when speaking of puncture of the kidney. Symptoms. — These are those common to all acute suppurations, 24 with the addition of renal symptoms, according to the extent to which the kidney is involved. The treatment is, of course, free incision and drainage. Calculus. Gravel and calculus are the most common cause of all the diseases we have been considering, but though they are usually the cause, they may be also in some instances the effect, being induced by the retention of the urine too long in the kidney, as in moveable kidney, and in hydro-nephrosis which results from some abnormality in the ureter. The presence of stone in the kidney, and the possibiUty of its removal by lumbar incision, have been known since the days of Hippocrates, but it is only during the last few years that the operation has been recognised as the proper treat- ment for most cases of renal calculus. In 1869 Mr. Thomas Smith read before the Medico-Chirurgical Society an admirable and suggestive paper, on the method to be employed in removing a stone from the kidney. In 1878 I attempted to carry his suggestions into practice, but was mistaken in my diagnosis, and only gave exit to a quantity of tubercular pus, with great relief to the sufferings of the patient. Two years later Dr. Coupland recommended the operation to a patient under his care in the Middlesex Hospital, and his colleague Mr. Henry Morris suc- cessfully removed the stone, and established the lumbar method of operating. I have performed the operation thirteen times with but one death, that of an elderly Frenchwoman, whose kidneys secreted no urine after the operation. Renal calculus is most common in the young, and after fifty years of age, urate of ammonia and uric acid being, according to Taylor, the most common nuclei in the respective periods. The oxalate or mulberry calculus, though not so common, is un doubtedly the one which causes the most severe symptoms and sufferings. I have placed on the table, a number of the calculi I have removed by nephro-lithotomy, and by nephrectomy. It is impossible to describe even briefly all the varieties and their special pathology, but fortunately they are all, if not left too long, susceptible of surgical cure by incision and removal, 25 Calculus may be single or multiple, may occur in one or both kidneys, and in any part of the organ, though most commonly in the pelvis, or in one of the calyces. It may be small, and fixed in the renal tissue, or acting like a ball-valve to the pelvic opening of the ureter, or large and smoothly coated with phos- phates, filling and distending the kidney (such a stone I show you here. No. 6 in my Nephro-lithotomies), or branched and extending from the pelvis through the various openings into the calyces ; these latter are rarely suitable for extraction, as they break easily and portions are very likely to be left behind (see Nephrectomy, 23). Lastly, there may be many small stones, or several of con- siderable size, with smooth facets from mutual friction. With such variety in number, situation, shape, and size, it is obvious that great ingenuity and a variety of instruments may be necessary for their successful extraction. Symptoms. — Pain in the loins and back, often shooting down the ureter, into the testicle in the male, and into the ovary in the female, and into the hips, thigh, and knee, aggravated by motion, especially if it be of a rough or jolting kind ; tenderness on pressure over the affected kidney ; haemorrhage, which is especially liable to follow such rough movements, the urine when passed being either smoky, bright red, or coffee-coloured ; and the presence in the urine of crystals, or of small fragments of the calculus, are the most common and important symptoms. In more advanced cases the presence of pus in the urine, with irritability of the bladder, especially at its neck just after the act of micturition, are also common. To these local symptoms must be added a number of reflex phenomena, especially disturbances of the digestive organs, indi- gestion, nausea, retching, vomiting, and flatulence. The latter, being often markedly troublesome in the colon on the affected side, sometimes amounting to actual intestinal colic, is in my experience one of the most common and early symptoms in the majority of cases, and is one which is very apt to be overlooked, or misunder- stood. Intestinal colic frequently precedes, and is apt to mask, the true renal colic, caused by the passage, or attempted passage of a stone down the ureter. 26 It must be borne in mind, however, that most of these symptoms may be present in a case in which no stone can be found, and they may be markedly and constantly referred to one side, whilst the stone is in the kidney on the opposite side — a sympathetic transference of pain from a diseased organ to its fellow, which I had frequently observed in the ovary, before I had any experience in renal surgery. In order to fix on your minds these two important facts, (i) presence of all the most important symptoms without a stone, (2) transference of pain from the affected to the healthy organ, I will read brief notes of two remarkable illustrative cases which have occurred in my own practice. In June, 1888, I was asked by the late Mr. Walter Coulson to see with him a young lady whom he believed to be suffering from renal calculus. She gave the following history : In February, 1875, scarlet fever; a chill soon after recovery was followed by frequent passing of gravel, with much pain in the back. In June, 1876, passed a small stone; other small stones were passed at varying intervals till July, 1884. Has passed no more stones, but has suffered constantly from a dull heavy pain in the left loin and back, with frequent attacks of acute cutting pain, reaching through into the left groin, accompanied by very frequent micturition, with pain and difficulty. In 1887 was said to have had an abscess in the left kidney, the pus passmg oft" in the urine. From this time blood was more or less constantly passed, the quantity varying from a few drops to several ounces. Early in 1887 she first saw Mr. Coulson, and he continued to treat her till I was called in, but without relief. When I saw her the bleed- ings were frequent and severe; she was suffering from constant nausea and frequent vomiting, could not walk more than a few yards, passed water frequently in small quantity and with diffi- culty, and I found it full of uric acid crystals, some of considerable size. Here, then, we seemed to have a typical case. I operated upon June 1 8th by a method which I shall afterwards fully de- scribe and discuss ; could detect no calculus from the peritoneal examination, none on opening the capsule and carefully palpat- 27 ing the whole kidney, none on opening the kidney through the loin and carefully exploring its whole interior. She made an excellent recovery, and on the anniversary of the operation wrote to me as follows : " I have had no return of the pain and other symptoms, and am now fairly strong, better than I have been for years, and can walk two or three miles without being very tired." The only possible explanation of such a case is, that the results of the original mischief remained after the stones had passed, and that nature was unable to put the kidney right, free incision, and possibly the breaking down of internal inflammatory deposits with my exploring finger, being necessary to set up healthy reparative action. I altogether dismiss the suggestion that the stone was small and escaped without our noticing it, because every particle of clot was washed and examined, and everything that had been used most minutely inspected, before anything was taken out of the operation-room. Besides, there are other cases which show that the symptoms may be present without a stone, though I know of none so perfect in all its details, and in its after history, as the one I have briefly given you. The following case, illustrating the transference of pain, and the most typical of several that I have observed, is even more remarkable : — In July, 1886, I was asked by my friend Dr. Geo. Johnson, to see a little girl, aged eleven, the daughter of a medical man, whom he believed to be suflering from renal calculus, and need- ing operative relief. The patient was fair, thin, and very delicate-looking. On examining her I could detect a large right kidney, but could not define the left at all. All her symptoms were on the left side, and I concluded, as had Dr. Johnson before me, that the left kidney was practically destroyed, and that there was compensa- tory enlargement of the right one. History. — Two years ago the urine was noticed to be full of " white slimy stuff," which disappeared under treatment, but re- appeared at Christmas, 1885, when she also passed red sand and blood. Just six months before I saw her she had her first attack 28 of left renal colic ; other attacks followed — one in February, two in ]\Iarch, one in April, two in May, and a very severe one towards the end of June. All were typical of left renal colic, no pain or uneasiness ever being complained of in the right side. I fully agreed with Dr. Johnson that it was a proper case for operation, as did Dr. Coupland, who had also seen the child, and who was present with Dr. Johnson at the operation. Dr. Johnson also agreed with the reasons which I urged in favour of my combined abdominal and lumbar operation, to be hereafter described, being adopted in preference to a simple lumbar incision. On August 4th, iSS6, Mr. Murray administered chloroform, and assisted by INIr. Malcolm, I made the usual lateral abdominal incision over the left kidney. The most careful examination failed to detect anything wrong either with the kidney or ureter, beyond a few minute superficial cysts on the surface of the former. I therefore passed my hand across to the other side of the abdomen, and found that the enlargement of the right kidney which we had detected, was due to its pelvis and calyces being packtd with these large stones, which I show you. I made my usual loin incision, and removed them. The patient made an excellent recovery, and remains in good health, having no further trouble in her left side, beyond a very short attack of colic just when she first began to move about, pro- bably due to some stretching of adhesions in the right side. Con- cerning this single recurrence, her father wrote, that during the attack she would not admit to pain over either kidney or ureter, but that when it had passed off next morning, she was distinctly tender on pressure over the left loin. Did time and space permit, I could give you notes of other cases, in which this transference of pain is quite distinctly shown by the unfailing test of operative examina- tion. Sometimes a careful examination, by combined lumbar and abdominal pressure, will reveal the actual presence of a stone as a hard projection from the surface of the kidney, but this is only possible when the stone is large, and the patient thin, with a lax abdominal wall. When all the symptoms of stone are 29 present the patient bears deep palpation badly, and is apt to throw the deep muscles into hard prominences which are very deceptive, so that I am always sceptical about the detection of a renal calculus by palpation. Needling. The presence of a stone in the kidney may in some cases be verified by striking it with a fine strong needle, introduced into the kidney from the loin ; this method finds favour with some surgeons, but I have never employed it. The needle may have to be introduced many times before the stone is struck, and I cannot but think that this proceeding is one which must be attended by a good deal of immediate risk, and with considerable danger of after ill effects. There must be danger of wounding some of the larger vessels, or of transfixing the kidney, and passing the needle into the bowel or peritoneum. And if many punctures are made it seems probable that they may become centres of degenerative change in the secreting structure of the kidney. The essence of good surgery, to my mind, is to see exactly what we are doing ; hence needling would not commend itself as a scientific proceeding, even if safe, and much more certain in detecting the stone than it has at present proved in the hands of its advocates. Pain, especially tenderness on pressure, haemorrhage, and renal colic are on the whole the most reliable symptoms, but they may all be present in tubercle and malignant disease ; so that the positive diagnosis of calculus is frequently impossible without an exploratory incision. Haemorrhage is a very important symptom, and is usually worse during the day and during movement, while it is less at night when the patient is at rest. Newman states, that the hcemor- rhage in cases of tumour and malignant disease, more often occurs when the patient is at rest in the recumbent position, but I do not know on what grounds he makes the assertion, and I have not been able to verify it by clinical observation. Another important symptom which may aid in distinguishing calculus from early tubercle, is the appearance in the urine of a 3° quantity of mucus ; this is often present with calculus, even before there are any other very decided symptoms. Renai. Colic. This is so important, not only as an indication of the presence of calculus or of some abnormal substance attempting to pass from the pelvis of the kidney along the ureter, but also on account of the important pathological conditions of which it is often a forerunner, that we must devote special care to its consideration. The pain which we call colic, is due to the violent spasmodic contractions of the ureter upon the foreign body, which it is attempting to expel, and will vary in severity according to the size, to the hardness, and to the roughness of this body. Thus a clot, a small hydatid, or a small, smooth, oval calculus will give rise to a very different amount of pain, from the passage of a rough round calculus, or of a sharp angular fragment. The pain will in these latter cases be also much more prolonged. The greater the resistance to the passage of the foreign body, the greater the pain, and the longer its continuance. The severity of the pain and the length of its continuance are also, to a great extent, an index of the amount of pathological change, which will result. Two forces act in expelling a foreign body from the ureter — the pressure of the accumulating urine from behind, and the contractions of the ureter itself; these two forces are, however, very apt to come into direct antagonism. The urine, forcing the foreign body along the ureter, causes pain by distension, and also by scratching the delicate mucous membrane ; if the body has a rough surface the result is involuntary muscular contraction, which grips the foreign body, narrows the channel below it, and thus delays its passage, and increases the pain of its expulsion, or brings it to a com- plete standstill, till relaxation of the muscle occurs, either from the paralysis of long-continued effort, or from the pain being diminished by exhaustion of the nerves. The indications for treatment during the attack are to place the patient at rest, the parts at rest by raising the shoulders and knees, the secreting function at rest by the hypodermic injection of morphia, and the 31 spasmodic contractions at rest by combining atropine or bella- donna with the morphia, while hot applications to the abdomen will also soothe the irritated nerves. The above drugs have also a most important general action in allaying pain and soothing the nervous system. The hot bath, or hot air bath, given while the patient reclines in bed, are also useful. So severe and prolonged is the agony of a bad colic, that con- vulsions may result, the pregnant woman abort, and the patient, even when a strong man, grovel on the floor, biting and clutching at anything within his reach. The attack is usually sudden, though some patients have ill- defined sensations which warn them of its approach ; often it is ushered in by a rigor, during which the temperature may rise very high, wdth violent retching and vomiting, then heavy perspiration, quickly followed by coldness, clamminess, and collapse ; there is constant desire to empty the bladder, though little or no urine is passed, and the act of micturition is a source of severe pain in the neck of the bladder, or at the end of the penis ; in the males too, the testicle on the affected side will often be violently and painfully retracted. I have not met with a case of retraction of the opposite testicle, though I suspect this sometimes happens. The opposite kidney may be excited to free secretion, or complete suppression may come on. It is obvious that the pathological results may be, and often are, very serious, especially when the attacks are frequent, or of long continuance ; the renal tissue is stretched and injured by the distension of the pelvis and calyces, and the ureter is stretched and damaged by the violent contrac- tions on the hard and rough or sharp edges of the calculus. Then if the stone does not pass down or slip back into the pelvis, but remains fixed in the ureter, hydronephrosis and gradual destruction of the secreting tissue of the kidney follow, or the other kidney may sympathise to such an extent that fatal sup- pression and uraemia supervene, as in the very interesting and instructive case recorded by Godlee, in the Transactions of the Royal Medico-Chirurgical Society, vol. Ixx. It is not uncommon for the stone to become fixed in the ureter, just at its entrance into the bladder wall. I have met with two such cases, and in one in which the kidney had become pyonephrotic and disorganised I removed it, and left the stone with a perfectly successful result. In the other I removed the stone by dilating the urethra, and cutting it out through the bladder, but a ureteral fistula resulted, and the urine was dis- charged into the pouch of Douglas. The patient, a woman of weak intellect, went out of her mind, became quite unmanageable, and died of exhaustion a fortnight after the operation. Calculous Suppression of Urine. There is sufficient evidence to prove that this can arise from the blocking of one ureter, the opposite kidney and ureter being quite healthy. It is therefore necessary, in such a case, if we are to save the patient from impending death, to decide, and to decide quickly, whether both ureters are blocked or only one, and if the latter, which of the two. I say the decision must be prompt, because Godlee's case shows that the return of excreting power in the healthy kidney may come too late to save life, if we await the efforts of nature. If it is clear which ureter is blocked, and if the kidney on that side is enlarged, temporary relief may be obtained by puncture through the loin, the sympathetic arrest of function in the healthy kidney being relieved, when the tension is taken oft' in the affected one. If, however, there be any doubt as to which kidney is blocked, I do not think puncture is justi- fiable, for our knowledge of the transference of pain shows that we may very likely puncture the wrong kidney, and if in such a condition the healthy kidney, with its function already arrested by sympathy, be punctured, it is extremely probable that the chances of its function being restored may be still further damaged, and of course there will be the same danger, accen- tuated by themore serious nature of the operation, in lumbar incision. The only proper course in such a case is immediate abdominal section, by Langenbiich's incision on the side on which the blocked ureter seems most likely to be found. Through this incision both ureters and kidneys can be thoroughly explored, and the further surgical procedure found necessary can be aided. If in any case it be clear that both ureters are blocked, both kidneys may be punctured through the loins to afford temporary relief, and to gain time for the careful consideration of the further surgical procedure to be adopted. Puncture is clearly of very limited value in calculous sup- pression, and is only useful as a palliative measure in some cases, and in others to give time for careful consideration as to the best procedure to adopt for a radical cure. Free incision through the loin may be more useful for definite information, and permanent relief by removal of the calculus ; but this, again, is entirely dependent upon the possibility of making previously an accurate diagnosis as to the side on which the block has taken place. Incision has two great advantages over puncture. The urine continues to flow away, and there is permanent relief of the tension, and the situation of the obstruct- ing calculus can often be defined and its removal effected. This latter advantage may, however, be lost if the stone is very low down in the ureter, as it cannot then be reached through a lumbar incision. In cases in which the abdomen has been opened, and the exact state of affairs made out, there should be no attempt to extract the stone through the peritoneum, but through a counter opening in the loin ; or if it be very close to the bladder it may be better to perform suprapubic cystotomy, still using the hand in the peritoneum as a guide and guard, during the extraction of the stone through the bladder. My experience in the fatal case already referred to would lead me to think that this is a much safer and better proceeding than the one I adopted. Whatever the exact condition found, and the ultimate procedure adopted for its relief, it must never be forgotten that the abdominal opening is merely diagnostic and explorative, and there must on no account be any attempt to open the ureter inside the peritoneum. There is nothing in surgery which I should more strongly condemn, and I have seen with amazement in Newman's tables, that some operators have performed nephro-lithotomy in suppurating kidney through the peritoneum. It is surely needless to point out that there can be no comparison between the dangers of such a. rash proceeding, 3 34 and those attending the combined operation, I am about to describe and advocate. We must now consider what incision is best, for the certain detection and removal of a renal calculus. Recognising the difficulty in the diagnosis of a stone, and the still further com- plication introduced by the transference of pain in some cases to the opposite side, and the importance of being able to exa- mine the other kidney and both ureters thoroughly, throughout their whole course, I proposed to open the abdomen by Langenbiich's incision over the suspected kidney, examine care- fully both kidneys and ureters, and having found a stone, to employ one hand in the peritoneum to fix the kidney and stone, and guard the colon, while with the other I could cut down upon the stone directly from the loin, merely making an opening through the loin tissues, large enough to introduce the finger, and the necessary forceps for the extraction of the stone. The opening of the peritoneum is primarily exploratory and diagnostic, and secondarily of great advantage in enabling the stone to be accu- rately and quickly reached and extracted. The loin incision does not interfere with the peritoneum, and no wound is made from the peritoneal surface of the kidney; it is much smaller and cleaner than the wound necessary in ordinary lumbar nephrotomy, requires no sutures, does not leave a weak place in the loin with the chance of hernia, a not uncommon result of the ordinary lumbar operation, and admits the necessary drainage-tube through a small channel, without risk of extravasation of urine into the tissues around the kidney, or of the troubles of secondary suppu- ration. Having carefully considered the details of this procedure, I performed my first nephro-lithotomy by it in December, 1883, with complete success. It so happened that my next case was a stout muscular male, and I hesitated, and finally decided to per- form the ordinary lumbar operation ; the loin was fat and deep, the stone, which I show you here, was large and firmly fixed in the pelvis and mouth of the ureter, and I had great difficulty in loosening it and extracting it ; it broke at the point, and I have little doubt that some fragment remained behind in spite of free flushing of the kidney with a warm antiseptic solution ; the 35 convalescence was extremely tedious, suppuration was profuse, the wound healed, and then suppuration recurred, and after much suffering the patient still has a fistula, with constant discharge of pus and occasional discharge of a little urine. I much wish, for his sake, that I had had the courage of my opinions, and the further experience which has confirmed my faith in the superiority of the combined method. My next case was also a male, and he was so emaciated and worn by the severity of his sufferings, and his inability to take nourishment, that I hesitated before I consented to operate, and at last decided to give the lumbar method another trial. I must confess that I was influenced by the wish to avoid any possible extra risk from the opening of the peritoneum, and also by the fact, that he seemed a typical subject for an easy lumbar opera- tion. This rough mulberry calculus was very firmly grasped by the pelvis, and I was a long time getting it out, and he was so collapsed, that I feared he would not live through the night. He rallied, however, made a good recovery, and remains in excellent health. My next case was the one fatal from immediate suppres- sion of urine. The operation was difficult, even by the com- bined method, owing to the fat abdomen and loin, and I much doubt if I should ever have got this small stone out by a simple lumbar incision. The patient was a bad subject, fifty-nine years old, and in broken health, from long-continued and severe suffering. At my tenth case, for special reasons which I need not detail, I consented to perform the lumbar operation. The stone was very small, and it was by mere chance, that when just about to give up the operation as hopeless, I detected it bedded in the secreting structure at the lower end of the kidney, in the situation marked A in fig. II. The organ was much damaged by my prolonged search, and the haemorrhage was so severe that the patient very nearly died more than once during the first few hours after the operation, and I was obliged to remain with her all night. Con- valescence was very slow, nausea and vomiting being frequently induced by movement, for months after the operation, and I much feared that some fragment of this very brittle little calculus had 36 remained behind; but I am hippy to say that she has graduaMy regained her health. I have now performed the combined operation ten times — twice in the male, and eight times in the female. All but the one fatal case already recorded have made rapid and satisfactory recoveries, with one exception, and this patient had a persistent fistula, for which her kidney was successfully removed by Dr. Savage, of Birmingham. I had feared to remove it, because I knew from my examination of the other kidney that it was also packed with stones. Dr. Savage knew nothing of this, and suc- cessfully removed the kidney. The patient, when I last saw her was in good health, but her condition is not an enviable one, for, with many stones in the pelvis of the single remaining kidney, she may at any moment be placed in great danger by the impaction of one of them in her only ureter. Let me recapitulate the advantages which I claim for the com- bined operation, as compared with the simple lumbar incision. We are certain that the patient has the usual allowance of kidneys. The chances of overlooking the stone, if there is one present in either kidney, are reduced to a minimum. I do not say that the abdominal handling is absolutely infallible, but in fourteen operations I have only once failed to find a stone, and the recovery and present health of this one patient, as already given in her own words, make it highly improbable that there was, or is, a stone in her kidney. This result compares very favourably with the large number of unsuccessful lumbar explora- tions already recorded. Greig Smith mentions twenty-five cases of unsuccessful lumbar exploration — i.e., no stone could be found. There is no fear of cutting into the healthy kidney while the stone is in the opposite one — a serious accident which my cases demonstrate as possible at any time by the lumbar method. There is no fear of accidental wound of either colon or peri- toneum, because (see note on case of lumbar nephrectomy in Lecture III.) they are guarded by the hand in the perito- neum, while the kidney and stone are fixed, so that a small, clean cut upon the stone is all the damage inflicted upon the loin tissues. There is consequently infinitely less risk of extravasa- 37 tion of urine, or of after suppuration, and no risk of a loin hernia. There is the great advantage of ascertaining what is the condition of the other kidney, and that of both ureters. What are the objections to be set against these advantages ? Simply the making of two cuts instead of one. The increased risk, due to the opening of the peritoneum, is practically ;/// — />., if the surgeon will take the pains to perform a thoroughly aseptic operation. I quite admit that this is the key of the position. If there is to be risk of septic infection of the perito- neum, then the combined operation is not justifiable; but I maintain that with proper care the mere opening of the perito- neal cavity and the manipulations in it necessary to examine the state of the kidneys and ureters, and to aid the execution of the lumbar extraction, are practically free from risk — certainly as free from risk, as a large wound made through the various loin tissues, by a surgeon who is not cleanly enough in his work, to avoid danger of infecting the peritoneum. I will give in their own words the opinions of several well-known operators on the question of the propriety of abdominal incision in some cases of calculus. Morris, who certainly is no believer in my method, for he does not even allude to it in his book, says, at page 465, "But should we under these circumstances be ever justified in examining both kidneys from within the abdomen ? I think we should if the patient be clearly going into a bad way, more especially if there have been at any time marked crystalline forms in the urine, and if a digital examination of the vesical ends of the ureters gives a negative result." In speaking of lumbar nephro-lithotomy, at page 472, he says, " It is no detraction from the value or safety of the operation to have to record twenty-four exploratory operations where no stone was found." To this I reply. Perhaps not, but is it not an excellent argument in favour of some more certain method ? In 1887 Bruce Clarke mentioned, at the Clinical Society, a case in which, with the lumbar incision, "an hour elapsed before even the kidney could be found," and he adds, " It would have been wiser to perform an abdominal operation." The patient died. In his speech at Leeds, he gives details of a most interesting case, in which a failure by simple lumbar nephrotomy was changed into a complete success, by the aid of a hand in the peritoneum.* Yet, in the same debate, Llorris spoke of the absence of any difficulty in finding the kidney by lumbar incision, and of the freedom from fatality and misfortune in this procedure. I know of at least one other case which has happened since, at one of the large London hospitals, in which the surgeon failed entirely to find the kidney by lumbar incision. Morris also said, " What was wanted was greater precision in diagnosis.'' Precisely, and this is what my combined method gives. Howard Marsh, in speaking on another occasion at the Royal Medico-Chirurgical Society, said, " One point in renal surgery seemed to be coming to the front — that many stones could not be reached from the loin. Our progress seemed to be in the direction of admitting the wisdom of abdominal exploration." Lumbar Nephro-lithotomy. I do not propose to enter into any detail, as to the method of making the incision in this operation, because it will be fully described under the head of Nephrotomy in my next lecture. In several cases the operation has been abandoned, because the kidney could not be found at all, and, as already stated, in a large number of other cases no stone could be found. The difficulties to be encountered are, however, often only begun when the incision has been made and a stone or stones found. If the stone is small and loose in the pelvis, it may be easily extracted by a lithotomy scoop or a pair of small lithotomy forceps ; but if it fills the pelvis, or is grasped firmly in the mouth of the ureter, or lies high up in one of the calyces, or is bedded in the renal tissue, much careful and-dextrous manipulation will be necessary, first to loosen, and then to grasp and extract the stone. In a thin patient the kidney may be fixed by counter pressure over the abdomen, but it is very liable to slip up under the ribs, and in a fat or mus- cular subject no aid is obtainable by such counter pressure, the * Brit. Med. Journ., Nov. i6, 18S9, p. lo6'7. 39 kidney constantly slipping about, and carrying the stone away from the extractor. When the operator is convinced that no stone remains, the interior of the kidney should be well flushed out with some warm antiseptic solution. I use i in 2,000 corrosive sublimate lotion. One or more rubber drainage-tubes are then introduced, up to the kidney, but not into its interior, and a few interrupted points of suture, and a large absorbent antiseptic dressing, com- plete the operation. I used to introduce the drainage-tube into the kidney for the first few days, but it often gives much pain, and I find that the cases heal more quickly, and the urine clears sooner, if the wounded kidney is left to take care of itself. The length of time during which urine is discharged from the wound, varies greatly in different cases, without any very apparent reason, and I do not think there is much difference in this respect be- tween the small incision in ray operation and the larger one of the lumbar method ; in the latter there is, however, often trouble- some suppuration long after the urine has ceased to flow. If no stone is found in the pelvis, each of the calyces must be carefully explored, and then the secreting tissue must be pressed between the fingers, one inside the kidney and one outside, and in parts where this cannot be done through a lumbar wound, the tissue must be pressed against the ribs or spine. Jordan Lloyd suggests the use of a small sound for exploring the calyces. I have been in the habit of using a No. 3 Duncan's uterine dilator, which answers well, and has a more convenient curve than the usual small bladder sound. Lister's sinus forceps and the ordi- nary nasal polypus forceps are useful, both for dilatation and extraction. In considering whether lumbar nephrotomy is practicable, the surgeon should always take into account, the conformation of the individual to be operated upon, because while in one patient there will be several inches between the last rib and the crest of the ilium, in another they will be found to be almost touching, and even when the body is bent over so as to separate them as far as possible, not more than an inch and a half of clear space is obtainable. It is in such cases that the possible low insertion of 40 the. pleura into the twelfth rib and the danger of wounding it re- quire to be especially kept in mind. The tissues divided in performing the lumbar section are, skin, fascia, latissimus dorsi, possibly serratus posticus inferior, the edge of the erector spinre, the external and internal oblique muscles, and the transversalis ; lastly the transversalis fascia, and then the areolar adipose capsule of the kidney is exposed. There are no vessels or nerves of any consequence, but a few branches of the lumbar arteries may require torsion or ligature. Fig. 3, which I have taken by permission from Mr. Bruce Clarke's work on the same subject as these lectures, shows very clearly the relations of the pelvis, ureter, and renal vessels to each other. I have reversed his figure, so as to look at the parts from behind, as they present themselves to the surgeon on lumbar section. The debate at Leeds, besides giving evidences of the varying views of well-known operators, clearly shows that the balance of opinion is shifting from the lumbar to the abdominal methods. Morris admits that in two of his lumbar nephro-lithotomies he was simply guided by the hard stone, and never really made out the kidney at all ; and that in another case of attempted nephrec- tomy, after incision and drainage of a traumatic urinary cyst, he could not define the kidney, and had to abandon the operation. Newman, from a study of the statistics of nephro-lithotomy, says that " early diagnosis and successful treatment go hand in hand." I say. Adopt the combined method, and you will soon perfect early diagnosis, and cure your patients before their kidneys have become disorganised. Tait, as usual, is a law unto himself. He says, " Whether the peritoneum be opened or not makes not a scrap of difference to the mortality, and makes very little difference to the technique of the operation." I wish, however, that he had condescended to tell us by what incisions he performed his nephro-lithotomies, for it so happens his totals agree with mine. We have each operated fourteen times, with one death, so that a comparison of method would have been interesting. 41 Bruce Clarke admits a large share of conversion to the abdominal methods in nephrectomy. Tait is the only one who gives his statistics completely — the other surgeons taking part in the discussion do not even give us enough material to guess at their results — and his statistics are not nearly so valuable as they might be, for he lumps all sorts of dissimilar cases together, under Nephrotomy, and says nothing as to the method by which each was done. Then his way of calculating percentage mortality is peculiar. He gives four exploratory operations, with no deaths, and includes them in reckoning his totals, and in a foot-note says that one of the cases died eight days after operation ; and finally, though he gives forty- three recoveries out of forty-four nephrotomies for all sorts of d'seases, he says nothing as to the condition after operation, and immediate recovery. The patients had their kidneys opened, and got over it ; but were they cured of their renal diseases ? The cases included in the table make me very sceptical as to this important point. I think the absence of statistics, and their- imperfection when given, is much to be regretted. In a com paratively new field of this kind, what we want to know is not how many operations, or what operations, can be or have been per- formed, but how many patients recover, and with what ease or difficulty. Anybody with moderate anatomical knowledge can remove a kidney, or a stone from it, but can he save his patient alive ? LECTURE II. "|\ /TR. PRESIDENT and Gentlemen, — I commence my lecture to-night with simple cysts of the kidney. These usually grow from some part of the cortex, and arise from some obstruction causing dilatation of the tubules or Malpighian capsules, they contain a pale non-urinous, but albu- minous fluid, often loaded with cholesterine, and occasionally with blood ; they are only harmful from the pressure and distorting in- fluence they exert on the secreting structure, and from interfer- ence with the ureter. They occasionally open into one of the calyces.* At page 129 of the 13th volume of the Pathological Trans- actions, Sir Henry, then ]\Ir., Thompson records a very interest- ing case in which the ureter, which passed through a portion of the cyst, was closed when the cyst was greatly distended by the pressure of the surrounding fluid. The sac communicated with one of the calyces, or with the pelvis of the kidney, for in its early history it occasionally emptied itself through the bladder, and later when Sir Henry tapped it, after a certain portion of the fluid was removed, and the pressure on the ureter thus relieved, the rest of the fluid passed off" by the bladder. The patient died from rupture of the sac into the peritoneum. f Similar serous cysts may arise in the areolar tissue near the kidney, as in other sub-peritoneal areolar tissue, and are probably inflammatory in their origin. The differential diagnosis of simple cyst, from hydronephrosis, may be very difficult, but the persistence and gradual increase in size, without alternate increase and decrease, will generally be observed in the simple cyst, or if it does com- * See case recorded by myself in Trans, of Int. Med. Congress, Copen hagen, 1884, Surgical Section Reports, Case 2, p. 147. t Simple cysts also form in the kidney in connection with interstitial nephritis (chronic Bright's disease) ; these rarely attain any large size, and as they usually affect both kidneys, are not amenable to surgical treatment, even if they are large enough to cause trouble and be diagnosed. 43 municate with one of the calyces, and occasionally empty itself through the ureter, the sudden admixture of a quantity of albu- minous fluid with the urine, should excite suspicion as to the true nature of the cyst. The differentiation of simple cyst of the kidney from the simple peri-nephric cysts named above, is pro- Kidney shown in section with simple Serous Cyst opening into one of its Calyces. Hole cut in Cyst Wall and Probe passed through into Calyx. bably impossible without exploration, and it may, even with explora- tion, be very difficult to make out the exact relation of the cyst to the kidney in the living subject. Fortunately this is not of surgical consequence, as the treatment of all these simple cysts is dentical. (See Nephrotomy.) Conglomerate Shiple Cysts. This form of simple cyst may cause great enlargement of the kidney; the cysts are separate from one another, very numerous and lined with epithelium ; they do not communicate with the secreting structure of the kidney, and only affect the pelvis and calcyces by pressing and dragging them out of shape. Both kidneys are usually affected, and the disease is commonly con- genital, but unilateral disease is occasionally met with, so that the surgeon cannot altogether ignore the disease. Similar conditions 44 afifect the liver, the spleen, and the thyroid. I once helped Sir Spencer Wells to explore an abdomen which contained an enormous liver aftected with this disease. Sir Spencer Wells believed the tumour to be ovarian. If so experienced a surgeon could be so misled by this disease, when affecting the liver, it would probably be far more likely to mislead, if occurring in one kidney only. Thiersch operated upon such a case, believing it to be hydatid of the liver. I show you here a good specimen of conglomerate renal cyst, which I removed by nephrectomy, from a lady aged forty-three. I shall refer to the case again when I deal with the operation of complete extirpation of the kidney (nephrec- tomy). I will only mention now that she had been seen at various times by some of the best known physicians in London, and that very different views had been expressed, tumour attached to the colon, and hydronephrosis, being among those most decidedly given. I myself at first thought it was a renal sarcoma, and then that it was hydatid ; this latter opinion I formed when seeing the patient in consultation with Sir Andrew Clark, and for the first time detecting a peculiar vibrating fluctuation. It was decided that I should puncture it, and this I did, obtaining smiU quantities of fluid from several cysts. I had never seen a case of the disease before, except in museums, and I certainly never suspected its true nature, till I had opened the abdomen, and gone too far with the operation to leave the kidney. The kidney and its fluid contents weighed 8| lbs. I think, having once seen a case, I might recognise another, but the diagnosis must always be very difficult, especially to differentiate this disease from some renal and circum-renal neoplasms (fig. 13). I should attach importance to the very peculiar vibration com municated to the hand on percussion, due, I imagine, to the partial and frequent check to the fluctuation wave, by the numerous thin septa separating the small cysts. If the other kidney can be made out to be similarly diseased, the diagnosis is pretty clear, but in my case, before the abdomen was opened, I could only say that the left kidney was large, and I thought that this was probably due to compensatory hypertrophy from extra work. 45 Hydatids of the kidney are not uncommon, but they are not nearly so common as those of the liver ; they rarely attain a great size, because the daughter cysts usually escape down the ureter, causing in their passage colic, which may easily be mistaken for that of calculus. They also cause hsemorrhage, and blocking of ureter and urethra. Their diagnosis can only be difficult in the comparatively rare cases in which none are passed in the urine. I shall refer to their treatment when I describe nephrotomy and its uses. It would seem natural now to pass on to the solid tumours of the kidney, but I think it will be more convenient if I first de- scribe scrofulous and tubercular kidney, and then I shall have finished the diseases in which puncture, or mere incision and drainage, can be more or less useful, and can deal with these operations before describing the tumours, which naturally lead up to the question of nephrectomy, and the various methods of per- forming it. Fig. 13. Conglomerate Cysts. Right Kidney. Removed by Abdominal Section. Opposite Kidney in early stage of same disease. Scrofulous and Tubercular Kidney. Under this double heading we have to consider two conditions, which, though both tubercular in origin, are in their^clinical his- 46 tory and results, as seen by the surgeon and pathologist, very difterent. The tubercle bacilli are found in the urine, and in the pus in both conditions, but are not, at least so far as my expefience goes, by any means always to bs found in either. I am not going now to discuss acute miliary tuberculosis, which usually attacks both kidneys equally, and is secondary to tubercle elsewhere, but that form of the disease which is occasionally unilateral, and is well seen in this preparation. No. 3,577, from the Royal College of Surgeons Museum.* Judging from the preparations in the museums, it is a rare condition, and it is not noticed in most of the pathological text-books. Newman, in his excellent lectures, merely admits its possible occurrence, in the following passage : " The conditions found after death do not always show clearly the course of events, and certainly do not prove that local renal tuberculosis does not exist, even though at the necropsy a dis- seminated tuberculosis may be discovered." I have seen the con- dition I am about to describe in three cases in the living subject, and in one I had a much later opportunity of examining the kid- neys, after the death of the patient. A consideration of these cases, has led me to conclude, that there is a primary renal tuberculosis, which may attack only one organ, and which does not necessarily pass on into the chronic, or scrofulous variety, with which we are all so familiar. The presence of tubercle in a single organ pre- supposes a lowered vitality, affecting especially this organ, or a part of it, and Newman has noted that in acute miliary tubercu- losis the area supplied by a single branch of the renal artery may alone be affected. Is it not possible, then, that there are cases in which the lining membrane of the pelvis of kidney, a part specially exposed to irritations likely to produce pathological change, may be primarily, and for a time solely, attacked ? Such cases would never be seen when kidneys were only examined after the death of the individual, but might occasionally be found in the post-mortem room, in subjects dying a sudden death from * The disease is more advanced here than in such cases as I am consider- ing, and I merely show the specimen because the small tubercles on the lining membrane of the pelvis are well seen, just as I have felt them in th^ living subject. 47 accident, or from some distinct acute disease. Given the pos- sibility of such a condition, and bearing in mind the result of incision and drainage in some cases of peritoneal tubercle, is it not more than likely that surgery may be able to arrest the disease, while it is still so very local? Speaking of these tubercles, Newman says, " Being due to the presence of a virus, they have a strong analogy to other inflammatory formations." Now we know that such inflammatory formations in other parts of the body sometimes require the aid of surgery to destroy the virus, and set up healthy action, may not local tubercle be susceptible to the same treatment? I believe that the following cases illus- trate my point, and that with the progress of renal surgery this very interesting subject will be farther demonstrated : — The first case is that already referred to, as operated upon by lumbar incision in 1S78, All the symptoms were those of calculus — pain over the kidney and down the ureter, with attacks of colic, then haemorrhages, and finally profuse suppuration, and enlarge- ment of the kidney. When I opened into the pelvis, I found its lining membrane covered with little seed-like tubercles, and there was no stone ; the patient was immediately relieved of all her symptoms, but the fistula persisted, and the other kidney becoming affected, she died of urcemia seven months after the operation. The post-mortem revealed extensive tuberculosis of the kidney operated upon, and of the rest of the urinary organs, the other kidney having evidently been more recently attacked, and pro- bably by extension up the ureter. In neither kidney was there ulceration or caseous deposit. The patient was at the time I operated upon her a stout, rosy woman, so much so, that I should have doubted her statements as to the pains she suffered, had I not seen her actually in great agony. The next case was that of a single woman of twenty-three, fair and stout, but pale and pasty-looking. The illness had commenced three years before I saw her, with sudden attacks of vomiting, usually in the night ; these were quickly followed by pain over the right kidney, shooting down the ureter, and to the inside of the thigh ; micturition was not painful, but when the pain was bad there were constant calls to empty the bladder ; pus ap- 48 peared in the urine comparatively early in the illness, and was passing, but not in large quantity, when she came under my care. The urine also contained a good deal of renal epithelium, some of the cells having large vacuoles in them. It was not examined for tubercle bacilli. She had never passed gravel, stone, or blood in any form, so far as I could make out. The case was sent to me as one of calculus, but I did not think that it was calculus. There was a distinct tumour in the situation of the right kidney, just as in the previous case, and in neither did it vary in size. I explored the kidney by lumbar incision in February, 1884. The kidney substance was softened and very vascular ; the lining mem- brane, though smooth and healthy, had under its surface several little growths (? tubercles), feeling like small shot. I drained the kidney and she got rapidly well, and in little more than a month wrote to say that the wound had quite healed, and that she was gaining strength. Some years afterwards she had some return of pain in the side, and I sent an order for her readmission to the hospital, but she wrote that the pain had passed away, and that she was quite well again. She continues well. The third case was one of those already referred to, as having been treated for hydro-nephrosis, by incision and drainage. The symptoms in this case were so like those of calculus, that I quite expected to find one, but found instead the little shot-like growths projecting from the lining membrane of the pelvis, and especially just in the mouth of the ureter, and I have no doubt that they extended into it, and caused obstruction to the passage of the urine. The drainage-tube has still to be worn, and attempts to do without it, cause recurrence of all the old symptoms. The patient has a tubercular history and appearance, and though she has gained in health since the operation, pus has begun to flow with the urine from this kidney in some quantity, and I much fear that the disease is progressing. The first of these cases shows that we may have a primary acute tuberculosis limited at the beginning to one kidney, and going on to a fatal termination by extension to the other kidney, and suppression of urine, without ulceration and caseous deposit, never becoming, in fact, the well-known scrofulous kidney. 49 The second case suggests, that if such a case is opened and freely drained, the disease may be arrested in its local form, and never become generalised. The third case is not yet concluded, but I fear it teaches us not to expect a cure in all cases from mere incision and drainage ; just as experience has shown, that some, but not all cases of tubercular peritonitis, may be arrested by incision and drainage. My contention, then, is, that there is a localised primary acute tuberculosis, occasionally met with in the kidney, and that it may be arrested by early incision and drainage, or may be only relieved as to its symptoms by this procedure, and may then infect the other kidney, and cause death in a few months by uraemia, with- out passing into the chronic or so-called scrofulous form. I do not deny that the majority of cases pass quickly into this chronic form, but, I think many might be arrested by a suffi- ciently early diagnosis, followed by free incision and drainage. Pathology. — I cannot better describe the scrofulous kidney than in the words of Newman : " The principal seat of the lesion is the apices of the papillse, in the calyces, or in the pelvis of the kidney, and from hence, partly by the blood stream and partly by the lymphatic channels, the material virus is carried within the substance of the kidney. The primary focus becomes occupied first by miliary tubercles, and subsequently by a caseous mass. In the course of a few weeks or months this mass forms an irregular softened area, which by pro- gressive peripheral infiltration spreads inwards. At the same time, by infection, new, and to the naked eye apparently inde- pendent nodules develop in the tissue around, while in more remote parts of the kidney, and in the mucous membrane of the pelvis, an eruption of opaque white nodules may appear. In recent cases, these diminish in size and number, the more dis- tant they are from the primary focus, but when the disease is of long standing the individual nodules cannot be distinguished. The constructive process which lias just been described is rapidly followed by a destructive one. The tubercular nodules, having attained a certain size, undergo caseous necrosis, break down, and when in the pelvis of the kidney they become replaced by 4 5° a tubercular ulcerating surface, or if within the renal parenchyma they are transformed into irregular globular cavities. These, as they enlarge, become elongated, and assume a pyriform shape and approaching the cavity of the renal pelvis, rupture into it. As the destructive process extends from within outwards, greater and greater portions of the renal substance become involved, until finally the whole of the medulla and a large portion of the cortex may be destroyed. This leads to the formation of a large cavity. But besides the encroachment on the renal tissue by tubercular disease, dilatation and sacculation of the organ may be caused by a blocking of the ureter, ultimately producing a tubercular pyo-nephrosis, which sometimes, when the other kidney is free from disease, destroys all vestige of urine-secreting tissue. Should only one organ be involved, the kidney may, by a drying-up of the contents of the pyo-nephrosis, become con- verted into a shrivelled, putty-like mass (fig. 14). But if the ureter be permeable, the urine washes away the collections of debris and the products of suppuration, which present a characteristic appear- ance, to be referred to presently." This debris, in its passage down the ureter, and through the bladder, often infects their mucous surfaces, and this infection frequently travels up the mucous membrane of the opposite ureter, and so infects the other kidney. Etiology. — The causes of primary tuberculosis of the kidney are obscure ; probably heredity is the predisposing element in most cases ; certainly it has been distinctly traceable in the cases which have come under my own observation, the local exciting cause being most commonly exposure to cold and damp, and in women very often during menstruation ; the specific virus is probably in the system, and then some accident determines the weakening cf the vitality in the part attacked. Symptoms. — These are unfortunately not very marked in the early stages ; kidney-ache, albumen, and traces of blood in the urine are usually the earliest. Later the urine becomes alkaline, contains pus, then triple phosphates, and debris oi the renal tissues, and is putrid. Later still, swelling of the affected kidney is dis- covered, colic alternates with discharges of pus through the 51 bladder, and suppression of urine, with fatal uraemia, may super- vene. Diagnosis. — Oi course if the tubercle baciUi can be detected in the urine, the diagnosis is certain. A small quantity of the deposit from the urine should be dried on a slide, then treated with aniline magenta or gentian-violet staining fluid ; then, with a twenty-five per cent, solution of nitric acid to remove the stain from all the material but the bacilli, and washed in pure water, the minute rods stained with the dye then become visible, with a power of 750 diameters. Fig. 14. Shrivelled Tubercular Kidney, containing Calcareous flatter (B. Clarke). Catheterisation of the ureters may be employed to decide whether one or both kidneys are affected, but I must confess that I regard this proceeding with suspicion, as being very likely to damage the healthy ureter, and by so lowering its vitality en- courage the disease to invade it. The endoscope may be a safer instrument, showing whether the urine issuing from both ureters, or only one, contains pus, but I have no experience in its use. It can only be useful to decide whether one or both kidneys are affected ; it does not help us 9.5 to the pus being tubercular or 5<2 calculous. The differential diagnosis of tubercle, and calculus, is in some cases very difficult ; in both in the early stages there may be pain, occasional slight haemorrhages, and slight albumi- nuria, but no pus, and no enlargement of the kidney. Later in both conditions there may be more serious haemorrhages, much pus, attacks of colic, and marked enlargement of the affected kidney. The evening rise of temperature, when present, is an important indication of tubercle, but it is not always present. The haemorrhage in tubercle, being due to the progressive ulcera- tion, is more irregular in its occurrence, and more constant, often coming when the patient is at rest, whereas in calculus it nearly always follows some unusual strain or movement. Patients with renal tubercle, even when it has advanced to complete destruction of the kidney, are often robust-looking, with bright colour ; but this, again, is an uncertain sign. The discharge of pus is more constant from a tubercular kidney, than from one containing a calculus, from which it often comes in .sudden gushes, the urine between times being comparatively clear. Newman states that in tubercular disease frequent micturition is invariably accompanied by pain. But this is not correct. I have seen more than one case in which there was little or no pain, and have had recently under my care a young lady who never had pain at all, till the kidney was punctured, and the disease thus diffused into the peri- nephric tissues. And, as I have already pointed out, the emacia- tion, careworn expression, fever, night-sweats, and anorexia, upon which he lays stress, as being distinctive of tubercle, may, at any rate in the early stages of the disease, all be absent. When the bladder becomes infected, micturition is still more frequent, and often terribly painful, but at this stage the diagnosis ceases to have the same interest for the surgeon, as the time for his aid has gone by. I will now remind you that we have considered the following affections of the kidneys : hydronephrosis ; pyonephrosis, due to the suppuration of a hydronephrosis, to injury to the kidney, to calculus, and to acute and chronic tuberculosis ; pyelitis ; renal abscess ; perinephric abscess ; calculus ; renal colic ; calculous sup- pression ; simple cysts ; simple conglomerate cysts ; and hydatids. 53 For all these conditions, puncture through the loin, and lumbar incision, have to be discussed. I have already sufficiently referred to needling for calculus, which is one kind of puncture. I have also called your attention to the precautions to be taken in per- forming aspiration by trocar and canula, but in this connection let me add two warnings : First, never, under any circumstance?, use for exploratory puncture that surgical abomination a grooved needle, for it will allow infiltraUon, or infection of all the tissues through which it brings the fluid. Always use a thoroughly aseptic trocar and canula, and a trustworthy aspirator, which will not admit air as the fluid is withdrawn ; or use a simple trocar and canula, with full Listerian precautions, not forgetting the now too often discarded spray. And whatever instrument you use, be careful in withdrawing it, as in withdrawing a catheter from the bladder, to bring out with it all the fluid it contains, and not to leave a portion of this in the tissues through vyhich the canula passes after leaving the kidney. I have seen the most distress- ing and disastrous results follow the puncture of a tubercular kidney, by a surgeon who is specially experienced in the treat- ment of renal disease. The second warning I would emphasise is, never to tap a suspected renal tumour through the anterior abdominal parietes, i.e., through the peritoneum. From this rash proceeding I have also seen immediately fatal results. I have just referred to the use of the carbolic spray as an alter- native to the aspirator ; and as I am one of the few who remain faithful to the spray, after even Lister himself has abandoned its use, I think I may be allowed to explain the present state of my belief in its efficacy. First, I believe it is useful during an operation, in keeping a moist antiseptic atmosphere over everything, so that minute dry particles are immediately caught and moistened by a strong solu- tion of a powerful germicide, while the hands of the operator and his instruments, as well as the tissues of the patient, are never allowed to become caked with dry blood, or wound secretion, mixed with and holding firmly small dry particles from the atmo- sphere of the room, or perhaps the still more dangerous moist par- ticles from the breath of those engaged in the operation, or 54 present as spectators. This constant moisture of everything with an antiseptic solution, especially when aided by frequent dip- ping of the hands and the instruments in a warm 2k per cent, solution of carbolic acid, renders the use of the sponges much more efficient in thorough and rapid cleansing of the wound and its surroundings, than is possible if the same parts are dry, and con- stantly drying with the temperature of the patient, and the warm atmosphere of the operating chamber. If it be urged that plain water will serve this purpose equally well, I deny the statement, because so-called plain water may, and frequently does, contain in a moist, and therefore quickly active condition, the very causes of wound infection. This brings me to the second advantage de- rived from the steam saturated with carbolic acid. It is urged that it is useless, because much stronger solutions fail as germi- cides, with certain potent germs, even when they are long exposed to their action. Those who argue thus, forget one important element in all surgery, i.e., the vitality and resisting power of the tissues. Now, I firmly believe that this vital action may be, and is, much aided, when the germs of infection are delivered over to the tissues weakened by being soaked in a strong antiseptic ; perhaps this does not kill them, but it renders them a much easier prey to the active leucocytes. If this has been or can be experimentally disproved, the record of the experiments has escaped my notice. Now let me direct your attention to the value of the spray in tapping a cavity filled with a putrefiable fluid, some small portion of which is certain to remain behind, however carefully we may try and empty it. If an open canula instead of an aspirator is used, air replaces, to some extent at any rate, the fluid withdrawn. Such air contains the dry or moist germs of simple putrefaction, or of some more deadly poison ; they are introduced into a fluid prone to change, and by its bulk removed from the vital influences of the lining membrane of the containing cavity, this being, moreover, weakened by disease, as in the lining membrane of the pelvis of the kidney in calculous, or tubercular disease. The result of such careless tapping is, that in a few hours or days, violent putrid irritation, or some deadly form of blood poisoning, develops in the disease sac. But 55 tap under the same conditions, with a carefully asepticised trocar and canula, under the spray, and let the air go in and out freely, and no harm results. I have done this over and over again, in every conceivable variety of cavity, and yet no putrefaction has followed. I have seen others perform exactly similar tapping, with a carefully purified instrument, but with no spray, and the procedure has been shortly followed by putrid suppuration, and all its dire results. This is demonstration by practical surgery. Let those who scofif at the spray explain the difference in results as they may, I have given you facts from a wide experience, and I have told you how I believe it acts, and till I get some better explanation I am content with my own, and I will continue to protect my patients with the spray. All I have said here applies with even greater force when we come to deal with the opening of the peritoneal cavity, because there the germs are, in this half- poisoned condition, introduced into the presence of a membrane of extraordinary vital power. The success recently attending so- called "cleanly surgery" is the best evidence of this extraordi- nary power of the peritoneum. Wash it well with simple water, which does not irritate it, and which does not allow lumps of material containing the germs to lurk in its recesses, and drain off the serum and blood for the first few hours, and it will, except in occasional cases, when the patient's vitality is too much lowered, or the virus introduced of too malignant a kind, make short work of the germs, which must be introduced in enormous quantities, both from the air and in the water. The frequent septicaemia in the early days of abdominal surgery, was due to three agencies — ■ carelessness in the introduction of infective material from without, on hands, instruments, and sponges ; irritation of the perito- neum by too much sponging ; and leaving little lumps of clot, and putrefiable material, shut up without drainage, in a hot cavity, bathed with serum, poured out from an irritated membrane, and serving to protect the germs in these little lumps from the active vitality of the peritoneum, by keeping them out of actual contact with its surfaces. All these mistakes are avoided in " cleanly surgery," but its results are not equal to pure " aseptic surgery," because it neglects the possibility of occasional de- 56 pressed vitality in the patient, becoming associated with specially active poison ; while real " aseptic surgery " provides against this, by taking care that in every case the germs shall have their vitality also lowered, as much as possible^ before they gain access to the peritoneum. My critics will immediately say. Do you, then, admit no disad- vantages from the cold spray, and the powerful poisonous and irritating chemical agent ? To them I reply that I fully admit the dangers, but that I can guard against them, and that experience teaches me, that when so guarded against, they are practically inert, and bear no comparison to the dangers of mere " cleanly surgery." The disadvantages are, working in a mild species of fog, a certain chilling of the patient's tissues, and the irritation produced by the local action of the caustic and poisonous carbolic acid. The first of these entirely disappears with a little use, and is far more than counterbalanced by the comfort of constant moisture ; the second is readily avoided by keeping everything well covered with sponges and towels, wrung out of a warm carbolic solution ; and the irritation of the antiseptic is easily reduced to a minimum if the lotions are carefully prepared, and the sponges are thoroughly squeezed, not too much used in rubbing peritoneal surfaces, and not left in the cavity either several at a time, or singly for long periods. I have not for years had reason to think that any of these disadvantages have damaged the chances of a patient, and certainly for the last ten years I have not lost a patient from carboluria, or carbolic ureemia, though I have occasionally seen, in my own practice, septic urcemia as the final fatal symptom, in a case in which, from the previous presence of putrid pus, I was unable, with all my care, to perform a thoroughly aseptic operation. I have now fully explained the extent and limitations of my faith in antiseptics, and I shall not agam refer to the subject, but I shall ask you to remember that when I am advocating any surgical procedure for the relief or cure of renal disease, I am advocating it only on the distinct understanding, that it is to be performed with every protection that antiseptics can give. Many things I would do on this understanding, which 57 I should consider utterly unjustifiable, and almost criminal, without such precautions. Of course criminality in such matters must depend upon our views and faith ; those surgeons who are unable to see these matters as I see them, and who conscientiously hold other views, may perform their operations without the safe- guards which I consider essential, and though I may think them blind and mistaken, I would not for a moment let it be thought that I accuse them of any worse fault; but holding the views I do, for me to perform operations dangerous to life, on any other system would be distinctly criminal. Puncture. Puncture of the kidney may be useful to clear up a doubtful diagnosis, as to an enlargement of the organ being solid, or in part fluid ; may be curative in simple serous cyst, or in hydrone- phrosis ; at any rate it may be tried in some cases, before per- forming any more serious operation, though the chances of thus obtaining a permanent cure are small. In renal and circum-renal abscess it may be a useful preliminary to free incision and drainage, but the latter procedure should follow immediately, when the exact situation of the pus is made certain by the puncture. I do not think it is ever justifiable to puncture in hydatid disease, for it is impossible thus to thoroughly evacuate the daughter cysts and membranes, and experience shows that sup- puration is frequently induced by puncture. Puncture is urgently indicated in calculous suppression of urine, but I have already sufficiently discussed this serious condition. I do not believe that puncture is ever justifiable in pyone- phrosis, for it is almost certain to allow escape of pus into the adipose areolar capsule, and into the other tissues around the kidney, and the perinephric suppuration thus started, whether simple or tubercular, adds greatly to the risk of any future curative operation, as I shall point out at greater length when I discuss nephrectomy. I shall not attempt to give anatomical guides for the selection of the exact point of puncture ; careful percussion in each case is the only safe guide. 58 Aspiration may also be justifiable as a means of temporary relief, when distension is causing great pain, and it is impossible to perform immediately a curative operation. It is also useful in the course of the operation for complete removal of the kidney, to avoid rupture and fouling of the wound, during the subsequent enucleation ; but the puncture is very difficult to close effectually, and in most cases it is far easier to enucleate the kidney when tense and full, than when relaxed by withdrawal of its fluid contents. I shall have more to say on this subject when de- scribing the details of abdominal nephrectomy. In introducing a needle or a trocar, care must be taken not to transfix the organ, and to keep the point well away from the hilum and renal vessels. After the withdrawal of the trocar, the site of puncture should be covered with a small dry antiseptic dressing, retained in its place by a round piece of adhesive plaster with snipped edges, and if there is a large hollow left, a pad of cotton wool, and a flannel binder, will add greatly to the comfort of the patient. Nephrotomy. Puncture is really a form of nephrotomy, but the operation I am about to describe, is that of exposure of the kidney by lumbar incision, followed by incision into the substance of the organ, or through the wall of its pelvis, either for the evacuation of fluid or for the digital exploration of its interior. In speaking of the complete extirpation of the kidney, I shall have to discuss both the lumbar and abdominal incisions, and shall give the reasons which make me prefer the latter ; but when the kidney is to be merely incised for the purposes named above, and for subsequent drainage, there can be no two opinions as to the lumbar incision being the only one at all justifiable. I have ■ already said that puncture through the peritoneum must not be thought of, still less must incision, when a track is to be left open for drainage. In lumbar nephrotomy some surgeons place the patient over a pillow in the semi-prone position, so as to widen the interval between the last rib and the crest of the ilium, as much as 59 possible, and in patients in whom this space is very narrow this position may be necessary, but it has obvious disadvantages in the future steps of the operation, and for simple exploratory incision, I have always found that I could work quite well with the patient laid flat on the back, with the side to be operated upon projecting well over the edge of the table. Fig. 15. Diagram to show the Position of the Kidneys from behind, and their Kelations to the Ribs and Vertebrae. The line across the Right Kidney marks the incision in Lumbar Nephrectomy. The external incision should be oblique, from near the lower border of the last rib, and the outer border of the erector spinse muscle, downwards and forwards towards the crest of the ilium, it may be from three to five inches in length, according to the space available in the individual, and according to the depth of 6o the loin tissues.* I generally find a three-inch incision quite long enough for the class of cases we are considering, and the risk of subsequent hernia, if the incision is long, must not be forgotten. The first incision may be freely made through the skin, the subcutaneous fat, and the outer layer of muscles ; the bleeding points should then be ligatured with prepared catgut, or fine silk ; pressure forceps are troublesome in the restricted space available ; the deeper muscles and lumbar aponeurosis should then be care- fully divided till the perinephric fat is exposed, the finger of the left hand guarding meanwhile the lower border of the rib, in case there is a low attachment of the pleura. The exposed fat should be carefully worked through with the finger, till the smooth surface of the kidney is reached. The necessary examination of its condition may now be made, and the point of incision into its substance, or pelvis, decided upon. The object to be attained will decide in which situation the incision shall be made ; when possible, I much prefer to incise the pelvic wall, for though the haemorrhage from the kidney substance, even when profuse at first, usually stops spontaneously, there are exceptions to the rule, one of which I have already mentioned in speaking oi lumbar nephro-lithotomy, and I have always found incisions in the pelvis heal well, with the single exception, in which Dr. Savage afterwards removed the kidney. Cicatrisation of a free incision into the secreting structure must be more liable to damage the organ for future use, than a cut in the pelvis, but it is quite conceivable that free incision into the secreting struc- ture, and its depletion by bleeding, may be necessary to obtain a cure, in some obscure cases, such as the one already described, in which I found no stone. Whether the incision be for the evacuation of a simple cyst, the emptying of a hydronephrosis, or to let out pus, or to remove a stone, the interior should be carefully examined by the finger, to estimate the condition of the lining membrane, to let out pockets of pus, or to find an encysted calculus. After the explora- tion the kidney should be well flushed out with some warm anti- * A reference to fig. 15 will show that this incision crosses the centre of the kidney, and fully exposes the back of the hilum. 6i septic solution, one or more rubber drainage-tubes introduced into the loin tissues/and up to the kidney, but not into its interior, the wound closed around the tube or tubes with interrupted sutures, which should embrace all the divided loin tissues, and the adipose areolar capsule. In some cases, for instance, if the kidney is too mobile, some of the sutures may include also its cut edges, or some deep sutures of kangaroo tendon may be intro- duced into the renal tissue, after the method of P. Gould. The discharge will, in all cases, be at first considerable, and a large absorbent antiseptic dressing should therefore be applied, and changed at least once in every twelve hours. I do not think, that this is one of the cases in which the use of the spray is abso- lutely necessary, as the main mass of the dressing can be removed, and the last small deep dressing easily replaced by a fresh one, without any fear of entrance of air, or of exposure of the open end of the tube, and the spray is very chilling to the large surface wet with urine and discharge, and close to the pleura. For the same reason I have long abandoned the use of the spray in amputations of the breast, as it is impossible, especially in clearing the axilla, to protect the chest from great chill. Indications for Nephrotomy. Having described the method of performing this operation, we must consider what are the indications for its use. It is almost as safe, and much more sure than puncture for the cure of simple cysts. It is, when aided by after drainage, the only proper treatment for hydatids, for abscess, whether in the sub- stance of the kidney or in the surrounding tissues, and it is often urgently indicated in calculous suppression of urine. It may be tried in hydronephrosis, though my own experience does not favour its employment in this disease. It may be used for the extraction of a calculus, but I have already fully stated my opinion on this matter. It is advocated by many surgeons in the various forms of pyonephrosis, but I would restrict it, in this con- nection, to simple pyonephrosis resulting from injury, and to primary tubercular pyonephrosis, when it can be diagnosed suffi- ciently early. I have already given notes of a case, in which I 62 believe that it resulted in a permanent cure of the latter condition, and also of the excellent result obtained in the traumatic case at Dublin. I will now give my reasons for objecting to the lumbar incision and drainage, in the more advanced cases of calculous and tuber- cular pyonephrosis, especially to this proceeding when used as a preliminary to nephrectomy. I object to it then, because without oftering any compensatory advantage, it leads to prolonged and exhausting suppuration, to infection of the loin tissues with the pus from the kidney, and to adhesions and fistulae, which make a future nephrectomy much more difificult and dangerous. I know that many surgeons, for whose opinions I have the greatest respect, have formed, and expressed, a different opinion on this matter. I cannot state their case better than by quoting from Greig Smith's "Abdominal Surgerj'," page 535. He says, " Nephrotomy for abscess is frequently a curative proceeding — more frequently, probably, than published records would lead us to suppose." I cordially agree with the first part of this state- ment, but I have my doubts about the latter. Cures of all kinds are pretty well known ; it is his failures that the bashful surgeon is so prone to bury in the recesses of his own memory, or note-books. He then proceeds, " Even if cure does not follow, no harm is done, but rather good. For the patient, in view of further operative proceedings by nephrectomy, has been tided over the immediate danger of an acute illness, and has gained strength, while the kidney is diminished in size, its vessels are smaller, its tissue is less friable, and its surroundings are more tolerant of surgical interference." From this view of the case I strongly dissent ; it may be true of the rare cases in which a fistula persists, after the opening of an acute renal or circumrenal abscess, but these are not the cases under discussion. It is the chronic cases of suppuration, the result of prolonged calculous irritation, or of advanced tubercular disease that we have to consider. The prolonged and exhausting sup- puration, which frequently follows a nephrotomy in these cases, cannot but weaken and injure the patient, and tend to produce amyloid disease in the opposite kidney. The diminution of the 63 size of the vessels, even if it occur, and such change must necessitate very prolonged drainage, is a matter of no conse- quence in these days of aseptic ligature and forci-pressure. The diminution in the size of the kidney is of equally little conse- quence, for this can, when advisable, be rapidly produced during nephrectomy, by the use of the aspirator. The advantage of the less friability of the kidney, and of the tolerance of surrounding parts, is dearly bought by the presence of a permanent fistula, and by the replacing of sofc and easily divided adhesions by dense cicatricial tissue, not to mention the extensive formation of adhesions in the track of the lumbar operation, which would have had no existence but for that operation. This fistulous track is cer- tain to be putrid, as are the contents of the kidney, after prolonged external suppuration ; for if putridity is not present, the sinus is pretty certain to heal ; but this cannot happen in the presence of multiple, or branched calculi, or of caseous masses in the deep recesses of the kidney. How, then, are we to protect the tissues freshly divided during the nephrectomy from this foul matter ? It is quite possible to enucleate a pyonephrosis entire, and without fouling of the wound, before there is a sinus, but quite impossible after there is one. I am glad to see, from the report in the British Medical Journal of November i6th, of the discussion on renal surgery at the Association meeting at Leeds, that IMorris, who has been one of the chief opponents of my views on this subject in the past, has now come over to my side, the only point now in dispute between us being the important one of lumbar, or abdominal, incision. As experience has converted him in one direction, I do not despair that further experience may convert him in the other. He is reported to have spoken on this subject as follows : — " I have till the last year or two advocated incision and drainage for pyonephrosis ; and repeated tappings, followed, if necessary, by nephrectomy for hydronephrosis, when large enough to form an abdominal tumour. The results of this treatment have, however, been disappointing, for the tapping has had to be again and again repeated, and nephrotomy has frequently been followed by urinary fistula in the loin. ... In three cases in the last 64 twelve months I have, therefore, performed lumbar nephrectomy, without any preUminary operative treatment, and in each instance the patient has made a rapid recovery." Later on he sums up the matter as follows : — " For the above reasons, I have come to the conclusion that nephrectomy, without previous incision or drainage, should be more frequently resorted to than has been the practice hitherto in these cases." I am glad to note, too, that IMorris has also some doubts, as to whether it will be always possible to remove a kidney by lumbar nephrectomy, when the perinephric adhesions resulting from slow effusion of urine behind the peritoneum, drainage, etc., are very dense and extensive. I can assure him that I have never found it impossible to remove one by the abdominal method, and so here again I nourish hopes of an extension of his conversion to my views. The only cases in which we can, in my opinion, gain any advan- tage by preliminary incision, are those in which the suppuration has already broken through the kidney wall, and become diffused into the tissues around the kidney. If by incision and drainage, in such a case, we can, without too great and prolonged a drain, reduce the large diffuse suppuration to a mere fistulous track, then, I think, a preliminary incision may be useful ; but this is not a preliminary nephrotomy, but the mere application of ordinary surgical rules to a diffuse suppuration outside the kidney. I think I might have gained something in two of my fatal nephrectomies, had I adopted this procedure. I doubt if it would have saved the life of either, but I think it very probable that it would have demonstrated the unfitness of the other kidney to bear any extra strain in the last case, and would have thus saved abdominal nephrectomy from the reproach of one fatal case. In the first case there was an enormous diftuse suppuration, behind and around the kidney, and I aspirated with temporary rehef, but without any real gain in the health of the patient ; then, when the pus reaccumulated, I proceeded to abdominal nephrectomy, and she died exhausted by the enormous discharge of pus from the extra-peritoneal abscess, but with no sign of peritoneal trouble. (See report of Case No. 20, in my paper on " Twenty-five Cases of Abdominal Nephrectomy," in the Transactions of the Royal Medico-Chirurgical Society for this year, 1S89.) The s2cond case was one of those I have operated upon since the publication of that paper, and the first nephrectomy that I have lost from suppression of urine. The patient was a young lady of twenty-five, suffering from chronic tubercular kidney, of two and a half years' duration, as far as symptoms are a guide. Seven months before I saw her the kidney had been tapped through the loin, the immediate result of the operation being a few ounces of curdy pus, the ultimate result being a large diffuse tubercular suppuration behind and below the kidney, with a great increase of suffering to the patient. She was in a very exhausted condition, and very weak, but I decided, after consultation with Dr. Broadbent, to give her the last chance afforded by nephrectomy. We were guided to this decision by the fact that the urine was of good specific gravity, did not contain more albumen than the pus would account for, and deposited urates copiously, although the excretion of urea was very low. We thought the latter was greatly to be accounted for by the small amount of food taken, and the entire rest in bed. The operation was a long and difficult one, and there was an enormous diffuse abscess cavity to be cleared out, after the kidney had been removed. I drained both by glass tubes in the abdomen, and by rubber tubes in a counter opening through the loin into the abscess cavity, but very little discharge came from either. Four hours afcerthe opera- tion 3 oz. of good urine were drawn off, in another four hours 40Z, more ; she then passed naturally 2 oz., and the same quantity at intervals, till 24 oz. had been passed in the twenty-four hours All the specimens were good, and the later ones were loaded with pink lithates, and free from albumen. At the end of the twenty- four hours she only passed i oz., and continued to pass small quantities frequently, till 1 1 oz. had been passed in twelve hours. During the whole thirty-six hours she was restless, slept but little and vomited frequently ; the temperature only rose to 99-8°, and then fell gradually to 98"6°, the pulse rising gradually from 100 to 120, and steadily losing power. After the thirty-six hours she ceased to pass any urine, and only i oz. was obtained by the catheter, and this was concentrated and albuminous. The pulse 5 66 now steadied to loS, the temperature remaining at 98'6'. Just forty- eight hours after the operation she had convulsions, became rapidly comatose, and died fifty-three hours after the operation, the tem- perature having fallen in the last hour of life to 97"^. I was not able to obtain any post-mortem, but it was quite clear that the other kidney, though able to secrete good urine, was not equal to the great strain thrown upon it. This extra work was evident from the large quantity of lithates which appeared in the urine, sooner than usual, after the operation. I think, if time had been gained by free drainage of the abscess, before the kidney was attacked, the result might have been different, but it is quite pos- sible that the kidney would not have been able to do its work during the early days, after the evacuation of this large abscess. I now give notes of a case to show how little may be gained, nay, rather how much may be lost, by nephrotomy and drainage, when the suppuration is still confined to the kidney — Case 2 in the table of twenty-five abdominal nephrectomies already referred to. The later history of this case, and the results of immediate nephrectomy in seventeen other cases of chronic suppuration (calculous or tubercular pyonephrosis), the pus being still confined to the interior of the kidney, prove absolutely the excellent results that can be obtained. Only two out of the seven- teen died — one from injury to the vena cava, and one from hemi- plegia, the result of the anaesthetic, the suppuration in the kidney having nothing to do with the death in either case. M. D., aged twenty-six, married five years, mother of two chil- dren, began to suffer pain in the back and right loin, in the early days of the second pregnancy, then pus appeared in the urine. An inflammatory attack a week after confinement was followed by the appearance of a swelling in the right side of the abdomen. Six months later she was placed under my care by my friend and colleague Dr. Prickett, with a large suppurating right kidney, the urine loaded with offensive pus, and the general condition about as bad as it could be. I had at that time only once performed nephrectomy, and I feared to risk it, and performed nephrotomy. At the end of a month's drainage, she was obviously steadily sinking, and I determined, as a forlorn 67 hope, to perform abdominal nephrectomy. Convalescence was rapid, the temperature being normal two days after the opera- tion, for the first time since she had been under my care. It rose to io4"6? after the nephrotomy, and was for days over 102?. Nothing was gained, and much was lost, by that preliminary in- cision. Adhesions were more extensive, and more dense ; there was the foul sinus to be dealt with, and her general condition, as evidenced by temperature, pulse, anorexia, heavy sweats^, etc., was made materially worse, while the nephrectomy at once changed everything. When last heard of, six years after the operation, she was in good health. My own first case, supported by the excellent results I have given you, in a long series of similar cases, has settled this question for me. Before leaving the operations of puncture, and of lumbar nephrotomy, let me briefly summarise the results of my ex- perience. I would restrict the use of puncture as follows : — 1. To decide, in doubtful cases, between solid and fluid tumours of the kidney. 2. To relieve painful distension, when nephrotomy, for some special reason, is not at once advisable, or possible. 3. To remove urine, or serum, or pus, from a very large tumour, to reduce its bulk during the performance of nephrectomy. 4. As a tentative attempt at cure, in some cases of simple cyst, or of hydronephrosis, though the chance of cure is, I think, very slight. 5. To localise the position of renal, or circum-renal abscess, when the physical signs are not clear enough for free incision. In such cases to be immediately followed by free incision, when the pus is found. 6. To gain time, and relieve the harmful tension in some cases of calculous suppression. I would restrict the use of nephrotomy — • I. To cases of calculous suppression, in which incision seems preferable to mere puncture, with the chance of being also able 68 to remove the stone, i.e., if further experience shows that this is a safer and better operation than my combined method. 2. For the cure, by subsequent drainage, of simple cysts, abscesses, and hydatids. The question of possible cure in some cases of hydronephrosis to be further tested. 3. For the cure, by subsequent drainage, of traumatic pyo- nephrosis or pyelitis, and in the early stages of tubercular suppuration. 4. For the possible cure of more advanced calculous or tubercular suppurations, when the patient will not submit to nephrectomy. 5. For the performance of nephro-lithotomy in some cases, it extended experience shows that this procedure possesses any advantages over the combined method, or when those who have no experience in abdominal surgery are compelled to operate. 69 LECTURE III. "IV/r R. PRESIDENT and Gentlemen,— I have now arrived at a very important branch of my subject — renal tumours. All swellings are, surgically speaking, tumours, and a large number of the conditions which we have already considered might, therefore, be classed under renal tumours ; some of them, such as the simple cysts and hydatids, are actually tumours, even in the strict acceptation of the term, but the tumours which we are now going to consider are the solid neoplasms. A very great variety of cell element?, and an equally great variety in the dis- tribution, or arrangement of these elements are found in renal tumours ; so that we have to consider not only simple sarcomatous and carcinomatous tumours, but a number of difterent varieties in each class, and some which bear such close resemblances to more than one class, that it is difficult to assign to them their exact place in a purely histological classification. There are, however, only a few of these tumours which are common, and a still smaller number which are suitable for surgical treatment, and it is to these, that I shall chiefly direct your attention, though we cannot afford altogether to forget the rarer forms, especially when engaged in the difficult task of differential diagnosis. Simple Neoplasms. Fibromata — Inflammatory. Simple. Cystic. Muscular. Fatty. Lipomata. Hsematangiomata, Osteomata. 70 Adenomata — Papillary. Glandular. Papillomata. Malignant Neoplasms. Sarcomata — Spindle-cell. Round-celL Alveolar. Adenoid. Muscular. Myxomatous. Lymphadenomata. Carcinomata — Encephaloid. Scirrhus. Colloid. Epithelioma. Cylindroma. OSTEOMATA AND H/EMATANGIOMATA. Of these I have nothing to say ; the very occurrence of true bone tumours is doubtful, and the small vascular tumours, which resemble telangiectasis of the liver, have never been seen of sufficient size to render them surgically important. The fibromata and lipomata are much more important, as they have already furnished material for some striking surgical triumphs. We need not consider the small inflammatory nodules [ncphriiis iittersiitia/is tuherosa of Virchow), as they are mere curiosities. Simple Fibroma and Fibro-lipoma. The simple fibroma, often attains a great size, and so do the mixed forms. The fibro-cyst, which furnishes the largest specimens, is probably always a degenerative form of the simple fibroma, the cavities being the result of breaking down of central portions of the growth. The tumours in which there is an admixture of muscular tissue, also attain an enormous size (myo- or rhabdo-fibroma). Those in which fat is present are Uke the cystic tumours, products of 71 degenerative change in the simple fibroma ; they often also attain a very great size. Bruntzel removed successfully a simple fibroma weighing over 37 lbs. Thomas a fibro-cyst weighing lo lbs. Wilks records a post-mortem at which a tumour variously diagnosed during life, proved to be a specimen of the degenerative fibro-cyst. Billroth operated unsuccessfully for a fibro-myoma which weighed 40 lbs. Spencer Wells successfully removed two fibro-lipomata, weigh- ing i6| and 145 lbs. respectively, and tore away a third of one kidney, with one of the tumours. The portion of kidney re- moved was not affected by the disease, and the formation of fat was found by Eve to be secondary, /.- ^ ^w. ^^. -^7- \^ /A CP^^K' 7^ ^ A7 y ^^ ^ { ..'>■ .< "; COLUMBIA UNIVERSITY LIBRARIES (hsl.stx) RD 575 T39 C.1 The surgery of the kicnevs. 2002249715 --tTf'-- '-■'■•>. •». -•">v^' mmmmmm ...'■u<,l 'S^fet: yf^r u S^ ■,:/ i^-'Y. }■>■•:<' i:^'i