Presented by 
 Lloyd D. Reeks, D. 0. 
 
 COLLEGE OF OSTEOPATHIC PHYSICIANS 
 AND SURGEONS LOS ANGELES, CALIFORNIA
 
 uSURGICAL DISEASES 
 
 OF THE 
 
 KIDNEY AND URETER' 
 
 INCLUDING 
 
 INJURIES, MALFORMATIONS AND 
 MISPLACEMENTS 
 
 BY 
 
 HENRY MORRIS, M.A., M.B. LOND., F.R.C.S. 
 
 VICE-PRESIDENT, AND CHAIRMAN OF THE COURT OF EXAMINERS, OF THE ROYAL COLLEGE 
 OF SURGEONS I SENIOR SURGEON TO THE MIDDLESEX HOSPITAL ; HONORARY 
 
 MEMBER OF THE MEDICAL SOCIETY OF THE STATE OF NEW YORK 
 
 AUTHOR OF THE HUNTERIAN LECTURES (1898) ON "THE ORIGIN AND PROGRESS OF RENAL 
 
 SURGERY," OF " INJURIES AND DISEASES OF THE GENITAL AND URINARY ORGANS " 
 
 AND OF "THE ANATOMY OF THE JOINTS," ETC. ETC.; AND EDITOR OF 
 
 " A TREATISE OF HUMAN ANATOMY BY VARIOUS AUTHORS " 
 
 WITH TWO COLOURED PLATES AND UPWARDS OF 
 TWO HUNDRED ENGRAVINGS 
 
 IN Two VOLUMES 
 
 VOL. I. 
 CASSELL AND COMPANY, LIMITED 
 
 LONDON, PARIS, NEW YORK $ MELBOURNE 
 
 ALL RIOHTS RESERVED
 
 Wl3oo 
 
 ^ I
 
 PREFACE. 
 
 &. = 
 
 U-> 
 
 IN this work an attempt is made to give a systematic account 
 
 c-*, (1) of the regional anatomy, the malformations and misplace- 
 
 ments, and the injuries and surgical diseases of the kidney 
 
 and of the ureter; (2) of the affections of the perinephric 
 
 and the peri-ureteral tissue; and (3) of the surgical treatment of 
 
 these several conditions as recommended and practised at the 
 
 present time by those most occupied in this branch of surgery. 
 
 Though largely based upon my personal experience, the 
 
 work, without pretending to be of encyclopaedic completeness, 
 
 is also the outcome of long and extensive study of the 
 
 writings of others. 
 
 The Transactions of the various societies, and every avail- 
 able journal in the English and European languages which 
 appeared during the decade following the passing for press in 
 November, 1884, of my Manual on the :< Surgical Diseases of the 
 Kidney " were carefully searched for articles relating to renal 
 and ureteral surgery, and abstracts were made of all that 
 were found. 
 
 Since 1894 the same plan has been pursued so far as was 
 necessary to keep abreast with all that was being accomplished 
 in this branch of surgery; but the labour became increasingly 
 arduous owing to the bewildering rate of production of material, 
 much of which, however, only corroborated settled opinions 
 or previously established facts. 
 
 When writing the Manual the difficulty lay in obtaining 
 information owing to the scantiness of material there was 
 barely an indication of the path to be followed. In writing 
 the present work the difficulty has been of the opposite 
 kind, and has lain in finding time to peruse and opportunities 
 
 .28334
 
 VI PREFACE. 
 
 to fully digest the many articles by the numerous contributors 
 the path having been trodden so hard. 
 
 Before February, 1880 (the date of the first nephrolithotomy), 
 besides G. Simon's incomplete work, not more than a score of 
 articles on renal surgery, chiefly on nephrectomy, had been 
 written ; whereas between 1880 and 1890 Bruce Clarke's Hunterian 
 Essay (1886), Treatises by Brodeur (1886), Newman (1888), Le 
 Dentu (1889), and Tuffier (1889), and over three hundred papers 
 had been published ; and between 1890 and 1900 Knowsley 
 Thornton's Lectures (1890), one volume of Kuster's still unfin- 
 ished work (1894), and about a thousand articles, lectures, and 
 reports on renal cases and operations appearedv 
 
 The development of the surgery of the ureter, which had 
 barely commenced ten years ago, has of late made remarkable 
 strides, as is shown by the fact that from 1894 to the present 
 time about one hundred papers on the subject have been 
 published, whereas in the five years immediately preceding, the 
 number might have been counted on the fingers of one hand. 
 
 The Manual written in 1883-1884 is the nucleus of Part I. 
 of this book; but that it is not more than a nucleus may 
 be inferred from the growth of the literature during the 
 last decade and a half and from the increase in personal 
 experience gained by twenty years of practice in renal surgery. 
 Part II. of this book namely, that on the ureter is entirely 
 new. 
 
 The work was commenced in the summer of 1897, and has 
 absorbed the whole of my spare time since then. 
 
 It has been my desire to include everything of value which 
 has been authentically established regarding the etiology, patho- 
 genesis, pathology, symptomatology, prognosis and treatment of 
 the subject matters concerned ; and where teaching or practice 
 differs to give the views of representatives of the various 
 schools. 
 
 If, as is quite certain to be the case, faults, both of omission 
 and commission are discovered by those who will take the 
 trouble to read these pages and to study their contents, I would 
 ask the reader to bear in mind how srreat a mass of material
 
 PREFACE. Vll 
 
 has had to be assimilated, and the constant interruptions, so 
 hostile to quiet study and any attempt at literary composition, 
 which must inevitably occur in the daily life of one engaged 
 in active professional work. 
 
 If it should seem to any of the numerous writers on the 
 subjects herein dealt with that his own work has not received 
 adequate recognition, I must ask him to pardon the inadvertence 
 and accept my regrets; and this I can do with the conscious- 
 ness of having honestly endeavoured to bring to my task a 
 spirit of absolute fairness, with the intention of making use 
 of every piece of instruction and every useful suggestion I 
 could glean, wheresoever it was found and with whomsoever it 
 originated. 
 
 It has been an object with me to make no statement which 
 is not justified by my personal experience, or supported by the 
 authority of one who has the right to speak from his own 
 experiments, practice, or observations. 
 
 It was at first my intention to give a bibliographical list at 
 the end of each subject, 'but it was found that in many cases 
 each of such lists would run into several pages of print, and 
 I therefore finally decided to simply give the names of the 
 authors referred to or quoted in the work. 
 
 A minor feature of the book is an attempt to make the 
 headlines to the pages of real use to the reader, so that by 
 merely turning over the leaves of the volume he can see at a 
 glance mention made of at least one of the leading points 
 described or referred to on each page. 
 
 It would have been impossible for me to complete this 
 work without assistance ; and I have pleasure in acknowledg- 
 ing my indebtedness to Miss Hannam, to Mr. Arnold Lawson, 
 Dr. W. E. Wynter, and Dr. Campbell Thomson for their services 
 in searching the periodical literature and other sources of 
 information, and in making abstracts and summaries therefrom 
 for my use. 
 
 To Drs. Wynter and Campbell Thomson I am further in- 
 debted for much assistance in revising and recasting certain 
 of the chapters of my Manual, and to the latter also for
 
 Vlll PREFACE. 
 
 constructing the index and for valuable help in correcting the 
 proof-sheets. 
 
 To Mr. Frank Steele I am under a great obligation for 
 the extremely careful manner in which he perused the proofs. 
 
 Mr. Clarke of the Royal Medical and Chirurgical Society's 
 Library, and Mr. Hewitt of the Library of the Royal College 
 of Surgeons, have also rendered me service by obtaining and 
 verifying many references. 
 
 Nearly all the illustrations are original, and for the most 
 part were drawn specially for this work ; this was the case 
 even with those which have appeared already in papers 
 published in the medical periodicals, and in my "Hunterian 
 Lectures." A great many of the drawings were made from 
 specimens removed during life from patients under my care. 
 Several are copies of specimens contained in the Museum of 
 the Royal College of Surgeons or of one or other of the Metro- 
 politan . Hospitals, and to the authorities of those Institutions 
 I am indebted for the privilege of being allowed to have 
 drawings made from the preparations. 
 
 A few of the figures are reproduced from other works, 
 and are, I hope, in every case properly acknowledged. 
 
 I have been very kindly supplied by my friend M. Recainier 
 of Paris with the cliches of two figures illustrating the regional 
 anatomy of the kidney, and by M. Albarran with cliches of 
 his ureteral cystoscope. 
 
 To Professor Arthur Robinson I am indebted for the great 
 care and trouble he has taken in verifying and correcting my 
 descriptions of the surgical anatomy of the kidney and ureter; 
 for checking the proof-sheets of these particular chapters, and 
 for some excellent original drawings which appear above his 
 name. 
 
 To Mr. Berjeau my thanks are expressed for the skill 
 with which he has made the drawings of recent and museum 
 specimens. The great majority of the figures are from his 
 pencil, and his ability in this class of work is well known 
 to the profession. 
 
 Mr. Butterworth I cannot too warmly thank for his admirable
 
 PREFACE. IX 
 
 and artistic engravings, and for the patience, care, and interest 
 with which he has executed them. 
 
 Finally I desire to acknowledge the great pains taken 
 with the work in the editorial and reading departments of 
 Messrs. Cassell & Co., and to thank the firm for the liberal 
 and courteous manner in which they have met my requests 
 and carried out my wishes. H. M. 
 
 8, Can-mi i.^ti Square, W. 
 May, 1901.
 
 CONTENTS OF VOLUME I. 
 
 $ art !. 
 SURGICAL DISEASES OF THE KIDNEY. 
 
 CHAPTER I. 
 REGIONAL ANATOMY OF THE KIDNEY 
 
 CHAPTER II. 
 ABNORMALITIES OF THE KIDNEY ... ... ... ... ... 18 
 
 CHAPTER III. 
 CLINICAL EXAMINATION OF THE KIDNEY ... ... ... ... 83 
 
 CHAPTER IV. 
 MOVABLE AND FLOATING KIDNEY ... .. ... ... ... 92 
 
 CHAPTER V. 
 INJURIES OF THE KIDNEY. SUBPARIETAL INJURIES ... ... 141 
 
 CHAPTER VI. 
 
 INJURIES OF THE KIDNEY (continued). INCISED AND PUNCTURED 
 
 WOUNDS ...... .................. 199 
 
 CHAPTER VII. 
 INJURIES OF THE KIDNEY (continued). GUN-SHOT WOUNDS ... 219 
 
 CHAPTER VIII. 
 ANEURYSM OF THE RENAL ARTERY ... ... ... ... ... 238 
 
 CHAPTER IX. 
 PERINEPIIRIC EXTRAVASATIONS, TRAUMATIC AND NON-TRAUMATIC... 255
 
 Xll CONTENTS. 
 
 CHAPTER X. PAGE 
 
 PERINEPHRITIS AND PERINEPHRIC ABSCESS ... ... ... ... 270 
 
 CHAPTER XI. 
 ACUTE AND SUBACUTE PYELO-NEPHRITIS WITHOUT SUPPURATION ... 303 
 
 CHAPTER XII. 
 SUPPURATION OF THE KIDNEY ... ... ... ... ... 317 
 
 CHAPTER XIII. 
 URINARY FEVER ... ... ... ... ... ... ... 350 
 
 CHAPTER XIV. 
 RENAL AND CIRCUMRENAL FISTULA ... 374 
 
 CHAPTER XV. 
 NEPHRECTASIS, OR RENAL DISTENSION ... ... ... ... 395 
 
 CHAPTER XVI. 
 TUBERCULOSIS OF THE KIDNEY ... ... ... ... ... 478 
 
 CHAPTER XVII. 
 RENAL SYPHILIS ... ... ... ... ... ... ... 519 
 
 CHAPTER XVIII. 
 TUMOURS OF THE KIDNEY ... ... ... ... ... ... 529 
 
 CHAPTER XIX. 
 TUMOURS OF THE RENAL PARENCHYMA ... ... ... ... 547 
 
 CHAPTER XX. 
 
 TUMOURS OF THE RENAL PARENCHYMA (continued}... ... ... 618 
 
 CHAPTER XXI. 
 TUMOURS OF THE RENAL PARENCHYMA (continued)... ... ... 633
 
 SURGICAL DISEASES OF THE 
 KIDNEY AND URETER. 
 
 PART I. SURGICAL DISEASES OF THE KIDNEY. 
 
 CHAPTEE I. 
 REGIONAL ANATOMY OF THE KIDNEY. 
 
 IT will be desirable to commence with a description of the normal 
 situation and regional anatomy of the kidney, so as to enable the reader 
 to readily refresh his memory respecting the means whereby it is 
 retained in its position, and the structures which must be cut through 
 or disturbed in the event of any operation upon the organ, or which 
 are likely to be involved by inflammation or suppuration or new 
 growths of the kidney. But first a word or two as to the size and 
 shape of the kidney. 
 
 The kidney measures about 4 inches in length, 2| inches 
 in its transverse axis, and 1^- to li inches in thickness. The loft 
 kidney is usually a little longer and a little narrower than the right. 
 The weight of each is from four to six ounces, being somewhat 
 heavier in the male than in the female. In form the kidney is 
 compressed from before backwards, so that it presents an anterior 
 and a posterior surface ; a long convex outer border, and a shorter 
 concave inner border with a deep notch, the hilum, at its mid-point ; 
 and an upper and a lower extremity, each of which is somewhat wider 
 than the transverse measurement of the central part of the organ , 
 the upper extremity being usually somewhat wider than the lower. 
 
 The anterior surface is convex and looks somewhat out 
 wards away from the sides of the bodies of the vertebrae, as well 
 as forwards. The posterior surface is flattened and is directed 
 somewhat inwards towards the tips of the spines of the vertebrae, a* 
 VOL. i. B
 
 2 SURGERY OF THE KIDNEY AND URETER. 
 
 well as backwards. Its upper two-thirds or thereabouts are under 
 cover of the eleventh and twelfth ribs, but its lower one-third descends 
 
 :; 
 
 Fig. 1. The Lumbo-costal or Vertebro-costal Ligament, attached to the transverse 
 processes of the first and second lumbar vertebrae, and to the twelfth rib, 
 which is long. (After f'araltettf and Recamier.} 
 
 below them. Occasionally the twelfth rib is too short to extend across 
 this surface of the kidney. Henle and Recamier describe a fibrous 
 ligament (vertebra-costal), which reaches from the tips of the transverse 
 processes of the first and second lumbar vertebrae upwards and 
 outwards, to be attached to the twelfth rib, or to the eleventh rib
 
 THE TUNICA ADIPOSA AND PERINEPHRIC FASCIA. 3 
 
 when the twelfth is abnormally short. This ligament is a process 
 of the anterior layer of the transversalis aponeurosis. The inferior 
 extremity of the kidney descends but a short distance below it 
 {Fig. 1). The thick rounded upper end of the kidney is about 
 one centimetre nearer the spinal column than the lower end, 
 and has a slightly more posterior position : the suprarenal capsule 
 descends a little upon its anterior aspect. 
 
 Borders. Owing to the oblique direction of the surfaces 
 and extremities of the kidney the outer convex border is inclined 
 somewhat upwards and backwards towards the parietes of the loin, 
 whilst the inner border looks somewhat down wards and forwards. 
 The outer border at its upper part is 3| inches from the middle line 
 of the body, and at its lower part it is 3f inches from this same line. 
 The hilum of the left kidney is 2 inches from the aorta, and the hilum 
 of the right kidney about 1 inch and f from the vena cava ; these 
 are important facts to bear in mind in performing nephrectomy. 
 
 The position of the kidneys is deep in the loins along the 
 sides of the last dorsal and first three lumbar vertebrae. The kidney 
 rests about equally upon the diaphragm and the anterior layer of 
 the posterior aponeurosis of the transversalis muscle, which separates 
 it from the quadratus lumborum muscle ; to a slight extent inter- 
 nally and inferiorly it rests also upon the psoas muscle. The 
 upper edge of the kidney corresponds with the space between the 
 eleventh and twelfth ribs, and the lower edge is nearly on a level 
 with the middle of the third lumbar spine. The right kidney as 
 a whole is lower than the left, but occasionally the left, owing to 
 its more elongated shape, extends downwards lower than the right. 
 
 The kidney is enveloped in a bed of areolo-fatty tissue. This 
 tissue is called the tunica adiposa, or fatty capsule. It is scarcely 
 marked in the infant or before the tenth year. It is thick and 
 abundant posteriorly as well as at the hilum and upon the convex 
 border ; but in front, between it and the anterior layer of the 
 perinephric fascia, it is very thin. It is a little thicker again 
 above and behind ; and below the inferior end of the kidney it 
 is very thick, and forms quite a cushion which is continuous 
 below with the cellulo-fatty tissue of the false pelvis. 
 
 This perinephric fatty tissue has a very striking appearance and 
 contrasts markedly with ordinary fat, being very soft and fine in 
 texture and of a delicate canarv-vellow colour. It is traversed bv
 
 4 SURGERY OF THE KIDNEY AND URETER. 
 
 very fine and loose cellular tissue fibres, which pass from the 
 proper fibrous capsule of the kidney to the perinephric fascia, and 
 which are rather stronger and better marked at the extremities 
 of the organ. It is itself but loosely connected with the proper 
 fibrous capsule of the gland ; but sometimes, after inflammatory 
 changes have taken place in it, the adhesion between them is 
 very intimate and even inseparable. 
 
 It is perhaps to this " packing " of areolar fatty tissue, more 
 than to any other single feature of its anatomy, that the kidney 
 owes its fixity of position in the recess of the loin. But in spite 
 of this, and of the restraint afforded by the perinephric fascia, 
 the vertebro-costal ligament and the peritoneum which covers 
 its anterior surface, the kidney has, in certain persons, an 
 undoubted tendency to shift from its bed and become displaced. 
 
 The amount of fat in the tunica adiposa is variable. In fat 
 pei-sons it is often very considerable, and may mislead one at 
 the bed-side examination as to the size of the kidney itself. 
 Again, when fat persons lose flesh rapidly the fatty elements of 
 the tunica adiposa are quickly absorbed, the capsule becomes loose, 
 and its connections both with the kidney and the surrounding 
 perinephric fascia are relaxed. 
 
 The perinephric fascia The kidney, covered by its proper 
 fibrous capsule, to be again mentioned later on, and embedded 
 in its adipose capsule which has just been described, is contained 
 within a sheath of thin fascia, which has of late been specially 
 studied by Anderson, Zuckerkandl, Gerota, Glantenay* and 
 Gosset, and others. This perinephric fascia consists of two layers, 
 an anterior and a posterior, which meet above and on the 
 outer side, but not on the inner side or below. To this fascia 
 is attached a very important role in the fixation of the organ 
 (Plate I., Figs. 2 and 3). 
 
 The anterior layer is thinner than the posterior, and 
 follows the course of the peritoneum which covers it. It passes 
 over the anterior surface of the kidney and suprarenal capsule, 
 and the structures at the hilum, and is continuous across the 
 middle line with the corresponding layer of the perinephric 
 sheath of the opposite kidney. On the left side it is, according to 
 
 * Glantenay and Gosset, " Le Fascia Peri-renal," Annales des Maladies 
 des Oryancs Genito-urinaires, 1S9S, p. 118 ct seq.
 
 PLATE I. 
 
 Fig. 1. Vertical Section of Kidney through the Pelvis and Calyces (the an- 
 terior half seen from behind). 1 and 1', the Capsule and Cortex ; 2, the 
 Pyramids of Malpighi ; 2', Papillit of Pyramids in section ; 3, the 
 Columns of Bertini ; 4, the interior of the Pelvis ; 5, the Calyces ; 6, the 
 Papilte anterior to the line of section ; 7, Section of a Calyx with the 
 entering Papilla ; 8, the Renal Artery ; 8', posterior branch of the Renal 
 Artery ; 9, the Renal Vein ; 10, the Ureter. (After L. Testut.) 
 
 Fig. 2. Vertical Anterior-posterior Section through the Kidney (diagrammatic). 
 1, Diaphragm ; 2, Retro-renal Fascia; 3, Perinephric Fat; 4, Paranephric 
 Fat ; 5, Pre-renal Fascia. (After Glantenay and A. Gosset.) 
 
 Fig. 3. Horizontal Section through the Kidneys (diagrammatic). 1, Peri- 
 toneum; 2, Pre-renal Fascia; 3, Retro-renal Fascia. (After fllnntennii 
 <r,i,1 A. flnwt.)
 
 Fig. 3. 
 
 [To face p. -1, Vol. I.
 
 THE PERINEPHRIC FASCIA. 
 
 Zuckerkandl, rather thicker than on the right. Above, it joins with 
 the posterior layer of the fascia, and becomes firmly attached to the 
 
 Fig. 2. Showing the relations of the Kidney to the Liver, Spleen, Colon, Stomach (E), 
 and Duodenum (n). xii., Twelfth Dorsal Vertebra; in, Left Colic Branch of 
 Inferior Mesenteric Artery. (After Farabcuf and Recamier.} 
 
 diaphragm (Fig. 21, p. 103); below the kidney it becomes gradually 
 
 thinner, and is finally continued into the cellular tissue of the iliac fossa. 
 
 The posterior layer is attached along the median line to the 
 
 bodies of the vertebrae and the inter-vertebral discs; it passes over
 
 6 SURGERY OF THE KIDNEY AND URETER. 
 
 the psoas and over the aponeurosis in front of the quadratus 
 lumborum, and having reached the external border of the kidney 
 it joins the anterior layer at the point of reflection of the peri- 
 toneum, and is continued indistinguishably with the sub-peritoneal 
 fascia (Fig. 22, p. 104). 
 
 By this arrangement of the two layers of the perinephric 
 fascia a sheath or investment is formed containing the kidney, 
 its cellulo-fatty capsule and its adrenal which is closed above 
 and along the outer border, but is open along the inner border 
 and below. This explains why the movements of the kidney 
 occur in an inward and downward direction, and how it is that 
 inflammations of the cellular tissue of the pelvis can ascend along 
 the ureter by continuity to the cellulo-fatty tissue around the 
 kidney and at the hilum. 
 
 The peritoneum adherent to the front surface of the kidney 
 is reflected off its convex border on to the abdominal wall. To 
 a certain degree the kidney can be moved under the peritoneum 
 covering it, but in addition to that the peritoneum moves with 
 the kidney. The kidney can also move within its fatty capsule, 
 as well as with that capsule within the perinephric fascia. 
 
 Relations to other organs. The front of the right kidney 
 is in contact above with the posterior part of the under surface 
 of the right lobe of the liver ; at the middle towards the left 
 side with the second part of the duodenum, and lower and to 
 the right with the hepatic flexure of the colon; and below, in 
 the angle of the hepatic flexure, with a coil of small intestine. 
 Where it is in contact with the liver and the small intestine it 
 is covered with peritoneum, but where it is in relation with 
 the duodenum and hepatic flexure it is devoid of peritoneum, and 
 it is in direct contact with the bare posterior surface of the 
 wall of the gut (Tig. 2). 
 
 The upper part of the front of the left kidney is separated 
 from the fundus of the stomach by the splenic artery, and then 
 comes in contact with the pancreas; lower down along its left 
 side it is in relation with the commencement of the descending 
 colon, and internal to the colon, with a coil of small intestine. 
 The external border of this kidney is in contact in the upper 
 two-thirds of its extent with the spleen and in the lower third 
 with the descending colon (Fig. 2). At its upper and lower
 
 STRUCTURES POSTERIOR TO THE KIDNEY. 7 
 
 ends and along the upper part of its left border, it is covered by 
 peritoneum ; the remaining parts are in direct contact with 
 the adjacent viscera without the intervention of peritoneum. 
 
 The connection of the suprarenal capsules with the kidneys 
 diminishes with age, and in the adult is not usually very firm, 
 owing to the interposition of a layer of cellulo-fatty tissue, which 
 does not exist in the foetus at full term. The right adrenal rests 
 upon the upper pole of the right kidney, and the left adrenal is 
 in relation principally with the upper part of the inner border, 
 and only slightly with the upper pole of the left kidney. 
 The connection is rather more intimate on the left side, because 
 the left suprarenal vein generally joins the renal vein, whereas 
 the right goes direct to the vena cava. The suprarenal capsule 
 is contained within the layers of the perinephric fascia, which 
 do not unite as described by Sappey at the level of the upper 
 pole of the kidney but pass, one in front of and the other behind 
 the adrenal, and only when above it become fixed together and 
 contract firm adhesions with the under surface of the diaphragm. 
 
 Surface anatomy. The kidney occupies a space which is 
 represented on the anterior surface of the body in Pig. 3. 
 A horizontal line through the umbilicus is below the lower edge 
 of each kidney ; a vertical line carried upwards to the costal 
 arch from the middle of Poupart's ligaments has one-third of 
 the kidney to its outer side, and two-thirds to its inner side, 
 i.e. between this line and the median line of the body. 
 
 On the posterior surface of the body its boundaries are in- 
 dicated by the following : (1) A line parallel with and one inch 
 from the spine between the lower edge of the tip of the spinous 
 process of the eleventh dorsal vertebra and the lower edge of 
 the spinous process of the third lumbar vertebra. 
 
 (2) A line from the top of this first line outwards at right 
 angles to it for 2f inches. 
 
 (3) A line from the lower end of the first transversely outwards 
 for 2 f inches. 
 
 (4) A line parallel to the first and connecting the outer ex- 
 tremities of the (2) and (3) lines just described (see Fig. 4). 
 
 The structures which cover the posterior aspect of the 
 kidney within this space are the following, enumerated in their 
 order from without inwards :
 
 8 
 
 SURGERY OF THE KIDNEY AND URETER. 
 
 (1) After reflecting the skin, the superficial fascia is exposed, 
 and ramifying in it are the external branches of the posterior 
 primary division of the eleventh and twelfth dorsal, and first, second, 
 and third lumbar nerves ; the posterior branches of the lateral cu- 
 taneous offsets of the tenth and eleventh dorsal nerves ; and 
 
 some small cutaneous branches 
 from the intercostal and lum- 
 bar arteries which ramify with 
 the corresponding nerves. 
 
 Beneath these is the deep 
 fascia. 
 
 (2) After removing the 
 deep fascia, the aponeurosis 
 and some of the lower posterior 
 fleshy fibres of the latissimus 
 clorsi muscle appear. 
 
 (3) Beneath the latissimus 
 are (a) the serratus posticus 
 inferior, the fibres of which 
 take an outward, forward, and 
 upward direction from the 
 spines of the vertebrae to the 
 lower ribs ; (6) the posterior 
 layer of the aponeurosis of 
 the transversalis muscle, 
 which, together with the 
 aponeurosis of origin of the 
 latissimus dorsi and serratus 
 posticus inferior, constitute the 
 fascia lumborum ; (c) to the 
 
 outer edge of the fascia lumborum, which itself corresponds to the 
 outer edge of the erector spince muscle, are the fleshy origins of 
 the internal, and the posterior free edge and the fleshy origin from 
 the twelfth rib of the external oblique muscles of the abdomen ; 
 {(1) all the twelfth rib except its head and, when long, its anterior 
 extremity (Fig. 1), the external intercostal muscle between it and 
 the eleventh rib, and about two inches of the eleventh rib near 
 its angle, and also a triangular area of the tenth intercostal muscle. 
 (4) The erector spince muscle : beneath and to the outside of 
 
 Fig. 3. Relative Position of the Kidneys 
 to the front surface of the Abdomen.
 
 STRUCTURES POSTERIOR TO THE KIDNEY. 
 
 this muscle the middle layer of the posterior aponeurosis of the 
 transversalis abclominis, and externally to this again the undivided 
 aponeurosis, and the fleshy fibres of the transversalis muscle. 
 Piercing the aponeurosis of this muscle at its outer part is 
 the anterior primary branch of the last dorsal nerve, its ac- 
 companying vessels, and the 
 ilio-hypogastric nerve. The 
 first lumbar artery gives off 
 a branch which pierces the 
 deep fascia and runs along 
 the outer border of the erector 
 spinse in the groove between 
 that muscle and the quadratus 
 lumborum. This branch is 
 often of considerable size. 
 
 (5) After removing the 
 erector spinne muscle and the 
 middle layer of the transversalis 
 aponeurosis and some of the 
 fleshy fibres of the transvers- 
 alis, we see the trunks of the 
 last dorsal nerve and its 
 accompanying vessels, and the 
 abdominal branches of the 
 second, third, and fourth 
 lumbar arteries and veins, the 
 levator cost* of the twelfth 
 
 rib, the tips of the trans- Fig< 4._R e lative Position of the Kidneys to 
 verse processes of the three the posterior surface of the Body, 
 
 upper lumbar vertebrae, the 
 
 posterior surface of the quadratus lumborum on which the lumbar 
 arteries rest, and the inter-transverse muscles. The first and the 
 last lumbar arteries pass in front of the quadratus, but the second, 
 third, and fourth pass behind that muscle. The edge of the quadratus 
 extends beyond the outer edge of the erector spinae below and 
 is well seen without disturbing the sacro-lumbalis or ilio-costalis 
 muscle, but above it is usually hidden beneath the erector (Fig. 5). 
 
 (G) In front of the quadratus lumborum is the anterior layer 
 of the posterior aponeurosis of the transversalis muscle, the last
 
 10 
 
 SURGERY OF THE KIDNEY AND URETER. 
 
 dorsal, ilio-hypogastric, and ilio-inguinal nerves and the outer 
 part of the psoas muscle ; and in front of these again is the 
 paranephric adipose tissue, the perinephric fascia, and the tunica 
 adiposa of the kidney. 
 
 (7) On removing or opening up the tunica adiposa, the whole 
 
 Serratus posticus 
 inferior 
 
 Erector spin* 
 
 External bonier of 
 quadratus lumborum 
 
 -t- Latissi 
 4 12th R 
 
 llth Rib 
 
 mus dorsi 
 
 Rib 
 Kidney 
 
 ] 2th dorsal nerve 
 Border of external 
 oblique musi-le 
 beneath latissi- 
 mus dorsi 
 Colon 
 
 L.nteral branch of 
 12th dorsal nerve 
 Tost, border of 
 extern, oblique 
 
 Ilio-hypogastric 
 nerve 
 
 Iliac branch of 
 ilio-hypogastric 
 nerve 
 
 Lumbo-ilio- 
 inguinal incision 
 
 Fi g. 5 Showing the relation of Structures behind the Kidney and in the Ilio-costal 
 space. (From a dissection by Professor Arthur Itobiiison.') 
 
 of the posterior surface of the kidney, the pelvis of the kidney, 
 and the commencement of the ureter are exposed. For this 
 purpose, however, it is necessary to drag the lower ribs upwards 
 with the tips of the fingers ; but the removal of the ribs is not 
 requisite unless the ilio-costal interval is unusually contracted. 
 It is common to find arterial twigs from the renal artery piercing 
 the capsules of the kidney, and ramifying in the adipose tissue.
 
 THE COSTO-DIAPHRAGMATIC HIATUS. 11 
 
 where they anastomose with branches of parietal vessels. Some 
 of the perinephric branches from the renal artery equal in size a 
 lumbar artery. 
 
 Posterior to as well as above the upper part of the kidney 
 is the diaphragm with its origins from the ligamentum arcuatum 
 externum and from the eleventh and twelfth ribs. Between the 
 
 Pneumo-gastric 
 nerve and 
 oesophagus 
 
 Fibrous arch over the 
 psoas muscles 
 
 4tli lumbar vertebra 
 
 Psoas muscles 
 Genito-crural nei 
 
 Diaphragm 
 
 llth rib 
 
 Diaphragmatic 
 pleura seen through 
 the costo-diaphrag- 
 matie hiatus 
 
 12th rib 
 
 Semi-circular 
 ligament of dia- 
 phragm, i.e. tlie 
 ligamentum arcua- 
 tum externum 
 
 Last dorsal nerves 
 
 Quadratus lum- 
 borum 
 
 Ilio-hypogastric 
 
 nerve 
 Ilio-inguinal nerve 
 
 Transvi-rsalis muscle 
 
 External cutaneous 
 nerve. 
 
 Fig. 6. Anterior view, showing Costo-diaphragmatic Opening. (After Ttstut}. 
 
 origin from the ligament and those from the eleventh and 
 twelfth ribs is the costo-diaphragmatic hiatus bridged, across by 
 a little cellular tissue and the pleura (see Fig. 6). The pleura 
 lining the eleventh and twelfth ribs and overlying the neigh- 
 bouring part of the diaphragm, and, in deep inspiration, the 
 wedge-shaped edge of the lung, intervene between the surface 
 of the body and the back of the left kidney at its upper end. 
 
 Below the right kidney, and below and to the outer side 
 of the left kidney, is the colon, in connection with which the 
 arteries and veins from and to the superior and inferior
 
 12 
 
 SURGERY OF THE KIDNEY AND URETER. 
 
 mesenteric trunks can be traced (Fig. 2). The right kidney is in 
 contact with the under surface of the liver, upon which it 
 makes a slight depression ; and the left kidney touches the 
 spleen, the splenic artery, and the pancreas, as described above. 
 
 The fibrous tunic of the kidney is a thin, smooth, but 
 firm and closely fitting envelope. Numerous fine elastic fibres 
 enter into its construction and give it considerable power of 
 stretching and contracting, according to the degree of vascular 
 tension of the organ. 
 
 This thin capsule adheres by minute processes of connective 
 
 tissue and capillary vessels to the 
 substance of the kidney, from off 
 which, in a healthy organ, it can, 
 however, readily be stripped. Beneath 
 the capsule there is an imperfect layer 
 of plain muscular fibres. 
 
 The capsule, following the hilum 
 or fissure in the renal substance, 
 passes into the sinus of the kidney 
 so as to become continuous around 
 the bases of the papillae of the 
 pyramids with the strong external 
 fibrous muscular and elastic tissues 
 of the calyces and pelvis of the 
 kidney. 
 
 If the ureter is traced upwards it 
 is found to lose its cylindrical form 
 on a level with the lower end of the 
 kidney, where it begins to expand 
 into a large funnel-shaped dilatation 
 known as the pelvis or infundibulum. After entering the hilum 
 the pelvis divides within the sinus of the kidney into two or 
 sometimes even several primary tubular branches (Fig. 7), which, 
 in turn, end in several short truncated but rather wide 
 pouches, named calyces, the mouths of which receive the 
 papillae. The calyces are connected with the bases of the papillae 
 in the following manner. The external fibrous tunic of each 
 calyx is continuous, as just stated, with the fibrous tunic of the 
 kidney ; the circular fibres of the muscular or middle tunic of 
 
 Fiic. 7. Cast of the Interior of the 
 Infundibulum and uprer end of 
 the Ureter. (Henle.) 
 
 u, Ureter ; p, pelvis or infuixlibuluin ; 
 c, calyces.
 
 THE CONSTITUENTS OF THE RENAL PELVIS. 13 
 
 the ureter are continued over the renal pelvis and terminate 
 where the calyces are attached to the papillae, forming the an- 
 nular muscles of the papillae (Henle). The longitudinal muscular 
 fibres can be traced for a short distance into the substance of 
 the kidney ; lastly, the internal or mucous coat of the calyx, 
 or at least its epithelium, is reflected over the papillae to become 
 continuous with the lining of the uriniferous tubes of the pyramid 
 which opens on the surfaces of the papillae. A single calyx often 
 surrounds two or it may be three papillae, so that the calyces 
 are less numerous than the pyramids of the kidney. The sinus 
 of the kidney is occupied also by the main branches of the renal 
 vessels, and by a quantity of fat ; this fat fills up the space 
 between the calyces, and serves as a soft and elastic bedding 
 for them and for the vessels of the kidney. 
 
 The relation of the structures at the hilum of the kidney, 
 i.e. of the structures which form the pedicle of the kidney. 
 Besides the dilated upper end (renal pelvis) of the ureter, the renal 
 artery and vein, a quantity of connective tissue, and a large 
 number of lymphatics and nerves enter into the formation of 
 the pedicle. 
 
 The renal artery is of large size ; large out of all proportion ta 
 the size of the organ it supplies. It arises from the side of the aorta 
 a little below the superior mesenteric artery, the right taking 
 origin generally a little lower down than the left. Owing to 
 the position of the aorta on the left of the middle line, the artery 
 of the right kidney is longer than the left and crosses behind 
 the inferior vena cava. Before reaching the hilum of the kidney 
 each artery divides into three chief branches, which sink into the 
 sinus behind the corresponding branches of the renal vein, two usually 
 being in front and one behind the pelvis of the ureter. Deeply 
 in the sinus of the kidney these branches break up into a num- 
 ber of smaller vessels which leave the sinus between the calyces 
 to enter the substance of the kidney between the papillae (see 
 Plate I., Fig. 1). Before entering at the hilum the artery gives 
 off one or two small branches to the suprarenal body and to the 
 ureter, and several twigs to the fatty and connective tissue around 
 the kidney. Some branches of the renal artery pierce the capsule 
 of the kidney to supply the circumrenal tissue. 
 
 The renal vein is a short wide vessel which, like the artery,.
 
 14 SURGERY OF THE KIDNEY AND URETER. 
 
 takes an almost horizontal course. Its primary branches, four 
 or five in number, issue from the hilum in front of the branches 
 of the artery, and then the vein continues in front of the renal 
 artery till it joins the vena cava. The vein from the right 
 kidney is usually a little lower down than that from the left, 
 but the left vein is longer than the right, and usually crosses 
 in front of the aorta, below the superior mesenteric artery and 
 alx)ve the third part of the duodenum, to reach the vena cava. 
 The left renal vein is joined by the left spermatic vein ; both 
 right and left renal veins receive tributaries from the suprarenal 
 capsule of their own side. 
 
 The lymphatics of the kidney are very numerous. The 
 superficial set form a plexus in the fibrous capsule. The deep 
 ones issue from the sinus with the blood-vessels, and both sets 
 end in the lumbar glands. 
 
 The nerves consist of filaments from both the sympathetic and 
 cerebro-spinal systems. They accompany the renal arteries and are 
 derived from the renal plexus and the lesser splanchnic nerve. 
 
 The connective tissue forms a packing for the other structures 
 in the renal pedicle. Peritoneum covers the front surface of 
 the pedicle, and sometimes, when the kidney is " floating," 
 more or less surrounds it. 
 
 The ureter. The manner in which the ureter is connected 
 with the kidney, and the relations of this tube at the hilum, 
 have just been described. We will here only briefly consider 
 the course of the ureter, and its anatomical connection with 
 the bladder, referring the reader for a fuller account to the 
 section on the anatomy of the ureter (Vol. II., p. 277). 
 
 The renal pelvis, formed by the union of the calyces, is directed 
 downwards and inwards from the hilum, and after becoming 
 gradually contracted assumes a cylindrical form opposite the lower 
 end of the kidney. Thence it is called the ureter proper (see Fig. 7). 
 
 The ureter measures about 12 inches (30 cm.) in length 
 in the adult, and is about the size of a goose-quill. The lumen 
 of the tube is by no means uniform. 
 
 As the ureter passes downwards and inwards to the brim 
 of the pelvis it lies immediately behind the peritoneum, and 
 has but a very loose connection, by means of cellular tissue, 
 with the parts on which it rests. These parts are the psoas
 
 PLATE II. 
 
 Figure showing the relation of the lower end of the Ureter to the Vesicula 
 Seminalis. The kidney, vessels, bladder, and rectum, with peritoneum 
 covering them, have been removed en masse and figured from their 
 posterior aspect. A, Abdominal Aorta ; V Inferior Vena Cava.
 
 PLATE II. 
 
 Ureter 
 
 Peritoneum 
 
 Ureter 
 
 (V'-iiin 
 
 Rectum i-ut 
 
 Bladder 
 
 Vas deferena 
 
 Right Yesicula 
 Seniinalis 
 
 Prostate 
 
 Rectum cut 
 
 :Toface p. 14, Vol. 1.
 
 THE COURSE AND RELATIONS OF THE URETER. 15 
 
 muscle and genito-crural nerve in the abdomen, the common 
 or external iliac artery as it crosses the pelvic brim, and in the 
 pelvis the internal iliac artery. In the abdominal part of its 
 course the ureter is crossed on both sides by the spermatic or 
 ovarian vessels, and, in addition, on the right by the third part 
 of the duodenum and the right colic and ileo-colic arteries, and on 
 the left by the left colic and sigmoid arteries, and at the 
 pelvic brim it is crossed by the termination of the ileum 
 on the right and by the first part of the rectum on the 
 left. The right ureter is close to the outer border of the 
 inferior vena cava. Having entered the pelvic cavity it 
 lies at first on the lateral wall running downwards and back- 
 wards on the obturator fascia, and crossing the obliterated hypo- 
 gastric artery and the obturator vessels and nerve on their 
 inner sides; in this part of its course it is covered internally 
 by peritoneum, which separates the left from the rectum 
 and the right from the terminal part of the ileum. After 
 reaching the level of the spine of the ischium it turns abruptly 
 inwards on the surface of the levator ani to the base of the 
 bladder, and its relations differ considerably in the male and 
 female. In the male it is crossed in front by the vas deferens, 
 which passes backwards and downwards between it and the 
 side of the bladder ; it touches the posterior part of the side of 
 the bladder and enters the base, If inches (4'3 cm.) from its 
 fellow of the opposite side and in front of the apex of the seminal 
 vesicle (Plate II.). In the female it is surrounded by numerous veins 
 derived from the uterine and vaginal plexuses ; it passes from one- 
 third to half an inch (813 mm.) above and to the outer side 
 of the lateral fornix of the vagina, crossing beneath the broad 
 ligament and uterine artery at the side of the neck of the 
 uterus, from which it is separated by loose connective tissue. 
 The distance between the cervix uteri and the ureter is from 
 three-quarters of an inch to one inch (1'8 to 2'5 cm.). The 
 ureter terminates in the base of the bladder. It is If 
 inches (4'3 cm.) from its fellow of the opposite side, and in front 
 of the anterior vaginal wall a quarter to half an inch (612 
 mm.) below the anterior fornix. 
 
 The ureter traverses the wall of the bladder obliquely for a 
 distance of three-quarters of an inch, and opens on the inner
 
 16 SURGERY OF THE KIDXEY AND URETER. 
 
 surface of that viscus by a narrow slit-like orifice, one inch 
 distant from the orifice of the opposite ureter, and about the 
 same distance behind the urethra. 
 
 After the ureters have pierced the outer and middle muscular 
 .strata of the bladder, the fibres of their own muscular coat are 
 disposed, according to Ellis, as follows : the internal, the most 
 numerous, are directed transversely, and unite with the corre- 
 sponding fibres of the opposite ureter ; whilst the remainder 
 join the submucous muscular layer of the bladder, and are directed 
 obliquely downwards over the " triangular space " to the sub- 
 mucous strata of the urethra. 
 
 Sir Charles Bell pointed out that on dissecting off the inner 
 coat of the bladder two strong fleshy bands (the muscles of 
 the ureters) are seen to descend from the orifices of the ureters 
 towards the urethral opening. Just behind the prostate these 
 bands are well marked and fleshy, and after uniting with one 
 another become tendinous, and are inserted into the lower and 
 back part of the middle lobe of the prostate. 
 
 As the ureters lie in the vesical wall they are much nearer 
 to the inner than the outer surface of the bladder, the muscular 
 coat being posterior to them. 
 
 Irregularities of the renal arteries. These are so com- 
 mon that some deviation from the regular condition is to be 
 expected in three cases out of every seven. The variations have 
 reference to the number, origin, branching, points of entrance 
 into the kidney, and, lastly, to the distribution of branches to 
 parts around. 
 
 It is much more common for the arteries to be increased 
 than decreased in number, and the greatest number is usually 
 found on the left side. Both renals have been seen arising by a 
 common stem from the front of the aorta (Portal). 
 
 Multiple arteries may be derived from the aorta, suprarenal, 
 lumbar or internal, external or common iliacs ; from the middle 
 sacral, the right hepatic, or the colica dextra. 
 
 According to Macalister additional arteries arise from the 
 various sources in the following order of frequency : 
 
 Suprarenal (very common) ; 
 2nd or 3rd lumbar ; 
 Right hepatic ;
 
 IRREGULARITIES OF THE RENAL ARTERY. 17 
 
 Colica dextra ; 
 
 External iliac ; 
 
 Internal and common iliac ; and 
 
 Middle sacral (very rare). 
 
 A unique case has been recorded by Otto in which a branch 
 from the right common iliac supplied the left kidney. 
 
 Renal arteries may enter the kidney on either surface, or 
 at either extremity ; but usually all the vessels pass in at the 
 hilum. 
 
 From the renal artery branches are given off almost constantly 
 to the suprarenal capsule ; occasionally also to the diaphragm 
 or its pillars ; to the colon, pancreas, or right lobe of the liver. 
 A branch to the testis may supplant the normal spermatic artery. 
 
 The renal veins are likewise liable to various abnormalities 
 as to their numbers and distribution. 
 
 The above variations occur unassociated as well as associated 
 with malformations and misplacements of the kidney. 
 
 VOL. i. c
 
 CHAPTER II. 
 ABNORMALITIES OF THE KIDNEY. 
 
 THE abnormalities of the kidney fall into three groups : 
 
 1. THE ABNORMALITIES OF POSITION. 
 
 2. THE ABNORMALITIES OF FORM, and 
 
 3. THE ABNORMALITIES OF NUMBER. 
 
 This last group is sub-divided into : 
 
 A. Single or unsymmetrical kidney, where one is entirely absent. 
 
 B. Solitary or fused kidney, where the two kidneys are massed 
 together. 
 
 C. Imperfect development, or atrophy of one kidney. 
 
 D. Absence of both kidneys. 
 
 E. Supernumerary kidneys. 
 
 1. THE ABNORMALITIES OF POSITION. MISPLACEMENTS 
 OF THE KIDNEY. 
 
 The study of misplacements of the kidney is important to the 
 clinical physician and practical surgeon who desire to escape 
 errors in diagnosis and catastrophes in operating. Such mis- 
 placements give rise to abdominal tumours, sometimes difficult to 
 diagnose. It is therefore necessary to remember that the kidney 
 is not always situated within the normal limits of its anatomy. 
 It is not very unfrequent for one or both kidneys to be some- 
 what misplaced, either as regards their distance from the spine 
 or their relation to the diaphragm above, or iliac crest below. Mis- 
 placed kidneys are very often somewhat misshapen. The kidney 
 may be movable as well as misplaced. M. Rayer, who was the 
 first to give a satisfactory account of this subject, divided mis- 
 placements of the kidney into two groups : namely, those in 
 which the misplacement is permanent, or, in other words, in 
 which the kidney is fixed in an abnormal position ; and those
 
 SIMPLE CONGENITAL MISPLACEMENTS. 19 
 
 in which the misplacement is not permanent, that is, where 
 the kidney is movable as w r ell as misplaced. Subsequent writers 
 have grouped these cases under three headings, namely, " simple 
 misplacement," " movable kidney," and " floating kidney." In 
 the simple misplacements the kidney may be higher or lower, 
 nearer to or farther from the spine than usual, or may have its 
 axes and borders altered in any direction, or may be turned 
 over upon its anterior surface, but yet thoroughly fixed in its 
 position, whatever that position may be. A kidney is "movable" 
 when, though appreciably mobile to a greater or less extent, it 
 is situated entirely behind the peritoneum. It is "floating" when 
 the peritoneal investment allows the kidney to float or drop 
 forwards, or to be moved in an upward or downward, or indeed 
 in any direction. 
 
 Simple misplacements may be either congenital or acquired, 
 (a) Congenital. Amongst the permanent misplacements of 
 the kidneys the most frequent is the horse-shoe kidney ; after 
 the horse-shoe variety the most common misplacement is into 
 a position over the sacro-iliac synchondrosis or the promontory 
 of the sacrum, or just below the bifurcation of the aorta, or in 
 the false pelvis just above Poupart's ligament. In such cases 
 it is common for the renal artery, or one of the renal arteries 
 when there are more than one to the same kidney, to be derived 
 from the aorta close to its bifurcation, or from the common 
 iliac artery of its own, or even of the opposite side. The supra- 
 renal capsule is occasionally, though by no means alwa}-s, mis- 
 placed along with the kidney. It was so in nine out of twenty- 
 four cases observed by Newman, who remarks : " Malposition of 
 the kidney does not necessarily involve an alteration in the 
 position of the suprarenal capsule" (Medical Press and Circular, 
 May 3rd, 1899). 
 
 Cruveilhier states (" Descriptive Anatomy ") that " when tht 
 kidneys are situated higher than usual, the suprarenal capsules 
 are placed on their inner side, and correspond with the renal 
 fissure ; when the kidneys occupy the pelvic region, the capsules 
 do not undergo the slightest change in their position, and no 
 longer have any connection with them." 
 
 Slight misplacements of the kidney are comparatively common 
 (in 1,000 post-mortem examinations Newman found twenty-four cases
 
 20 SURGERY OF THE KIDNEY AND URETER. 
 
 in which the position of one or both kidneys might be described as 
 abnormal), but usually have no clinical significance whatever, and 
 unless special attention is directed to them these slight alterations 
 in position may easily be overlooked in post-mortem examinations. 
 The more pronounced misplacements as when the kidney occupies 
 the iliac fossa or rests on the promontory of the sacrum, between 
 the rectum and bladder, or by the side of the uterus are much 
 rarer, and when they occur may give rise to grave symptoms 
 and complications, and have led to fatal disasters in practice. 
 
 In women, such malpositions have given rise to serious ob- 
 struction during parturition ; and to great suffering at the 
 menstrual periods, owing to the contact of the misplaced kidney 
 with the ovary (Folk's case). 
 
 It is more frequent for one kidney to be misplaced than for 
 both. Newman has reported a case in which the right kidney 
 was misplaced to a position a little to the right of the promon- 
 tory of the sacrum, and the left into the left iliac fossa. The 
 left kidney is much more commonly at fault than the right. 
 Forster (Virchow's Archiv, 1858, xiii., 275) mentions a case 
 in which the left kidney was misplaced into the right loin, yet its 
 ureter, after descending behind the colon, entered the bladder on 
 the left side : it was not a case of the ureter of a right kidney 
 opening into the left side of the bladder. Durham recorded 
 four cases of simple misplacement which had come under his 
 own knowledge, two at Guy's Hospital, and two in private prac- 
 tice. These were all congenital ; in three the left kidney was 
 involved, and in one the right. In each, the kidney lay over 
 the corresponding sacro-iliac synchondrosis, and extended more 
 or less into the true pelvis in front of the sacrum or its 
 promontory. In two of them the kidney was misshapen as 
 well as misplaced. The sex of the two Guy's cases is not given. 
 The other two cases were both men. Durham remarked, " Thus 
 within two years four cases of misplacement of the kidney have 
 fallen under my observation. Such abnormalities, therefore, 
 cannot be extremely rare. At the same time, it must be stated 
 that on searching through the records of more than 1,000 post- 
 mortem examinations, made at Guy's during the last few years, 
 I have only been able to find the two cases quoted above." 
 To this statement I may add, that during the twenty-four years
 
 FREQUENCY OF CONGENITAL MISPLACEMENTS. 21 
 
 ending 1897, in the post-mortem records of the Middlesex 
 Hospital, containing 0,536 examinations, there were but four 
 instances of misplaced kidneys. One was in a lad, aged nineteen 
 years, who died of chronic Bright's disease, and the left kidney 
 was situated upon the common iliac vessels. The second was 
 in a man, aged fifty-seven ; here the right kidney was on the 
 brim of the true pelvis, lying upon the external iliac vessels, 
 with its lower end applied against the right side of the bladder: 
 in this case there was a double ureter. The third instance 
 was that of a boy, aged sixteen, in whom the right kidney was 
 found to be firmly fixed, but rotated in such a way that its 
 upper end was much nearer the spine than usual. The fourth 
 occurred in a female, aged forty, and was exhibited by Dr. 
 Voelcker (Trans. Path. Soc. Lond., 1896, p. 173). In this case 
 the right kidney was situated in the right iliac fossa, and the 
 right renal artery arose from the right common iliac artery. 
 The right suprarenal body was in its normal position. The 
 uterus was unicoriiis, there being 110 trace of the right half of 
 this organ. 
 
 During the ten years ending 1882, the Guy's Hospital post-mortem 
 records contain the accounts of 4,632 examinations, and amongst 
 them there are seven instances of misplaced kidneys. The analysis 
 of these seven cases is as follows : Three were in men, three in 
 women, and one in a child aged eight months, who had both 
 kidneys misplaced into the pelvis. Two were left kidneys, one in a 
 man, one in a woman ; three were right kidneys, two in women, 
 one in a man. In the child both kidneys were separate ; in 
 one case (a man) the two kidneys were united, and rested on 
 the promontory of the sacrum ; the union was not horse-shoe- 
 shaped. In two instances the misplacement was acquired ; once 
 owing to enlargement of the liver and tight lacing, the right 
 kidney was displaced downwards, and turned completely over ; 
 and once owing to the drag of a large renal cyst in a woman, 
 whose liver was enlarged and contained a withered hydatid cyst. 
 In one case the right kidney was malformed and misplaced on 
 to the psoas muscle at the brim of the pelvis, and was lying 
 011 its back. In another case (man, aged forty-five) the right 
 kidney was below the brim of the pelvis ; and another (man, 
 aged twenty-six) the left kidney was lying chiefly below the
 
 22 SURGERY OF THE KIDNEY AND URETER. 
 
 brim of the pelvis, in the depression between the psoas and the 
 vertebrae, and it could be pushed so far upwards that half of 
 it came to be above the pelvis. Putting these several figures 
 together, there are seen to be 12,768 post-mortem examina- 
 tions yielding thirteen instances of misplaced kidney. We may, 
 therefore, expect on the average to find at least one out of every 
 thousand bodies containing a misplaced kidney. 
 
 A case in which both kidneys were displaced on to the brim 
 of the pelvis has been recorded by Potherat (Soc. Anatomique, 
 February, 1889). The right kidney was in a large measure destroyed 
 by cystic degeneration without any naked-eye alteration of its 
 ureter, while the left kidney was considerably augmented in 
 volume, apparently due to a compensatory hypertrophy. The 
 suprarenals occupied their normal situations. This anomaly was 
 also associated with a displacement of the duodenum, which was 
 situated in front of the inlet of the pelvis. 
 
 Sometimes the misplaced organ is abnormal in size, or form, 
 or in respect to its ureter or blood-vessels. In one case in which the 
 left kidney was in front of the fifth lumbar and firs): sacral verte- 
 brae, its long axis was almost vertical, but the usual position of 
 the organ was reversed, so that its convex border looked to- 
 wards the right and its hilum towards the left (Farquharson).* 
 
 Some deviation of the large intestine from its normal posi- 
 tion has been often found associated with the misplacement of 
 the kidney, more especially of the left kidney. When the left 
 kidney occupies the iliac fossa, or is situated over the left sacro- 
 iliac synchonclrosis, there is generally no sigmoid flexure in the 
 left iliac fossa ; but the descending colon passes across the middle 
 line, and the rectum commences on the right side of the sacrum. 
 Malformations of the genital organs, such as undescended testicles, 
 rudimentary vas deferens, double uterus and vagina, are also 
 frequently associated with this condition. The peculiarities 
 in the origin and connections of the blood-vessels and ureters, 
 the malpositions of the large intestine, and the malformations 
 which are found associated with misplaced kidney, suggest, if 
 they do not prove, the congenital nature of the misplace- 
 ment. In structure the misplaced organ is, as a rule, quite 
 normal. 
 
 *Jouni. Anat. and Phys., April, 1894, p. 303.
 
 SIMPLE ACQUIRED MISPLACEMENTS. 23 
 
 (6) Acquired. Simple misplacements result from pathological 
 enlargements of neighbouring organs, such as the liver, spleen, 
 pancreas, and suprarenal bodies ; and from the pressure of tu- 
 mours. Laennec saw a right kidney which had been jammed 
 down opposite the iliac crest by the liver. Tight lacing is 
 sometimes the cause of downward displacement of the kidney. 
 The right is more frequently affected than the left, because the 
 liver is less able to resist the compression than the organs in 
 the left hypochondrium. In this way the head of the right 
 kidney gets sometimes dislocated from its position between 
 the liver and diaphragm, and the whole organ becomes turned, 
 so that its long axis is in the antero-posterior direction, with the 
 upper end projecting forwards between the liver and the colon. 
 Such a kidney may be movable, and it is said sometimes to have 
 compressed the colon or vena cava. Wilks and Moxon have seen 
 the kidney in this position, but there were no ill effects in their 
 cases. 
 
 In one of the Guy's cases (No. 417, 1874) above referred to 
 (p. 21), the liver was large, contained two masses of cavernous tissue, 
 and was much pushed down by tight lacing. The right kidney 
 was displaced downwards and inwards towards the median line, 
 was turned completely over, and was lying 011 the psoas muscle and 
 the spinal column, with its anterior surface posteriorly, and the 
 ureter running downwards and inwards in front of the kidney. 
 Its position was oblique from above downwards and outwards; 
 its upper end, being behind the duodenum, pushed that part 
 of the gut well forwards from the spine ; the lower end came 
 to the surface between coils of the small intestine ; the colon 
 was below the kidney. The kidney was not easily moved 
 upwards or downwards, but was easily replaced in its natural 
 position as regards its surfaces, and could also be brought 
 into a line with the long axis of the body. (This is case iv. in 
 the Report of the Committee of the Pathological Society, vol. 
 xxvii. of the Transactions, p. 472.) 
 
 The kidney may be displaced in an upward, or downward, 
 or lateral direction ; or it may be rotated upon itself so that 
 the hilum looks upwards, outwards, directly forwards or back- 
 wards. Kuysch has figured a right kidney with its hilum above 
 and its convex border below, and its ureter passing behind the
 
 24 SURGERY OF THE KIDNEY AND URETER. 
 
 kidney. It occurred in a woman, aged forty, who died of heart 
 disease with pleuritic and peritoneal effusions. A good example 
 of acquired misplacement is amongst those in the Guy's Hospital 
 case books (No. 247, 1879). A woman, aged fifty-seven, who died 
 of phthisis, had in her liver a cured hydatid, the size of a Tan- 
 gierine orange. The left kidney was displaced on to the brim 
 of the pelvis by a large cyst in its lowest part, which contained 
 a pint of yellow fluid. The fluid had a urinous odour, and 
 there were echinococci in it. The cyst had dragged the 
 kidney down ; and the cyst itself occupied the greater part 
 of the pelvic cavity. The glandular substance of this kidney 
 and all the rest of the urinary organs were normal, except that 
 the other kidney (the right) only weighed three ounces. An 
 instance of misplacement upwards of the right kidney above the 
 level of the last rib, probably the consequence of perinephritis 
 in very early life, will be described in the section on malformed 
 kidneys. 
 
 The acquired, like the congenital misplacements of the kidney, 
 have been mistaken for abdominal tumours.* They have also 
 been known to obstruct or otherwise complicate labour ; but, as 
 a rule, the malpositions which are unattended by mobility of the 
 kidney are only discovered on post-mortem examination, and 
 give rise to no symptoms during life. A calculus, even of con- 
 siderable size, may be impacted in the ureter of a misplaced 
 kidney, and give rise to no symptoms whatever. Such a case 
 is recorded by Mr. Canton.t A man, aged twenty-seven, died of 
 bronchitis ; there had been no renal symptoms ; the right kidney 
 was quite normal, but the left was situated below the bifurca- 
 tion of the aorta, and between the common iliac arteries ; it 
 was lobulated and of a rudely oval shape, with its pelvis directed 
 forwards, and dilated, owing to the impaction of an oxalate of 
 lime calculus, which weighed two and a half drachms, in the 
 upper part of the ureter (Fig. 8). 
 
 In Biiidley's case, quoted by the Committee of the Pathological 
 Society of London, a uric acid calculus, weighing a hundred 
 grains, was found in the pelvis of a misplaced and very " mov- 
 able " right kidney ; but there is 110 mention made of any renal 
 
 * See pp. 27--20. 
 
 t Path. Soc. Trans., vol. xiii., p. 147.
 
 MISPLACED KIDNEY MISTAKEN FOR TUMOUR. 
 
 25 
 
 symptoms during life referable to the misplacement, mobility, 
 or calculus. 
 
 When occupying a position within the true pelvis the misplaced 
 kidney may be discovered accidentally by vaginal or rectal ex- 
 amination. In this event it has to be distinguished from a 
 morbid growth or an inflammatory swelling ; and the diagnosis 
 will rest chiefly on the size and growth and elastic character of 
 
 Fig. 8. Representing tabulated appearance of the Kidney, and its relations 
 to the Aorta and Sigmoid Flexure of the Colon. 
 
 Misplaced and malformed left kidney. Misplaced sigmoid flexure of colon. (Canton, Path. Trans.) 
 
 the misplaced body, and in the want of the usual fulness 
 and resistance in one or the other loin. If the swelling has 
 a reniform outline, the diagnosis will be facilitated. But, as 
 frequently happens in congenital misplacements, and also in the 
 acquired cases when the misplacement is due to an alteration 
 in the organ itself, the kidney has not the usual form, so that 
 the want of the characteristic outline must not unduly influence 
 the diagnosis.
 
 26 SUIIGERY OF THE KIDNEY AND URETER. 
 
 If the degree of suffering caused by the misplaced kidney 
 necessitates surgical treatment, nephrectomy will in most cases be 
 the only available resource, unless it be possible to fix the kidney 
 in a position in which it will cease to cause pain. A case has 
 been recorded by Owen (Med. Press and Circ., May 10, 1899), in 
 which nephrectomy was performed for a misplaced kidney which 
 gave rise to constant abdominal pain. The kidney could be felt 
 by rectal examination as a tumour lying in the concavity of the 
 sacrum, but its nature could not be definitely diagnosed. Laparo- 
 tomy proved it to be a well-shaped left kidney, which Avas success- 
 fully enucleated from its bed behind the rectum, and removed. 
 It is, however, quite exceptional for simple misplacement of the 
 kidney to need any treatment at all. 
 
 2. THE ABNORMALITIES OF FORM. MALFORMATIONS 
 OF THE KIDNEY. 
 
 By " malformations " of the kidney is here meant congenital 
 deviations from the natural form and size of that organ. 
 
 The kidney becomes changed in outline and dimensions by 
 various diseases. Thus, hydro-nephrosis, pyo-nephrosis, cystic 
 enlargements, morbid growths such as sarcoma and cancer of 
 the kidney, tubercle, and the scarred, contracted, and atrophied 
 condition which results from Bright's disease and interstitial ne- 
 phritis, are all so many forms of " misshapen " kidney. These are 
 described under their several headings. Here we are concerned 
 only with congenital malformations of the kidney. 
 
 Formerly such malformations were only physiologically in- 
 teresting ; now, owing to the fact that operations upon the 
 kidney are daily being performed, they are clinically of 
 importance. They are important from this point of view 
 (1) because malformed kidneys are frequently the result of fusion 
 of both kidneys, so that there is but one renal mass in the 
 body ; (2) because malformed kidneys, even when only one kidney 
 is involved, are generally misplaced ; and (3) because when a 
 misplaced kidney is also misshapen, the difficulty in diagnosing 
 the nature of the abdominal tumour which may be formed is 
 greatly increased, and the probability of injurious treatment being 
 adopted is much enhanced. The following case recorded by
 
 CONGENITAL MALFORMATIONS OF THE KIDNEY. 27 
 
 Durham in the G-uy's Hospital Reports * of 1860 shows the 
 importance of bearing in mind the last statement. 
 
 A gentleman, aged forty-five, after suffering from a severe 
 attack of fever, noticed for the first time a tumour deeply seated 
 in the hypogastric region, and somewhat to the left of the middle 
 line. This tumour was oval in form, somewhat elastic to the 
 touch, and fixed. It was not nodulated, nor did it possess any 
 distinctive elevations and depressions. Manipulation gave rise 
 to very disagreeable sensations, but not to acute pain. Con- 
 siderable alarm was felt by the patient, especially as some members 
 of his family had died from " tumour in the abdomen." More 
 than one skilled opinion was taken by the patient, and the con- 
 clusion arrived at was that a " tumour of doubtful character " 
 existed in the lower part of the abdomen, for which iodine oint- 
 ment was to be applied, and iodine of potassium taken internally. 
 This treatment was continued for some time, but of course with- 
 out effect ; the patient never thoroughly recovered his health 
 and strength, and between four and five years after first noticing 
 the tumour he died of pulmonary disease. At a post-mortem 
 examination the tumour was seen to be nothing more than 
 the left kidney misplaced and malformed. The right kidney 
 was normal in form and position. Both kidneys were healthy 
 in structure and of usual weight. The left kidney had no 
 hilum, and did not possess the characteristic shape. When 
 divested of fat it presented two depressions, one of which ex- 
 tended obliquely across the anterior surface, and the other was 
 on the inner and posterior aspects ; thus it was indistinctly 
 divided into three portions. The ureter resulted from the junction 
 of four branches ; of these, two came from the upper and pos- 
 terior part, while the two principal ones came from the anterior 
 and lower part ; these branches joined one another about an inch 
 from their several points of exit from the kidney. 
 
 There were three arteries, one from the aorta, just above its 
 bifurcation, one from the common iliac artery of the opposite 
 side, and one from the internal iliac of the same side. These 
 branches entered different parts of the kidney ; the chief supply 
 was derived directly from the aorta. There was one principal 
 vein, which passed from the internal and posterior part of the 
 
 * Third series, vol. vi., p. 407.
 
 28 SURGERY OF THE KIDNEY AND URETER. 
 
 organ into the vena cava, just above the junction of the two 
 common iliac veins. The suprarenal capsule was large, flat, and 
 in its normal position. The kidney was situated over the left 
 sacro-iliac synchondrosis, and extended somewhat on to the pro- 
 montory of the sacrum, and by its lower part into the true pelvis. 
 
 In this instance the kidney was first discovered as a " tumour " 
 after the patient had become emaciated by the fever ; and, owing 
 to its abnormal shape, no suspicion of its being a misplaced 
 kidney seems to have arisen ; but, as Durham remarks, 
 " had a correct diagnosis been made, how much alarm and 
 anxiety the patient and his friends might have been spared, and 
 how much irritating and useless treatment might have been 
 avoided ! " 
 
 Diagnosis. But the question, " How is error to be avoided, 
 and a correct diagnosis to be made ? " remains to be considered. 
 It must be allowed that this is no easy matter, because the 
 abnormality of form deprives us of a characteristic aid to 
 diagnosis which fortunately exists in most cases of movable 
 kidney. There is 110 hilum, perhaps ; and if there be, it will 
 almost certainly lack the normal relation to the rounded extremi- 
 ties and the concave and convex borders of the kidney, for neither 
 the rounded extremities nor the natural oblong outline of the 
 kidney may be present. The smooth, firm, but elastic surface 
 of the swelling gives but little information ; for a lobulated or 
 deeply grooved kidney may feel quite smooth and uniform when 
 covered by a thick layer of circumrenal fat, as in Durham's case 
 and others. The misshapen organ may be movable and capable 
 of being pushed back into the loin ; but it is far more likely to 
 be fixed as well as misplaced. If the kidney is displaced a tvmpanitic 
 note may be elicited by percussing over the ilio-costal interspace 
 behind, and there may be the loss of the usual resistance in the 
 loin. Neither of these conditions, however, can be depended upon, 
 because the region naturally occupied by the kidney is sometimes 
 filled up In" a quantity of condensed fatty tissue when the kidney 
 is misplaced. Xor is there anything constant in the characters 
 of the malformation which can be used as a guide. As will be 
 shown directly, there is great variety in the change of shape. 
 There are, however, two signs which should assist the surgeon 
 to a right judgment: these are (1) the peculiar disagreeable,
 
 VARIETIES OF MALFORMATIONS OF THE KIDNEY. 29 
 
 sickly, faint sensation, without acute pain, which is sometimes 
 caused by manipulation of the kidney ; and (2) the fact that 
 if an abdominal or pelvic tumour is formed by a malformed 
 kidney the tumour is one which does not progressively increase 
 in size. The peculiar sensation, provoked by pressing upon or 
 otherwise manipulating the kidney, is as characteristic in its way 
 as the testicular pain which is caused by manipulating or pressing 
 the testicle. It is a combination of sickening, fainting, and 
 aching sensations ; not actual pain, though it may be accom- 
 panied by pain along the thigh or over the hypogastrium. 
 
 Close and repeated examination of the urine, especially after 
 manipulation of the swelling, or during constipation of the bowels, 
 may show occasional alterations in quantity or composition, or in 
 both ; and there may be periods of painful or frequent micturition 
 brought on by muscular efforts, by manipulation of the tumour, 
 or by pressure upon it by hardened and retained faeces . These 
 are the only diagnostic signs, so far as I am able to gather, of a 
 tumour caused by a malformed kidney. 
 
 Form. The varieties of malformations of the kidney are 
 very numerous, but may be classified as follow : 
 
 1. Variations in size. 
 
 2. Malformation of one or both kidneys without any junction 
 or fusion of the organs. 
 
 3. Fusion of the two kidneys either in the form of a " horse- 
 shoe " kidney or some other irregular-shaped mass. 
 
 1. Variations in size. The commonest of these variations is the 
 so-called congenital atrophy, in which one of the kidneys is very 
 small, and this is of importance to the surgeon, since there is 
 always the fear, though fortunately a remote one, that such may 
 be the condition of the remaining kidney after nephrectomy has 
 been performed on the opposite side. 
 
 I have endeavoured to estimate what this risk is by the ex- 
 amination of a vast number of post-mortem records, and I find that 
 the condition occurs in. rather less than one in every five thousand 
 cases (see p. 39). In these cases the atrophied kidney consists 
 of a mass of connective tissue, quite useless for secreting purposes, 
 or it may be represented by a cyst. 
 
 2. Malformations of a kidney without fusion. The second class 
 of malformed kidneys is that in which the two organs are not
 
 30 
 
 SURGERY OF THE KIDNEY AND URETER. 
 
 in any way joined or fused with each other, but one or both of 
 them are malformed. The malformed organ may occupy its 
 natural position, or may be misplaced. Fig. 9 shows an hour- 
 glass constriction of a kidney. An interesting case of mal- 
 formed and misplaced kidney has been described by Mr. Canton 
 
 and figured (Fig. 8, p. 25). 
 
 In this class the commonest 
 variety is tabulation of the organ. 
 Sometimes the lobulation is as 
 marked as in the foetal kidney. 
 In one case of which I have 
 notes,* this was the condition of 
 both the kidneys of an old 
 woman, aged seventy. In an- 
 other case from the same records 
 (vol. 1881, No. 106), both the 
 kidneys of a man, aged thirty- 
 one, besides being lobulated, were 
 also much flattened, owing pro- 
 bably to the fact that the renal 
 arteries came off from the aorta 
 between two aneurvsms, so that 
 doubtless the renal blood supply 
 had been much disturbed. This 
 was a combination of congenital 
 and acquired abnormality of form. 
 In a third case (1881 vol., No. 
 211) both kidneys of a woman, 
 
 aged fifty-five, were much lobulated, and a deep transverse fissure 
 divided the anterior surface of the left. In these cases, and in 
 others of marked congenital lobulation of which I have the notes, 
 the kidneys were in their natural position. In a fourth case 
 (vol. 1879, No. 110) the left kidney was misplaced and malformed, 
 having a trilobate shape, with three arteries derived from different 
 parts of the aorta. Its hilum was in front, and its ureter came 
 off from its anterior surface. Its posterior surface was marked 
 by a sulcus, in which the common iliac artery rested. This 
 kidney was situated upon the left common iliac vessels. The 
 
 * Middlesex Hospital Register, vol. 1874, No. 5; Surgical. 
 
 Fig. 9. Hour-glass Constriction of 
 Kidney. (Guy's Hospital 
 Museum, Xo. 1585.)
 
 VARIETIES OF MALFORMATIONS OF THE KIDNEY. 
 
 patient was a lad, aged nineteen, who died of chronic Bright's 
 disease. In another instance (vol. 1879, No. 77), in a woman 
 who died of carcinoma of the right side of the chest, the right 
 kidney was granular and contracted and " curiously deformed." 
 It was very small, and almost completely divided into two equal 
 parts by a deep constriction. The left kidney was twice the size 
 of the right. In another (vol. 1874, No. 1) both kidneys of a 
 woman, aged forty-five, were found malformed, the right being 
 quadrate in shape, R'gi^- Left, 
 
 and the left pris- 
 matic ; they were 
 in their proper 
 situations, and 
 their structure was 
 healthy. 
 
 In a case the 
 notes of Avhich I 
 obtained from the 
 manuscript records 
 of Guy's Hospital * 
 (vol. 1880, No. 
 402), both kidneys 
 of a woman, aged 
 thirty-five (who died of suppurative perimetritis and endo- 
 carditis), were found malformed, and the right one was misplaced 
 as well (Fig. 10). The right kidney lay upon the psoas muscle at 
 the brim of the pelvis, and as it were upon its back, its shape 
 being " altered and difficult to recognise." The hilum was on 
 the anterior surface, and out of the hilum passed the pelvis, 
 the ureter taking an oblique direction across the kidney from 
 above downwards and outwards. The left kidney was in its 
 proper position, but lying like the right, as it were upon its 
 back, with its pelvis emerging from the anterior aspect, Snd its 
 ureter passing across the anterior surface. The hilum of each 
 kidney formed pari of a deep fissure, which cut the organ almost 
 into two. so that the appearance suggested to some ,was that 
 
 * Not the Guy's Hospital Reports, to which a distinguished author 
 on renal surgery who copied the illustration from my earlier book refers 
 it. The case lias never been published elsewhere. 
 
 Fig. 10. Two Malformed Kidneys joined by a transverse 
 band of fibrous tissue. Diagrammatic (Guy's 
 Hospital MS. Records.)
 
 32 SURGERY OF THE KIDNEY AND URETER. 
 
 there were four kidneys. Each organ had, however, but a 
 single pelvis and ureter. Another remarkable condition about 
 these oddly shaped kidneys was a tough white tendinous band 
 running from one to the other at their lower part (Fig. 10). This 
 band was part and parcel of the capsules of the two kidneys, 
 and represented the isthmus which lies across the spine in the 
 common form of horse-shoe kidney. The right kidney had two 
 arteries derived from the aorta and entering the fissure on the 
 front surface of the organ. The left kidney had three arteries, 
 two of which entered the under surface of the lower part of 
 the organ, the other ran with the vein to the hilum on the 
 front. One of the two vessels to the lower part came from the 
 common iliac artery. 
 
 Lastly, in some cases, deformity of the kidneys seems to have 
 depended upon the structures immediately in contact with the 
 organ, especially when the latter is misplaced. I have mentioned 
 above one case in which the posterior surface of a kidney was 
 deeply grooved by the common iliac artery. M. Aube reported 
 a case of left kidney misplaced between the common iliac arteries, 
 and flattened, having its anterior surface divided into three parts 
 by two depressions formed by the passage of two arteries. Other 
 similar cases might be quoted 
 
 3. Fusion of the kidneys. In the third class of malformations 
 the two kidneys are fused together. 
 
 The best-known variety of this class is the so-called horse-shoe 
 kidney, but there are several other ways in which the two organs 
 may be united into one mass, such as the sigmoid and the discoidal. 
 Fusion of the two kidneys is always accompanied by some dis- 
 placement, and the mass is generally situated at a lower level 
 in the abdomen, and nearer the middle line, than usual. The 
 malformations due to fusion belong more properly to the next 
 section, and are therefore described under " abnormalities in 
 number." 
 
 As a guide to the relative frequency of the various misplace- 
 ments and malformations, the following analysis of ten years' 
 post-mortem examination at two London hospitals is appended. 
 At Guy's Hospital, out of the total number of cases during the 
 ten years ending 1882, namely, 4,032, there were fourteen instances 
 of misplaced or malformed kidneys. Of these fourteen cases :
 
 FREQUENCY OF MALFORMATIONS. 33 
 
 7 were misplaced, including two slightly movable. 
 1 was very movable. 
 
 were horse-shoe shaped. 
 
 3 were malformed. Of these three, one was a fused and misplaced 
 
 renal mass ; in another, both kidneys were malformed and the right 
 one was misplaced as well ; the third was simply malformed, being 
 elongated in shape and having two ureters. The details of two of 
 these cases have been given above ; those of the case of fusion 
 will be given farther on. 
 
 At the Middlesex Hospital, out of the total number namely, 
 2,010 of post-mortem examinations, there were nineteen cases 
 of malformation. Of these nineteen cases : 
 
 9 were lobulated ; in four cases both kidneys, in five only one organ 
 
 being thus affected. 
 6 were congenitally atrophied as to one kidney. 
 
 1 was horse-shoe shaped. 
 
 4 were malformed, but not fused. 
 4 were atrophied from disease. 
 
 In one case the same kidney (right) was congenitally lobulated 
 and atrophied. In another both kidneys were lobulated, and the 
 left one had a deep transverse fissure across its front surface. 
 In a third the left kidney was lobulated, misplaced, and 
 trilobate. In a fourth case an atrophied kidney was almost divided 
 into two parts. In a fifth case one kidney was quadrate and 
 the other prismatic. 
 
 There was no record of movable kidney and none of 
 double pelvis or ureter in the reports for this period of the 
 Middlesex Hospital. A double renal pelvis is, however, so 
 common that it is now probably rarely deemed worthy of record. 
 
 It will be noticed in the above analysis of the Middlesex Hos- 
 pital cases that there were six cases of congenital atrophy of 
 one kidney. This is not to be read as six cases of absolute con- 
 genital deficiency of one kidney. On the contrary, there was 
 not one such case amongst them. The smallest of them seems 
 to have weighed one and a half ounces. Of the four cases of 
 atrophy from disease, in one the kidney substance was " entirely 
 atrophied/' and in another " the kidney was so small and atrophied 
 that scarcely any renal tissue was left, and there was no ob- 
 struction in the ureter." 
 
 VOL. I. D
 
 34 SURGERY OF THE KIDNEY AND URETER. 
 
 Since the above statistics were compiled a further analysis of 
 3,926 cases has been made from the post-mortem records of the 
 Middlesex Hospital, 1884-1897, with the following results : 
 There were five cases of congenital atrophy of one kidney ; hi 
 one of these the left kidney was only represented by a 
 small mass of tissue, and another is described as lobulated and 
 undeveloped and in a foetal condition. In addition to these 
 there were two cases of atrophy from imp*ervious ureters. 
 There were ten horse-shoe kidneys. There were three cases 
 of misplaced kidneys ; in one case the kidney was situated on 
 the brim of the pelvis with its lower end touching the bladder, 
 in another the right kidney was firmly fixed and rotated, 
 so that its upper end lay considerably nearer the spine than 
 usual, and in the third case the organ was situated in the 
 pelvis. 
 
 There were two cases of floating kidney, and in one of these 
 both kidneys were affected. In the case in which one kidney 
 was affected it was the right organ, and the kidney could be 
 made to describe a segment of a circle, the radius of which 
 was 5 inches, its centre being near the lower margin of the 
 left hepatic lobe. In the second case both kidneys are de- 
 scribed as being unduly movable, and the right could be moved 
 down below the brim of the pelvis and across to the left of the 
 middle line, but there is no special description of its mesenteric 
 attachment. 
 
 There were sixteen cases of double ureters, and in two of these 
 the lower duct opened into the urethra. In one case there was 
 a double ureter 011 each side. 
 
 In the Guy's Hospital analysis, as given above, the total 
 number of cases in which the kidney was either " atrophied," 
 " wasted," or " shrunken " was forty-seven. Xot one of these, 
 however, was an instance of complete non-development or con- 
 genital deficiency ; but all cases of small kidneys from Bright's 
 disease and interstitial nephritis are included. 
 
 I have collected fifty-four cases of various malformations which 
 were published in the several American and English journals 
 during the ten years 1883-1893: an analysis of which shows the 
 following relative frequency of the different kinds of abnormalities 
 usuallv met with :
 
 COMPARATIVE FREQUENCY OF VARIOUS MALFORMATIONS. 35 
 
 11 were cases of congenital absence of one kidney. 
 8 congenital atrophy or ill-development of one kidney. 
 
 1 congenital atrophy or ill-development of both kidneys. 
 
 8 horse-shoe kidney. 
 
 9 misplacements of one kidney. 
 
 2 congenital polycystic kidney. 
 2 malformation of the ureter. 
 
 2 congenital hydro-nephrosis (l double, 1 due to pressure of the 
 
 ureter by a branch of the renal artery). 
 
 5 double ureter (in 2 cases the doubling was on both sides). 
 
 2 absence of ureter (in 1 case the kidney was a collection of small cysts). 
 
 2 solitary conjoined kidney. 
 
 1 atresia of vesical orifice of ureter. 
 
 1 atrophy following obliteration of ureter of non-congenital nature. 
 
 3. THE ABNORMALITIES OF NUMBER. 
 
 To the surgeon of the present day the absence of a 
 kidney is a subject of vast importance, and one which must 
 be duly taken into account when nephrectomy is contemplated. 
 Though there are certain conditions in which it is less 
 improbable than usual that only one kidney exists (as, 
 for example, when some congenital deformity or abnor- 
 mality, more particularly of the genital organs, is present), 
 there are, on the other hand, cases in which the surgeon may 
 be sure that his patient is possessed of both kidneys. In some 
 instances of hydro-nephrosis and in some calculous cases the 
 complete plugging of one ureter is known to have occurred by 
 the alteration in the symptoms during the course of the disease, 
 and yet in despite of the occlusion urine continues to be excreted. 
 The urine voided naturally in such case must come from a 
 second kidney. So, too, must it in cases of renal fistula with a 
 free draining away of urine from the fistula and an equally, or 
 more, abundant excretion through the urethra. Still there are 
 cases in which less definite evidence is obtainable, and then it is 
 important to know the average probability of only one kidney 
 being present. I shall endeavour now to answer this question. 
 
 But first let us inquire what is understood by single kidney. 
 Morgagni* divided these cases into two classes, namely, those 
 in which one renal mass is made up of two kidneys, and those 
 in which one kidney only has been formed. These latter 'he 
 subdivided into those in which the single kidney occupies the 
 * Letter xlviii., art. 16.
 
 36 SURGERY OF THE KIDNEY AND URETER. 
 
 loin as usual, and those in which it is misplaced on to the spine 
 or into some central position. In Morgagni's day (1769) several 
 cases of each class had been collected, and they have been since 
 made use of by later writers, especially by Raver. The term 
 " solitary kidney " had frequently been used as a general name 
 for all cases in which there was only one renal organ ; but 
 llokitansky limited this name " solitary kidney " to the renal 
 mass which consists of the fusion of the two kidneys ; and he 
 employed the name " unsymmetrical kidney " in cases in which 
 one kidney only is present, and its fellow altogether deficient. 
 Rokitansky's definition of an " unsymmetrical kidney " was, a 
 kidney which " is normal in position and conformation, and 
 occasionally rather enlarged, its fellow being deficient." Exception 
 must, however, be taken to this definition, because the existing 
 kidney may be abnormal either in conformation or position. 
 In a case* in which the absence of one kidney led to a disastrous 
 result after nephrectomy, the only existing kidney occupied the 
 left iliac region. 
 
 There is a real distinction between the two classes described 
 by Morgagni and llokitansky, and named by the latter " solitary " 
 and " unsymmetrical." But a third class of single kidney must 
 be added to these two, namely, those in which the second organ 
 is " atrophied," for in not a few individuals one kidney is so 
 little developed or so completely destroyed that there is practically 
 but one kidney present. To the surgeon who is contemplating 
 nephrectomy there is 110 practical difference between congenital 
 absence, extreme congenital atrophy, or rudimentary develop- 
 ment of one kidney, and total destruction of one by disease. 
 There are, then, at least three varieties of single kidney, two 
 of them being forms of deficiency of one kidney, and the third 
 a fusion of the two kidneys into one mass. 
 
 A. Unsymmetrical kidney, i.e. entire absence of one kidney. 
 
 B. Solitary kidney, i.e. fusion of the two kidneys into one 
 mass. This class includes the horse-shoe kidney. 
 
 C. Atrophy ; including congenital rudimentary kidney, or 
 congenital atrophy. 
 
 It would seem that quite a host of examples of con- 
 genital absence of one kidney in man as well as in the lower 
 
 * New York Med. Journ., Feb. 17, 1883 ; Dr. W. Polk.
 
 FREQUENCY OF " UNSYMMETRICAL KIDNEY." 37 
 
 animals have been met with ; and the first impression made 
 by the numbers of recorded eases is that single kidney must be 
 quite a common event. Morgagni refers to many. Raver col- 
 lected about fifty cases, Mosler twelve, Roberts refers to five others, 
 and I have the notes of four cases dissected by Bland -Sutton. 
 If, however, the cases referred to by Raver are carefully inves- 
 tigated we find that few of them are satisfactorily reported ; 
 and if we bear in mind that Raver's investigations extended 
 over a great part of the literature of a century and included 
 the results of researches which went back to very early times ; 
 that most of the cases quoted by him had been enumerated 
 by Morgagni and other previous writers, and did not come 
 immediately under his own observation ; and, lastly, that we 
 have no record as to the proportion which these cases bore 
 to the total number of subjects examined, it is obvious that 
 we cannot draw any conclusion whatever from them as to the 
 frequency of the congenital absence of one kidney. 
 
 Some years ago I made a careful examination of the descriptions 
 of forty-six cases of single kidney derived from sources quoted by 
 Raver. Of these, two were horse-shoe shaped ; in six the two 
 kidneys were fused and the renal mass occupied the median 
 line ; in four others the two kidneys were probably fused, and 
 the renal mass w r as situated on one side or other of the spinal 
 column. In one of these four the renal mass was on the right side 
 of the spine, and had two pelves and two ureters, both of which 
 joined the right side of the bladder : Morgagni mentions this 
 case as one of unsymmetrical kidney, and not as resulting from 
 fusion. In six cases there was complete atrophy of one kidney, 
 the result either of defective development or of disease ; eleven 
 were cases of too doubtful a nature to classify ; seventeen were 
 cases of unsymmetrical kidney. In twelve of these seventeen the 
 corresponding ureter was absent ; in ten of them it is distinctly 
 stated that there was 110 trace of the ureter, or words to that 
 effect ; in the other two it is mentioned that there was no 
 ureteral orifice in the bladder on the side of the absent kidney. 
 In the other five the ureter may, perhaps, be assumed to have 
 been absent because 110 mention of one is made. 
 
 In nine of the seventeen cases here included under " un- 
 symmetrical " kidney a doubt might be felt as to whether they
 
 38 SURGERY OF THE KIDNEY AND URETER. 
 
 were not really fused or solitary kidneys ; in four of them it 
 is stated that the renal mass was " double size," " very large," 
 or much larger than an ordinary kidney, but in none of the 
 nine are any particulars given as to the ureter or ureters. 
 
 Twenty -two of the cases tabulated were in adults. Ten occurred 
 in women, ten in men, and in three the sex is unstated. 
 
 Four were in young persons between four and fifteen years 
 of age ; three girls, and one boy aged four years. 
 
 Two were in foetuses. 
 
 One was in a foetal monster. 
 
 Seventeen cases are so recorded as to afford no information 
 as to either age or sex. 
 
 Of these forty -six cases, in eight only is the single kidney 
 stated to have been misplaced, namely, the two horse-shoe shaped, 
 and the other six fused renal masses. These all occupied a 
 position in the median line. In the other cases it is either 
 stated or implied that the existing kidney was in one or other 
 loin. 
 
 The forty-six cases show the various ways in which there 
 may exist only one renal mass, and give a fair idea of the pro- 
 portion the various forms bear to one another ; but they do 
 not in the least assist in answering the question, " How often, 
 Or in what percentage of cases, may we expect to find a single 
 kidney ? " Only the examination of a great number of post- 
 mortem records can furnish the answer. I have attempted this, 
 with the following results. 
 
 At Guy's Hospital in the ten years ending 1882, 4,632 post- 
 mortem inspections were made, and only one case of congenital 
 absence, or of an undeveloped rudiment, of one kidney was 
 found. This was in a man, aged forty. 
 
 At the Middlesex Hospital in the twenty-four years ending 
 1897, 0,530 inspections yielded two cases of congenital absence, 
 and one other, in which the left kidney was represented by a 
 " mass of connective tissue." 
 
 At St. Bartholomew's in the ten years ending 1884, 3,800 
 medical post-mortems yielded no case of congenital absence, or 
 undeveloped rudiment, of one kidney. 
 
 At the Hospital for Sick Children, Great Ormond Street, in 
 the ten years ending December, 1884, the total number of post-
 
 FREQUENCY OF " UNSYMMETRICAL KIDNEY." 39 
 
 mortem examinations was 936, and amongst them was one case 
 of congenital absence of one kidney, and one of extremely defec- 
 tive development. The former occurred in a male, aged five 
 years and four months. The left kidney alone was present. 
 It weighed four and three-quarter ounces, which is about the 
 weight of two normal kidneys of a child of five and a half years 
 old. The pelvis and ureter were proportionately large. The 
 organ appeared to be quite healthy. There was no trace of a 
 right kidney or ureter, and no indication whatever of a ureteral 
 orifice on the right side of the bladder. 
 
 The case of extreme congenital atrophy of one kidney 
 occurred in a new-born male with imperforate rectum who lived 
 only five days. The right kidney measured one inch, and its 
 pelvis was much dilated ; the left kidney measured only one- 
 third of an inch, and was smaller than a haricot bean. 
 
 By adding the above figures together we have a total of 15,904 
 post-mortem examinations, yielding six cases of absence or extreme 
 atrophy of one kidney ; so that it would seem that the propor- 
 tion of cases in which congenital absence of one kidney is to be 
 looked for is once in every 2,650 cases. 
 
 That this estimate is not far from being correct I am 
 the more persuaded by the statements apparently very wide of 
 one another of Dr. Robert F. Weir of New York and Dr. 0. 
 Petersen. Dr. Weir* states that "the single kidney is found 
 about once in five thousand bodies," and Dr. Petersen f says that 
 only once was the kidney wanting in 1,500 post-mortem 
 examinations of his own. By adding Weir's and Petersen's 
 cases together we get two cases of absence of one kidney in 6,500 
 bodies examined, i.e. one in 3,250, a proportion somewhat lower 
 than that in the London cases. Other investigators give a 
 somewhat greater frequency ; thus Sangali found three cases in 
 5,348 necropsies, and Henzies two cases in 1,790 necropsies ; but 
 averaging from my own and other statistics we find one case of 
 single kidney in 2,400 bodies examined. 
 
 The figures which I have obtained from the four London 
 hospitals and given above may be taken as representing the 
 
 * New York Med. Journ., Dec. 27, 1884. Dr. Weir does not give the 
 data of his estimate. 
 
 t Med. Times and Gazette. Oct. 7, 1882.
 
 40 SURGERY OF THE KIDNEY AND URETER. 
 
 proportion of cases of imsymmetrical kidney and of extreme 
 congenital atrophy or defective development. They do not, 
 however, represent the proportion of cases of horse-shoe kidney 
 and other forms of fused kidneys, nor of kidneys atrophied by 
 disease, nor those congenitally small or atrophied kidneys which 
 weigh from an ounce or an ounce and a half upwards, and 
 possess some though not a full amount of glandular substance. 
 
 I have referred in some detail to these deficiencies under 
 the sections on malformed, atrophied, and horse-shoe kidney ; 
 but for readiness of comparison the following figures may be 
 repeated. Xineteen horse-shoe kidneys were found in 18,244 
 examinations, i.e one for every 1,000 (about). One fused kidney 
 other than horse-shoe shaped occurred in 12,104* inspections; 
 59 " atrophied," " small," " shrunken," or " wasted " kidneys in 
 8,178 inspections. This last number is in addition to the two 
 cases of mere rudimentary kidney included above in the six cases 
 of absent kidney. 
 
 The result of this investigation points, then, to the following 
 conclusions : (1) The probability of a person having only one 
 kidney owing to congenital absence or non-development of the 
 other, is exceedingly small. (2) That there is a much larger risk 
 of meeting with a horse-shoe shaped or otherwise fused renal 
 mass ; and a very much greater risk still of finding one of the 
 kidneys wasted or atrophied by disease. (3) That the fused 
 kidneys are generally situated in the median line of the body. 
 (4) That the presence of a renal mass in any abnormal position 
 should be sufficiently suggestive of there being but a single kidney 
 to prevent nephrectomy being performed without first ascertain- 
 ing whether a second kidney is present or not. 
 
 It has been suggested that the non-development of one kidney 
 is due to mechanical causes, such as pressure exerted by other 
 abdominal organs during foetal life ; but we have no definite 
 knowledge on this subject. 
 
 In cases of a kidney wasted or atrophied by disease, the clini- 
 cal history and characters of the urine would generally afford a 
 guide and warning ; but despite all care there must sometimes 
 
 * The 12.104 arc from Guy's, Middlesex, and the Children's Hospital. 
 In the Bartholomew's Hospital cases no mention is made of such a case ; if 
 these be added, then the proportion is one in 15,908.
 
 VARIATIONS OF POSITION OF " UXSYMMETRICAL KIDNEY." 41 
 
 Ije a risk in iiephrectomy, whether abdominal or lumbar, of 
 leaving behind no vestige of sound kidney tissue, if the operation 
 is resorted to for certain classes of cases, such as tuberculous 
 disease, and calculous pyelitis in which both kidneys may have 
 been afflicted at some time or other. 
 
 Congenitally small kidneys are often healthy in structure ; 
 but it is doubtful at present how long life could be sustained 
 with only one ounce, or one and a half ounces, of healthy renal 
 substance. We know that we are endowed with much more 
 than twice the quantity of renal tissue necessary for active and 
 fairly vigorous life, but we do not know the minimum amount 
 which is requisite for comfortable and active existence (see case 
 by Eustachius, mentioned on p. 70). 
 
 A. " UNSYMMETRICAL KIDNEY." 
 
 This is the true type of congenital absence of one kidney. 
 There is one normal, or at least functionally normal, kidney, and 
 its fellow is altogether deficient. The left kidney is more fre- 
 quently absent than the right. The corresponding suprarenal 
 capsule is wanting in only about one out of every ten cases 
 of congenital absence of the kidney. On the other hand, two 
 adrenal bodies may be attached to a misplaced renal mass, as 
 in a case of Liebmann's, in which a single kidney with two 
 adrenals associated with it was situated in the pelvis. 
 
 F. Craven Moore * in an analysis of 226 recorded cases of un- 
 symmetrical kidney, says that it was absent in 32 and present 
 in 83 out of 115 cases in which mention is made of it. 
 
 Situation. The existing kidney may be situated in its 
 natural position, or may be misplaced on to the spine at the 
 pelvic brim, in the iliac fossa, in the true pelvis, or in 
 some other direction. Maeckel has stated that when the kidney 
 is situated in the pelvis it retains its lobulated and foetal appear- 
 ance throughout life. This is not borne out by all the cases. 
 Thus in Folk's case,t a young woman, nineteen years of age, 
 had but one kidney, which was misplaced, and occupied the left 
 iliac fossa. It was fixed between the crest of the ilium and the 
 brim of the pelvis, and was covered on its front surface by 
 
 * Journal of Anatomy and Physiology, April, 1899, p. 400. 
 t New York Medical Journal, February, 1883.
 
 42 SURGERY" OF THE KIDNEY AND URETER. 
 
 peritoneum. The left ovary lay directly upon the kidney. The 
 ureter pursued its normal course in the pelvis to the bladder, 
 and was about twice the natural size. There was no trace of 
 a second ureter to this kidney, nor of a right kidney or right 
 ureter. The organ was quite normal in structure, and smooth 
 on the surface. So with kidneys lying on the sacrum. 
 
 There are instances in which it is very difficult to say whether 
 the existing renal organ is an " unsymmetrical " or a " solitary " 
 kidney, by " solitary " being meant a fusion of the two organs 
 in which the fusion is complete. Neither the size of the renal 
 mass, nor the number of the ureters, nor the manner in which 
 the ureter opens into the bladder, can alone settle the 
 doubt. 
 
 But setting aside all doubtful cases, there are a number of in- 
 stances of "unsymmetrical kidney" occupying the natural position 
 in the loin. Dr. Beadle informs me that in a male, aged forty- 
 five, who died August 19th, 1897, in Lanark Asylum, he recently 
 found an "unsymmetrical kidney" of nearly double the normal 
 weight in the normal position. The left kidney and suprarenal 
 capsule were absent. There was no left ureter, and there was a 
 slight depression or pouching of the trigone of the bladder cor- 
 responding to the position of the opening of a normal left 
 ureter. 
 
 The right kidney, which weighed eight ounces, was normal in 
 appearance and position, had only one pelvis and ureter, which, 
 however, was dilated to the diameter of about one-third of an inch. 
 
 The absence of one kidney gave rise to no symptoms, and 
 there was no albumen in the urine. 
 
 Sir Dyce Duckworth * recorded the case of a woman whose 
 right kidney occupied the right loin, but there was no left kidney 
 or ureter. The right organ, greatly enlarged, weighing nine 
 ounces, and measuring five inches in width at its central part, 
 possessed one ureter, which passed to the right side of the fundus 
 of the bladder, which it entered as usual. 
 
 Dr. Greenfield's (second) case f is one in which there was 
 entire absence of the right kidney, renal vessels, and ureter, and 
 also of the testis, vas deferens, and vesicula seminalis on the same 
 
 * Path. Soc. Trans., vol. xx., p. 232. 
 t Ibid. vol. xxviii., p. 164.
 
 CONDITION OF " UNSYMMETBICAL KIDNEY." 43 
 
 side. The subject was a male, aged fifty-nine, who died of extra- 
 vasation of urine and urinary fistulae. The left kidney was 
 slightly enlarged, but not misplaced. 
 
 In a case contained in The Guy's Hospital Post-mortem Records 
 the left kidney of a woman, aged forty, was entirely wanting, as was 
 also the left renal artery. The right kidney was converted into 
 a large sacculated cyst of about double the size of the natural 
 kidney, and having only a thin layer (barely two millimetres) 
 of kidney tissue in its walls. The sac was full of ropy pus and 
 coagulum ; and the ureter was dilated to the size of the little 
 finger, its lining membrane being thick and warty. The cause 
 of the pyo-nephrosis, for such it was, proved to be stricture of 
 the urethra and contracted thickened bladder. Dr. P. W. 
 Macdonald * relates a case of absence of right kidney and ureter 
 in a female epileptic maniac, who died of phthisis. The left 
 kidney was in its normal place, and had a single ureter of 
 ordinary size which opened into the bladder on the left side. 
 The kidney weighed nine ounces. 
 
 Dr. Turbint of Tiflis has recorded an example of congenital 
 absence of the left kidney in a prisoner sixty years old. The 
 ureter on the same side was absent. At the site of its termi- 
 nation in the bladder there was a diverticulum a few centimetres 
 long. The size of the existing kidney is not given. Dr. Turbin 
 had collected eight cases from literature ; five times the left 
 kidney was wanting, three times the right. In 0. Petersen's 
 only case in 1,500 post-mortem examinations (Deutsche Medicinal 
 Zeitung), it was the left kidney which was wanting. 
 
 I have the notes of two cases of congenital absence of 
 one kidney, i.e. " unsymmetrical " kidney ; one was that of a well- 
 formed fo?tus born at full time, the right kidney only being 
 present, and twice its natural size, and the ureter being much 
 dilated. There was no trace of the left kidney, ureter, or vessels. 
 The second case was also one of a foetus, born at full time, 
 and. the right kidney only was present. There was no trace 
 of the left kidney, ureter, or vessels. The existing kidney was 
 simply a congeries of cysts. 
 
 Other similar cases in which the organ was not misplaced 
 
 * Lancet, May 30, 1885. 
 
 t Amer. Journ. Med. Sciences, Jan., 1883, p. 239.
 
 44 SURGERY OF THE KIDNEY AND URETER. 
 
 might be quoted. Several such are included amongst Raver's 
 cases. 
 
 Mr. Gubbin * exhibited to the Sheffield Medico-Chirurgical 
 Society a right kidney, weighing thirteen ounces, but otherwise 
 normal, taken from a man, aged twenty-four, who died of haema- 
 temesis. The left kidney, ureter, and suprarenal capsule were 
 entirely absent, and the left lobe of the liver weighed only a 
 few drachms. Instances have been met with of single kidney 
 twice the usual size in sheep, horses, and the common fowl. 
 
 Instances of an uiisymmetrical kidney occupying an abnormal 
 position, resting upon the lumbar vertebra?, the promontory 
 of the sacrum, or sacral bodies, are less frequent than those 
 which are situated in the loin. 
 
 Dr. M. Watson, in an interesting paper in the Edinburgh 
 Medical Journal^ recorded a case in which the right kidney, 
 with its ureter, was entirely absent, and there was 110 trace of 
 the entrance of a ureter into the bladder of that side, the 
 mucous membrane being quite smooth. The left kidney, which 
 was not larger than usual, was circular in form and tabulated 
 on the surface (thus corroborating Mseckel),* and was situated 
 close to the brim of the pelvis, in front of the common and 
 external iliac arteries of that side. The left ureter was much 
 dilated at the hilum, and nearly double the normal size, except 
 at the point of entrance into the bladder, where it was quite 
 natural. This unusual position of the kidney had forced the 
 distended bladder towards the opposite side of the pelvis. Tho 
 artery to this kidney came off from the fork of the aorta, and 
 entered the upper end of the kidney after dividing into two trunk 
 branches. 
 
 Size. It has been stated many times that when there is 
 only one kidney it always exceeds the natural size. But this, 
 though fairly constantly, is not invariably, correct. An uiisym- 
 metrical kidney, like a renal mass composed of two kidneys 
 closely fused together, may lie either of much greater magnitude 
 than the normal kidney, or not at all in excess of the normal. 
 Care must be taken not to confuse genuine hyperplasia with 
 
 * Brit. Mtd. Jouni., Jan. 20, 1SS3. 
 t July, 1874, p. 13. 
 I See p. 41, ante.
 
 ANATOMICAL CHARACTERS OF SINGLE KIDNEY. 45 
 
 enlargement of a " single kidney " from disease. When an 
 " unsymmetrical kidney " is enlarged and the enlargement is not 
 due to disease, the increase in size is really a hyperplasia or 
 increase in the number of the elements, not a hypertrophy or 
 increase in the size of the individual elements of the organ 
 (Craven Moore). 
 
 Age. Cases are met with in the foetus, and at all ages up 
 to eighty years and upwards. Newman* gives the ages of 17 
 cases of single kidney found in persons who died after the age of 
 sixt} 7 years, 8 of them being over seventy and 2 over eighty. 
 
 Sex. Single kidney has been found almost twice as often in 
 males as in females. 
 
 Shape. The natural shape of the single kidney is commonly 
 maintained, or, if at all. it deviates only slightly from the normal ; 
 in some cases, however, it has been found "rounded," "globular," 
 " quadrilateral," " lobulated," or otherwise abnormal in outline. 
 
 Vessels. The renal vessels of the single kidney are sometimes 
 increased in number, or size, or in both. If the unsymmetrical 
 kidney is also misplaced the vessels are commonly derived from 
 the iliac or middle sacral artery. On the side on which the 
 kidney is absent the vessels are also absent, or merely rudimen- 
 tary, running into the fatty tissue or adjacent lymphatic glands. 
 
 Ureter. The renal pelvis and the ureter, as a rule, are 
 normal. There are, however, many exceptions to this rule. In 
 most cases the ureter is absent on the side of the defaulting 
 kidney, and when present it is fibrous or rudimentary or present 
 only at its lower extremity. Asymmetry of the bladder has 
 been occasionally observed, the ureteral orifice and the plica 
 ureterica being absent. 
 
 Number of ureters in "unsymmetrical" and "solitary" 
 kidney. As to the ureters, it is most frequent in fused kidneys 
 to find two pelves and two ureters, which pass down to the 
 bladder, there to enter in the usual manner ; but, on the one 
 hand, in some clear instances of fusion of two kidneys there has 
 been only one ureter, which has entered the bladder in the mesial 
 line ; and, on the other, there are instances where two kidneys 
 were present, one of which had two separate ureters which 
 either united before reaching the bladder, or entered separately 
 
 * Medical Press and Circular, vol. i. (1899).
 
 46 SURGERY OF THE KIDNEY AND URETER. 
 
 into the same side of the bladder, whilst the ureter of the op- 
 posite kidney entered as usual on its own side of the bladder (see 
 Vol. II., Part II., Chapter II.). 
 
 When a single kidney, whether of ordinary size or of much 
 greater dimensions, has a single ureter entering the corresponding 
 side of the bladder, there can be no doubt of its " unsymmetrical " 
 character. When a renal mass with faint or marked traces of 
 separation into two masses has two ureters, which enter in the 
 usual situations, one on each side of the bladder, there can equally 
 be no doubt of the " solitary " mass being the result of the fusion 
 of two kidneys. But between these types there are all degrees 
 and variations ; and a difference of opinion as to the congenital 
 absence of one kidney, or the congenital fusion of the two, may 
 therefore possibly arise. There is great room for doubt in a case 
 recorded by Ogston in the British Medical Journal (1879, vol. i., 
 p. 591) in which a ureter passed down to the opposite side of 
 the bladder from a cyst attached to the lower end of the only 
 existing kidney. This seemed to be a fused kidney mass com- 
 posed of a normal kidney and a misplaced and very hypoplastic 
 organ ; yet in favour of its being an " unsymmetrical " kidney is 
 the fact that the genital passages and ovary on the side of the 
 defective kidney were absent. 
 
 Morgagni describes the case of a woman w-ho died of dysentery, 
 and whose body was dissected by Valsalva ; the left kidney was 
 altogether deficient, but the deficiency was supplied by the right 
 kidney, which was twice as large as natural, and was furnished 
 with a double pelvis and ureter. Both the ureters went to the 
 riglit side of tlie bladder. 
 
 Morgagni also mentions the cases of Panarolus and Laubius 
 (also referred to by Rayer) as instances in which one kidney 
 only was formed, and was lying on one side of the spinal column 
 as usual, i.e. like an ordinary " unsymmetrical " kidney ; but he 
 adds that there were two pelves and two ureters, and that one 
 of the ureters inserted itself into that part of the bladder to 
 which no kidney corresponded, thus differing from the arrange- 
 ment met with in the woman dissected by Valsalva. 
 
 It would thus seem that in these two cases (of Panarolus 
 and Laubius) the condition was more like fusion of the kidneys, 
 in which the " solitary '' organ was lying on one side of the spine,
 
 CO-EXISTING ABNORMALITIES. 47 
 
 than " unsymmetrical " kidney. Morgagni, however, includes them 
 in the class which .Kokitaiisky has named "unsymmetrical." 
 
 Morgagni refers to no less than nineteen other cases, which 
 he classed under the same heading ; but many of them are merely 
 described by their reporters as instances of " one kidney only " ; 
 in some of these examples the renal mass seemed to be made 
 up of the two kidneys. 
 
 Associated Deformities. Congenital absence of one kidney 
 may be associated with other defective developments. A case 
 has been reported by Edridge-Green in which a congenital 
 absence of the right kidney was associated with absence of 
 the Fallopian tube and ovary on the same side and the presence 
 of two thumbs on the right hand and two accessory auricles. 
 Craven Moore says that in 33 per cent, of 226 cases collected by 
 Ballowitz and others, more or less extensive congenital defects 
 of the genital organs are recorded. In males, absence of the 
 vas deferens, vesicula seminalis, and ejaculatory duct on the 
 same side has been met with most frequently ; an atrophic state 
 or even a complete absence of the testis on the same side has 
 been observed in a very few instances, as in Craven Moore's 
 case, and presumably in a case reported by Greenfield in the 
 Pathological Society's Transactions (vol. xxviii., p. 164). In the 
 female, uterus bicornis has occurred most frequently ; septate 
 uterus with duplication of the vagina, uterus unicornis, absence 
 of the Fallopian tube, absence and atrophy of the ovary, have 
 been observed. Sir W. Turner, M. Exhaquet, Voelcker, and 
 others, and, more recently, IST. Bishop Harman (Journal of 
 Anatomy and Physiology, vol. xxxii.), have reported cases of 
 absence of one kidney and its vessels, associated with uterus 
 unicornis. 
 
 B. " SOLITARY " KIDNEY, OR THE FUSION OF TWO KIDNEYS INTO ONE. 
 
 It has been shown in the preceding statements that there 
 may be two kidneys in the body, but only one of them occupying 
 the loin, the other organ being movable or misplaced : even 
 both may be movable or misplaced. But when both are mis- 
 placed they are generally more or less united. 
 
 We have now to consider in some detail the various degrees 
 in which the kidnevs mav be fused into one mass.
 
 48 
 
 SURGERY OF THE KIDNEY AND URETER. 
 
 Rokitansky has well described the two extreme degrees of 
 fusion in the following words : " The lowest degree of fusion 
 is seen in the horse-shoe kidney (ren imguliformis) ; the two 
 kidneys are united at their inferior portions by a flat riband- 
 like or rounded bridge of tissue, which crosses the vertebral 
 column. In the higher degrees the two lateral portions approach 
 one another more and more, until they reach the highest degree. 
 
 Fig. 11. Fused Kidneys. (Guy's Hospital Museum, No. 1583.) 
 
 in which a single disc-like kidney lying in the median line, and 
 provided with a double or a single calyx (pelvis), represents com- 
 plete fusion." 
 
 Fig. 11 shows the two kidneys fused, displaced, and turned 
 with their hila away from each other ; the left shows an 
 hour-glass constriction. The blood-vessels are abnormal. The 
 fusion is but slight, and each organ has its own vessels and 
 ureter. 
 
 An excellent example of an intermediate degree of fusion
 
 VARYING DEGREE OF FUSION. 49 
 
 is described by Dr. Coupland. The general configuration is that 
 of the normal left kidney, but with traces of lobulation (see 
 Fig. 12). The upper and larger part of the mass is formed by 
 the left kidney ; the lower and smaller part, which is less than 
 half the size of the upper, represents the right kidney ; whilst 
 the elongated central portion between the two ureters represents 
 the renal tissue which usually unites the right and left halves 
 of a horse-shoe kidney. The convex border of the upper part, 
 i.e. of the representative of the left kidney, looked upwards and 
 
 Fig. 12. Fused Kidney; and the Bladder from the same subject, showing the normal 
 Orifices of the Ureters. (Preparation in the Middlesex Hospital Museum.) 
 
 to the left ; the convex border of the lower part, i.e. of the 
 representative of the right kidney, looked towards the median 
 line, and therefore towards the right, as it normally does. In 
 the hilum of the left organ the ureter was in front of the renal 
 vessels ; in the hilum of the right organ the ureter and renal 
 vessels have the normal relations to one another. Both ureters 
 pass clown in front of the organ, as is usual hi horse-shoe 
 kidney. The right ureter crossed the middle line about the brim 
 of the pelvis, and opened at its usual place into the bladder. 
 The bladder, with the orifices of the ureters, is also seen in the 
 woodcut. The whole renal mass weighed G| ozs., and measured 
 6 s x 3^ inches. 
 
 VOL. I. E
 
 50 SURGERY OF THE KIDNEY AND URETER. 
 
 This is a good example of what may be regarded as a tran- 
 sitional form of solitary kidney, i.e. of a form holding an inter- 
 mediate position between the horse-shoe kidney and that in which 
 no indication of a division into two parts can be discovered ex- 
 ternally, except perhaps by a bridge of {enal tissue between the 
 distinct and non-communicating pelves of the two ureters. 
 
 A very similar specimen to that described by Dr. Coupland 
 is reported and illustrated in Virchow's Archiv for November, 
 1884. 
 
 Under the title of a case of congenital S-shaped fusion of 
 both kidneys, Dr. G. Broesike of Berlin describes* a condition 
 which, as distinct from the more usual " horse-shoe " kidney, he 
 calls the " ren sigmoideum," from the resemblance of the con- 
 genital organs to the Roman letter S. The union in this pre- 
 paration (Fig. 13) occurred between the upper extremity of the 
 right kidney and the lower end of the left, the latter alone re- 
 taining its normal situation in the body ; the right kidney thus 
 lay wholly to the left of the middle line, and at first sight it 
 was thought to be a case of complete absence of this organ. 
 
 The subject from which the preparation was made was a 
 well-nourished male adult. It is not recorded whether the 
 right adrenal was present ; but the site of the kidney was occu- 
 pied on this side by a considerable quantity of fat. The left 
 adrenal lay on a level between the eleventh and twelfth dorsal 
 vertebrae ; and the left kidney occupied nearly a normal position. 
 Its hilum was markedly excavated, its vessels consisting of a 
 much-divided renal artery and a single vein, the latter passing 
 normally in front of the aorta. The origin of the ureter lay 
 behind the vein, and between the arterial branches. United 
 by renal substance to the lower end of this kidney was the right 
 organ, which occupied a deeper but otherwise similar situation 
 to what it would have had on the right side. Its hilum was 
 thus directed to the left, its convex border being to the right, 
 i.e. towards the median line. This second and deeper-lying 
 kidney was smaller than the other, and clearly marked off from 
 it by an oblique furrow traversing the anterior surface, and 
 lodging the left ureter in its passage downwards and outwards. 
 Posteriorly there was no indication, on the smooth surface, of a 
 
 * Virchow's Archiv, xcviii., p. .338 (November, 1884).
 
 VARIATIONS IN " FUSED " KIDNEY. 
 
 51 
 
 division between the congenital organs. The whole of this 
 " double kidney " had an S-shaped form, and extended on the 
 left side of the vertebral column from between the eleventh and 
 
 Fig. 13. Fusion of two Kidneys in S-shaped manner. (Virchow's Archiv.) 
 Mei.l, Median line ; Ao, aorta ; Nn, suprarenal capsule ; LX, left kidney : RN, right kidney ; L U, 
 loft ureter; K U, right ureter; L AT, left renal artery; L Vr, left renal vein; R Ar, right 
 renal arteries ; R Vr, right renal vein ; H, urinary bladder. 
 
 twelfth dorsal vertebrae to the middle of the last lumbar. The 
 hilum of the lower (right) kidney was somewhat deeply exca- 
 vated. The renal vein passed out above the ureter in front of
 
 52 SURGERY OF THE KIDNEY AND URETER. 
 
 the organ, and crossed in front of the aorta. The arterial supply 
 was by two trunks, one of which arose from the aorta, about 
 three centimetres above its bifurcation, and entered the convex 
 border of the organ ; the other came from the left common 
 iliac artery, and terminated near the lower border of the hilum. 
 From the upper of these arterial trunks sprang a tolerably large 
 vessel, probably the inferior mesenteric. As regards the ureters, 
 the left, after passing along the furrows between the conjoined 
 organs, ran downwards close to the hilum of the lower kidney, 
 and thence in its usual course to the base of the bladder. The 
 ureter of the lower (right) kidney, after a short course close 
 to and parallel with the foregoing, passed transversely across the 
 median line opposite the first sacral vertebra to the right common 
 iliac vein, and thence took its normal direction on the right 
 side of the pelvis to the bladder. 
 
 Dr. Broesike, in a few remarks on fusions of the kidneys, 
 says that Mseckel's (1812) original hypothesis of their origin in 
 an arrest of development, although more recently adopted by 
 Miihlhauser (1861), has been disputed by Schultze, and also by 
 Friedlowsky (1869), who, on the ground of cases of his own, 
 and the investigations of Ktippfer (1865), concluded that the 
 kidneys must first be developed separately, the fusion and change 
 in site being a secondary occurrence, taking place during fretal 
 life. The case above described accords better with this latter 
 doctrine. For, according to Kiippfer, the permanent urinary 
 system of mammals arises in the form of the so-called " renal 
 canals," as blind offshoots from the posterior wall of the Wolffian 
 ducts. These offshoots subsequently form the ureters and renal 
 pelvis, and around the latter are grouped cells which eventually 
 constitute the renal parenchyma. The " renal canals " necessarily 
 undergo many changes in position, so that for a certain time 
 both kidneys lie in front of the bifurcation of the aorta, and 
 rest with their concave margins close together. To interpret 
 the case described, one must assume that the normal changes 
 of position did not take place equally on both sides, in. that the 
 right " renal canal " remained behind the left in its development, 
 so that at a certain time the two kidneys, instead of being pre- 
 cisely facing each other, came to occupy different levels. At 
 this early stage the kidneys are composed of separate lobes (the
 
 VARIATIONS IN "FUSED" KIDNEY. 53 
 
 reiiculi), and in their subsequent fusion to form the kidney it is 
 conceivable that the lobes of both kidneys became united into 
 one mass. This implies that the altered position of the organs 
 preceded their conjunction.* 
 
 Vaughaii has recorded a case in which the two kidneys were 
 fused at right angles to each other and formed an L- shaped 
 mass on the right side ; the vertical portion was in its usual 
 position, with its hilum on the inner side, but the horizontal 
 portion apparently lay on its back, with its hilum on the anterior 
 surface, and extended two centimetres across the aorta just above 
 its bifurcation. The mass was grooved in such a way as to 
 suggest its division into five lobules, j 
 
 There are other forms of the solitary kidney ; e.g. there are 
 in some cases four lobules or masses, looking like a quadruple 
 instead of a double kidney (Fig. 14, Botallus's case). Oleson 
 of Chicago has recorded a somewhat similar case in a young 
 adult in whom a horse-shoe kidney was accompanied by two 
 adventitious kidneys : these latter were turned with their hila 
 directed obliquely outwards and downwards, and their inferior 
 margins were continuous across the front of the aortic bifur- 
 cation. Each of these four kidneys was anatomically and 
 apparently functionally perfect, with pelvis, ureter, vein and 
 artery, and they only differed from normal kidneys in fusing 
 imperceptibly into each other.J The ureters on each side arose 
 normally from a perfect pelvis, passed vertically down behind 
 the kidney tissue, and drained the pelvis of the other kidney 
 011 that side by an opening at its most dependent portion, 
 continuing thereafter in its normal course. 
 
 In other instances again the two organs are fused into an 
 unshapely mass, as in a specimen with a double ureter, mentioned 
 
 * Dr. P. W. Macdonald (Lancet, May 30, 1885) figures a solitary kidney 
 having the general shape of the ordinary organ, but which on section " seemed 
 to be one large kidney, with a smaller one joined on to its upper end. The 
 smaller pelvis had separate and distinct pyramids." The renal mass weighed 
 Hi ozs. ; it had two ureters and two pelves. The ureters entered the bladder 
 normally ; the one from the smaller pelvis passed behind the other to enter 
 the bladder as the right ureter. This kidney was situated on the spinal column, 
 and rested on the second, third, and fourth lumbar vertebrae. 
 
 t G. Tully Vaughan, New York Med. Journ., 1897, vol. ii., p. 659. 
 
 I Annals of Surgery, 1894.
 
 54 
 
 SURGERY OF THE KIDNEY AND URETER. 
 
 by Wilks and Moxon as having been removed from the pelvis, 
 not the abdomen, of its possessor. 
 
 The solitary kidney, then, is a compound organ, composed 
 of two kidneys fused together ; one of these at least must be, 
 and very generally both of them are, misplaced. 
 
 1A 
 
 Fig. 14. Fusion of Kidneys. The fused mass has a quadruple appearance. 
 
 (After BotaUus.) 
 
 A, Aorta ; v c, vena cava ; R A, renal arteries ; i A, iliac artery ; H A, hypogastric artery ; B v, renal 
 
 veins ; UR, ureters. 
 
 Solitary kidneys may be classified, according to their degree 
 of fusion, into 
 
 1. Horse-shoe kidney ; 
 
 2. Intermediate varieties ; 
 
 3. The completely united, or disc-like kidney. 
 
 As a rule, each of these forms of solitary kidney has at least 
 two ureters. Sometimes, however, though with exceptional rarity,
 
 VARIATIONS IN "FUSED" KIDNEY. 55 
 
 when the two kidney's are united over the promontory of the 
 sacrum, there is only a single ureter. 
 
 In a case related by Delafield* the solitary ureter opened 
 into the bladder in the median line.f It is not, however, quite 
 certain, from Delafield's own account, that this was a fused renal 
 mass, and not an unsymmetrical kidney ; though most probably, 
 as Wilks and Moxon have assumed, it was an instance in which 
 the two kidneys were united. 
 
 In each form of fusion of the kidneys the hilum is directed 
 forwards, and the ureters descend over the front of the organ. 
 
 Rokitansky says : " The more intimate the union is, the more 
 the hilum of the kidney is directed forwards, so that whereas 
 in the lowest degree it is indicated by an evidently increased 
 development of the posterior labium of the hilum, the hilum 
 in the highest degree of fusion occupies the anterior surface of 
 the solitary kidney." 
 
 The same observer also remarks, that the more considerable 
 the fusion is, the lower are the kidneys situated ; so that the 
 completely fused organs are commonly placed over the promontory 
 or in the concavity of the sacrum. 
 
 He was quite aware, however, that the "solitary" kidney, 
 like the " unsymmetrical kidney," may be situated on one or 
 other side of the vertebral column ; but only in " exceptional 
 cases." 
 
 Cruveilhier J says : " It is not very uncommon to find only 
 one kidney, which is almost always formed by the union of the 
 two by means of a transverse portion crossing in front of the 
 vertebral column, and having its concave border directed upwards. 
 Sometimes the two united kidneys are situated in the right or 
 left lumbar region, or in the cavity of the true pelvis." 
 
 Wilks and Moxon speak of having seen two kidneys on the 
 right side and none on the left, but they do not state w r hether 
 there was fusion or not. 
 
 1. The horse-shoe kidney. This is the commonest form of 
 fusion of the kidneys as well as the most frequent of the per- 
 manent misplacements of the kidney. 
 
 * Delafield's " Post-mortem Examinations and Morbid Anatomy," p. 206. 
 
 t Wilks and Moxon, p. 497. 
 
 | "Traite d'Anatomie Descriptive."
 
 56 SURGERY OF THE KIDNEY AND URETER. 
 
 Cruveilhier, in the passage just quoted . from his treatise on 
 descriptive anatomy, refers to it as " not very uncommon " ; 
 and Velpeau says, *'I have frequently found the two united in 
 front of the spine. "* 
 
 In a typical example the two kidneys are united at their 
 lower ends by a mass of renal substance of varying thickness, 
 which in the large majority of cases passes in front of the aorta, 
 but occasionally it has been known to pass between that vessel 
 and the vertebral column, as in a case reported by Nixon f. The 
 
 Fig. 15. Horse-shoe Kidney, seen from behind. (Middlesex Hospital Museum.) 
 Each kidney receives two large arteries, which spring from the aorta with an interval of ]J in. between 
 
 their points of origin. 
 
 connecting band of renal tissue forms a curve with the convexity 
 almost invariably directed downwards ; the kidneys, throughout 
 their extent, are much nearer the spinal column than normal, 
 and at their junction rest across the vertebral column ; they 
 are also situated more horizontally and lower down than normal. 
 The ureters, usually two in number, as a rule pass over the 
 front of the renal isthmus, and end normally in the bladder. 
 
 There is a double set of arteries and veins, as would be 
 expected, in the fusion of two healthy kidneys (see Fig. 15); 
 but the arterial supply in these cases is very variable both in 
 number and mode of origin, and frequently differs on the two 
 sides. Stmthers has reported a case in which there were two 
 
 " Treatise on Regional Anatomy," p. 23G. Translation by Hancock. 
 t Med. Press and Circ., vol. xliii.
 
 VARIATIONS IN HORSE-SHOE KIDNEYS. 57 
 
 arteries for each lateral lobe and one for the isthmus.* When 
 there are more than two arteries it often happens that one or 
 more of them arise from the common iliac.f Cotton has recorded 
 a case in which there were no renal arteries proper at all ; a 
 few twigs only entered from the aorta, and the main supply 
 apparently came from underneath the organ. 
 
 Though this is the most ordinary type of horse-shoe kidney, 
 instances are met with in which one or other of these characters 
 is modified. The upper ends instead of the lower ends of the 
 kidney may be joined together, and then the concavity instead 
 of the convexity of the curve is downwards. 
 
 Morgagni refers to two instances in which the convexity was 
 upwards, one being in a monster (Winslow's case). 
 
 Mseckel * says that in rare cases the concavity is downwards. 
 
 The bond of union may be either fibrous or glandular. Some- 
 times it is thin and flat, being little, if anything, more than 
 fibrous tissue ; in other cases a thin broad layer of renal sub- 
 stance, with a vertical groove in front and behind, joins the two 
 organs ; or a narrow band of renal tissue is the uniting medium. 
 
 Francus described the isthmus in his specimen as being " of 
 very great vastness and amplitude." 
 
 Raver, who stated that he had seen many examples of horse- 
 shoe kidney, gives particulars of three, in each of which the 
 isthmus was placed across the vertebral column. In one, the 
 two kidneys were united below by a flat band of renal substance ; || 
 in a second case the uniting band was larger, and approached 
 a little more in appearance the form of a small kidney ; whilst 
 in the third case there w r as a distinct kidney uniting the other 
 two, each of which was equally distinct in outline. 
 
 He enumerates thirty-four authors who have narrated cases 
 of horse-shoe kidneys. Several of these are ref erred to by Mor- 
 gagni, and some of them have been quoted by almost every 
 writer since Raver's time. 
 
 The ureters may pass behind instead of in front of the semi- 
 circular mass ; this is, however, very rare. 
 
 * Journ. of Anat. and Phys., vol. xxviii., p. 303. 
 
 t Path. Soc. of Brooklyn, 1884. 
 
 1 Path. Anat., i., s. 616. 
 
 S Morgagni, Letter xlviii., art. 16. 
 
 || Atlas, p. xxxix., Fig. 2.
 
 58 SURGERY OF THE KIDNEY AND URETER. 
 
 Wilks and Moxon are alone in stating that the ureters, as 
 a rule, pass down behind ; but Durham * refers to a case described 
 in the post-mortem register of Guy's Hospital for 1859 (No. 36), 
 in which " the ureters passed behind the organ." " This," Durham 
 says, " was a very good example of the ' horse-shoe kidney.' 
 It weighed thirteen ounces and a half ; and was formed, as 
 usual, by the lower ends meeting over the spine, thus making 
 the convexity downwards. The structure was healthy." 
 
 Though usually there are two pelves and two ureters, and 
 a corresponding number of arteries and veins, there are exceptions 
 to this also. 
 
 Monquiot f found a kidney from seven to eight inches long 
 placed transversely across the lumbar vertebrae, which had four 
 pelves, four ureters, and as many arteries and veins. 
 
 There is a specimen in St. Mary's Hospital Museum having 
 three ureters, two belonging to one half and one to the other. 
 
 Roberts mentions a specimen in which the two ureters of 
 a horse-shoe kidney crossed each other on their way to the bladder. 
 
 GebhardJ saw a case in w r hich one of the two ureters of a 
 horse-shoe kidney had five branches ; the other ureter was simple. 
 
 Other variations in the horse-shoe kidney occur. 
 
 In one of Sandifort's cases (see Raver) the left part of the 
 horse-shoe kidney was larger than the right ; but both had more 
 arteries than normal. 
 
 Sandifort, in a second case, found in a male subject the left 
 kidney absent from the left loin ; it was placed on the right side 
 below the right kidney, with which it was united into a crescent 
 (horse-shoe), and with which it formed an extraordinary shape. 
 
 Morgagni's case was a girl, aged six, who had a solitary kidney 
 differing from most in this, " that the right lobe was distant 
 from the left by no very great interval, the right being laid 
 upon the left in the lower part, and divided with a sulcus on 
 its anterior surface alone, so that an isthmus was formed not 
 less slender than the lobes." 
 
 The frequency of horse-shoe kidney may be judged of by 
 
 * Guy's Hospital Reports, 1860, p. 407. 
 
 t Journal des Savans, 1878, Mai 16 ; and Rayer, vol. iii. 
 
 I Vide Haver, vol. iii., p. 771. 
 
 Ibid.
 
 FUSION AT A SINGLE POINT. 59 
 
 the following figures : Of a total of 18,244 examinations at Guy's, 
 St. Bartholomew's, the Middlesex, and the Hospital for Sick 
 Children, Great Ormond Street, the records of which have been 
 looked over for the especial purpose, there were nineteen instances 
 of horse-shoe kidney, or about one in every 1,000 post-mortems. 
 
 There are many specimens contained in pathological museums. 
 In 1861 Dr. Gibb* looked through the London museums and 
 found nineteen specimens which present various anomalies in 
 regard to number of ureters and renal arteries. Others may 
 have been added since. But neither museum specimens nor 
 the records of cases in the Pathological Transactions can furnish 
 the relative frequency of the abnormality. The above figures, 
 however, help to do this. Oleson states that the case of 
 anomalous horse-shoe kidney described above (p. 53) was the only 
 case of horse-shoe kidney he met with in 507 recent necropsies ; 
 whereas he found in the same post-mortem subjects three cases 
 of renal malposition all affecting the right kidney, which in each 
 instance lay at the margin of the false pelvis. 
 
 2. The intermediate variety of solitary kidney is typified 
 in the cases already referred to, by Dr. Coupland and Dr. Broesike, 
 the shapes of which are seen in Figs. 14 and 15. Ebstein describes 
 such-like cases under his second form of " fusion of two kidneys 
 at single points." He says : " In the second form the union 
 takes place in the middle by the two hila. In slight grades 
 of the anomaly it is only a small connecting bridge which 
 unites the kidneys with one another. The highest grade has 
 been observed by Maeckel,t but even in that case the upper 
 and lower ends were separated. In a few exceedingly rare cases 
 the supernumerary renal parenchyma is not united to the two 
 kidneys, so that the middle piece constitutes an. independent 
 kidney, which receives blood from both the lateral parts, but 
 also possesses in part independent vessels." + In this variety 
 the fused kidneys may occupy the normal position of one of 
 them, as in Coupland's case and Yirchow's ; or the partially 
 fused mass may be misplaced altogether either to the middle 
 line of the abdomen or into the pelvis. 
 
 * Path. Soc. Trans., vol. xiii., p. 133. 
 t Path. Anat., vol. i., 8. 616. 
 | Ziemssen, vol. xv., p. 777.
 
 60 SURGERY OF THE KIDNEY AND URETER. 
 
 An interesting example of the intermediate variety is included 
 amongst the cases of which I have the notes. It occurred in 
 a man who died in Guy's Hospital. The two kidneys formed 
 an irregularly shaped mass which weighed thirteen ounces, and 
 was lying on the front of the promontory of the sacrum. It 
 was not horse-shoe shape, and the vessels and ureters were 
 arranged most unusually. The central part of the mass was 
 fissured by a sulcus, in which the ureter for the left kidney 
 coursed downwards and the vein for the same upwards, passing 
 into the vena cava just above the junction of the two iliacs. 
 v v In the right half of the mass the ureters 
 
 and vessels, instead of being situated cen- 
 trally, were on its outer side ; the ureter 
 being in front of the vessels as in the left, 
 and as is usual in fused kidneys. The arterial 
 supply consisted of two or three arteries 
 for each half of the mass about the size of 
 the radial artery which were derived from 
 the common iliac arteries, and entered the 
 lower part of each kidney (see Fig. 16). The 
 suprarenal capsules were in their normal 
 Fig. i6.-Diagrammatic. itiong The renal 8u bstance, to the naked 
 
 u, Ureters ; A, arteries ; 
 
 v, veins. eye, was healthy. 
 
 3. The completely united variety of 
 
 solitary kidney is that in which the two organs approach one 
 another so completely that they form a single disc-like mass 
 provided with a double or a single pelvis. It is what Eokitansky 
 called the " highest degree " of fusion of the two kidneys. These 
 completely fused organs sometimes lie in the median line over the 
 lumbar vertebrae or the promontory of the sacrum, or in the 
 hollow of the sacrum ; but this is not nearly so uniformly the 
 case as it is with the horse-shoe variety, the isthmus of which 
 commonly rests across the lumbar vertebrae. 
 
 In 1756 Haller illustrated a specimen of complete fusion of the 
 two kidneys (Fig. 17) ; the mass occupied the median line, and 
 possessed two ureters; its arteries were derived from the aorta, 
 iliac, and spermatic. 
 
 Dr. Greenfield* has described a case in which a kidney mass 
 
 * Path. Soc. Trans., vol. xxviii., p. 162 ; case 1.
 
 COMPLETE FUSION. 61 
 
 weighing seven and a half ounces, and measuring five inches 
 in length, occupied the normal position of the left kidney. The 
 general outline of this mass was nearly like the left kidney, 
 though natter and wider at the lower part. It was slightly 
 lobulated, but there was no indication of division into two parts. 
 The hilum was 011 the anterior surface and much farther out- 
 
 vc" 
 
 , VA 
 
 fiV 
 
 - sE&^r 
 IA&V 
 
 Fig. 17. Two Kidneys blended, and occupying a median position. -(After Holler.) 
 
 A, Aorta ; v c, vena cava ; v A, vena adiposa ; R v, renal vein ; a p A & v, spermatic artery and vein ; 
 i A & v, iliac artery and vein ; UR, ureters ; v, iliac vein. 
 
 wards than usual, and was divided into two distinct parts, upper 
 and lower, separated by a bridge of kidney substance. The two 
 ureters and their pelves were quite distinct, and did not com- 
 municate in the organ. The upper passed somewhat inwards 
 in the usual direction, and then downwards. The lower passed 
 nearly vertically downwards in front of the organ, lying in a 
 furrow on the anterior surface, which produced a sort of 
 bifid extremity. On cutting into the organ a faint line of
 
 62 SURGERY OF THE KIDNEY AND URETER. 
 
 demarcation, running obliquely across it, seemed visible at first, 
 but was lost after the organ had been kept in spirit. There 
 were two distinct sets of uriniferous tubules and pyramids. The 
 structure was healthy. The ureters entered the bladder as 
 usual, one on each side. The artery was single and in the 
 normal position of the left renal artery, but it divided near the 
 hilum into two trunks, which gave branches to the two divisions. 
 The suprarenal capsules were normal. Lee Dickinson has also 
 related a somewhat similar case in which there was no kidney 
 on the right side, while the left resembled two kidneys joined 
 together longitudinally, the fusion being complete. There were 
 two ureters, the upper of which entered the bladder on the right 
 side.* 
 
 Dr. Kelly t has recorded a very remarkable case in which 
 a right-sided kidney mass in a female was lying vertically along 
 the spine, having a convex outer border. It weighed ninety- 
 three ounces. There were three arteries and two ureters. The 
 upper ureter descended in the usual manner, and was situated 
 most anteriorly in position in front of all the vessels ; the lower 
 one, after passing behind it, followed the course of the left 
 common iliac artery, and entered the bladder in the usual place. 
 
 Sir Dyce Duckworth * mentions a specimen which was in the 
 Pennsylvania Hospital Museum, of a renal mass which was 
 situated on the right side of the pelvis instead of in the abdomen ; 
 it had two ureters, which entered the bladder at the usual places, 
 and two renal arteries. The general outline of the mass was 
 circular. 
 
 Dr. Butler has figured a case of fused kidneys of elongated 
 form which reached from the lx>dy of the fourth lumbar ver- 
 tebra to the middle of the sacrum. It measured five inches 
 in length by three and three-quarters in breadth ; it had a central 
 longitudinal fissure or raphe better marked behind than in front, 
 and two ureters, terminating at the bladder in the usual manner, 
 but united above in a single pelvis which was attached to 
 the middle of the anterior surface of the renal mass. Four 
 arteries supplied the mass : one large trunk from the fork of 
 
 * Trans. Path. Soc., vol. xlvi., p. 80. 
 t Trans. Path. Soc., vol. xix., p. 274. 
 I Trans. Path. Soc., vol. xx., p. 233.
 
 RUDIMENTARY KIDNEY. 63 
 
 the aorta, two from the left internal iliac, and one from the 
 right internal iliac. 
 
 There is a single renal mass in St. Bartholomew's Hospital 
 Museum twelve inches long. 
 
 In Dr. Delafield's case the two kidneys were united over the 
 promontory of the sacrum, and there w r as only a single ureter 
 which entered the bladder in the median line. In a case 
 mentioned by Wilks and Moxon the two kidneys were united 
 into an unshapely mass which lay in the pelvis. 
 
 Morgagni * gives a case (Valsalva's), already referred to, in which 
 both ureters went to the right side of the bladder. It was hi a 
 woman who died of dysentery, and who had no left kidney ; 
 but this deficiency was supplied by the right, which was twice 
 as large as natural and had two pelves as well as two ureters. 
 It is doubtful whether this should be regarded as a " fused " 
 or an " unsymmetrical " organ. Craven Moore refers to it as an 
 example of a double abnormality, namely, " unilateral aplasia 
 with complete duplication of the ureter and pelvis on the opposite 
 side, and not fusion." 
 
 C. ATROPHY OF ONE KIDNEY. 
 
 Atrophy of the kidney may be either congenital, or the 
 consequence of disease. 
 
 Diagnosis between congenital absence and congenital atrophy 
 or imperfect rudimentary development. Congenital absence of 
 one kidney must not be confounded with congenital atrophy, 
 or, more properly speaking, rudimentary development of one 
 kidney. Clinically, and to the surgeon who is contemplating 
 nephrectomy, their importance is practically the same. It is 
 sometimes difficult to say whether there is congenital absence 
 or congenital atrophy. For instance, Ebstein tells us that he 
 found, in a man, aged twenty-four, whose left kidney was 
 greatly hypertrophied, " a pale reddish mass of connective tissue, 
 surrounded by considerable adipose tissue," at the upper end of 
 the right ureter. " This mass was smaller than the normal 
 suprarenal gland ; no glomeruli and no uriniferous tubules could 
 be discovered in it " ; yet a very narrow ureter and renal pelvis, 
 as well as a very small representative of the renal artery, 
 
 * Letter xxxi., art. 25; xlviii., art.. 16.
 
 64 SURGERY OF THE KIDNEY AND URETER. 
 
 were connected with this mass. Ought this to be considered 
 a specimen of atrophied kidney, or of congenital absence of the 
 kidney with the pelvis and ureter of that side imperfectly de- 
 veloped ? Ebstein regards it as an instance of congenital 
 atrophy, and this opinion is probably the right one. 
 
 Morgagni agreed with the doctrine of Aristotle, which is that 
 the kidney has been congenitally absent in cases in which no 
 vestige of either emulgent vessels or ureter or kidney exists, 
 as was the case in a little girl dissected by Poupart, and in the 
 priest, and in the woman dissected by Valsalva ; and he formed the 
 same conclusion regarding cases in which, though some trace 
 of ureter or emulgent vessels is present, there is evidence in 
 the great size and double pelvis and ureter of the existing kidney 
 to show that it was Nature's intention from the beginning that 
 the functions of two kidneys should be discharged by a solitary 
 renal mass. He further considered that there is evidence of 
 congenital absence of kidney, even though neither ureter nor 
 emulgent vessels were wanting, when nothing but fat occupies 
 the renal region. He found such a condition in a healthy whelp 
 which he dissected in Bologna in 1702. The ureter, though 
 joined with the bladder, was but a solid cord ending above in 
 slender striae, just before it reached the fat ; and the emulgent 
 artery, much smaller than natural, ended in small ramifications 
 which only crept through the fatty tissue above described. 
 
 In a large majority of cases in which one kidney is absent 
 we find the ureter absent too, but when a rudimentary kidney 
 is present, no matter how rudimentary the minute mass may 
 be, either the upper or lower end, if not the whole, of the ureter 
 is generally more or less developed. 
 
 This accords with Valentine's teaching, " that the ureter, the 
 pelvis of the kidney, and the uriniferous tubules are formed in 
 a general blastema, independently of one another," and with the 
 descriptions of recorded cases. Craven Moore believes the cause 
 of the malformation is directly related to the Wolfnan duct and 
 its offset the metanephric duct. If complete aplasia of the 
 Wolffian duct obtains, the vas deferens and the ureter, the renal 
 pelvis and renal tubules, are absent ; but if the development of 
 the Wolffian itself has proceeded, but short of giving rise to the 
 offset which would have eventually formed the metanephric duct,
 
 THE URETER OF AN ATROPHIED KIDNEY. 65 
 
 develop from the metanephric duct (ureter, pelvis, renal tubules) 
 fail. If the metanephric duct is rudimentary the ureter will be 
 so also, or the duct may be fully formed but fail in its sub- 
 division into tubules. 
 
 I have noted the presence or absence of a ureter in all the cases 
 1) of atrophy of one kidney, and (2) of unsymmetrical kidney, 
 which have been recorded in the fifty volumes of the Transactions 
 of the Pathological Society ; there are ten instances of atrophy, 
 in seven of which the corresponding ureter was more or less 
 developed, while in the other three there was 110 note about the 
 ureter ; there are seven instances of congenital absence of one 
 kidney, and in only one of them was the ureter stated to be 
 present ; in four there was no trace whatever of ureter, and 
 in two it is stated that even the ridge bounding the trigone 
 of the bladder, and on which the ureter normally opens, was 
 wanting ; in the remaining two the condition of the ureter 
 was not stated. In twelve out of seventeen " unsymmetrical " 
 kidneys in Raver's list the corresponding ureter was absent (see 
 analysis of Raver's cases given oil page 37 supra). 
 
 Dr. M. Watson * gives the post-mortem notes of a man who 
 was the subject of epileptic attacks. The left kidney was larger 
 than usual, and weighed nine and a half ounces, whilst the 
 right was reduced to the size of a large bean, measuring 
 an inch and a half by one inch. This little mass was 
 situated in the usual position of the right kidney, but pre- 
 sented to the naked eye on section 110 trace of any subdivision 
 into cortical and medullary substance. Microscopically it was 
 composed of fibrous tissue, with here and there isolated tubes 
 much larger than the ordinary renal tubules ; these tubes were 
 filled with cells and connected with what appeared to be well 
 developed Malpighian capsules. The persistence of the tubules 
 and Malpighian capsules is the more noticeable because there 
 had never existed any outlet for their secretion. The ureter 
 had 110 connection whatever with this rudimentary kidney ; 
 though pervious at the bladder, it degenerated into a fibrous 
 cord in the neighbourhood of the kidney, and was lost in the 
 loose subperitoneal connective tissue before reaching the atrophied 
 organ. 
 
 * Edinburgh Medical Journal, July, 1874, p. 15. 
 VOL. I. F
 
 66 SURGERY OF THE KIDNEY AND URETER. 
 
 Is atrophy congenital, or induced by disease ? The 
 pathologist may sometimes have difficult}- in determining whether 
 one kidney was originally undeveloped, or had been destroyed 
 by disease. Horgagni* knew that the kidney is sometimes so 
 contracted by disease as to make good pathologists think that 
 the organ was originally deficient. In support of this statement 
 he refers to three cases described in the Sepulchretum. In one, 
 the case of a girl, though there was nothing in the place of 
 the kidney, there was a ureter going down to the bladder from 
 the side of the vena cava, to which it seemed to have become 
 agglutinated, after the kidney was consumed.f In another, 
 that of a woman, instead of a right kidney there was seen "a 
 certain kind of involucrum," a membrane which Morgagni sup- 
 posed often remains behind when the kidney has been destroyed, 
 and which has been described as a " purse " or " bag " by many 
 observers. 
 
 The causes of secondary atrophy of the kidney, or, in 
 other words, atrophy due to disease, are numerous, but chronic 
 Bright's disease is by far the commonest. As the result of wasting 
 from Bright's disease, the two kidneys of an adult will seldom 
 weigh together less than one and a half or two ounces, though often 
 less than three ounces. Wasting of the kidney is not an in- 
 frequent result of obstruction of the ureter, as will be described 
 under hydro-nephrosis ; and in cases of obstruction of the urine 
 from stricture of the urethra or stone in the bladder, localised 
 wasting of the kidney, the result of previous interstitial nephritis, 
 is by no means uncommon. In these latter cases the surface 
 of the kidney is fissured, and the whole organ more or less 
 shrivelled and atrophic, and bands or areas of fibrous or scar 
 tissue are to be seen in its substance. Embolism, again, leads 
 to a very similar scarred and atrophic condition. 
 
 Bradford has made some very interesting experiments in 
 this connection to determine whether obstruction of the ureter 
 could produce atrophy of the kidney. He exposed the ureter 
 
 * Morgagni, Letter xi., art. 14. 
 
 t This is probably the same case that Blasius gives ; the subject was aged 
 twenty-four, and the left kidney was wanting. The left ureter was a fibrous 
 cord without lumen, and a mass of white solid matter as large as two walnuts 
 was attached to the vena cava.
 
 ATROPHY FROM OBSTRUCTION OF URETER. 67 
 
 of a dog, ligatured it with silk, and then divided it as close to 
 the bladder as possible. After a variable period (eleven to forty 
 days) a second incision was made in the abdominal wall above 
 the first one and the free end of the ureter found and brought 
 up to the surface of the abdomen. The wound was then sutured 
 so that the extremity of the ureter was left protruding from 
 its lower angle, and it was secured in this position by two horse- 
 hair sutures passing through the ureter and the edges of the 
 skin. The ureter was then incised and the retained urine allowed 
 to escape, the amount being measured if possible. The animal 
 was then kept for periods varying from seven to fifty-one days. 
 
 In all cases the ligature of the ureter was followed by disten- 
 sion of the kidney, and a quantity of altered urine, varying from 
 40 cc. to 70 cc., was let out at the moment of incising the ureter 
 at the second operation. In the great majority of cases the 
 fluid was clear and contained an abundant amount of urea. 
 
 After the second operation, which, as Bradford states,* simply 
 consisted in draining the distended and dilated kidney, this organ 
 resumed its normal shape very closely, but became very much 
 smaller than it was previously. It did not become a shrivelled 
 sac as might have been expected, but to the naked eye assumed 
 the form of a normal but very small kidney. The ureter did 
 not take part in this result, but remained thickened and dilated. 
 Microscopical examination showed the atrophy to be due to 
 (1) diminution in size of the renal cells, (2) disappearance of 
 many tubules, and (3) the crowding together of the remaining 
 tubules. 
 
 Another interesting point in connection with these valuable 
 experiments was that in 110 case was ligature of the ureter fol- 
 lowed by suppression of urine, as has been described in human 
 beings after obstruction of the ureter. 
 
 The kind of atrophy which, however, is most likely to lead 
 to surgical difficulties and catastrophes is the congenital. 
 
 In the secondary forms of atrophic kidney, the clinical history, 
 the age, and the state of the urinary secretions and passages 
 of the patient, are pretty sure to guide one to a correct diagnosis. 
 But in congenital atrophy even the most careful may be betrayed 
 into error. It occurs independently of intrarenal pressure, of 
 
 * Path. Soc. Trans., vol. xlix., p. 169.
 
 08 SURGERY OF THE KIDNEY AND URETER. 
 
 interstitial nephritis, or of embolism ; but is due to some defect 
 of development, and is often dependent on the rudimentary size 
 of the renal artery. 
 
 The rudimentary kidney varies widely; sometimes it is 
 foetal in size, and lobulated ; sometimes it is represented by a small 
 group of vesicles, sometimes by a small mass of fibrous or fatty, 
 or fibro-fatty tissue, sometimes by a mass of white solid substance 
 attached to the vena cava, and sometimes it is cystic, with patches 
 of secreting substance on the cyst. Wilks and Moxon met 
 with a case in a young man aged twenty-three, who died of 
 chronic albuminuria, in whom there were but two pyramids 
 in each kidney, the kidneys themselves being very small, owing 
 to deficient development. In a case reported by Sutherland 
 and Edington * the left kidney was represented by a globular 
 thin-walled cyst measuring 3'5 cm. in diameter, which was tensely 
 filled with a clear dark-brown fluid containing urea. The upper 
 part of the cyst showed a small amount of solid tissue measuring 
 roughly 2 cm. by 1 cm. ; this was separated at its edge from 
 the cyst by a definite furrow. This solid tissue was found 
 microscopically to consist of distorted renal tubules in an 
 abundant fibrous stroma. The cyst occupied the middle line 
 in front of the sacral promontory, being freely movable and sus- 
 pended by its vessels. The left ureter was represented by an 
 attenuated cord-like structure arising from the furrow at the 
 upper extremity of the cyst. There was no lumen in this structure, 
 and after a short course it passed to the left angle of the trigone, 
 where there was a slight depression, but no definite orifice. The 
 cyst was suspended from the aorta by two vessels. These arose 
 from the anterior aspect of the aorta to the right of the middle 
 line and at a distance of about 1 cm. below the origin of the 
 inferior mesenteric artery, and they entered the cyst at the 
 furrow above mentioned. The right kidney was hypertrophied 
 and normal in situation. The specimen was removed from a 
 child three years of age, who had died of broncho-pneumonia- 
 Albumen was found in large amount in the urine, but only 
 for six days before death. 
 
 Another interesting case belonging to this class was reported 
 by Lawrence, in which the atrophied kidney was displaced and 
 
 * Glasgow Medical Journal, Feb., 1898.
 
 VARIATIONS IX RUDIMENTARY KIDNEY. 69 
 
 associated with anomalous ureters and vessels.* The kidney 
 was represented by a triangular shaped mass which measured 
 one inch in length, two-fifths of an inch in breadth, and one- 
 quarter of an inch in thickness, and the upper part tapered to a 
 point which corresponded to the point of termination of the renal 
 artery, which ultimately broke into five branches before entering 
 the organ. From the posterior internal surface there issued 
 two pairs of tubes ; of the inner pair one tube arose from near 
 the upper extremity, the other from near the lower angle. The 
 outer pair arose one tube alx>ve the other, and much closer to- 
 gether, from near the middle of the surface. 
 
 These tubes united to form two tubes of from 2 to 2i mm. 
 in width, which on being traced downwards were found to pass 
 behind the common iliac vein and artery, and after a course 
 of one inch and a quarter united to form a single tube, 
 measuring 4 mm. in diameter at its upper part. This tube, 
 thick walled, especially at its lower part, the author thought 
 was to be regarded as the pelvis of the ureter ; it passed down 
 in the pelvic cavity towards the base of the bladder, became 
 somewhat narrower at its middle part, but wider again and 
 twisted in its lower third, where it had a width of 6 mm. After 
 a course, of 3 inches it terminated at the level where the vas 
 deferens crosses the ureter, by abruptly contracting to a narrow 
 thin-walled tube measuring not more than 1 mm. in width. 
 The latter tube the author considered should be regarded as the 
 ureter. There were no other associated abnormalities. 
 
 It is fortunately much rarer to find the atrophy present in both 
 kidneys, but it may occasionally occur, and Tennentt records a 
 case of this kind in which the patient, aged 28, died from uraemia. 
 At the post-mortem examination the left kidney measured 2| 
 inches in length and weighed less than one ounce; its surface 
 was very irregular ; the pelvis was a double one ; the right 
 kidney was 3i- inches in its longest diameter and weighed 2^ 
 ounces. Its pelvis was divided into three divisions, the upper of 
 which was subdivided into two. The surface of this kidney was 
 also very irregular, and the upper part was more atrophied 
 than the lower. There was no obstruction anywhere, and the 
 
 * Journ. of Anat. and Phys., 1897, pp. 599. 
 t Glasgow Med. Journ., vol. xxxi.
 
 70 SURGERY OF THE KIDNEY AND URETER. 
 
 condition was looked upon as one of congenital atrophy and 
 malformation. It is, however, not unlike a case of chronic inter- 
 stitial nephritis. 
 
 Northrup * has reported a case of a child five weeks old who 
 died from extraneous causes, in whom after death there was 
 a mere rudiment of the left ureter, which terminated at its upper 
 extremity in a bulbous tip 1 cm. long and 2 mm. broad, which 
 represented the undeveloped kidney. This rudiment was found 
 lying on the left common iliac artery at the level of the last 
 lumbar vertebra ; no vessels of any kind could be traced into it. 
 Other defective and peculiar conditions noticed by Ebstein and 
 Watson have been mentioned above. 
 
 It has been stated above that the ureter of the congenitally 
 atrophic kidney varies much. Sometimes it is a fibrous cord 
 without a lumen (Blasius) ; sometimes it is twisted on itself, ending 
 in a reduplication, and thus having no communication with the 
 bladder ; sometimes it is short and narrow, and has an opening 
 into the bladder no larger than a pin-hole ; sometimes it is of 
 normal size and appearance, and passes down from the atrophied 
 kidney to open quite naturally into the bladder. 
 
 All kinds of variations as regards the renal vessels of the 
 atrophic organ have been described. 
 
 The atrophic kidney may be also misplaced, as in Dr. 
 Ewart's case.f 
 
 It is more than probable that congenital atrophy or deficiency 
 of one kidney predisposes to chronic renal disease, and to 
 albuminuria in early and young life. Eustachius found in the 
 body of Bonifacio Corneo one kidney the size of a chestnut, and 
 sound ; but the other large and in a state of suppuration from 
 calculous pyelo-nephritis. He thought that the stimulus of 
 disease had drawn blood from the healthy to the calculous kidney, 
 and hence the shrinking of the healthy organ. But it is much 
 more probable that the small healthy kidney was atrophic from 
 birth, and that its vessels were originally small in proportion. 
 The case is of importance, because it shows with how small an 
 amount of functionally active renal tissue life can be sustained. 
 
 The frequency, or rather infrequency, of congenital atrophy 
 
 * Trans, of New York Path. Soc., 1889. 
 
 t See Trans, of Lond. Path. Soc., vol. xxxi., p. 187.
 
 ABSENCE OF SYMPTOMS OF SINGLE KIDNEY. 71 
 
 of one kidney, the atrophied organ being for all practical purposes 
 quite wanting, may be judged of from the fact that there are 
 only six such examples recorded in the whole fifty volumes of the 
 Transactions of the Pathological Society ; and from the fact that 
 15,904 post-mortem examinations at St. Bartholomew's, Guy's, 
 the Middlesex, and the Hospital for Sick Children, Great Ormond 
 Street, yielded only three cases of extreme atrophy or extreme 
 want of development of one kidney. 
 
 The figures of the Middlesex and Great Ormond Street Hospitals 
 show that a disproportion in size of the two kidneys from 
 some amount of, but not extreme, congenital atrophy of one of 
 them, occurred twelve times in 7,472 subjects. In most of these 
 cases the opposite kidney was much enlarged, so that there was 
 quite an average normal amount of renal tissue, though con- 
 tained unequally in the two organs. In one case in which this 
 was not so (a child aged two and a half years), one kidney 
 weighed two ounces and the other three-quarters of an ounce. 
 
 In addition to these, there were two cases of atrophy from 
 impervious ureters, but whether they were of congenital origin 
 is not quite certain. 
 
 General remarks on unsymmetrical, solitary, and imperfectly 
 developed, or congcnitally atrophied kidneys. 
 
 Symptoms and diagnosis of single kidney. There are no 
 symptoms which can be attributed to unsymmetrical, solitary, 
 or imperfectly developed kidneys. The cystoscope and ureteral 
 catheter might aid in diagnosing the absence of one kidney. If 
 the renal substance of the existing organ is healthy the excretion 
 of urine goes on naturally, and the health and physique of the 
 person may be perfect. An " unsymmetrical," or any of the other 
 varieties of single kidney, is consistent with healthy life. 
 
 Many persons with an unsymmetrical kidney have lived to 
 advanced life, and died of disease unconnected with their kidney. 
 In solitary kidneys the danger to life from possessing only a single 
 organ is not nearly so great, because there are, as a rule, two in- 
 dependent pelves and ureters, and therefore the risks of plugging 
 of one ureter are much the same as when the kidneys are dis- 
 tinct and in their proper positions. This is even more true of 
 horse-shoe kidneys than of the more completely fused organs.
 
 72 
 
 SURGERY OF THE KIDNEY AND URETER. 
 
 Dr. Beadle's (of Glasgow) case of a male with absence of left 
 kidney, left ureter, and left suprarenal capsule lived to forty-five 
 years of age. And this may be taken as a type of " unsym- 
 metrical" kidney, for the majority have been met with in in- 
 dividuals of middle age, although, as previously mentioned, many 
 have been found in persons of much more advanced life and 
 
 Fig. 18. Horso-.shoc Kidney with Calculus in each Ureter. (Middlesex Hospital 
 
 Museum.) 
 
 even after the eightieth year. The complications which may 
 involve a single kidney, and which indeed seem prone to arise, 
 make life much more precarious on the score of renal diseases. 
 
 Albuminuria. Probably, as has been above stated, there is 
 a tendency to chronic albuminuria in early or young life in 
 persons with one kidney atrophied. 
 
 Tendency to formation of renal calculi. AVhen only one 
 kidney exists, and that an " unsymmetrical " organ, there would 
 seem to be a considerable disposition to renal calculus. Of 
 the twelve cases of unsymmetrical kidney collected by Mosler, 
 death was due more or less directly to calculus in the pelvis
 
 DISEASES OF SINGLE KIDNEY. 
 
 73 
 
 or ureter in nine of them. In the other three, cancer of the 
 bladder and rectum involving the ureter, nephritis, and the 
 consequences of obstruction due to severe congenital phi- 
 mosis, were respectively the causes of death. In the case of 
 cancer (Tulpius), a calculus had been passed per rectum in early 
 life, and there was an opening from the ureter into the rectum 
 through which part of the urine escaped. 
 
 In Raver's list, six cases of unsymmetrical kidney were affected 
 with calculus, but three of these are the same as Hosier's. Rayer 
 also gives one case of atrophic and one of fused kidney affected 
 
 Fig. ISA. Horse-shoe Kidney with a Tubular Carcinoma four inches in its chief 
 diameter. (Hunterian Museum, No. 3584K.) 
 
 with calculus. In the atrophic case the atrophy was caused by a 
 calculus ten drachms in weight, and the kidney was suppurating 
 and entirely destroyed. Mr. T. "Wilmott* published a case of 
 a patient with only one kidney, in whom there was a sacculated 
 nephritic abscess due to impaction of a calculus the size of an 
 almond in the commencement of the only ureter. There was 
 no kidney on the right side. The left kidney weighed twenty- 
 eight ounces. The patient was a woman aged thirty. Manbyf 
 recorded a case of cancer of an unsymmetrical kidney in a 
 painter, aged forty-eight years. Gould met with a horse-shoe 
 kidney, in a woman aged sixty, in which was a tubular carcinoma 
 
 * Brit. Med. Journ., Nov. 24, 1883, p. 1014. 
 
 t Lancet. April 11, 1885.
 
 74 SURGERY OF THE KIDNEY AND URETER. 
 
 (see Fig. 18 A). The illustration (Fig. 18) shows a very interesting 
 condition of things in which double calculous nephritis occurred in a 
 horse-shoe kidney, in consequence of the impaction of a calculus in 
 each ureter. The patient was admitted into the Middlesex Hospital,* 
 and died three days after with symptoms of uraemic poisoning. 
 
 v Orifice of the left 
 ureter. 
 
 Fig. 19. Horse-shoe Kidney, with Ureters and Bladder. The left half of the renal 
 mass was converted into a large thin-walled pyo-nephrotic cyst. (Middlesex 
 Hospital Museum.) 
 
 Nephrectasis. In other cases of unsymmetrical kidney there 
 has been hydro- or pyo-nephrosis due to some cause unde- 
 tected ; in one or two instances the quantity of urine excreted 
 was very small, the bladder was small, and the patient sub- 
 sequently died dropsical. 
 
 * Mod. Ret)., 892 : P. M. If eg. 170 (1894).
 
 DISEASES OF SINGLE KIDNEY. 75 
 
 Sometimes one-half of a horse-shoe organ is completely destroyed, 
 the other half being quite uninvolved. This is seen well in the 
 accompanying figure (Fig. 19), taken from a specimen added to 
 the Middlesex Hospital Museum by Mr. Andrew Clark ; one-half 
 of the horse-shoe was converted into a cyst filled with pus ; the 
 cause of the disease was not ascertained. The patient had passed 
 pus with his urine during life. Sutherland and Edington* have 
 described and illustrated a horse-shoe kidney, taken from a male 
 child, one-half of which was pyo-nephrotic and had given rise to an 
 abscess in the perinephric tissue ; in addition there was an abscess 
 in the left half of the isthmus. The right half of the organ was 
 normal. Somewhat similar but less well-marked cases are recorded. 
 
 In a case, of which I have notes, one-half of the horse-shoe 
 kidney was dilated and suppurating, and the cellular tissue 
 around it was inflamed. 
 
 Chronic nephritis. In the case of a young man, aged 
 twenty -seven, with horse-shoe kidney, reported by Dr. Gibb,f 
 the entire organ was in a state of Bright's disease. 
 
 Abnormal pressure - effects of horse-shoe kidney. Piccol- 
 homiiius I and Azzaritti have hinted that ill consequences some- 
 times arise from the pressure of the isthmus of a horse-shoe 
 kidney on the aorta and vena cava ; the latter, in this way, 
 accounted for an aneurysm in the first part of the abdominal 
 aorta (i.e. between the pillars of the diaphragm), which eroded 
 the vertebrae and subsequently ruptured into the left pleural 
 cavity. Generally, however, the isthmus is very thin, or even 
 fibrous, and does no harm by its pressure on the large vessels. 
 Nor is there, so far as I know, any reason for attributing to 
 it any disturbance of the sympathetic system. 
 
 Abdominal tumour caused by single kidney. The size 
 of the single kidney is, in some instances, very great. In Dr. 
 Kelly's case of complete fusion the renal mass weighed ninety- 
 three ounces. No tumour however was detected during life. 
 
 Morgagni refers to a case in which one kidney, as the result 
 of atrophy of the other, was ten times larger than natural ; and 
 to another case in which a kidney weighed thirty-five pounds ; 
 
 * Glasgow Medical Journal, February, 1898. 
 
 t Path. Soc. Trans., vol. xiii., p. 132. 
 
 J Morgagni, Letter xlviii., art. 16 ; vol. iii., p. 719. 
 
 Path. Soc. Trans, vol. xix., p. 274.
 
 76 SURGERY OF THE KIDNEY AND URETER. 
 
 and again to a third, noticed also by Fantonus, in which the 
 single kidney was more than twice this (thirty -five pounds) weight. 
 
 Other cases are referred to as of " surprising bulk and mag- 
 nitude " (Fernelius) ; or as " of an almost incredible magnitude 
 and breadth " (Boreus). In these cases, however, it is probable 
 that disease was superadded to hypertrophy. 
 
 It might easily happen that a horse-shoe kidney, or two 
 kidneys more or less completely fused, and situated in the median 
 line of the abdomen or in some part of the pelvis, would 
 give rise to the opinion that a morbid growth existed. This 
 would be more especially apt to occur if the abnormal kidney 
 mass could be readily felt by palpation of the abdomen, or by 
 examination per rectum or per vaginam ; and still more likely 
 if, in addition, the person was an invalid, or suffered from pains 
 in the abdomen or pelvis, clue to some other cause ; or if hydro- 
 nephrosis or pyo-nephrosis affected the organ thus misplaced. 
 
 In the days before abdominal surgery was much practised, 
 as well as since ovariotomy has been established as one of the 
 most successful of operations, renal tumours had been recognised 
 amongst the " causes of false pregnancy." From the writings of 
 those who had preceded them, even the earliest ovariotomists 
 might have been, and doubtless some of them were, cognisant 
 of the possibility of such errors in diagnosis. But by the mistakes 
 of ovariotomists, nephrectomy was performed before removal of 
 the kidney was admitted to be, or had been advocated as being, 
 a scientific operation. 
 
 In the Sepulchretum, amongst the conditions "which resemble 
 pregnancy is mentioned prominence of the belly from the size 
 and position of a solitary kidney. 
 
 Rhodius, in 1661, recorded a case of solitary kidney which 
 occupied the middle line, and was of such a size that the woman 
 was thought to be pregnant.* 
 
 Yesalius wrote j that sometimes in those who " have the 
 belly exceedingly prominent, and the order of the ribs vitiated, 
 he had seen a solitary kidney, and that a very large one, placed 
 upon the vena cava and the large artery." Eustachius J refers 
 
 * Raver's " Maladies des Reins." 
 
 t " De Corpore Humani fabric^," lib. v., cap. 10. 
 
 \ " De Renibus," cap. 10.
 
 SINGLE KIDNEY SIMULATING PREGNANCY. 77 
 
 hesitatingly to the same prominence of the abdomen, but does 
 not confirm it by the account he gives of a solitary kidney lying 
 on the middle of the spine. Morgagni could not doubt that 
 when a bulky solitary kidney rests on the spinal column the 
 belly would be prominent ; he quotes the case of a woman who 
 was supposed at first to be pregnant, but in whom the abdominal 
 enlargement was proved on dissection to be due to a solitary 
 kidney. He adds that Spigelius might have suspected pregnancy, 
 had the subject been a female, in a case of solitary kidney very 
 similar to that of the woman just mentioned. 
 
 Morgagni adds, however, that the suspicion of pregnancy 
 in such cases can only occur to the individual who is about 
 to make the post-mortem inspection, because during the life 
 of the woman the clinical history and duration of the tumour 
 would prevent one from going astray in one's diagnosis. The 
 solitary, centrally placed kidney will probably have been of con- 
 genital origin ; the pregnancy of but a few months' duration. 
 
 When, however, one or other of the kidneys has grown large 
 from disease, we must quite recognise the possibility of com- 
 mitting an error in diagnosis. 
 
 It is, indeed, far less probable that a single kidney, even if 
 of large size, when situated over the vertebral column, will be 
 mistaken for pregnancy or ovarian cyst or uterine myoma, than 
 that a cystic or solid tumour of the kidney will be thus 
 regarded. The important point in either case, however, is for 
 the surgeon who contemplates operative treatment to ascertain 
 whether the kidney is single or not. The cystoscope and the 
 ureteral catheter may afford information. 
 
 In some thin subjects the kidney can be made out in the loin 
 by manipulation and palpation. But this is not always possible. 
 
 Malformations and deformities. There is one feature which 
 has been found associated sufficiently often with misplaced, movable, 
 unsymmetrical, horse-shoe, and other forms of solitary kidney, to 
 make it worthy of special attention. I refer to malformations 
 and abnormal developments of other parts and organs of the 
 body as well as of the urinary organs. While treating of mis- 
 placed kidneys, I mentioned that the large intestine is compara- 
 tively frequently transposed or abnormally disposed, but many other 
 and more striking and noticeable deformities have been also observed.
 
 78 SURGERY OF THE KIDNEY AND URETER. 
 
 From a list of such cases which I have met with in my 
 reading or otherwise it is evident that defects of the generative 
 organs are very prone to be associated with abnormalities of 
 the kidneys. 
 
 The practical rule for surgeons to bear in mind is, therefore, 
 that if nephrectomy is contemplated on a person who has any 
 congenital malformation or deformity, and more especially if 
 the malformation or deformity is of the genito-urinary system, 
 very particular care should be taken to ascertain whether there 
 are two kidneys or only one. 
 
 3. ABNORMALITIES OF NUMBER (continued). 
 
 D. ABSENCE OF BOTH KIDNEYS. 
 
 The absence of both kidneys has many times been observed by 
 Raver and others in the foetus and in children still-born at full 
 time. Beclard* states that the kidneys are often wanting in 
 acephalous monsters, but that one kidney at least is always present 
 when a certain length of the vertebral column is developed. M. 
 Moulon* of Trieste has recorded the case of a young girl, 
 fourteen years old, who died of chronic gastro-enteritis, and in 
 whom neither kidneys nor ureters were found. The umbilicus 
 was situated where ordinarily the " mons veneris " is. The sym- 
 physis pubis was replaced by a wide gap, covered only by the 
 skin. The bladder was wanting. The urachus, very large 
 and long, was lost gradually in the integuments. The umbilical 
 vein greatly surpassed that of an adult. The uterus, ovaries, 
 and Fallopian tubes were perfect. The external genitals were 
 very defective, and the anus, which was inordinately large, 
 opened where the vaginal orifice should have been. From 
 birth this girl had been subjected to a continual discharge of 
 a liquid very like urine from the umbilicus. The fluid which 
 flowed thence had such a penetrating odour that it was impossible 
 for her to change her linen often enough to be free of smell. 
 M. Moulon concluded that the blood in this case gave up those 
 constituents which go to form the urine, to the liver ; and that 
 they were conveyed by the umbilical vein to the umbilicus and 
 
 * Beclard, " Mem. sur les Acephales," Bullet, de la Faculte de Mt'd. de 
 Paris, tome vi., p. 497. 
 
 t Archives Generates de Medecine tome xvii., p. 424.
 
 VICARIOUS FUNCTION OF OTHER ORGANS. 79 
 
 there excreted. The liver was gangrenous, as were the intestines 
 in spots throughout their extent. The pancreas was converted 
 into a sac of pus, and the great omentum was in part de- 
 stroyed. 
 
 Raver quotes M. Moulon's case, but with great mistrust ; 
 he considers that the real condition was atrophy of i the bladder, 
 and that the kidneys were congenitally misplaced, but overlooked 
 because not properly searched for at the post-mortem examination. 
 This opinion does not seem to be borne out by the description 
 of the post-mortem examination, for from the report it would 
 appear that all the abdominal and pelvic contents were thoroughly 
 investigated. 
 
 If M. Moulon's case is trustworthy, it enables us to under- 
 stand certain published cases of congenital hydro-nephrosis, and 
 others of anuria lasting over many months. 
 
 Vieusseux of Geneva speaks of a case of prolonged sup- 
 pression of urine in a young girl of eleven years of age. The 
 suppression lasted seventeen months and then the excretion 
 of urine was re-established. 
 
 Dr. Folk's f case has proved that a young person of nineteen 
 years of age can live for nearly twelve days after being suddenly 
 deprived of her only kidney ; and that during the last days 
 of her life a small quantity of fluid containing urea was discharged 
 from the bladder. This fluid, it is true, might have been a small 
 quantity of urine which was left in the ureter after the neph- 
 rectomy, and which only slowly reached the cavity of the bladder. 
 But vomiting and purging are frequent symptoms during 
 suppression, and by these means some of the constituents of 
 the urine are removed from the blood, though at length 
 exhaustion supervenes, and death, preceded by coma, occurs. 
 Such cases, while they show how difficult it is for the excretion 
 of urea and uric acid to be efficiently carried on by tissues and 
 organs suddenly called upon to perform such unaccustomed 
 functions, do not disprove, but on the contrary help somewhat 
 to make us give credence to the idea that when both the kidneys 
 are congenitally deficient life may be rendered possible for a 
 
 * Journal Medical ; Corvisart, Leroux, et Boyer, tome vii. ; Vendemiaire, 
 An. XII. (October, 1803). 
 
 }New York Medical Journal, Feb. 17, 1883.
 
 80 SURGERY OF THE KIDNEY AND URETER. 
 
 time by the liver and intestines assuming the renal functions. 
 Vieusseux's case shows that life may continue for many months 
 together, in spite of complete cessation of all secretion from 
 the kidney, in a young person whose renal organs had pre- 
 viously performed and subsequently resumed their full functions. 
 Numerous cases of foetuses without kidneys, but in many if 
 not all other particulars fully developed, show that the absence 
 of renal organs is not incompatible with intra-uterine development 
 and existence up to full time. 
 
 Mayer of Bonn published * a case of a still-born male infant 
 of full term in which the lungs, heart, liver, spleen, and greater 
 part of the intestines were normally developed, and the suprarenal 
 capsules were about twice their normal size, though the kidneys, 
 ureters and urinary bladder were completely wanting. The 
 gall-bladder, external genitals, sigmoid flexure, rectum, and anus 
 were also absent. The spinal cord terminated in a club- 
 shaped extremity opposite the second dorsal vertebra, though 
 the vertebral column was continued as far as the fourth sacral 
 vertebra. The sciatic, obturator, and crural nerves were 
 almost of normal size ; but the abdominal sympathetic 
 was less developed than usual around and about the intestinal 
 arteries. The abdominal aorta was nearly normal, but gave off 
 no renal branches. The testis and epididymis on each side were 
 small, and the vasa deferentia terminated in cellular tissue in 
 their serous tunic. There were other -minor vices of conformation 
 besides the above. As Mayer remarked, it appeal's from this 
 case that the most important functions of animal and organic 
 life can go on, at least during intra-uterine life, without the 
 assistance of the urinary organs. Mayer also raised the question 
 whether the development of the spinal cord is not a necessary 
 condition for the development of the urinary organs, and he 
 refers to the Memoire of Tiedmaim, in which this theory is 
 discussed. 
 
 Rayer, who cites Mayer's carefully reported case very full}', 
 gives references to several analogous cases ; as well as to cases 
 of double monsters (la duplicite monstrueuse par inclusion) in 
 which the kidneys were wanting. 
 
 * Zeitschrift fur Physiologie ; and Journal des Progres, tome iv., p. 281 
 (1827).
 
 MICROSCOPICAL STRUCTURE OF SUPERNUMERARY KIDNEY. 81 
 
 Chaussier* also exhibited the trunk of a foetus in which 
 there were neither kidneys, uterus, nor urinary bladder. 
 
 I will again remark that it is interesting and important to 
 the surgeon to notice how frequently abnormalities of the external 
 or internal genital organs, or of both, co-exist with the absence 
 of one or both kidneys. 
 
 E. SUPERNUMERARY KIDNEY. 
 
 Supernumerary kidneys are extremely rare and are usually 
 found accidentally after death, as they do not give rise to any 
 symptoms which indicate their presence during life. 
 
 An example of this condition is recorded in the report of the 
 Supervising Surgeon General of the Marine Hospital^ Service 
 of the United States, 1885 (pp. 148-150). 
 
 The subject was a man, aged thirty-nine : a third miniature 
 kidney was found in the hilum of the left kidney and attached 
 by a small duct (its ureter) to the ureter of the left kidney. 
 
 This supernumerary organ was 2 cm. in length and 1'2 cm. 
 in breadth, while its greatest thickness was 1 cm. It was invested 
 by a capsule, and the inferior extremity of the organ was slightly 
 thicker and more rounded than the superior. 
 
 On section the portion corresponding to the cortex of a true 
 kidney was thin and darker in colour than the rest of the cut 
 surface, which was pale and granular in appearance. There was 
 110 clear definition of pyramids, but at the hilum there was a 
 distinct space, from the margin of which pyramidal bundles of 
 tubes radiated into the mass of the organ. This space or pelvis 
 communicated freely with the duct that appeared to represent 
 the ureter, which was 10 cm. long and pervious for about 2' 5 
 cm. from the pelvis. A small artery and vein accompanied 
 this tube, and both of these were pervious. 
 
 Microscopical examination showed it to possess a structure 
 strongly resembling that of a kidney, in the tubular arrangement 
 of epithelial cells, the existence of an intertubular stroma and 
 of interspaces and Malpighian tuft-like bodies, but there was 
 110 structural evidence that it had ever undertaken physiological 
 secretion. 
 
 * Bull, de la Faculte de Med. de Paris, p. 35 (1810). 
 VOL. I. G
 
 82 SURGERY OF THE KIDNEY AND URETER. 
 
 Newman, again, mentions a case in which the supernumerary 
 gland was represented by a small pear-shaped body lying close 
 to the upper margin of the left kidney. It was supplied by a 
 branch of the renal artery, and had a distinct ureter, which passed 
 into the left ureter half an inch below the pelvis of the left 
 kidney. 
 
 An interesting example of a third kidney which was also 
 movable is recorded by Watson Cheyne.* The supernumerary 
 gland was in this case discovered during laparotomy ; it was 
 well developed and situated on the right side of the lower part 
 of the spinal column just at the brim of the pelvis. It had its 
 own ureter and blood supply and was from three to four inches 
 distant from the right kidney, which could be felt in the right 
 loin ano* was apparently of normal size. The left kidney was 
 also felt, and seemed rather smaller than the right. The third 
 kidney in this case was quite movable. 
 
 * Lancet, 1899, vol. i., p. 215.
 
 83 
 
 CHAPTER III. 
 CLINICAL EXAMINATION OF THE KIDNEY. 
 
 HAVING described the anatomical relations of the kidney, its 
 malformations and abnormalities, it will be well, before giving 
 an account of the various affections of the organ for which sur- 
 gical treatment is required, to draw attention to the methods of 
 examining the kidney in the consulting room or at the bedside. 
 
 In every case in which the kidney is supposed to be 
 affected, answers have to be sought to three questions : 
 
 First, Is the kidney really affected ? 
 
 Second, Is one only, or are both kidneys, involved ? 
 
 Third, If only one, which kidney is at fault? 
 
 In the following pages the difficulty in giving satisfactory 
 answers to these questions will again and again be pointed out, 
 more especially in reference to new growths, renal calculus, and 
 tuberculosis. A satisfactory reply, in many cases, can only be 
 obtained after an exploratory operation or ureteral catheterisation. 
 These methods of examination are fully described and discussed 
 later on. What is aimed at here is to give the reader some 
 directions which may assist him to properly investigate a case 
 w'thout or before having recourse to either the cystoscope and 
 the ureteral catheter, or the knife. 
 
 There are three steps in making a bedside examination which 
 ought to be invariably followed, namely (1) inspection, (2) palpa- 
 tion, (3) percussion. 
 
 1. Inspection. The front of the abdomen and the lumbar 
 regions should be uncovered to the skin, and should then be 
 carefully inspected : first, as the patient lies on his back, next, 
 whilst he is on his abdomen, then on one side and on the other, 
 and finally if thought desirable when in the sitting or the 
 erect posture. 
 
 If a kidney is normal in size, in fixity, and situation, no 
 evidence of its existence is furnished by inspection. If, on the 
 other hand, the kidney is " floating," or is enlarged by calculus or 
 tubercle, or is in a state of " iiephrectasis "that is, of distension
 
 84 SURGERY OF THE KIDNEY AND URETER. 
 
 by urine, pus, or blood its presence is often revealed to the eye 
 of an experienced observer. A " floating " kidney often slightly 
 presents against the anterior abdominal wall between a vertical line 
 drawn through the anterior axillary border and another through 
 the nipple as a smooth convex tody; and posteriorly, in the ilio- 
 costal space on the same side, the parietes have a forward " dip " or 
 depression. A flaccid, pendulous abdomen, and what is called by 
 the French venire trilobe, is often associated with movable kidney. 
 An enlarged kidney, whether the enlargement is due to nephrectasis 
 or to a new growth, may efface the natural hollow of the loin, 
 or even cause some actual fulness there, but rarely projects or 
 protrudes backwards to any distinct degree. If of large size, it 
 will bulge the abdominal wall, laterally, to a very appreciable 
 extent ; but its most decided tendency is to expand forwards. 
 
 2. Palpation. By palpation AVC learn the position, degree 
 of mobility, the outline or form, the volume, consistence, the 
 irregularities of surface, and the degree of sensitiveness or tender- 
 ness of the kidney. It must be borne in mind, however, that 
 many normal kidneys are quite beyond the reach of palpation ; 
 that they cannot be distinguished by the most careful manipula- 
 tion ; and are not brought within the grasp of the examining 
 fingers, even on the deepest inspiration. The kidney in some 
 persons may even be very much enlarged without being amenable 
 to palpation, and this is especially the case if the enlargement or 
 distension takes place principally or entirely in the upper half 
 of the organ : the expansion in that case occurs in an upward 
 direction and the enlarging kidney expands beneath the diaphragm, 
 increasing at the expense of the thoracic rather than of the 
 abdominal organs. 
 
 To properly palpate the kidney, the patient should be lying 
 on his back, with his shoulders slightly raised upon a firm pillow, 
 the lumbar spine resting quite flat upon the sofa or mattress, 
 and the lower limbs very slightly flexed. He should be encouraged 
 to breathe naturally and easily and keep his thoughts as much 
 as possible from the examination. There is a tendency very 
 much greater with some patients than with others to arch 
 the lumbar and lower dorsal spine as soon as the surgeon 
 commences his examination. This should be avoided if possible, 
 because, when the vertebral column is curved forward, there is
 
 I :.\ AM [NATION OF KIDNEY BY WMANUAL PALPATION. 
 
 85 
 
 a tendency for the kidney, even when of natural size, to become 
 unduly prominent, and to advance towards the abdominal parietes. 
 This is more especially the case in women, and when the kidney 
 is at all movable (see an observation by Sir AY. Jemier. referred 
 to on p. 532). 
 
 Another tendency with many patients is to contract the 
 muscles of the abdominal parietes as soon as the surgeon places 
 his hand upon the Ixxly, thereby hardening the abdominal wall, 
 which thus presents an effective barrier to palpation. 
 
 The patient, being in the required position, should be close 
 
 Fig. 20. Position of the Patient and of the Burgeon's hands when palpating 
 
 the Kidney. 
 
 to the edge of the bed or couch on the same side as the kidney 
 which is to be first examined, and should afterwards change 
 to the opposite side of the bed for the examination of the other 
 kidney. The surgeon then places the fingers of one hand on 
 the loin over and also just below the last rib, and the fingers of 
 the other hand flat upon the front of the abdomen just below 
 the costal margin (Fig. 20). He should be on the same side of 
 the patient as the kidney he is about to examine, and should 
 be sitting or kneeling at the bedside, so as to have his lower- 
 most forearm as nearly as possible level with the patient's body. 
 When examining the right kidney, the left hand should be 011 the 
 loin, the right in front ; when examining the left kidney the 
 right hand should be on the loin, and the left on the front of 
 the abdomen. With the hand on the loin the lumbar parietes 
 should be gently but firmly pressed forwards, and sustained so ; 
 then the fingers of the hand in front should gently and steadily
 
 86 SURGERY OF THE KIDNEY AND URETER. 
 
 depress the anterior abdominal walls upwards, backwards and 
 outwards. The kidney, if enlarged or displaced at all, will now 
 be felt between the two hands, and even if not enlarged, the 
 lower third or half of the organ will, in some persons, be 
 detected by the fingers during natural respiration. 
 
 Should this not be the case, the patient should be directed 
 to take a long, deep inspiration, and suddenly, but without mus- 
 cular effort, to allow the air to escape from his lungs : in other 
 words, he should make a long-drawn " sigh." The hand behind 
 still maintains forward pressure on the loin, and the hand in 
 front quickly follows the receding abdominal wall as it becomes 
 relaxed in the expiratory movement. Thus the kidney, which 
 otherwise cannot normally be felt, can often be seized between 
 the fingers of the two hands before it has time to regain its 
 normal position. This method becomes even more efficacious if 
 the patient takes a second and a third similar " sigh " whilst 
 the surgeon maintains and increases the deep pressure he has 
 made after the first and second. 
 
 With one hand placed on the front of the abdomen, nothing 
 satisfactory can be learned, except when (1) there happens to 
 be a " floating " kidney which rides forwards against the anterior 
 abdominal wall ; or (2) the kidney is much displaced to- 
 wards or into the iliac fossa, or on to the front of the spine ; 
 or (3) the kidney i.s much enlarged. Palpation with a single 
 hand, placed on the loin, affords, as a rule, no information 
 whatever. 
 
 When the kidney can be seized between the fingers of the 
 two hands placed as above directed, then by jerking forwards 
 the fingers of the hand behind, the kidney can be felt to 
 come with an impact against the fingers of the hand in front ; 
 and vice versa, if the fingers on the front quickly press the organ 
 backwards, it comes with a slight jerk against the fingers behind. 
 Bright, years ago, observed this antero-posterior movement as 
 being a feature of some renal enlargements. Guyon has dignified 
 it by a special name, calling it renal ballottement. This baHotte- 
 ment is not always present : kidneys which have long been the 
 seat of irritation as in calculous and tuberculous disease, and in 
 many instances of nephrectasis with suppuration excite chronic 
 changes which lead to adhesions sufficiently firm to prevent any
 
 OTHER METHODS OF BIMANUAL PALPATION. 87 
 
 movement of the kidney, either within, or together with, its peri- 
 iiephric investment. 
 
 Palpation is sometimes assisted by raising the patient's shoul- 
 ders so that he assume the semi-recumbent attitude. 
 
 In testing for mobility of the kidney it is sometimes advan- 
 tageous to place the patient in the knee-elbow posture, or even 
 in the upright position. 
 
 As a rule, however, I find it best to get the patient to roll 
 over on to the opposite side and then to employ bimanual 
 palpation whilst he takes a long-drawn breath, as described on 
 the previous page. 
 
 A movable kidney, which persistently declines to leave its 
 proper place as long as the dorsal posture is maintained, will 
 very frequently fall at once towards the front of the vertebral 
 column below the costal margin as soon as the lateral position 
 is assumed and a deep inspiration is taken. 
 
 The bimanual method of Glenard* consists in placing one 
 hand on the eleventh costal arc, with the thumb in front and 
 the middle finger behind ; then crowding back the abdominal 
 walls with the other hand placed on the umbilical region ; then 
 by compressing the intervening structures between the fingers of 
 the two hands, the kidney, as it descends on the patient taking 
 a deep inspiration, will be detected by the thumb of the hand 
 which is embracing the costal arc. The surgeon sits facing the 
 patient, either on the same side as, or opposite to, the kidney 
 which he is about to examine. 
 
 Chloroform narcosis greatly assists renal palpation, more 
 especially in persons with strong reflex muscular contractions ; 
 in those who have very rigid abdominal walls, or whose muscles 
 instantly recoil on the slightest pressure ; and also in persons 
 with a large amount of adipose tissue. 
 
 With kidneys which are not movable, which are but slightly 
 if at all enlarged, or the enlargement of which affects only the 
 upper pole of the kidney, chloroform does not render much assist- 
 ance. Moreover, under chloroform, the renal sensibility is, of 
 course, lost, and no information is afforded as to whether tender- 
 ness is present or not. 
 
 Pressure 011 a normal kidney, though it causes the peculiar 
 
 * Glenard: "Les Ptoses Viscerales," p. 376 et seq.
 
 88 SURGERY OF THE KIDNEY AND URETER. 
 
 feeling which is spoken of as renal sensibility, does not excite 
 pain ; but a sudden sharp pressure or compression between the 
 fingers will generally provoke pain if the kidney is inflamed or is 
 the seat of calculus. 
 
 By palpation we ascertain not only the size, position, mobility, 
 and sensitiveness of the organ, but we ascertain also the character 
 and the outline of a swelling. The kidney is rounded oft" on 
 every aspect, and though the inner border is often lost against 
 the spinal column, yet, when the notch at the hilum can be 
 made out, the margins of the notch, like those of the rest of 
 the organ, ' have a rouncled-off character. The absence of any 
 sharp or bevelled edges distinguishes renal from hepatic and 
 splenic enlargements. 
 
 3. Percussion. Percussion is practically of no use for the 
 purpose of delimitation of the normal kidney. It is only of 
 importance in the diagnosis of enlargements of the kidney 
 from enlargements of other organs within the abdomen. 
 
 Anteriorly, there is resonance over a renal enlargement, 
 owing to the large intestine being in front of the kidney. 
 
 Bowel is never thus placed in front of a splenic enlargement, 
 and only rarely in front of one of hepatic origin. As a renal 
 enlargement expands, the large bowel becomes displaced to the 
 side of the tumour ; the ascending colon to the median side of 
 the right kidney, the descending colon to the outer side of the 
 left kidney. Coils of small intestine may give a resonant note 
 over the front of a swelling either of the right or the left kidney, 
 if the enlargement is but moderate and is insufficient to bring 
 the kidney into direct contact with the anterior abdominal walls. 
 
 Posteriorly, there is no line of resonance between the kidney 
 and the vertebral column, though there is normally a wide reso- 
 nant area between the vertebral column and the spleen or a 
 splenic tumour. There is no space between the kidney and the 
 spinal groove into which the finger tips can be depressed, as 
 there is between the spleen and the spinal column. 
 
 Other means of examination. The X rays have now been 
 repeatedly employed in cases of suspected calculus ; and in some 
 cases with admirable effect. But the results are most unre- 
 liable ; shadows having been found when no calculus was present, 
 and no shadow obtained when a calculus existed ; and were the
 
 OTHER MEANS OF EXAMINING THE KIDNEY. 89 
 
 negative results allowed to influence surgical treatment, many 
 patients who are now cured by operation would be left to linger 
 on in suffering till they die (see chapter on Renal Calculus, 
 Vol. II., p. 43). 
 
 The plionendoscope, in the hands of its inventor (Bianchi), appears 
 to have given information as to the area of kidney dulness, and 
 if reliable it would help in discovering the sub-diaphragmatic expan- 
 sion in cases of enlargement of the upper pole of the kidney. 
 
 It has not, however, found favour as a means to diagnosis in 
 the London hospitals so far as I can ascertain. 
 
 The freezing test of the functionating power of the kidney 
 has been much extolled. It consists in the fact that the normal 
 blood has a freezing point O36 C. below that of distilled water, 
 and a diminution of the freezing point down to O50 C. or lower 
 indicates that the kidneys are not functionating properly. 
 
 The freezing point of the urine is less reliable, but when below 
 O'O C. renal insufficiency is indicated. 
 
 Catheterisation of the ureter. The objects of this procedure 
 are threefold, namely (1) to collect separately, for separate exam- 
 ination, the urine from the two kidneys ; (2) to test the patency 
 of the ureter and renal pelvis ; (3) to treat certain cases of neph- 
 rectasis, or of stricture of the ureter. 
 
 Cystoscopic inspection of the ureteral orifices. By this 
 means indications are sometimes furnished of the condition of the 
 kidneys : (1) by the character of the urine escaping from the ureter ; 
 (2) by the state of the ureteral orifice itself, and of the mucous 
 membrane of the bladder immediately surrounding the orifice. 
 
 Catheterisation of the ureter and cystoscopic inspection of the 
 ureteral orifices will be considered further on (Vol. II., p. 301). 
 These methods in some cases give clear answers to the questions : 
 "Is urine being excreted by two kidneys or only by one?" "Is 
 one kidney only, or are both kidneys, involved ? " and " If only 
 one is diseased, which kidney is at fault ? " 
 
 When the urine collected from a ureter is chemically or bac- 
 teriologically abnormal we have, of course, proof of the kidney 
 or the ureter from which it comes being diseased. But in view 
 of the fact that a kidney very defective in structure may yield a 
 certain amount of normal urine, we must not infer the soundness of 
 an organ from the absence of any abnormality in the urine derived
 
 90 SURGERY OF THE KIDNEY AND URETER. 
 
 from it. It was to overcome this source of error that experiments 
 were made with coloured substances injected into the subcutaneous 
 tissue, with the object of w T atching their progress through the 
 kidneys, as indicated by their appearance in the urine. 
 
 The methylene blue test. Many substances have been 
 used to test the permeability or excretory capacity of the kidneys, 
 but most of them require that the urine should be submitted 
 to a chemical analysis which, in some instances, is of a prolonged 
 and delicate character. To obviate this necessity, Achard and 
 Castaigne* employed the methylene blue test. The permeability 
 of the kidney to this substance seems, from experiments and 
 clinical observations, to be in very close relation to the capacity 
 of the kidney to eliminate urine of normal characters. 
 
 The normal appearance in the urine of the blue and of ehro- 
 mogen affords a very strong presumption in favour of the integrity 
 of one, at least, of the two kidneys ; but the cystoscope or the 
 ureteral catheter is needed to determine if either of them, and if 
 so which, is at fault. 
 
 The test has been employed in many different diseases, but 
 in particular in persons with renal disease, and it has been 
 observed repeatedly that the commencement of the appearance 
 of the blue in the urine is delayed in nephritis and in the various 
 forms of renal obstruction. 
 
 The method of applying the test is as follows : (1) Empty 
 the bladder ; (2) inject 1 cm. of a 5 p.c. sterilised solution of 
 methylene blue beneath the skin of the buttock or thigh ; (3) get 
 the patient to pass water an hour after the injection, and every 
 hour afterwards as long as the urine is at all coloured blue. 
 
 The blue ought to appear in the urine within an hour, and 
 should increase in amount for several hours, when it should 
 diminish, and disappear entirely after thirty-six to forty-eight hours. 
 
 Chromogen, which is detected by adding a few drops of acetic 
 acid to boiling urine, is eliminated normally with the blue, but in 
 smaller quantity 
 
 According to the kind and degree of pathological changes in 
 
 "Diagnostic de la Permeabilite rcnale," Soc. Mid. des Hop., 30 Avril 
 et 18 Juin, 1897; also Revue G<'-n<''rale Gaz. des Hop., 11 Juin. 1898, 
 Xo. 6G. See also Ann. des Mai. des Organ. G>'nito-urinaires, 1899-
 
 RENAL ELIMINATION OF METHYLENE BLUE. 91 
 
 the kidney there will be a greater or less delay in the commence- 
 ment of the elimination of the blue ; the period during which 
 it is being eliminated will be more or less prolonged ; or the 
 blue may fail entirely to appear in the urine, chromogen alone 
 being present, and that only in very small amount. 
 
 A permeable or healthy kidney allows the blue to pass in 
 great quantity ; an impermeable, defective, or diseased kidney 
 allows of its passing only in small quantity, or not at all. This 
 is the one proposition about which there is complete accord. 
 
 Hepatic affections have a disturbing effect upon the renal 
 functions, especially in states of nervous polyuria and compensatory 
 hypertrophy; and various other circumstances and conditions seem 
 to be able to influence the length of time after the injection 
 before the blue appears, as well as the duration of the period 
 during which it continues to appear. 
 
 Nor does there seem to be absolute certainty, as yet, as to 
 the conditions affecting the presence of chromogen. 
 
 The phloridzin test. It has been known for many years that 
 phloridzin produces glycosuria.'* Recently Dr. Pavyf showed that 
 when it was injected into the renal artery of a dog it produced 
 the immediate appearance of a large quantity of sugar in the xirine 
 from the kidney of the same side, and a little later in that from 
 the opposite kidney. 
 
 Drs. Casper and RichterJ show that the artificial glycosuria 
 resulting from the administration of phloridzin is modified in a 
 decided manner by the functional activity of the kidney being 
 diminished on one or both sides, according to the distribution and 
 extent of the disease. 
 
 The efficiency of renal secretion is deduced from the rapidity 
 with which the sugar appears. Normally its appearance is within 
 half an hour or an hour after the subcutaneous injection of the 
 drug. Catheterisation of the ureter is requisite to determine whether 
 one or both kidneys are concerned in eliminating the sugar. 
 
 Note. Reference may be made to the preliminary chapter on Tumours 
 (Vol. I., p. 529), and to the account of the Operative Treatment of 
 Renal Calculus (Vol. II., p. 131 et seq.\ respectively, for Remarks on the 
 Diagnosis of Renal Enlargements, and for the Method of Exploring the 
 Kidney by Lumbar Incision. 
 
 * Dublin Med. Journ., 1862, p. 39. t Path. Soc. Lond., Nov. 6, 1900. 
 
 I Berl. klin. Wchns., July 16, 1900, p. 643.
 
 92 
 
 CHAPTEK IV. 
 MOVABLE AND FLOATING KIDNEY. 
 
 THE first recognition of abnormal mobility of the kidney dates 
 back into the far past, but more attention than ever before has 
 been given to it since Martin of Berlin, in 1878, performed the 
 first nephrectomy for movable kidney, and Halm of Berlin, in 
 1881, published an account of the first operation for fixing a 
 movable kidney. 
 
 Centuries ago it was made the subject of a chapter by Mesue, 
 of Venice (see editions 1497, p. 187, and 1561). Other ancient 
 writers on the mobility of the kidney are Francis Pedemontanus, 
 in 1581 and 1623 (p. 75), and Eiolan, in 1682. 
 
 In modern times Gigon of Angouleme, Raver, Fitz, Dell, 
 Landau, oSTewman, and many others have described the symptoms 
 which it causes, and have pointed out the relation between mov- 
 able kidney and hydro-nephrosis. 
 
 Natural movements of the kidney. A certain limited 
 amount of movement in a vertical direction is natural to the kidney 
 in each one of us ; it ascends with expiration and descends 
 with inspiration; it descends also, slightly, by the force of 
 gravity in the upright position. Movements the result of deep 
 respiration can be detected on bimamial examination in thin 
 persons whose thoracic walls are not unusually long or deep ; 
 they are daily witnessed by surgeons accustomed to operate upon 
 the kidney, and can easily be demonstrated on the dead body 
 as soon as the abdomen is opened and before any of the viscera 
 are removed. 
 
 The range of the natural movements varies with the sex 
 and in different persons of the same sex ; but it probably does 
 not much exceed an inch or an incli and a half. It is greater in 
 the female than the male, a difference which llosenthal states exists 
 in infancy and young life as well as in the adult. This is not what 
 would have been expected considering that in young children, 
 males and females alike, the type of respiration Ls the abdominal ;
 
 HOW HEN'AL MOYKMKXTS ARE LIMITED. 93 
 
 and in women the type of respiration is what is called superior 
 costal, i.e. the movements of respiration are less extensive in 
 the lower and more so in the upper part of the chest : 
 whereas in man it is the inferior costal type, i.e. the whole 
 chest and the sternum, as well as the diaphragm, are subject 
 to a wide movement in inspiration. An anatomical reason for 
 this greater mobility in females is, however, afforded by the 
 observation of Deletzine and Volkoff (Med. Mod., Mars 10, 
 1897), who point out that in the female the renal fossa is not 
 so deep and its width at the inferior part is much greater. 
 
 Natural means whereby the movements of the kidney 
 are restrained. The kidney, unlike the liver or the uterus, 
 has no special ligaments for keeping it in its place, and very 
 varied opinions have been advanced by different writers as to 
 how this is effected. We will not enter into a discussion on 
 this subject. It will be sufficient to refer the reader to Chapter I. 
 for a description of the renal pedicle, the fatty capsule of 
 the kidney, the perinephric fascia, and the vertebro-costal liga- 
 ment. Though all these structures, together with the peritoneum 
 and, last not least, the intra-abdominal pressure, take part in 
 retaining the kidney in its normal position, it is, probably, to 
 the way in which the kidney is packed in its fatty cushion within 
 the perinephric fascial sheath (Figs. 21 and 22, pp. 103 and 104), 
 rather than to any other single factor, that the chief importance 
 must be attached. In the infant the fatty capsule does not exist, 
 and it is the peritoneum which is the chief agent in giving fixity 
 to the kidney. 
 
 What is meant by movable and floating kidney. The 
 distinction made between a movable and a floating kidney is 
 not the same with all who use the terms. Some have given 
 to them an anatomical, some a clinical definition. Those who 
 use the term floating kidney with an anatomical meaning include 
 under it only the kidneys which have a distinct mesenteiy a 
 mesonephroii ; whereas those who give to it a clinical significance, 
 imply that the movements of the kidney are such as permit 
 it to rise or float towards the anterior abdominal walls, whether 
 it has a mesentery or not. 
 
 The committee of the Pathological Society of London, appointed 
 to inquire into the matter of displaced, movable, and floating
 
 94 SURGERY OF THE KIDNEY AND URETER. 
 
 kidneys, found evidence to show that " the peritoneum may be 
 flaccid and loose to such an extent as to allow the kidney to move 
 under it so as to come in contact with the walls of the belly ; 
 or to leave its natural place and pass to or below the brim 
 of the pelvis, or, indeed, in some cases to encroach upon the 
 opposite side of the belly. A like mobility or " floating " of the 
 kidney may be due to the presence of a mesonephron." 
 
 The committee, taking into their consideration the clinical 
 resemblance of all very freely moving kidneys, whether they have 
 a mesonephron or not, and also the fact that " both these ana- 
 tomical varieties merge by insensible degrees into one another," 
 would style every very mobile kidney " floating," no matter what 
 its anatomical relations to the peritoneum ; and every slightly 
 or moderately mobile kidney " movable." Other writers, like 
 the late Sir William Jenner, consider " a floating kidney is a 
 kidney that has a mesentery, a fold of peritoneum attaching 
 it very loosely to the spine ; a floating kidney can be moved 
 about to a considerable extent, to the extent of the length of 
 its mesentery. A movable kidney can only be passed up and 
 down a little ; it slips a little under your fingers." * But this 
 is to confuse the anatomical and clinical features, and to leave 
 out of sight those equally " floating " kidneys which have no 
 mesentery. It implies that the degree of mobility depends on 
 the presence or absence of a mesonephron ; and therefore that 
 a clinical difference indicates an anatomical distinction, which is 
 not by any means correct. 
 
 In my former book on the " Surgery of the Kidney " (1885), 
 I adopted the strictly anatomical definition because at the time of 
 writing the few surgeons who had operated upon the kidney were 
 divided into two groups, namely, those (1) who advocated the lumbar 
 or extra-peritoneal operation, and (2) those who preferred the trans- 
 peritoneal or intra-peritoneal ; and it was only right that one of the 
 earliest and most inflexible of the advocates of the lumbar method, 
 when writing on the subject of movable kidney, should candidly 
 recognise the cases in which an operation could not be performed 
 without opening the peritoneal cavity, and in which therefore 
 the objections made against the trans-peritoneal method as an 
 operation for general adoption did not, in their entirety, hold 
 
 * Brit. Mcd. Journ., vol. i., p. 43 (1809).
 
 DISTINCTION BETWEEN "MOVABLE" AND "FLOATING" KIDNEY. 95 
 
 good. But to-day, when surgeons almost uniformly practise the 
 lumbar operation for all cases except for large renal tumours 
 and some few other very exceptional conditions, there is no 
 object in emphasising a rare anatomical feature connected with 
 the peritoneal covering of the kidney, which is entirely without 
 any real practical importance. We shall here use the terms, 
 therefore, with a strictly clinical meaning. 
 
 A " movable kidney " is one which moves abnormally freely behind 
 the peritoneum. The peritoneum should, normally, only pass over its 
 anterior surface and overlie the anterior layer of the perinephric 
 fascia. The natural movement of the kidney takes place within the 
 tunica adiposa. The abnormal movements occur behind the peri- 
 toneum in three forms. If the natural movement simply becomes 
 exaggerated the kidney is said to be " movable," but it still moves 
 only w r ithin its own fatty capsule. In other instances the adipose 
 tissue, being more firmly connected with the proper fibrous capsule 
 of the kidney, moves with it within the perinephric fascia. The 
 third condition is where the kidney moves within the fatty capsule 
 and that again within the sheath of perinephric fascia. 
 
 The " movable " kidney is entirely shut out from the peritoneal 
 cavity, it does not hang or project into it like the small intestines 
 or the caecum, for example, do ; it occupies its position between 
 the peritoneum in front and the muscular parietes behind ; but 
 within this position the kidney moves more or less freely and 
 widely. There is no, or no appreciable, movement forwards, no 
 " floating " towards the anterior abdominal walls. These are the 
 commonest forms of moving kidneys ; they are the most difficult, 
 indeed are often quite impossible to detect clinically or until 
 the loin is opened in the course of an exploratory operation. 
 These include the cases which I am in the habit of describing 
 as kidneys with a " cinder-sifting " movement. 
 
 A " floating kidney " is one which, whether it possesses a 
 mesonephron or not, moves freely forwards so as to rise or 
 "float" towards the anterior abdominal wall as well as vertically 
 and laterally; this "forward" movement or "floating" makes the 
 distinction between it and the "movable" kidney. It is not 
 possible to distinguish until the abdomen is opened, or the 
 kidney is explored through the loin, whether a floating kidney 
 has a mesonephron or not.
 
 96 SURGERY OF THE KIDNEY AND URETER. 
 
 A floating kidney with a mesoiiephron is of course always 
 congenital, and is necessarily associated with an elongation of the 
 renal vessels. In some cases of floating kidney with a mesoiiephron 
 it has been noticed that all the processes of the peritoneum were 
 unusually long ; the foramen of Winslow very large owing to 
 the laxity of the gastro-hepatic omeiitum ; the great omentum 
 very large, and the mesocolon long and lax. It is possibly true 
 of this class what Glenard says of nephroptosis generally, namely, 
 that eiiteroptosis may exist without nephroptosis, but not 
 nephroptosis without eiiteroptosis. The statement is certaiiily 
 not correct if applied to " floating " kidney Avithout a meso- 
 nephron, and still less is it so if applied to "movable" kidney 
 as well as floating kidney. In. ninety-eight* cases of movable 
 or floating kidney which I have operated upon, the number 
 in which anything approaching hepatoptosis or eiiteroptosis was 
 present could be counted on the fingers of one hand. 
 
 A floating kidney without a mesonephron may be acquired 
 and the renal vessels become elongated. Thus a " movable " 
 kidney which for a while had been limited to an up-aiid-dowii 
 movement may by degrees become a " floating " kidney owing 
 to the loosening of the peritoneum from the lumbar portion of the 
 abdominal wall ; but though the mobility of such a kidney may 
 ultimately equal in extent that of a kidney with a mesonephron, 
 the change in the relation of the peritoneum to the kidney does 
 not convert it into or make it resemble a true mesentery or 
 mesonephron. A floating kidney with a mesonephron is very 
 much less common than one without a mesentery : indeed it is 
 excessively rare. It has been repeatedly asserted that a true 
 mesonephron has never yet been observed, and does not occur. 
 But the term mesentery does not imply anatomically a complete 
 investment of the whole organ by the peritoneum, otherwise 
 it could not be applied to the peritoneal covering of the caecum 
 and colon. The layers need not actually meet behind ; they 
 still form a mesentery if they cover the poles and borders and 
 
 * Though the number of my operations for movable kidney has been in- 
 creased since this was written, and the number of cases of movable kidney 
 as to which I have been consulted still more so, yet the number of cases 
 in which eiiteroptosis existed has been quite infinitesimal : and in not one 
 of the more recent cases has there been marked mobility of either the 
 liver or intestines or spleen.
 
 PATHOLOGY OF MOVABLE KIDNEY. 97 
 
 a considerable part of the posterior surface of the organ. Those 
 who deny the occurrence of a mesonephron must have over- 
 looked some illustrative published cases. 
 
 Dr. William Henderson * of Clifton, reported a case in which 
 the right kidney was found perfectly movable, and suspended 
 " by a prolongation of the peritoneum enclosing the kidney and 
 forming a distinct mesentery, which allowed it to move in all 
 directions." Dr. Priestley t recorded a case in which the 
 peritoneum formed a distinct mesentery for the kidney. More 
 recently (in April, 1883) Dr. Lindsay Steven showed a specimen 
 of kidney with a partially formed mesonephron, at a meeting 
 of the Glasgow Pathological and Clinical Society .J The line of 
 attachment of the renal mesentery in Dr. Steven's specimen corre- 
 sponded to the upper half of the internal border, and a small 
 area of the upper portion of the posterior surface of the kidney. 
 The movement of the lower part of the kidney was thus much 
 more free than that of the upper. 
 
 In Mr. Keetley's case the right kidney of a woman, aged 
 sixty-eight, was found to have two layers of peritoneum forming 
 w r hat resembled a mesentery ; they were independent of each 
 other behind, but they covered the kidney so as to move with 
 it freely in all directions. The kidney did not simply move 
 behind the peritoneum. 
 
 For convenience of description the terms movable and floating 
 kidney will be used indiscriminately, except when one or the 
 other type is specially referred to ; it will then be designated by 
 the term " movable behind the peritoneum," or " floating kidney 
 without a mesonephron," or " floating kidney with a mesonephron/" 
 as the case may be. 
 
 Pathological anatomy. Sometimes the adipose capsule of 
 the kidney is large and loose, and permits of the movement 
 of the organ within it ; in other instances it closely surrounds 
 the kidney, and moves with it ; w T hilst in others again the kidney 
 moves within its adipose capsule, and the capsule also moves, 
 about with the kidney behind the peritoneum. The amount, 
 
 * Med. Times and Gaz., vol. ii., p. 501. 
 t Ibid., vol. i., p. 262 ; 1857. 
 | Glasgow Med. Journ., Oct., 1883, p. 309. 
 Path. Soc. Trans., vol. xxvii., p. 469. 
 VOL. I. H
 
 98 SURGERY OF THE KIDNEY AND URETER. 
 
 of fatty tissue varies very much ; in the most movable cases 
 there is often little or none ; but a considerable amount of mo- 
 bility of kidney is consistent with a fair amount of fat when 
 the two move together within the perinephric fascia. The fatty 
 tissue is soft and very fine ; if it becomes tough and fibrous, 
 the kidney tends to become more fixed. 
 
 The peritoneum. If the kidney floats it is either owing to 
 its possessing a mesentery, or to the peritoneum becoming 
 elongated by continuous dragging upon it by the weight of .the 
 kidney after it has once begun to lose its natural fixity of posi- 
 tion. With the yielding of the peritoneum the anterior layer 
 of the perinephric fascia also yields. There are all degrees of 
 yielding, between the mere looseness which allows of the kidney 
 unduly moving behind the peritoneum, and its floating freely 
 towards the front of the abdomen or across the median line 
 with all the freedom it would possess with an elongated mesentery. 
 
 In some cases the peritoneum congenitally has a more extensive 
 connection with the kidney than usual, covering its convex border 
 and advancing more or less over the posterior surface. In these 
 intermediate forms there is no mesonephron, and owing to some 
 irregularities in the arrangement of the peritoneum the kidney 
 may not be even covered on its anterior surface by the perito- 
 neum, but be unsupported and free to move between diverging 
 processes of the peritoneum. The case published in Mr. Durham's 
 article in the Guy's Hospital Reports (3rd series, vol. vi., p. 413), 
 is one in point. 
 
 The kidney. The structure of the kidney is normal, or 
 if it be not so the pathological change in. it is usually entirely 
 independent of the mobility. There is one pathological condition, 
 however, which is due to the mobility, and which is not seldom 
 met with by the surgeon when performing nephropexy. It is 
 n certain degree of nabbiness and softness of the renal tissue 
 due to sacculation of the calyces from frequent moderate renal 
 retention. These are cases of commencing or early hydro-nephrosis 
 which give no clinical sign of an enlargement. I have on some 
 occasions, where with the mobility there has been intermittent 
 fulness or hardness over the renal region, found the kidney 
 so advanced towards hydro-nephrosis that I have hesitated between 
 fixing or removing the organ ; and in one case the kidney was
 
 HYDRO-NEPHROSIS IX MOVABLE KIDNEY. 99 
 
 subsequently removed because the fixation, which was very com- 
 plete and extensive, failed to relieve the intermittent attacks. 
 It is more than probable that in some cases where hydro- 
 nephrosis has been present with a movable kidney there has been 
 some other overlooked condition, such as a valve or stricture 
 or an abnormal renal vessel, which was the cause of the hydro- 
 nephrosis, whilst the latter, in turn, was the cause of the mobility. 
 Since my attention was first directed to Kiister's and Fenger's 
 plastic operations on the ureters I have always looked for and 
 on several occasions found one or other of these causes present ; 
 in some of the cases I have corrected the obstruction before 
 fixing the kidney, in others in which the atrophy of the paren- 
 chyma has been very advanced I have performed nephrectomy. 
 
 A floating or movable kidney may contain one or more calculi, 
 or may be associated with pyo-nephrosis or pyelonephritis; and 
 though these may be coincidences, still we must recognise the 
 fact that in a person with a movable kidney and a tendency to lithiasis 
 the renal retention which the mobility of the kidney so often 
 occasions may induce the deposition of some of the urinary salts 
 from the retained urine. The renal retention and the con- 
 gestion and engorgement of the kidney which occur with the 
 crises of a floating kidney may also induce a condition favourable 
 to septic micro-organisms,' and thus a hydro-nephrosis may be 
 converted into a pyo-nephrosis, or a suppurative pyelo-nephritis 
 may be started. Such morbid changes, however, bring the 
 patient under notice not for mobility of the kidney but for the 
 symptoms due to the calculus or the suppurating proce.- 
 
 The ureter. Gigon, in 1856, gave the explanation of the occur- 
 rence of hydro-nephrosis with movable kidney. He attributed 
 it to the kinking of the ureter, which, fixed by the peritoneum, 
 cannot follow the kidney in its wanderings ; and thus a curve 
 is formed with its convexity upwards, which becomes the more 
 pronounced as the kidney falls lower and lower. Gigon thought 
 this curvature might render the passage of urine, temporarily, 
 even quite impossible. Landau, Terrier, and Ban do in have 
 accepted or revived this explanation, and it has become established 
 as an accepted fact by the observations and published records 
 of many surgeons. This curving of the ureter can be shown 
 to take place in the deacl body when the kidney is pushed
 
 100 SURGERY OF THE KIDNEY AND URETER. 
 
 downwards ; and Legueu found that the curvature was pro- 
 duced when the ureter followed the kidney in its displacement. 
 Navarro and Tuffier have demonstrated experimentally, by mobi- 
 lising the ureters of dogs, that ureteral curvatures are followed 
 by renal retention. Further proof of the same fact, though 
 less convincing, is furnished by the observation of Albarran,. 
 who found, when catheterising the ureter in two women with 
 mobile kidneys but no hydro-nephrosis, that the catheter, which 
 was arrested at the height of 12 to 15 cm., could be made to 
 penetrate further on raising the kidney. Still it cannot be 
 assumed that in ' every case of curvature there will be renal re- 
 tention, or, conversely, that renal retention in a mobile kidney 
 is in every case caused by kinking or a curve of the ureter. On the 
 one hand the case I record in treating of the ureteral anastomosis 
 (see Fig. 184, p. 545, Vol. II.), in which there was a very considerable 
 curve of the ureter of a mobile kidney made permanent by tough 
 adhesions, but without any trace of there having been renal reten- 
 tion ; and, on the other hand, the by no means very infrequent 
 association of mobile kidney with hydro-nephrosis from valve 
 formation or stricture, warrant this opinion. Nor can it be held 
 as proved that in every case, in which the kidney is movable, 
 the mobility is the primary cause of the curvature. So far as 
 clinical observation alone can inform us (which I admit is not 
 convincing evidence because of the impossibility of being sure that 
 the kidney had not the " cinder-sifting " movement long before it 
 was detected as a movable kidney) the mobility itself and the 
 curvature are in many cases secondary to some other renal lesion, 
 such as calculus, nephrectasis, or tumour. Sight ought not to be 
 lost of the possibility that a hydro-nephrotic or other form of 
 enlarged kidney may become movable by its weight or otherwise. 
 Thus, W. Walter (Manchester) records a case in which nephrectomy 
 was performed for a floating cystic kidney. The patient was a 
 woman, aged forty-two, from the lower part of whose kidney there 
 projected a cyst containing ten ounces of a pale straw-coloured 
 fluid of sp. gr. 1013, and highly albuminous. A tumour had existed 
 for six years, but had caused no trouble till three years after it 
 was first noticed. 
 
 Associated movements of other abdominal viscera. In my 
 earlier work it was mentioned that in some cases of floating
 
 EXTEROPTOSIS, HEPATOPTOSIS. 101 
 
 kidney the foramen of Winslow was very large, the great 
 omentum and mesocolon large and long, and all the pro- 
 cesses of the peritoneum unusually long. Landau found that 
 at least half the patients with movable or floating kidney 
 have prolapse of the uterus or vagina, or cancer, or retro- 
 flexion of the uterus, hernia, or weakness or laxity of the 
 perineum or abdominal w^alls. Glenard, in an elaborate work 
 on enteroptosis, has pointed out the frequency with which the 
 liver, intestines, and kidney of the same person are suspended at 
 a lower level, unduly lax in their positions, and movable. He 
 has described four degrees of nephroptosis, and expressed the 
 opinion that nephroptosis never exists without enteroptosis.* 
 Ewald, 011 the other hand, in a review of what has been written 
 on Glenard's disease in France and Italy, arrives at the conclusion 
 that there is no relation between nephroptosis and general splanch- 
 noptosis in the sense that the former must be unconditionally 
 followed by the latter. The conclusion of Ewald is the one 
 which will most commend itself to surgeons who see much of 
 kidney surgery and movable and floating kidneys. My own 
 personal experience is that the persons who consult a surgeon 
 on account of a wandering or movable kidney are as a rule free 
 from undue mobility or ptosis of any other abdominal organ. I 
 have only once been consulted, with a view to the question of 
 treatment of a mobile kidney, where the patient was considered 
 to be the subject of enteroptosis. This patient was sent to me 
 by a physician as a case of Glenard's disease. She was a woman 
 with very lax abdominal wall, a very movable kidney, and a 
 somewhat movable liver. She was quite relieved of all her symp- 
 toms, both renal and intestinal, by iiephropexy, and remains well 
 now several years after the operation. 
 
 I have twice operated in cases with very marked hepatoptosis 
 without movability of kidney. In a few cases I have found the 
 
 * Glenard, "Les Ptoses Viscerales," 1899. Glenard writes upon the 
 influence exercised by the respiratory movements upon the mobility of 
 the kidney with all the portentousness of having made a discovery. 
 Originality is simplified by overlooking what has previously been done by 
 others. Reference might have been made to the writings of Dickinson, 
 and to pp. 27, 34, 486, 490 and 491 of my "Surgical Diseases of the 
 Kidney," which was written in 1883-84 and published in November, 1884, 
 a year or two prior to Glenard's first papers on the subject.
 
 102 SURGERY OF THE KIDNEY AND URETER. 
 
 liver movable with a moving right kidney, and in one case in 
 which I fixed a movable left kidney the spleen was movable 
 and much lower in position than normal, though capable of being 
 pushed up. Cunningham has noticed adhesions to the colon 
 of a movable kidney ; and in Durham's case, mentioned above, 
 the floating left kidney was associated with, and Durham thought 
 was caused by, the malposition of the descending colon. 
 
 Associated defects and deformities, Besides the abnormalities 
 of the renal vessels, persisting foetal lobulation, and an occasional 
 malformation of the kidney itself (Herczel), malformations of 
 the colon and liver (Pasteau), varicose veins (Tufner), and 
 marks of physical and mental degeneracy (Albarran) have been 
 noticed in persons with wandering kidney. Albarran, who has 
 elaborated a " theory of degeneration " or congenital predisposition 
 to nephroptosis, supports it by these associated deformities and 
 the occasional occurrence of movable kidney in different members 
 of the same family (Stapfer). 
 
 The vessels of the kidney may be elongated, but in other 
 respects are, as a rule, normal. The elongation of the renal 
 artery and vein is often seen in operations, and has been repeatedly 
 found in post-mortem examinations. The renal artery has been 
 met with nearly five inches in length, and Tuffier states that in 
 one case the right renal vein was long enough to allow of the 
 kidney being drawn through the lumbar wound as far as to the 
 patient's buttock without causing any traction upon it. The 
 artery is more frequently elongated than the vein. When the 
 kidney is drawn through the lumbar wound the vena cava yields 
 somewhat to the traction and presents a marked convexity at 
 the level of the attachment of the vein and on the side of the 
 traction. In the acquired cases of floating kidney (those without 
 a mesentery) the elongation of the vessels is also as a rule acquired. 
 This is shown by their undue slenderness as well as their undue 
 length. Durham noticed this condition, and it has since also 
 been observed in other cases.* An abnormal origin of the artery 
 of a movable kidney suggests the congenital nature of the mobility. 
 The suprarenal capsule commonly does not move with the 
 
 * Leguen, Soe. Anat., 1895, p. 565 ; Gosset et Glantenay, Soc. Anat. 
 1897, p. 210 Pasteau, Soc. Anat., 1897, pp. 213 and 269 ; Watson, Journ. of 
 Cutaneous and Genitourinary Diseases, 1S97 p. 315.
 
 DEGREES OF MOBILITY 
 
 103 
 
 kidney, and, except as regards its relation to the kidney, occupies 
 its natural situation in the body. 
 
 The extent of movement varies greatly. As stated above, a slight 
 degree, i.e. an inch or thereabouts, inwards, upwards, or down- 
 
 Fig. 21. Longitudinal Section sho\ving the arrangement of the capsule of the 
 
 Kidney. (After Gerotd}. 
 1, llth rib ; 2, 12th rib ; 3. posterior lamellae of the peri-renal fascia; 4, fat situated behind peri-renal 
 
 fascia ; 5, insertion of the anterior and posterior lamellae of the fascia to the diaphragm ; 
 
 6, anterior lamellse of the peri-renal fascia ; 7, vessels of the hiluix of the kidney ; 8, section 
 
 of colon. 
 
 wards is not abnormal, but the kidney is prevented from moving 
 outwards by the normal arrangement of the perinephric fascia 
 (Figs. 21 and 22). The degrees of abnormal mobility are: (1) 
 when the kidney moves up and down so that the lower half comes
 
 104 
 
 SURGERY OF THE KIDNEY AND URETER. 
 
 between the fingers of the two hands during deep inspiration ; 
 (2) when the greater part or even the whole of the kidney can 
 be [grasped during a deep inspiration, but ascends again during 
 
 Pig. 22. Transverse Section showing the relations cf the Capsule of the Kidney. 
 
 (After Gcrota). 
 
 1, Psoas ; 2, sacro-lumbalis group ; 3, quadratus luntborum ; 4, peritoneum ; 5, kidney ; 0, anterior 
 lamelhe of the peri-renal fascia ; 7, colon ; 8, sub-peritoneal fascia. 
 
 expiration ; (3) when the whole kidney descends below the exam- 
 iner's fingers and can be retained below them after the patient 
 makes a full expiration. In some of the more extreme cases the 
 kidney is often out of position during natural respiratory movements.
 
 TRANSVERSE AND VERTICAL ROTATION. 105 
 
 The peritoneum may be sufficiently loose to allow the kidney to fall 
 below the brim of the pelvis, or against the anterior abdominal 
 parietes, or across to the opposite side of the spinal column, moving 
 through a circle with a diameter of eight or nine inches.* 
 
 It is evident, therefore, that the greatest freedom of movement 
 does not of itself indicate that the kidney possesses a mesonephron, 
 or that the peritoneum covering the kidney is in any way 
 abnormal except in the greater laxity of its attachments the 
 perinephric fascia and the subperitoneal fatty tissue of the loin 
 also being abnormally loose. A kidney without a mesonephron 
 having as great a range of movement as a kidney with a meso- 
 nephron may give rise to all the same clinical features. 
 
 The kidney in some cases, besides moving vertically and laterally, 
 has also a rotation movement either round a transverse axis 
 through its hilum or round a vertical axis. In the former case 
 it is the lower pole usually which swings forwards and inwards, 
 and this is by no means very uncommon combined or other- 
 wise with the lateral and vertical movements. Sometimes, but 
 more rarely, it is the upper pole which comes inwards and for- 
 wards. In the vertical rotation the convex lx>rder advances. The 
 moving kidney may also be deformed or flexed upon itself by 
 adhesions from slight perinephritis, or as the result of a former 
 nephrotomy. I have elsewhere mentioned a case where the two 
 poles were approximated towards the hilum. 
 
 Etiology. The callings of persons do not seem to have 
 any bearing on the causation of movable kidney. Statistics 
 differ as to the frequency of its occurrence : Ebstein and Neu- 
 mann, whose figures are based on post-mortem records, taken to- 
 gether, give 16 cases in 14,698 autopsies. Judging from the records 
 of my own hospital, these figures are unreliable, because, unless 
 the mobility were actually sought for in each Ijody, only the most 
 striking cases would attract notice. Its frequency in the living 
 female is variously stated between 3 and 46 per cent. Edibohls 
 records 90 cases in 500 women. Glenard, who saw 537 cases 
 in eight years, gives the percentage at 22 in every 100 women.f 
 
 { " * Dr. Bindley's case, Path. Soc. Trans. Lend., vol. xxvii., p. 473. 
 
 t These figures of Gle"nard are based upon the assumption that every 
 kidney is " movable " the lower pole of which can be grasped between 
 the fingers of the two hands on the patient taking a deep inspiration.
 
 106 SURGERY OF THE KIDNEY AND URETER. 
 
 Lindner and Kiittner consider 20 per cent, of women are affected. 
 Probably 7 to 10 per cent, is near the mark. In men the pro- 
 portion is less than 8 per cent. Skorczewsky states that in 
 1,422 patients whom he examined during life, 32 females out 
 of 1,030, and 3 males out of 392, were the subjects of mobility 
 of kidney. But it is hardly necessary to say that inferences 
 drawn from clinical examination of the abdomen do not carry 
 with them the conviction of post-mortem inspection, if the inspec- 
 tion is made with special reference to the question of mobility. 
 On the one hand, it is impossible to say after palpation that 
 the kidney is only normally movable ; whilst on the other, the 
 diagnosis of movable tumours of the abdomen is admittedly difficult, 
 and in many instances what has been positively asserted to be 
 a mobile kidney during life has, on post-mortem examination, 
 or 011 the operating table, turned out to be something very 
 different. It is quite certain, however, that the greater number 
 of persons whose kidneys are unduly movable know nothing 
 about it and do not suffer in the least from it. But it is far 
 from uncommon to find after death that a kidney is mobile, though 
 it was not known to be so during life. 
 
 Pathogenesis of movable kidney. Deletzine and Volkoff, at a 
 meeting of the Society of Eussian Physicians of St. Petersburg hi 
 1897,* stated as the result of certain observations and experiments 
 made by them on the dead body : that the cadaver being placed 
 vertically and the abdomen opened in this posture it is seen that the 
 kidneys descend very little unless the vessels or ligaments are elon- 
 gated ; that neither the diminished resistance of the abdominal walls, 
 nor the increased weight of the kidney, nor the wasting of the peri- 
 renal fatty tissue permits the descent of the organ unless a 
 mesonephron is present ; and that the adipose capsule is not 
 an obstacle to renal ptosis. The rapid evacuation of a septic 
 fluid, repeated pregnancy, pneumothorax, and artificial employ- 
 ment of respiration favour displacement of the kidney (Litten 
 and Israel) ; traumatism in the renal region plays a very im- 
 portant role in etiology. Casts show that the renal couches are 
 not so deep (long) in women as in men but are wider below in 
 women ; and that they are also more superficial and wider on 
 the right than on the left. Ectopy of the kidney is essentially 
 
 * See La Mi-dec int.- Modertie, Xo. 20, Mars 2O, 1897, p. 158.
 
 MOVABLE KIDNEY IN CHILDREN. 107 
 
 connected with these modifications of form of the " loges " of the 
 kidneys. 
 
 It is certain that the proportion of women affected is greatly 
 in excess of the males, and this more especially in the severer 
 forms of mobility. Here again the figures vary greatly. Out of 
 1,1 70 cases collected by Legry, 87 per cent, were in women, 
 whereas Lanceraux's and Landau's figures, added together, give 
 330 females to 50 males, or 1 male to every 6 or 7 females. 
 Skorczewsky's figures show the relative proportion to be 1 male 
 to every -1 or 5 females. Certainly men rarely, as compared 
 with women, require nephropexy. My own operation list shows 
 98 operations for movable kidneys, 88 being performed upon 
 women and 10 on men: thus only 11'3 per cent, were males, 
 or 1 male to every 8'8 females. The right kidney is from twelve 
 to thirteen times more often affected than the left. The reasons 
 assigned for the greater frequency of the mobility of the right 
 kidney are the weight of v the liver, its little proneness to yield 
 to tight lacing, and its descent with every act of deep inspiration ; 
 the greater length of the right renal vessels ; and the fact 
 that the ascending colon is less firmly bound to the right kidney 
 than the descending colon is to the left. Zuckerkandl has described 
 an aponeurotic layer which lines the peritoneum on the anterior 
 surface of the left kidney and, he considers, contributes to fix 
 it. The connection of the left suprarenal capsular vein with the 
 renal vein gives the left kidney a further mainstay, as the capsule 
 remains in its position and does not follow the kidney in its. 
 abnormal movements. Both kidneys are involved about once 
 out of twenty cases (Landau). Schiff, Heslop, Wiltshire, G. 
 Hunter, and others, have recorded cases of mobility of both 
 kidneys, and of double kidneys. I have operated upon several 
 women for fixation of both kidneys. 
 
 Between 80 and 90 per cent, of the cases occur be- 
 tween the ages of twenty and fifty, the greater proportion of 
 them being between the thirtieth and fortieth years. Many 
 winters speak of cases of movable kidney in girls, some have 
 noticed cases in infants, Stiller* in children of six, nine, and ten. 
 Rosenthal collected twenty -six cases in young girls. Herczel 
 records one in a girl of eighteen, Guyon one in a girl of twenty. 
 
 * Stiller, Wiener Med. Woch., 1889, Xos. 4 and 5.
 
 108 SURGERY OF THE KIDNEY AND URETER. 
 
 M. Comby and 31. Guinon* brought, to notice several cases 
 in girls between one month and fourteen years. Comby 
 collected in a few months six such cases. Several of the little 
 patients had marked dyspeptic troubles and dilated stomachs, 
 engorgement of the liver and ptosis of the other abdominal 
 viscera. In two of the patients, the subjects of hereditary 
 syphilis, both kidneys were movable. The symptomatology of 
 movable kidney in children is the same as in adults. 
 
 Herczel gives three reasons why the majority of cases occur be- 
 tween twenty and forty, namely, (a) the fluxional hyperaemia of 
 the kidney at the catamenial period ; (b) childbirth ; (c) ectopia 
 of the genitals. Kiittner thinks movable kidney as frequent 
 in young girls and women who have never borne children as in 
 others. Miiller, Warneck and Lindner also refer to the frequency 
 of movable kidney in hulliparae, and on that ground oppose 
 the theory that relaxation of the abdominal walls produces it. 
 
 In women' the affection very commonly arises during the 
 child-bearing period and just subsequent thereto. Pregnancy 
 has a share in its production, and a very large proportion of the 
 cases occur in women who have borne children quickly or nu- 
 merously. The condition, however, is not uncommon in women 
 between twenty and twenty-five who have never been pregnant. 
 
 The way in which pregnancy conduces to movable kidney 
 is (1) by the sudden loss of intra-abdominal pressure after delivery ; 
 (2) by the forcible contractions of the diaphragm during par- 
 turition and the consequent downward pressure more especially 
 exercised on the liver and right kidney ; (3) by the subsequent 
 loss of muscular resistance in the abdominal walls and their 
 pendulous flaccid ity after parturition (Hertzka, Landau, Senator, 
 and others) ; and (4) by the too early resumption after delivery 
 of the erect posture, and of physical occupation, without wearing a 
 proper abdominal support : hence it is that the movable kidney is 
 rather more often found amongst the poorer classes. It has been 
 repeatedly stated by those who have had good opportunities 
 of judging that at least 10 per cent, of the poor women of Austria 
 and of Holstein who have l:>orne children have a movable kidney. 
 Becquet believes that the kidneys are associated with the 
 generative organs by means of the connection between the 
 
 * La Semaine M'dicale, p. 200, Mai -20, 1897.
 
 FLUXIONAL HYPER.EMIA. 109 
 
 plexus ovaricus and the plexus renalis in the congestion 
 which affects them during menstruation ; and that in this 
 way their displacement is the consequence of the changing 
 volume and weight of the kidney. Similarly he explains the 
 renal pain which is so often felt at the menstrual periods,, 
 especially by those subject to dysmenorrhoea Certain it is; 
 that there is in many cases an increase during menstruation in 
 the severity of the symptoms, and in the sense of weight and 
 dragging experienced by some women with movable kidney. 
 I have on several occasions observed a remarkable increase 
 in the size of a movable kidney during the menstrual period, 
 and in one case under my care the late Sir Matthews Duncan 
 mistook a movable kidney during the catamenia for a malignant 
 tumour of the kidney, and he readily acknowledged the error 
 of diagnosis after examining the patient again a few days later. 
 Herczel also attaches importance to the fluxional hypersemia 
 of the kidney during menstruation as a cause of movable kidney. 
 Glenard and Turner state that the painful movable kidney is 
 one phenomenon of an organic defect of all the tissues, and is. 
 often associated with laxity of other organs, and not infrequently 
 is but one symptom of the general condition known as entero- 
 ptosis or Glenard's disease, hi w r hich all the principal abdominal 
 organs are found to have dropped to a lower level, owing to- 
 a relaxation of their ligaments and of the abdominal walls. The 
 connection between general intestinal ptosis and movable kidney, 
 as taught by Glenard, is, however, not at all well established. 
 Ewald's opinion against it has been quoted before, and Guttman 
 and Senator regard it as rare. Albarran's experience, like my own, 
 is that the great majority of cases of nephroptosis are independent 
 of enteroptosis. 
 
 Rapid general emaciation and the absorption of the fatty 
 elements of the adipose capsule of the kidney, even in persons 
 not emaciating in other parts of the body, as well as a primative 
 deficiency of the perinephric fatty tissue, favour, if they do not. 
 determine, the mobility of the kidney. Keen* confirms this view. 
 
 The deficiency in the fatty capsule of the kidney I believe 
 to be one of the most important of the causes of movable kidney, 
 especially the absence or loss of the thick mass of it at the lower 
 
 * Annals of Surgery, August, 1889.
 
 110 SURGERY OF THE KIDNEY AND URETER. 
 
 pole of the organ. Certainly, of the cases which I have operated 
 upon the kidney has been most movable in those who have 
 lost much fat or who have always been spare. The type of 
 woman who, in my experience, has the most suffering from this 
 affection is the spare, slender, small-waisted figure with a long 
 thorax. In many of the cases in this type of physique there 
 has been no fatty capsule to clear off the kidney, which has sud- 
 denly shot out through the wound as soon as the parietes have 
 been cut through and a little pressure has been exerted on the 
 front of the organ. 
 
 Riolan, writing in 1682, said, " The cause of this " (displace- 
 ment and falling forwards of the kidneys) " arises, not only from 
 the diminution of the fat with which they are enveloped, but 
 also from the fact that, having become too large and heavy, 
 in consequence either of tumours developed in them or of stones 
 included in their pelvis, they are borne down by their own weight." 
 The latter part of Riolan's explanation may account for the not 
 very rare association of movable kidney and hydro-nephrosis. 
 Mesue, writing in 1561, also had insisted on the mobility of 
 the kidney consecutive to renal tumour. One of HerezeFs cases 
 is etiologically interesting in reference to spinal curvature from 
 rachitis. The left kidney first sank and became abnormally 
 movable, whereupon intermittent hydro-nephrosis appeared from 
 temporary obstruction of the ureter caused by slight bending 
 and twisting of the tube. He thought movable kidney and 
 hydro-nephrosis are often associated. Tight lacing, by the inter- 
 mittent compression of the waist by the corset, is another probable 
 cause. Deletzine and Volkoff* have made an exhaustive study 
 of the renal fossae by measurements and casts, and they find 
 that in well-formed females the renal fossae are narrower and 
 more open below than they are in men, and therefore a dis- 
 location of the kidney by violence or by corset pressure is more 
 apt to occur. Cruveilhier states that he has often observed 
 the right kidney to be mobile, and likewise displaced a long way 
 from its natural position, in women who have worn tight stays. 
 Mobility may be associated with the misplacement from this 
 cause. Koranye has also insisted on the injurious effect of corsets, 
 and of shoes and boots with high heels. Velpeau discovered 
 
 * Die Wanderniere.
 
 INJURY A CAUSE OF MOVABLE KIDNEY. Ill 
 
 a movable kidney in the right iliac region of a woman who 
 subsequently died of peritonitis ; the misplacement of the kidney 
 was presumably caused by the drag of a hernia of the caecum 
 into the femoral sac (Raver). Bartels was the first to call at- 
 tention to the frequent co-existence of movable right kidney 
 and dilatation of the stomach. Litten noticed the frequent co- 
 existence of dilatation of the stomach and nephroptosis. In forty 
 cases of dilatation of the stomach he found twenty-two cases of 
 displaced kidney, and he considered the dilatation of the stomach 
 the primary affection. Ewald, Osier, Nbthangel, and others 
 admit the frequency with which the two conditions co-exist, 
 but consider it a mere coincidence. Kiittner, Linder, and others 
 consider that floating kidney is either a congenital anomaly or 
 at any rate that there is a strong congenital predisposition. Tuf- 
 fier and Albarran attach much importance to the congenital 
 theory. 
 
 Finally, in many instances the immediate cause of the mobility 
 has been of a traumatic nature, such as a blow or kick on the 
 loins, a jerk, or some severe and sudden concussion. A military 
 officer who fell upon his feet from a horse suffered a violent 
 concussion of his entire body, and subsequently both his kidneys 
 became movable (Henoch). Such cases are more like dislocations. 
 But in other cases in which the mobility has been attributed 
 to violence the injury was inflicted years before the first symptoms, 
 so that the abnormal movement must have been very slowly 
 developed. Arnim mentions a case in which the woman was tossed 
 by a bull twenty-one years before, Kispert one in which a woman 
 fell off a mule eleven years before, and in a case of my own the 
 patient was thrown off a camel between two and three years 
 before I removed her kidney for a large movable hydro-nephrosis. 
 Violent or repeated coughing, constant and sudden straining efforts, 
 a sudden twist or flexion of the body are other slighter traumatic 
 causes to which the undue mobility has been attributed. 
 
 Symptoms. The symptoms of a movable kidney are of 
 two kinds, viz. the subjective or those experienced by the patient, 
 and the physical or those which can be detected by the hand 
 of the surgeon. In the mild cases there is often an entire absence 
 of any sign whatever, and the condition, as has been stated, 
 is only discoverable on post-mortem examination. In cases of
 
 112 SURGERY OF THE KIDNEY AND URETER. 
 
 a more severe form, but in which, owing either to the stoutness 
 of the patient or to the movement of the kidney being only 
 in a vertical or lateral direction, no physical signs are de- 
 tectable, the subjective symptoms may be acute. 
 
 Pain. Movable and floating kidneys give rise to more or less con- 
 tinuing pain, to renal crises, manifold disturbances of the digestive 
 organs, of the heart and large blood-vessels, of urinary secretion and 
 micturition, of biliary excretion, of intestinal functions, and of 
 the nervous system. The symptoms arise partly from the mis- 
 placed organ itself, and partly from the effect of the misplacement 
 on the surrounding viscera. Some of the most common symptoms 
 complained of are a constant or frequent sensation of pain and 
 dragging or weight in the loins and side of the abdomen, pain 
 between the shoulders and at the back, stiffness of the back 
 and sense of dragging from the side affected, an occasional sense of 
 something moving, which in severe cases has been described 
 as resembling the movements of a foetus in utero. Rosenberger 
 speaks of continued crampy pains in the abdomen. Acute 
 paroxysms of intense pain resembling renal colic, dull aching 
 pains in the loin or abdomen, and neuralgic pains in the course 
 of the great nerve trunks of the affected side (Haver), may all 
 occur. The pain sometimes disappears on lying down, but may be 
 aggravated if not actually induced by walking and standing. In 
 some cases the pain becomes gradually worse and remains severe 
 even for hours after assuming the recumbent posture. 
 
 Gastro-intestinal disturbances. Disturbances of the digestive 
 system are especially prominent ; vomiting, often frequent and severe, 
 sometimes preceded by a burning sensation in the epigastrium, 
 together with symptoms of gastritis and sometimes actual dilatation 
 of the stomach, occurs ; in the large intestine the most common condi- 
 tion is one of obstinate constipation which may in some cases amount 
 to temporary obstruction : occasionally there is irregularity of the 
 bowels or diarrhoea. All these symptoms are probably produced 
 either by actual pressure or by the dragging of the misplaced 
 kidney upon the intestine. Folds of peritoneum have been ob- 
 served passing from the kidney to the duodenum in such a way 
 that when they are pulled upon, the lumen of the duodenum 
 is narrowed or even occluded, as in a case recorded by Franks. 
 Macalister, who has also observed similar folds, believes that
 
 RENAL CEISES : JAUNDICE. 113 
 
 the}' are by no means uncommon and that they furnish a natural 
 and adequate explanation of the gastric disturbances which occur 
 in these cases. The gastric symptoms are liable to acute ex- 
 acerbations or " crises," as first described by Diet! in 1864. They 
 consist of violent attacks of colic attended by nausea and vomiting, 
 and these may be accompanied by abdominal distension and 
 tenderness, and sometimes by a rise of temperature and signs 
 of collapse. These renal crises are variously attributed to 
 twisting and traction on the renal vessels or on the nerves of 
 the pedicle, and to curvature and torsion of the ureter. Often 
 all these conditions exist at the same time in different degrees, 
 and thus cause renal congestion, digestive disturbances and pain 
 through the sympathetic plexus, and renal retention of urine. 
 The crises do not depend on the amount but on the direction of 
 displacement, and are produced by rotation as well as by other 
 occasional movements. Transient attacks of jaundice are said not 
 to be uiifrequent, but I have never personally witnessed them ; they 
 are probably dependent in some way upon the dragging of folds of 
 peritoneum on the duodenum as above described, for the idea that 
 there is ever direct pressure of the kidney upon the bile-ducts is not 
 borne out by anatomical investigation, except possibly in such a 
 case as Lindner's (p. 126), in which a floating kidney with stones in 
 the pelvis pushed against the gall-bladder and gave the appearance of 
 a tumour of the gall-bladder, but in that case there was no jaundice. 
 Litten (Char. Annalen, 1880, p. 93) observed in a woman, aged 
 thirty-seven, with a right floating kidney, frequent pain in the 
 right hypochoiidrium with temporary intense jaundice twice 
 in a fortnight, lasting four days and eight days respectively, and 
 he attributed it to temporary compression of the bile-ducts by the 
 kidney. Landau refutes the possibility of this on anatomical 
 grounds, and Lindner quotes a case in support of Landau in a 
 woman, aged forty-one, in which 011 abdominal section it was 
 proved that neither the kidney nor its pedicle came anywhere near 
 the biliary ducts and that their compression was impossible. Autopsy 
 supports Landau's theory: a right floating kidney, if carefully 
 drawn forwards or downwards, causes traction on the duodenum 
 at a point 2 to 3 cm. below the junction of the biliary ducts, 
 and though it does not occlude the lumen it interferes with the con- 
 tents of the bowel sufficiently to impair digestion and cause biliary 
 
 VOL. I. i
 
 114 SURGERY OF THE KIDNEY AND URETER. 
 
 obstruction. Symptoms of chronic appendicitis are considered 
 by Edebohls to be a very frequent complication of movable kidney 
 on the right side, and he explains this on the supposition that 
 the misplaced organ produces an indirect pressure upon the 
 superior mesenteric vessels, which become compressed between 
 the pancreas and the bodies of the vertebrae, and thus a chronic 
 congestion of the appendix and colon is produced which is suffi- 
 cient in the case of the appendix to give rise to definite symptoms. 
 
 Venous obstruction. In other cases signs of venous obstruc- 
 tion show themselves by osdema of one leg; and thrombosis of 
 the vena cava due to this cause has also been recorded. 
 
 Urinary symptoms. In most uncomplicated cases the urine is 
 healthy and is as a rule voided in the normal way ; in many 
 cases there is some albuminuria from time to time, but if the 
 urine is habitually albuminous the albumen will be due to some 
 pre-existing or co-existing independent disease. Still there are 
 cases, not so very few, in which urinary symptoms are com- 
 plained of. Kiittner speaks of frequent straining in order to 
 urinate, and of slight polyuria. Apolant draws special attention, 
 in the case of a woman, aged fifty, with very serious abdominal 
 disturbance due to a floating kidney, to a symptom which had 
 been overlooked, namely, excessive polyuria. I have operated 
 upon several cases in which slight pyuria or hsematuria and 
 frequent ardent desire to micturate were symptoms in movable 
 kidney. 
 
 Renal paroxysms. Cases of movable kidney are occasionally 
 apt to give rise to very acute symptoms after some severe 
 or unusual exertion. These attacks are quite sudden and 
 are characterised by acute abdominal pain, hardening of the 
 abdominal wall uniformly, or locally, especially on the affected 
 side faiiitness, giddiness, and other symptoms of collapse, or 
 even death from shock ; during these attacks the kidney 
 can often be felt enlarged from congestion and renal reten- 
 tion of urine, and is extremely tender. The urine becomes 
 scanty and may contain albumen, casts, or even blood, but again 
 becomes normal when the attack passes off, and then polyuria 
 sometimes follows, as it may do after any severe nervous shock. 
 These symptoms are probably due to some displacement of the 
 kidney produced by the exertion, and to the organ becoming
 
 DEFORMITIES OF RENAL PELVIS. 115 
 
 compressed possibly between the last rib and the vertebral column 
 (Gilewski). Acute hydro-nephrosis is sometimes thus produced, 
 although the cavity of the kidney in these cases may be far 
 too small to cause an appreciable tumour. 
 
 This acute condition * has been long known, and has received 
 the name of " renal incarceration " from its analogy to cases of 
 strangulated hernia ; but Bruce Clarke,f who recorded some 
 cases in 1893, proposed to revert to the term " acute renal 
 dislocation," used by the ancient writers, + who considered the con- 
 dition more allied to the displacement of the head of a bone than 
 to a strangulated hernia. Another explanation of these acute 
 attacks is that they are due to torsion of the renal vessels from 
 rotation of the kidney, and Newman has recorded cases of transitory 
 hydro-nephrosis accompanied by acute pain with casts and albumen 
 in the urine, in which torsion of the vessels was verified by 
 operation. Newman also records a case in which the symptoms 
 of uraemia usually appeared suddenly when the kidney was dis- 
 placed, and disappeared in from twenty to forty-six hours : oliguria 
 or anuria, severe pain in the renal regions, sickness, nausea, vomit- 
 ing, dimness of sight, severe and persistent headache and lethargy, 
 with occasional paroxysms of excitement, were the symptoms. 
 
 In many cases the kidney may become permanently hydro- 
 nephrotic, and this may happen either through a permanent 
 kink in the ureter or through an obstruction at its origin in the 
 renal pelvis. Temporary hydro-nephrosis may also result from a 
 frequently recurring curvature or twist of the ureter, or a 
 curvature rendered permanent by secondary adhesions; but the 
 obstruction must be either intermittent or incomplete for hydro- 
 nephrosis to be caused. Obstruction often arises secondarily to 
 some dilatation of the pelvis, for as the sac dilates, the orifice 
 of the ureter is considerably modified, and often opens so obliquely 
 in the wall of the sac that no free flow of urine can possibly 
 take place ; while in other cases an unequal dilatation of the renal 
 pelvis causes a valvular fold to project over the mouth -of the 
 
 * Morris's "Surgical Diseases of the Kidney," 1885, pp. 42 and 311, 
 312 and 313; and Morris's Cavendish Lecture, 1893. 
 
 ]Roy. Med. and Chirurg. Trans., 1893. 
 
 I See Lancereaux, art. "Rein," Diet. Sciences Med, 1876, and "Le9ous de 
 Clinique Medicale," Paris, 1894. See also Landau. 
 Clin. Soc., 1896.
 
 116 SURGERY OF THE KIDNEY AND URETER. 
 
 ureter (see Part II., Vol. II., Chapter IX., on Stricture of the Ureter). 
 These hydro-nephrotic conditions may exist for a long time 
 without its being possible to detect them, but the weight of a 
 hydro-nephrotic kidney usually increases the sense of dragging 
 and many other of the subjective symptoms. If the flow of 
 urine becomes completely stopped by a twist in the ureter, 
 atrophy of the kidney will be the result. 
 
 There is no doubt that movable kidney like many other causes 
 of physical suffering, slight as well as severe, may lead to the 
 development of hysteria in a girl 'or woman who had previously 
 shown no signs of any such neuropathic tendency, and that this may 
 be completely cured by nephropexy. There are other individuals 
 of a neurotic temperament who have shown signs of hysteria before 
 the kidney has been known to be movable and whose condition 
 is aggravated by the knowledge. But hysteria and neurosis are 
 not by any means invariable accompaniments of movable kidney. 
 Some of the most painful cases, which are slowly developed after 
 a slight injury, and still many more that occur without any 
 assignable cause, are met with in healthy, physically and mentally 
 active women, who are completely invalided against their will 
 by the pain and digestive troubles caused by the nephroptosis. 
 Though the patients have perseveringly, but in vain, tried belts, 
 diet, and prolonged recumbency, they obtain the most complete 
 and gratifying results from fixation by operation. During the 
 course of the disease the general health of the patient is naturally 
 much impaired ; languor, debility, loss of flesh, hypochondriasis, 
 great restlessness, great anxiety, hysteria, perversions of sensation 
 or of the special senses, and many other neurotic signs are, some 
 or other of them, commonly present. In the female, pregnancy 
 and the menstrual periods are usually occasions of increased 
 suffering ; in males and females alike constipation and impaction 
 of hardened faeces in the colon add to the patient's distress. 
 
 To repeat, in a few words : the subjective symptoms excited by a 
 movable kidney are usually of three types : (1) pain, with occasional 
 crises of severe suffering, amounting sometimes to great agony, 
 and a pretty constant sense of weight and sometimes of movement 
 in the abdomen ; with aching in the back and side, and a sense 
 of dragging weight in the loins ; (2) troubles of digestion, such 
 as nausea, flatulence, sickness, loss of appetite, and other symptoms
 
 REPETITION OF PALPATION DESIRABLE. 117 
 
 of dyspepsia and irregularity of the bowels ; (3) symptoms of 
 neurasthenia and hysteria ; (4) occasionally but comparatively 
 rarely there is some change in the urine or in the functions 
 of the urinary organs generally ; (5) more rarely still some 
 complication due to mechanical compression or dragging, such 
 as intestinal obstruction, jaundice, or great gastric dilatation, 
 or, finally, enteroptosis. 
 
 The physical signs, when any such exist, are the presence 
 of a movable tumour of characteristic renal outline, which 
 on palpation is painful, or gives rise to a peculiar sickening 
 sensation. The movement may be slight or considerable. When 
 the kidney is movable in a "cinder-sifting" manner there may be 
 no movement detected by palpation. I have on several occasions 
 operated where the symptoms have been marked, but the mobility 
 was only actually detected after the kidney had been explored 
 through the loin. In thick-set persons or persons inclined to 
 be stout there may be a wide range of movement of this kind 
 unrecognisable by bimanual palpation. In other cases of great 
 mobility, either of the " movable " or " floating " type, there are 
 times when the kidney cannot be felt or made to move. Kiittner 
 points out the importance of more than one examination where 
 movable kidney is suspected, and I am always careful never to 
 declare that a kidney is not movable because I cannot feel it 
 move, if any trustworthy observer has pronounced it to be 
 movable.* I have sometimes reduced a " floating " kidney, and 
 nothing that I could do at the same examination would make 
 it come down again, yet the next day it has been as freely 
 floating as ever ; on the other hand, a woman, thirty-seven years 
 of age, was able with her right hand to bring a movable 
 right kidney out of the right hypochondrium into the umbilical 
 region without any pain, and so that it could easily be grasped 
 through the flabby abdominal walls (Armin). 
 
 In several cases the kidney could be pushed upwards 
 under the ribs, downwards into the pelvis, and inwards across 
 the median line. When the mobility is considerable, the abdom- 
 inal parietes, which are sometimes very flaccid, permit of the 
 tumour being quite grasped by the fingers of the surgeon ; 
 the tumour will be found to fall below the margin of the ribs 
 
 * See author's Cavendish Lecture, 1893, for typical cases.
 
 118 SURGERY OF THE KIDNEY AND URETER. 
 
 and towards the umbilicus or the pelvis when the patient sits 
 or stands ; to roll from side to side according to the inclination 
 of the body ; and to be easily pushed back into the loin when 
 the recumbent posture is resumed. 
 
 A "floating" kidney does not generally fall spontaneously into 
 the loin whilst the patient lies on her back, but, on the contrary, 
 has a tendency to rise forwards and towards the median line as 
 soon as the pressure which has thrust it backwards is removed. 
 Respiratory movements as well as the position of the body in- 
 fluence the position of. the kidney ; deep inspiration forces it 
 dowTi wards, forcible expiration allows it to ascend. When the 
 degree of mobility is but slight, only a small part of the kidney 
 may be tangible, and that only on deep inspiration; when 
 moderate, half or three-quarters of the organ will be felt 
 between the margin of the thorax and the umbilicus. The 
 tumour gives a sensation of smoothness and firmness with its 
 extremities rounded. The direction of its long axis is not by 
 any means always the same, but is frequently oblique from above 
 downwards and inwards. Percussion over the tumour gives 
 usually a tympaiiitic sound, or, as Roberts styles it, " a muffled 
 tympanitic note," owing to the pressure of some coil of bowel 
 between it and the parietes. Percussion over the vacated loin 
 elicits a more or less distinctly resonant note ; and there is a 
 sense of deficient resistance in the ilio-costal space. These signs 
 are lost, however, as soon as the kidney is thrust back into its 
 proper position. 
 
 Occasionally there is no recess in the loin to indicate the 
 place vacated by the kidney ; on the contrary, fat sometimes 
 accumulates there and shapes itself to the under surface of the 
 liver or spleen, as the case may be. The right lobe of the liver, 
 when enlarged or displaced by tight lacing, may effectually keep 
 the kidney out of the loin.* In a case recorded by ]3r. Tuckwell 
 the right kidney fell back by its own weight into its proper 
 position as soon as the liver was removed. 
 
 I have previously described (p. 84 et seq.) the best way of making 
 the examination of the kidney by palpation. The method of Raver, 
 
 * See a paper by the author "On the Clinical Confusion between 
 Distension of the Gall-bladder and Movable Kidney," Brit. Med. Journ., 
 February -2, 1895.
 
 ROTATION, TILTING, AND VERSION. 119 
 
 Jenner, and Freund was to place one hand below the costal margin 
 behind, and press forwards whilst the other hand compresses the 
 tumour from the front. Some surgeons prefer the methods of 
 Glenard, or Israel, or of Guyon. But there is no reason why all 
 of them should not be employed. 
 
 By palpation one can not only make out that the kidney 
 moves too freely, but also whether it rotates or moves upwards 
 and downwards, or inwards. In many cases if an attentive manipu- 
 lation is employed the kidney will be detected rotating on its own 
 transverse axis so that the liiltim comes to look upwards and 
 inwards ; occasionally, but much more rarely, the hilum is turned 
 downwards and inwards. When the patient is rolled over on to 
 the sound side the convex border of the kidney can sometimes 
 be felt to tilt inwards towards the median line, so that the posterior 
 surface has a slight outward inclination. Again, the upper pole of the 
 kidney in exceptional cases can be detected nearer to the anterior 
 abdominal wall than the lower pole, having the form of displace- 
 ment described first by Potain as " anteversion," a form of movable 
 kidney which he says is generally mistaken for hepatic or pyloric 
 tumour. Again, the size and shape can sometimes be made out, 
 although owing to the increase caused by fiuxional hyperaemia, 
 it is easy to be deceived as to the size of the organ, by feeling 
 it through the abdominal parietes. Sometimes the organ is more 
 or less deformed by adhesions, flexion on its own axis, or after 
 the failure of a previous nephropexy. 
 
 In exceptional cases the tumour may occupy the iliac fossa ; 
 and there may be great displacement without the kidney being 
 at all felt through the abdominal parietes, as, for example, when 
 the organ is overlaid by an enlarged and displaced liver or falls 
 behind an enlarged uterus. The pulsation of the renal artery 
 has been observed by some writers ; epigastric (forcible aortic) 
 pulsation, and congestive enlargement of the movable kidney, are 
 very common. 
 
 Diagnosis. It must be said at once that in no case can 
 w y e be justified in concluding that a patient's sufferings are due 
 to a movable kidney unless we can actually feel the kidney to 
 be unduly movable. Even then, though all the typical symptoms 
 may be described and complained of, we must not decide that 
 the movable kidnev is the cause of them until we have made
 
 120 SURGERY OF THE KIDNEY AND URETER. 
 
 a careful investigation of the other organs of the abdomen and 
 pelvis, and of the way in which their functions are discharged. 
 So frequently are symptoms which are caused by the kidney referred 
 to some other organ, so varied are the nervous and other disorders 
 associated with the female genital organs, that it is often most difficult 
 to say how much of the neurasthenic symptoms, how much 
 of the abdominal pain and backache, how much of the gastro- 
 enteric disorder, or how much of the disturbed urinary functions 
 is due to the movable kidney and how much to some other 
 morbid condition, or indeed to a hysterical temperament. The 
 neurotic element especially makes the diagnosis always difficult and 
 the result of nephropexy or any other form of treatment uncertain. 
 Turner recorded the case of a woman with movable kidney compli- 
 cated by intercostal neuralgia on the same side (" Congres francais 
 de Chirurgie," 1880). In cases in which one-sided pain, occasional 
 renal crises, and some amount of gastro-intestinal disorder occur, 
 with perhaps a little pus or blood occasionally in the urine, and 
 frequent or painful micturition, but no physical signs of mobility 
 of the kidney, the diagnosis must be left until the kidney is 
 explored. Stone, hydro-nephrosis without a palpable tumour, or 
 ureteral stenosis or valve may cause the same group of symptoms, 
 but so also does the " cinder-sifting," " movable " kidney. It 
 matters not therapeutically that we cannot make a diagnosis, for 
 the condition can be ascertained by lumbar exploration, and 
 corrected by the appropriate operation, and, what is more im- 
 portant, cannot be cured by any other means. This " cinder- 
 sifting " form of movable kidney is one of the renal affections 
 which are capable of being readily remedied by surgical means, 
 but which must go undetected until the lesion has far advanced 
 and the kidney in great part destroyed, if physicians and prac- 
 titioners lean implicitly upon the results of the Eontgen rays as 
 the test of the presence or absence of renal calculi. Such reme- 
 diable renal affections are often discovered unexpectedly in the 
 search for a renal calculus which does not exist. 
 
 The diagnosis between a " movable " or " floating " kidney 
 and a movable abdominal tumour is usually sufficiently easy, 
 although there are numerous instances of mistakes made by 
 most capable clinicians. A " floating " kidney has been sometimes 
 diagnose:! as something else, but what in my experience happens
 
 SOURCES OF ERROR IN DIAGNOSIS. 121 
 
 far more frequently is that some other movable tumour is diag- 
 nosed as a movable kidney. Probably the commonest error is 
 to mistake an enlarged gall-bladder for a " floating " kidney ; 
 but even a movable right lobe of the liver has been regarded 
 as a floating kidney when felt through rigid or fat abdominal 
 parietes ; and cases are on record, and others must have come 
 under the notice of most surgeons who see much of renal practice, 
 in which a movable spleen, cancer of the caecum,* cancer 
 of the stomach (Edward Apolant), tongue-shaped lobe of the 
 liver, an iiitraperitoiieal abscess, an ovarian cyst or dermoid (Smith, 
 quoted by Frank), a uterine myoma and tumours of the omentum 
 or mesentery have been mistaken for a floating kidney, or vice 
 versd. Smith's case is noteworthy because nephrorrhaphy was 
 successfully performed from the peritoneal side in the course 
 of an exploratory laparotomy performed oil account of the 
 uncertainty of diagnosis between an ovarian tumour and a 
 floating kidney. It is between floating kidneys with or 
 without a mesonephroii and other tumours that most of the 
 errors are made. The cinder-sifting movements of the " mov- 
 able " kidney, confined as the organ is behind the peritoneum 
 to contact with the lumbar parietes, is not likely to be mistaken 
 for the tumours having a more central or anterior position or 
 which can be moved in many directions. For the movable, de- 
 formed lobe of the liver and for malignant disease of the caecum 
 the right " movable " kidney may be mistaken, whilst the left is 
 sometimes mistaken for the spleen, or the spleen for it. 
 
 In examining any tumour of the abdomen the possibility of 
 its being a movable or floating kidney should always be remem- 
 bered. Small ovarian dermoids and pedunculated uterine myo- 
 mata are diagnosed by the position of the attachment of their 
 pedicle, and bj* moving in an arc whose centre is below and 
 not in the hypochondrium, and by paying attention to the history. 
 They cannot be reduced entirely into the loin behind the ribs, 
 unless their pedicles are very long, and they will in most cases 
 be felt by vaginal and rectal examination when crowded down- 
 wards into the true pelvis. 
 
 "It is only a small ovarian tumour with a long pedicle which 
 
 * See cases by the author in the Lancet, April 27, 1895, p. 1047, 
 and also a case by E. Owen, Lancet Vol. I., 1S95, p. 1054.
 
 122 SURGERY OF THE KIDNEY AND URETER, 
 
 can be mistaken for a floating or movable kidney. The latter 
 may be recognised by its characteristic shape, though it is often 
 so misplaced that the hilus is turned upwards. The kidney 
 is usually felt between the umbilicus and the false ribs, and 
 may be pushed upwards and downwards, or laterally, to a varying 
 extent, or into the lumbar region to the normal position of the 
 kidney. When the kidney is pushed away from this position 
 the sound on percussion becomes tympanitic." * 
 
 I have removed a small parovarian cyst holding about 
 eighteen to twenty ounces of fluid, which varied its position ; 
 some days it could be made out from the front of the abdomen, 
 sometimes not ; the percussion note over it was always resonant, 
 but a swelling could always be felt per vaginam on one side 
 (left) of and to the back of the uterus, and the direction of dis- 
 appearance of the swelling was always downwards into the pelvis. 
 The tumour had not increased appreciably in size, but it gave 
 rise to frequent sickening pain. The absence of the renal outline, 
 the low position, the pelvic connection of the tumour, and the 
 fact that the tumour could not be pressed upwards or inwards, 
 and more especially not towards the loin, excluded the possibility 
 of its being a kidney, though the shifting position, the invariable 
 resonance over its front surface, the sickening pain excited by 
 pressure, and the want of increase in its size, might have led 
 to confusion but for rectal and vaginal examination. 
 
 An ovarian tumour with a long pedicle would have more liberty 
 of movement than a parovarian cyst, but its preference for the 
 pelvis and its resistance to being forced into the loin when pressed 
 upon, as well as its shape, its tendency to increase in size, and most 
 probably the absence of resonance on percussion over it, would serve 
 to indicate its nature and to contra-indicate a movable kidney. 
 
 A distended gall-bladder is not unfrequently confused with 
 a movable kidney. Sometimes the two conditions co-exist and 
 then usually one is diagnosed and the other overlooked, and 
 indeed I have seen^both present in the same person so many 
 times that I have come to the conclusion that there is in some 
 instances a causal relationship between them. Oil comparing 
 the two conditions Ve find these facts : 
 
 * Spencer Wells, Dublin Quarterly Journ. of Med. Science, Feb.-May, 
 1867, ]). 140.
 
 DIAGNOSIS FROM ENLARGED GALL-BLADDER. 123 
 
 (1) That movable kidney and enlarged gall-bladder are each 
 much more frequently met with in women than in men. 
 
 (2) The right kidney is many times more frequently movable 
 than the left. 
 
 (3) Movable kidney and enlarged gall-bladder often occur 
 in the same person. 
 
 The probable explanation of the frequent occurrence of the 
 two conditions in the same person is that they are due to tight 
 lacing, which, while it causes displacement and mobility of 
 the kidney, also causes displacement of the liver, kinking 
 of the gall-ducts and formation of gall-stones as a result of the 
 obstruction to the flow of bile. Moreover, the two conditions 
 tend to produce each other, for while downward pressure^of the 
 liver induces mobility of the kidney, the latter in its turn drags 
 on the duodenum and bile-ducts and so tends to obstruct their 
 channels. 
 
 In considering how we can diagnose the one class of 
 cases from the other, the first and most important thing to 
 bear in mind is that the enlarged gall-bladder as well as the 
 kidney is a frequent cause of movable abdominal tumour. 
 This is far from being sufficiently recognised. The second is, 
 always to inquire if there has been a distinct attack of jaundice. 
 The third is that the tumour caused by an enlarged gall-bladder 
 can in almost all cases at all times be felt, whereas a movable kidney 
 (unless also enlarged or ec topic) cannot. The latter is sometimes 
 easily detected, at others not at all. An enlarged gall-bladder 
 is always easily felt by pressure on the front of the abdomen. 
 Fourthly, the fact that the size of the tumour varies from 
 time to time goes for nothing in the diagnosis, unless it is clear 
 that with the diminution of the swelling there invariably follows 
 a marked increase in the quantity of urine voided. 
 
 Movable kidneys are frequently of smaller size than normal, and 
 are often degenerated in texture as well as diminutive in size ; but 
 for all that they have a tendency to swell from vascular turgescence, 
 or, if hydronephrotic, from accumulation of urine ; owing to 
 their shifting position they are also more palpable at one time 
 than at another. A distended gall-bladder also will vary in size 
 if the cystic duct is blocked by a calculus which from time to 
 time slips back into the gall-bladder, and thus opens the channel
 
 124 SURGERY OF THE KIDNEY AND URETER. 
 
 for the escape of the pent-up bile or mucus. But with few 
 exceptions there is always evidence of some swelling as long as 
 the cause of the obstruction remains unremoved. Fifthly, a gall- 
 bladder with calculi feels much harder than a movable kidney. 
 
 A sixth feature is the range and character of the mobility. 
 However free the movements of a gall-bladder, they take place 
 in the arc of a circle the centre of which is a point beneath 
 the edge of the right lobe of the liver. Around this point the 
 free or lower extremity can be moved to the left and to the 
 right of a vertical line drawn through the axis of the swelling, 
 and further in the direction towards the left than towards the 
 right. It can be pushed upwards and it can be also pushed 
 backwards ; but unless the liver as a w r hole is unduly mobile 
 (and the whole liver is sometimes movable to a very remarkable 
 extent) the gall-bladder cannot be pushed downwards towards the 
 pelvis, though it descends a little on deep inspiration. 
 
 The kidney, on the other hand, moves bodily from place to 
 place within the limits of its loose connections ; it will go up 
 or down or inwards towards the median line or beyond it, and 
 it has a special tendency to slip, like a greasy mass, beneath 
 the finger tips upwards and backwards, into its normal position 
 unless prevented from doing so by the pressure of the other 
 hand on the abdominal wall above it. The kidney, in other 
 words, has a tendency to spring back into its proper position 
 in the loin ; whereas the enlarged gall-bladder, though it can, 
 in many cases, be pushed so far back into the loin that its free 
 end can be readily felt in the ilio-costal space behind, has the 
 tendency to spring back again to its position in the front of the 
 abdomen. 
 
 In presence of a distended gall-bladder it is generally possible 
 to grasp the kidney, or at any rate its lower extremity, between 
 the two hands by pushing the tumour forwards and towards 
 the median line with the back of the finger tips of the right 
 hand, and at the same time pressing forwards the loin with 
 the fingers of the left hand in the manner described 011 p. 84. 
 In this way the two organs are separately distinguished at the 
 same moment. The kidney may likewise be thus found to move 
 independently of the tumour formed by the gall-bladder. This can 
 often best be accomplished with the patient lying on the left side.
 
 UNRELIABLENESS OF INFLATION. 125 
 
 Iii the descriptions of the symptoms of movable kidney too 
 much stress is apt to be laid upon an undue hollowness and 
 resonance, with diminished resistance, in the loin. These are 
 very unreliable symptoms because (1) in some positions of the 
 trunk and thighs there is much hollowness in the ilio-costal 
 space when the kidney is in its proper place ; (2) the mass of 
 muscle and fat in this region often prevents a tympanitic note 
 being elicited when the kidney is displaced ; and (3) the natural 
 position of the kidney is so much under cover of the lower part 
 of the thorax that hollowness of the loin and resistance in the 
 ilio-costal space have no bearing upon it naturally. 
 
 Another diagnostic feature to which too much importance 
 has been attached is the relation of the colon to the tumour. 
 Normally the colon is on the outer side of the right kidney 
 and the transverse colon below and behind the gall-bladder ; 
 and Ziemssen pointed out that if the gut is inflated with air 
 the kidney is pushed backwards and the gall-bladder upwards. 
 But it is so common for the ascending colon and the hepatic 
 flexure of the colon to be considerably displaced inwards and 
 downwards, especially when either of these affections exists, that 
 the result of inflation is very misleading. The so displaced colon 
 on becoming inflated will push the kidney upwards, just as, in 
 the natural position of the viscera, it does the gall-bladder. 
 
 Aspiration of the swelling has sometimes been proposed as 
 a means of diagnosis ; but apart from the danger attaching to 
 this procedure there is the further objection that the character 
 of the fluid withdrawn from a gall-bladder may have none of 
 the characters of bile. In many cases the contents of a distended 
 gall-bladder are of a dropsical nature, very like the fluid of a 
 hydatid cyst ; in other cases it is glairy mucus quite unstained 
 by bile ; and in others again it is pus. 
 
 In the doubtful cases an exploratory incision is the only means 
 of positively deciding the diagnosis ; and as this, is quite free 
 of risk it should be early resorted to, with full confidence that 
 if the tumour be an enlarged gall-bladder the earlier it is dealt 
 with by operation the better for the patient ; and that if it 
 be a movable kidney nephrorrhaphy will relieve the symptoms 
 and prevent hydronephrotic changes which sooner or later may 
 destroy the kidney.
 
 126 SURGERY OF THE KIDNEY AND URETER. 
 
 In a case recorded by Dr. Lindsay Steven, a floating kidney 
 with a fairly perfect mesonephron was found associated with a gall- 
 bladder greatly distended, and with its duct occluded by a large 
 calculus. I have recorded six cases typical of the confusion between 
 enlarged gall-bladder and movable kidney (Brit. Med. Journ., Feb- 
 ruary 2, 1895). Lindner records a case of a woman, aged forty- 
 five, on whom laporatomy was commenced with the intention of 
 removing the gall-bladder ; after opening the abdomen, it was 
 found that the distended gall-bladder, forming a hard pear-shaped 
 movable tumour, was pressed upon by a very small floating 
 kidney with several stones in its pelvis. The exploration was 
 abandoned and all pain entirely disappeared. 
 
 Apolant gives the case of a nurse, aged fifty, a unipara, who for 
 eighteen years had slight trouble and for three years dyspepsia, 
 vomiting, cephalalgia and increasing emaciation, with a movable 
 right kidney (diagnosed as cancer of the stomach). She passed 
 a gall-stone, but the pain increased afterwards. 
 
 There are many patients sent to Carlsbad, as was this one of 
 Apolant, who have both affections, movable kidney and gall-stones, 
 or perhaps dropsy of the gall-bladder ; and there are others whose 
 symptoms are all due to movable kidney but are wrongly attri- 
 buted to some hepatic or cystic lesion. 
 
 Cordier has noted six cases in which gall-stones were associated 
 with movable kidney, due, as he attributes, to compression of 
 the common bile-duct. Von Tischendorf (quoted by Frank) took 
 the opportunity of an operation for biliary calculus to perform 
 nephrorrhaphy from the peritoneal side. The operation was 
 quite successful. 
 
 The size and outline of the tumour, its ascertainable attach- 
 ments, its want of tendency to increase, its smooth surface, the 
 sickening pain 011 pressure, the want of resistance in the loin, 
 especially when the patient is on her hands and knees ; and the 
 facility with which the movable kidney can be pressed back into 
 the loin, are the features which will guide to a correct diagnosis. 
 If in a tumour, having the size and general form of a kidney, 
 what corresponds to a hilum can be detected, the diagnosis will 
 be assisted. Though it will sometimes be very difficult to avoid 
 error, we must repeat that the diagnosis will often be readily 
 made if only the possibility of a movable kidney be kept
 
 CIRCUMSTANCES INFLUENCING PROGNOSIS. 127 
 
 in view when examining a doubtful or unusual abdominal 
 tumour. 
 
 Prognosis. Movable kidney cannot be said to cause death, 
 however destructive of the comfort and activity of life. In the 
 majority of cases it does not interfere with excellent health or 
 even with comfort. There are cases in which it has under- 
 gone a spontaneous cure either by means of adhesions the result 
 of perinephritis or of peritonitis, or after pregnancy, or in con- 
 sequence of the patient becoming stout. By inflammatory processes 
 it may become fixed in some abnormal position or refixed in its 
 natural fossa, just as it may after pregnancy and in increasing 
 corpulency. Perinephritis, by indurating the fatty capsule, tends 
 to make fast the kidney. There are other cases in which neither 
 the degree of mobility, nor the subjective symptoms it causes, 
 increase ; and again others in which, there is a gradual augmenta- 
 tion of the lesion and its ill consequences. 
 
 I am disposed to think that in those cases, not a few, where 
 vague abdominal pains and gastro-intestinal disorders, with some- 
 times more or less neurasthenia, have existed for a long time, 
 often several years, without any ascertainable cause, and then at 
 length one kidney is discovered to be movable, the renal mobility 
 has existed throughout, but in the " cinder-sifting " form, and has 
 gone on increasing till it begins to assume the floating type, and 
 then it is detected at the bedside. 
 
 When it has been provoked by some slight injury or has come 
 on without any apparent cause, and one kidney alone is affected, 
 there is no reason to apprehend that either the other kidney or 
 any of the other organs will follow suit. If, on the contrary, some 
 degree of enteroptosis has been present from the onset of the 
 nephroptosis, then we must expect other displacements soon to 
 follow, including that of the opposite kidney ; and with the increase 
 of the nephro-enteroptosis we must expect dyspepsia, chronic or 
 sub-acute gastritis, or gastric dilatation, possibly prolapse of the 
 rectum, or procident uterus, or flaccid reducible hernia and general 
 decline of health. If enteroptosis does not complicate the nephro- 
 ptosis great benefit or complete cure of the pain and the gastro- 
 intestinal symptoms may be expected from nephropexy, even when 
 there is some mobility of liver or spleen. I have mentioned a 
 case of so-called Glenard's disease on p. 101, in which perfect
 
 128 SURGERY OF THE KIDNEY AND URETER. 
 
 immunity from all the symptoms followed the operation. By a 
 coincidence I removed a kidney for calculous pyo-nephrosis in the 
 same week from the husband of this woman, and as I occasionally 
 see one or other of them I know that she has remained quite well 
 since her operation nearly five years ago. 
 
 Besides the tendency for the mobility to increase there is also 
 a tendency for the kidney itself to undergo degenerative or inflam- 
 matory lesions. Intermittent and simple hydro-nephrosis, due to 
 repetitions of kinking or of curvature of the ureter, intestinal 
 obstruction due to compression of the bowel by the displaced 
 kidney (Kidd and Gilford), jaundice from dragging on the duo- 
 denum (Litten, Hale White), chronic appendicitis (Edebohls), and 
 later on, pyelo-nephritis and pyo-nephrosis from septic infection of 
 the dilated renal pelvis, are complications which are occasionally 
 provoked by movable kidney. 
 
 Slight chronic pyelitis, from repeated congestion, may give rise 
 to pyuria. The congestion from torsion of the renal vessels may 
 cause slight haematuria ; and Schilling speaks of albuminuria in 
 14 per cent, of the cases of movable kidney. When these conse- 
 quences of unrelieved mobility of kidney are borne in mind and 
 considered side by side with the safety of nephropexy, there 
 ought to be no hesitation in suitable cases in advising the 
 operation. 
 
 The cases which afford the least favourable prognosis are those 
 in which there is a large nervous or hysterical element. It is 
 very difficult in them to say how far the symptoms find an 
 organic basis in the movable kidney, how far the symptoms are 
 magnified by the neurotic temperament, and whether they w r ill 
 not continue after an operation, possibly even as bad as or worse 
 than before. 
 
 The occurrence of renal crises makes the prognosis, so far as 
 the kidney is concerned, very unfavourable if no operation be per- 
 formed. In one case in which these crises were very severe they 
 are said to have caused death from shock (Cordier, quoted by 
 Albarran), but this is probably a unique result. 
 
 Treatment. In many cases the symptoms, if any exist, are 
 so slight that no treatment is requisite. In other cases, in which 
 symptoms are only present after exercise, such as riding on horse- 
 back, dancing, long standing, or much walking, such forms of
 
 USELESSNESS OF MASSAGE. 129 
 
 exertion should be, if possible, avoided. In cases in which symp- 
 toms occur even during quietude, exercise will have to be restricted 
 as much as possible, or refrained from entirely, with the hope, 
 a forlorn one however, that cure may follow from keeping the 
 recumbent position for some months. Functional disorders of 
 the bowels, especially constipation, should be corrected ; and 
 anaemia and loss of tone of the muscles should be dealt with 
 by appropriate internal remedies and abdominal massage. 
 
 As there is evidence which seems to justify the conclusion 
 that the absorption of the circumrenal fat, whether as part of a 
 general emaciation or not, is one amongst the causes of movable 
 kidney, it has been proposed that the patient, in addition to wear- 
 ing a belt and pad, should be kept upon a fat-making diet with 
 a view to increasing the natural packing of the kidney. Such 
 treatment, besides the improbability of its succeeding, has the 
 further disadvantage of being likely to increase the digestive 
 troubles, even if it could be tolerated by the system or entertained 
 by the aesthetic sentiments of the sufferer. 
 
 Massage. Massage recommended by Kumpf to be employed in 
 the manner of a tremulous pressure below the kidney, combined 
 wjth massage of the abdominal walls, with the object of obtaining 
 retraction of the peritoneum, is based upon an erroneous view 
 of the causation of movable kidney, is useless in nephroptosis, 
 however beneficial the abdominal massage may be in giving tonicity 
 to flaccid muscles in enteroptosis or in keeping up their tonicity 
 during recumbency if absolute rest is tried hi a case of movable 
 kidney. It could not, moreover, be tolerated in some cases 
 attended by much abdominal pain and tenderness. 
 
 Bandages and belts. Tight lacing must be avoided, and 
 when the muscular parietes of the abdomen are weak and flaccid, 
 as they often are, an abdominal belt or stout, closely-fitting jersey 
 should always be worn to support the parietes. If painful or 
 dyspeptic symptoms are constantly caused by the mobility of the 
 kidney a specially fitted pad and belt might be tried to retain 
 the kidney in its proper place. Varying forms of trusses and 
 bandages have been devised for this purpose, and they require 
 to be modified and adjusted in each case. 
 
 A stout bandage, provided with a pad which is worn over 
 the kidney, has in some cases given relief. Care must be taken, 
 
 VOL. i. j
 
 130 SURGERY OF THE KIDNEY AND URETER. 
 
 however, never to apply the bandage until the kidney has 
 been reduced into its proper place, and to prevent the bandage 
 or truss from shifting its position, and for this purpose under- 
 straps, or elastic tissue let into the jean or webbing, are useful 
 adjuncts. 
 
 Newman employs " a well-fitting abdominal elastic bandage, 
 extending from the line of Poupart's ligament to the level 
 of the sixth or seventh rib. The bandage should be made 
 to fit the body accurately and firmly, without exerting undue 
 pressure at any point. It may be made of one piece, or, 
 what is much better, of strips of elastic bandage sewn together, 
 and united in the middle line in front by means of steel slips, 
 similar to those used to fix stays." Before getting up for the 
 day, the patient should slip upwards over the lower extremities 
 a jersey fitting the abdomen tightly, and outside this an air 
 pad should be applied over the kidney after it has been restored 
 to its place, and the broad elastic bandage should be buckled 
 over the pad. A collapsible air pad, which can be inflated by 
 means of a tube and stop-cock after it has been adjusted to the 
 abdomen, is made for the purpose. With this or such-like ap- 
 pliance some patients are made very comfortable, and are rendered 
 capable of taking really a considerable amount of exercise. Very 
 much depends upon the care with which the belt, or bandage, 
 is applied, and I have known much comfort and an entire freedom 
 from crises from their use during the time the patient was under 
 my daily supervision, and was not allowed to rise until I had 
 myself adjusted the kidney and pad ; but as soon as the patient 
 passed out of my care and was left to put on the bandage for 
 herself all her troubles returned. This lady suffered the most 
 severe renal crises I have ever witnessed, and had often to be 
 kept under chloroform for three or four hours at a time. She 
 was quite cured by nephropexy performed in 1889, and has 
 led a very active life up to this day.* 
 
 The necessity for this care in reducing the kidney before 
 applying the bandage, and in preventing it from descending below 
 the bandage, is easily understood, by remembering that the prin- 
 ciple of treatment is the same as wearing a truss for a hernia; 
 but that there is this great difference in the two conditions 
 
 * Sec Table V., Case 10, of the author's "Hnnterian Lectures."
 
 RISKS AND FAILURE OF BELTS. 131 
 
 namely, that the patient can tell for herself when she has reduced 
 the hernia, but not whether the kidney is in place, except by the 
 pain caused by wearing the pad over it in its unreduced position ; 
 nor can every patient acquire the knack of reducing the kidney 
 for herself. 
 
 Not a few women, too, find a belt so irksome and uncomfort- 
 able that they positively refuse to continue wearing it, especially 
 when they realise that they can never be cured by the treatment, 
 that though the belt may keep the kidney up in place, it cannot 
 end in fixing it there, and that to give continuing comfort it 
 must be worn for life. The surgeon on his part knows that the 
 cases which are benefited by belts are just those which give the 
 best results from nephropexy, and that in the great majority of cases 
 the cure by operation is permanent and radical. Under these 
 circumstances he ought to feel it his duty to put the operation 
 and the alternative modes of treatment before the patient in 
 the same way that he does in the case of the radical cure of 
 hernia, pointing out the risks to the kidney from its remaining 
 movable, the relief but not cure which may be hoped for from 
 the bandage, and the prospect of complete cure from and the slight 
 risks of nephropexy. 
 
 Dr. Hare has recorded a case in which the mobility of the 
 kidney markedly diminished after two pregnancies, probably 
 owing to the gravid uterus acting as a temporary mechanical 
 support to retain the kidneys in their places. 
 
 Electricity, friction, the shower bath, and cold douches, to 
 give tone to the flaccid abdominal walls, are other means which 
 have l)een resorted to for fixing the kidney in its place. But 
 they are not successful. 
 
 When the symptoms of so-called strangulation of the kidney 
 occur, complete repose in the recumbent posture, hot fomenta- 
 tions to the painful part of the abdomen, and anodynes, especi- 
 ally morphia injections or suppositories, are indicated. 
 
 In a considerable proportion of cases of movable kidney the 
 symptoms are so constant, disabling, or severe, and so little 
 relieved by rest and appliances, that some more radical measure is 
 requisite. There are two operations which have been employed, viz. 
 nephrorrhaphy and nephrectomy. The technique of these opera- 
 tions is fully described in the chapters devoted to operations on
 
 132 SURGERY OF THE KIDNEY AND URETER. 
 
 the kidney (Vol. II., pp. 172-276). An operation should be advised 
 when the symptoms are severe and are not relieved by rest, quietude, 
 and mechanical appliances ; when, though relieved by rest in the 
 recumbent position, they occur in persons who cannot maintain this 
 position, either from the circumstances of their life or from their 
 mental inability to endure the restrictions of such a life ; and 
 when mechanical appliances cannot be borne, or seem to increase 
 rather than to mitigate the symptoms, and the patient cannot 
 move about gently or even sit without suffering. In cases in 
 which, in. spite of palliative treatment, paroxysms of nephritic 
 colic, fainting, sickness, vomiting, and pain radiating far and 
 wide in the course of the branches of the lumbar plexus of nerves 
 occur frequently, the only possibility of relief is surgical operation. 
 
 Nephrectomy. This, the first surgical operation ever adopted 
 for movable or floating kidney (1878), is no longer admissible 
 in the treatment of these lesions. It has given disastrous results : 
 out of thirty cases nine were fatal (Macalister) ; a terrible 
 mortality for a lesion which is not a cause of death, although 
 one which, if allowed to continue, may cause the destruction 
 of the kidney. It is now universally condemned, thanks to 
 the conservatism practised in renal as in other branches of 
 surgery. It is suitable in certain cases of diseased movable 
 kidney, whether the disease is engrafted on the movable kidney 
 or the mobility is secondary to the disease e.g., in cases of 
 extreme hydro-nephrosis, in certain cases of pyo-nephrosis, of 
 pyelo-nephritis and of tuberculous kidney and malignant tumours ; 
 but under these circumstances it is the disease, not the mobility 
 of the kidney, which determines the selection of the operation. 
 
 It may be resorted to after nephrorrhaphy has failed, as 
 it was successfully in Gilmore's patient, but not until after a 
 second, or possibly even a third attempt has been made and 
 failed. Whilst nephropexy repeated more than once on the 
 same kidney does not make nephrectomy any the more dangerous 
 or the less practicable, nephrectomy exposes the patient to possibly 
 fatal danger should the other kidney afterwards become diseased. 
 Hagar gives a case in which, after nephrectomy of the right kidney 
 had been performed, dislocation of the left occurred and a calculus 
 was formed in the left renal pelvis. Nephropexy was performed 
 on the calculous organ, and death occurred from uraemia.
 
 XEPHROPEXY A SAFE AND SUCCESSFUL OPERATION. 133 
 
 Xephrectomy may also be performed when nephrorrhaphy is out 
 of the question, as in certain cases of misplaced movable kidney, 
 which cannot be pushed back into the loin. In Folk's unfortunate 
 case the unsymmetrical kidney occupied the iliac region, and, though 
 freely movable in all directions, it could not be moved out of the 
 iliac fossa into the loin, and no fixing apparatus was of any use. 
 In fact, the mobility of the kidney in this case had little to 
 do with the distress suffered ; the symptoms were due to the 
 intimate relationship between the displaced kidney and the left 
 ovary. 
 
 Xcphropcxy has proved to be an operation which is both 
 safe and successful, and it has therefore naturally almost entirely 
 superseded nephrectomy. 
 
 Collected statistics show the average mortality to be but 
 slightly over 1 per cent., and my own tables,* giving all the 
 operations of this nature which I had performed up to March, 
 1898, show fifty-seven cases without a single death. My 
 results up to the present are ninety -eight operations, with 
 one death from cardiac thrombosis in a stout female whose 
 kidney was incised and explored before being fixed. Tuffier 
 says that his own statistics show thirty operations with one 
 death from tetanus on the thirtieth day. Tillmanns performed 
 sixteen operations without death ; success was lasting and complete 
 in six, in four there was no relapse, in two relapse, and in the 
 remaining four the wounds healed by first intention, but no 
 subsequent report of them had been obtained. Frank records 
 the results in sixteen cases in the Friedrichsain Hospital, Berlin : 
 eight were completely successful, three were too recently done 
 to be included in the successes, of one he had no subsequent infor- 
 mation, one died, and three died from other causes between the 
 dates of operation and of Frank's communication (1889). He col- 
 lected forty^one published cases (English, French, German, and 
 Italian), together with his ow r n, making fifty-six cases in which the 
 results were known, with two deaths, i.e. nearly 4 per cent. 
 
 Albarranf has analysed the results in 374 collected cases of 
 nephrorrhaphy from the point of view of the risks of the opera- 
 tion. There were seven deaths within a period of less than four 
 
 * "The Origin and Progress of Renal Surgery " ("Hunt. Lectures," 1898). 
 t Traite de Chirurgie, edited by Le Dentu and Delbet, 1900, c. viii.
 
 134 SURGERY OF THE KIDNEY AND URETER. 
 
 months after the operation ; but only four of them were in any way 
 due to the operation, and in three out of the four he says the cause 
 of death was some septic complication which might have been 
 avoided. These figures give a death-rate of rather more than 
 1 per cent. Turner in 1891 reported to the French Congress 
 of Surgeons his results in fourteen operations anah'sed from 
 the point of view not only of operation risks, but of remote 
 subsequent results ; thirteen recovered, one died. Ten of the 
 patients had been kept in sight for three years, and out of the 
 ten, in nine the kidney was solidly fixed. 
 
 From all these statistics taken together, it may be safely said 
 that the operative risks of nephrorrhaphy in all hands are not 
 more than 2 per cent., and that excluding rare and exceptional 
 accidents, such as tetanus and the unexpected causes of deaths 
 which follow any event whatever, surgical or otherwise, the opera- 
 tion in experienced hands is practically without any risk whatever. 
 Nor are the accidents attending or following the operation frequent. 
 In one of my own cases in which the ureter was distorted, dis- 
 placed, and obscured by adhesions fixing it to the lower pole 
 of the kidney, I divided the ureter unintentionally, united it 
 by Van Hook's method of uretero-ureteral grafting, but subse- 
 quently had to remove the kidney ; in another case of extremely 
 hydro-nephrotic kidney which I fixed, hoping to save the kidney, 
 nephrectomy was subsequently performed. I have on four 
 occasions performed nephropexy upon kidneys which had previously 
 had the operation done upon them by other surgeons. I have 
 not had to repeat the operation in any of my own cases, nor 
 have I heard of a second operation having been performed by 
 any other surgeon on any kidney which I have fixed, although 
 I am aware that in a few of the earlier operations by a 
 plan different from the present methods the kidney did not remain 
 completely fixed. In one case a young woman with ankylosed 
 hip from old tuberculous disease, and extreme lateral curvature 
 the operation was followed by profuse suppuration, which continued 
 for some weeks, and afterwards by a sinus ; but the patient made 
 a good recovery. Lauenstein speaks of right-sided pleurisy and 
 suppuration of the wound occurring in a case in which he fixed 
 a floating right kidney, but nine months afterwards the patient 
 was known to be quite cured.
 
 NEPHEECTOMY SUPPLANTED BY NEPHROPEXY. 135 
 
 The advantages of nephropexy over nepkrectomy are so 
 obvious that they perhaps scarcely need to be pointed out. They 
 are the following : (1) The amount of excreting renal tissue 
 remains practically the same after nephropexy ; (2) the possibility 
 of there being only one kidney is a matter of no moment ; (3) the 
 greater mortality of nephrectomy is avoided. 
 
 In selecting lumbar nephrectomy for movable kidney the 
 surgeon is bound to be absolutely sure of his diagnosis. If there 
 is the smallest ground for doubt, the abdominal operation would 
 be alone justifiable, because it affords an opportunity of ascer- 
 taining the presence of a second kidney and of verifying the 
 nature of the movable tumour before commencing to excise it. 
 
 To perform lumbar nephrectomy for what is supposed to be 
 a painful movable kidney, and afterwards to discover that the 
 moving tumour had not been taken away, nor the patient's 
 sufferings relieved, would be as terrible a reflection upon the 
 surgeon as it would be a cruel misfortune for the patient. 
 
 Frank mentions as peculiarities following the operation, tender- 
 ness on pressure in one case, intermitting hydro-nephrosis in 
 another, gastric symptoms w r ith discomfort and vomiting on pres- 
 sure being made over the lower pole of the kidney in a third. 
 He also says that pains do not always disappear with fixation, 
 and, vice versa, may disappear without absolute fixation. 
 
 Nephropexy for pain. If the case is correctly diagnosed, if 
 the patient is not the subject of marked hysteria, and if the 
 kidney by the operation is fairly firmly fixed and in such a 
 manner as to permit the free passage along the ureter of 
 the urine, pain w r ill be cured in 90 per cent, of the cases. 
 When the pains do not cease after the kidney has been firmly 
 fixed it is because they are due to some other cause and the 
 diagnosis has not been absolutely correct, as in a case sent to 
 me after nephropexy had been performed without relief of pain, 
 which was subsequently proved to be due to an ulcer of the 
 stomach ; or because there is such a degree of hydro-nephrosis 
 with resulting obliquity of the orifice of the ureter to the 
 renal pelvis that the fixation does not remedy the renal deten- 
 tion, or again, because there is some other condition of the 
 kidney as well as the mobility which required nephrotomy or 
 some other treatment.
 
 136 SURGERY OF THE KIDNEY AND URETER. 
 
 Its effect on hypercemia of the kidney. Terrillon published 
 a case of nephrorrhaphy for a very freely floating left kidney, 
 hypertrophied (? congested) to four times its natural size and the 
 cause of very violent abdominal pains. The operation com- 
 pletely cured the pains and was followed by the reduction of 
 the kidney to nearly one-half its volume. 
 
 The effect on the size and sense of weight of the kidney when 
 the enlargement is due to engorgement is often quite remarkable. 
 This is only what might be expected. The same thing is seen 
 in untwisting and fixing a movable spleen, and in one very 
 striking case, on detaching adhesions of the liver, I saw a rapid 
 subsidence in the size of that organ which had been extensively 
 enlarged by the congestion caused by the adhesions. 
 
 Effect of nephropexy on the disorders of the digestive system 
 and on the action of tlie bowels. This is often not so satisfactory 
 as the effect in removing pain ; nor can we be surprised at this 
 when it is remembered upon how many social, functional, and 
 organic conditions the gastro-intestiiial symptoms are dependent. 
 Flatulent dyspepsia and constipation are the two symptoms of this 
 group which I have most frequently seen persist, but there have 
 been very few patients amongst those I have operated upon and 
 whom I have been able to follow who have not acknowledged appreci- 
 able improvement in these respects. Turner found that the symptoms 
 of this class had disappeared in half the cases operated upon. 
 
 Effect on nervous phenomena. Turner gives the same pro- 
 portion of successes in reference to the symptoms connected with 
 the nervous system. Albarran from his statistics infers that 
 36 per cent, received no benefit whatever, and that 14 per cent, 
 were only improved. If my own results are more favourable 
 than these figures show it is because I have as far as possible 
 only operated upon patients who have been the subjects of renal 
 crises, or such disabling pain and discomfort as to materially 
 impair their physical activity, and who before and after the kidney 
 became movable had shown no accentuated signs of a hysterical 
 temperament. Operations upon hysterical patients for the relief 
 of subjective symptoms, even when they are based upon a real 
 ascertained physical basis, are not only apt to fail in giving relief, 
 but too often open avenues of thought which end in fresh com- 
 plaints or in an aggravation of the original ones.
 
 MOVABLE KIDNEY A CAUSE OF NEURASTHENIA. 137 
 
 It undoubtedly happens sometimes that a person is credited 
 with being neurotic and her symptoms are attributed to hysteria 
 because owing to an insufficient investigation of the case a movable 
 kidney (or some other definite physical cause for the symptoms) 
 is overlooked ; but, on the other hand, we must avoid the opposite 
 error of overlooking the hysterical element and attributing all 
 importance to the nephroptosis. To do this is to court failure. 
 Shifter quotes fifteen cases in which hysteria is said to have 
 been developed as a sequel of movable kidney, and Marfan has 
 published a case illustrative of this phenomenon. Albarran, 
 basing his reasoning on the maxim that neurasthenia or hysteria 
 is not developed at will, that a determining cause must act upon 
 a soil already prepared, and that this preparation, as the teaching 
 of the school of Salpetriere has shown, is a direct or indirect 
 hereditary neuropathy, has arrived at the following theory 
 regarding nephroptosis : that movable kidney is a mark of 
 degeneracy in a great number of the persons who possess 
 it ; that these patients often exhibit characteristic signs of 
 neurasthenia or hysteria; that on a soil so favourable for the 
 hatching of nervous symptoms some slight traumatic or other cause 
 produces the mobility of the kidney, and then comes the develop- 
 ment of the symptoms. The movable kidney acts the part of 
 a veritable internal traumatism, and the resulting nervous 
 phenomena ought to be interpreted in the light of traumatic 
 hysteria or traumatic neurasthenia from an internal cause. He 
 sees some similitude between these cases and the cases of railway 
 brain or spine of the English. He argues that, as it is known 
 that as long as the cause persists the neuropathic or hysterical 
 state is aggravated, we should not hesitate because of the uncer- 
 tainty of the therapeutic effect to operate upon the movable 
 kidney when the nervous symptoms are very pronounced, if 
 belts or bandages and other palliative means have been found 
 insufficient. It is then necessary, he thinks, to operate, well 
 knowing the speculative nature of the result ; at the same time 
 he considers that every mechanical means should be tried before 
 resorting to operation in this group of cases especially. 
 
 There are sceptics who refuse to credit nephropexy with all 
 the good it does. They say that much of the beneficial effect 
 is due to the prolonged rest after the operation, to the regularity
 
 138 SURGERY OF THE KIDNEY AND URETER. 
 
 of the mode of living whilst preparing for and after the operation, 
 to the moral effect of an operation on the patient, or to the 
 mere exploratory incision, or the possible undoing of a kink or 
 twist in the ureter in the manipulation of the kidney. It is 
 also argued that " the incision in the renal capsule may relieve 
 tension or divide nerves the subject of lithemic irritation " 
 (H. M. Taylor), and thus cure the symptoms mistakenly 
 attributed to a movable kidney. But these are not real 
 arguments against the operation. As regards the beneficial 
 effect of rest I have had experience which leads me per- 
 sonally to attach next to no value to it, for in several instances 
 in which I have operated with most gratifying results the patients 
 have kept the recumbent position for months, six or nine 
 months, before the operation, without the least improvement 
 from it. As regards the other just mentioned circumstances 
 to which it is suggested the benefit might be due, they one and 
 all tell in favour of operation, as they are all brought into action 
 by the performance of nephropexy. 
 
 In the case of a woman, aged forty-seven, operated upon by 
 the late Mr. Henry Thompson of Hull* nephropexy was followed 
 by tetanus; but with our present knowledge of the etiology of 
 that disease we may feel assured that unless the bacillus is com- 
 municated through the use of an infected instrument tetanus 
 cannot be caused by any operation on the kidney. All opera- 
 tions, even the simplest operation in surgery, are on the same 
 level in this respect. 
 
 The conclusions as to the treatment of movable and floating 
 kidney by nephropexy at which I have arrived are the following. I 
 would, however, preface my statement of them by repeating 
 what I have said above respecting belts and bandages for 
 uncomplicated movable or floating kidney, namely, that I have 
 no great faith in their efficacy, that they increase pain and 
 otherwise do harm if not accurately applied, and that many 
 patients will not submit to wearing them. 
 
 1. When movable kidney is associated with enteroptosis no 
 operation should be performed on the kidney unless it is evident 
 that the more serious symptoms are due to the mobile kidney alone, 
 and not until after the trial of a well-fitting abdominal support 
 
 * Lancet, Jan. 20, 1900, p. 157.
 
 AXIOMS OX NEPHROPEXY. 139 
 
 and the careful dietetic and medicinal treatment of gastric and 
 intestinal disorders. Should these means fail and the kidney 
 evidently be mostly at fault, nephropexy, followed by the wearing 
 of an abdominal belt, should be tried. 
 
 2. When a movable kidney is complicated by a movable 
 liver, or when both kidneys move, the same rule should be followed 
 as in general enteroptosis ; and in the case of both kidneys 
 moving they should be fixed one after the other at an interval 
 of a week (when both organs have been giving trouble), so that 
 convalescence from both operations may be taking place simul- 
 taneously. I have in several instances operated upon both organs, 
 and in all but the one where the ureter of the right kidney 
 was divided (see p. 134), with the most satisfactory result. 
 
 3. When the movable kidney is complicated with hysteria 
 or neurasthenia all palliative means should be tried before re- 
 sorting to an operation, and the patient's friends should be 
 informed of the uncertainty of the result from operation. The 
 statistics show that a cure may be hoped for by nephropexy 
 in about half of these cases. 
 
 4. For uncomplicated movable or floating kidney in which 
 the principal symptoms are pain and gastro-intestinal troubles 
 the question of operation ought to be placed before the patient, 
 as it is in the case of radical cure for hernia, and the operation 
 may be confidently advised and carried out without any previous 
 trial of belts or rest. 
 
 5. When renal crises are a feature of the case, nephropexy 
 ought to be strongly urged, because of the impossibility of keeping 
 the kidney in its proper place by a belt, and of the constant 
 danger of hydro-nephrosis and the recurring pain of moderate 
 renal retention due to kinking of the ureter, even if the renal 
 crises can be kept under control and the more severe degrees of 
 ureteral curvature or twisting can be prevented. 
 
 6. When a movable kidney gives rise to 110 inconvenience an 
 operation ought not to be thought of and a belt need not be worn. 
 
 There are several ways of performing nephropexy, each of which 
 is fully described in one of the chapters on operations (Vol. II., p. 220 
 et seq.). One or two points, however, connected with the operation 
 for floating kidney should be touched upon here. In the operation 
 for a floating kidney with a mesonephron the peritoneum has to
 
 140 SURGERY OF THE KIDNEY AND URETER. 
 
 be opened in making the lumbar incision, and it may also have 
 to be in the case of floating kidney without a mesonephron. 
 Under these circumstances the kidney should be pushed fully 
 back into the loin, into the posterior angle of the wound, and 
 the serous covering of the kidney should be sutured to the peri- 
 toneum of the abdominal wall this will secure strong adhesions 
 which will hold the kidney firmly in its place. 
 
 Eosenberger employed this method in a case of " movable " 
 kidney where he had to tear apart the thick adipose masses which 
 covered the kidney, as well as to divide the peritoneum. Hoffa, 
 who examined Rosenberger's patient some time after the operation, 
 said that the union was much firmer than in Hahn's patients, 
 whom he had also examined, where the kidney had been sutured 
 extra-peritoneally by Hahn's method. 
 
 When the liver or the spleen is lower in position than usual, 
 it may happen that the one or the other and not the kidney 
 presents at the bottom of the lumbar wound, and the peritoneum 
 in these cases runs the risk of being opened. No harm ensues 
 if it be. The liver or the spleen, as the case may be, should 
 be pushed well up, and if necessary two or three sutures may 
 be inserted, connecting its peritoneal capsule with the peritoneum 
 of the parietes ; then a similar method can be employed to 
 fix the kidney, or the rent in the peritoneum can be closed and 
 the kidney fixed extra-peritoneally. Sometimes the liver is so 
 much pushed down that the kidney occupies the iliac fossa and 
 cannot be brought into the ilio-costal space until the liver has 
 been forced upwards. Such a condition may make it impossible 
 to fix the kidney in its proper place, but it will rarely be 
 found impossible to keep the liver sufficiently well up to enable 
 the kidney to be fixed close up to the lower ribs. I have in one 
 case found this low displacement of the kidney and liver associated 
 with hydrops of the gall-bladder and a calculus in the cystic 
 duct. The calculus was discovered by palpation through the lumbar 
 wound. The patient was turned on to her back, and after removing 
 the calculus and emptying the gall-bladder from the front, I fixed 
 the kidney extra-peritoneally through the loin incision. The 
 operation was followed by an excellent result and the lasting 
 relief of all the symptoms.
 
 141 
 
 CHAPTER V. 
 
 INJURIES OF THE KIDNEY. 
 
 WOUNDS of the kidney have been described by almost all syste- 
 matic writers. Celsus pointed out the principal symptoms of 
 injuries to these organs as being " pain extending to the groin 
 and testicle, difficult micturition, and hsematuria, or the discharge 
 of blood itself along the urethra." A special dissertation on 
 them was published by Gittler* at Leipzig as far back as 1596. 
 Chopart gives a chapter on wounds of the kidney in his " Des 
 Maladies des Voies Urinaires" (Paris, 1791), and cites several 
 instances, four, at least, of recoveries from incised and punctured 
 wounds. A good deal of information on the nature of wounds 
 of the kidney is given by M. Hevin,f in his admirable historical 
 and critical memoir on nephrotomy. Rayer, in his exhaustive 
 classical work, " Traite des Maladies des Reins " (vol. i., 1839), 
 gives excellent general descriptions of the various forms of 
 wounds, contusions, and ruptures of the kidney, as well as brief 
 summaries of the literature of the subject, and the full notes of 
 ten cases of wounds and thirteen cases of contusions and ruptures 
 of the kidney, which he had gathered from the published records 
 up to his time. 
 
 Otis, in the second volume (of part ii.) of the surgical portion 
 of the " History of the War of the American Rebellion," published 
 in 1876, collected together a large mass of information from many 
 sources respecting the several kinds of injuries to the kidney, in 
 addition to the reports of cases, fatal and otherwise, which occurred 
 during the course of the war. 
 
 Prior to the appearance of this history, Joel Ravel (1870) 
 and Bloch (1873) had published papers or theses on the subject, 
 and since this date, and more especially during the last twelve 
 years, the number of writings and the collection of cases have 
 increased at a rapid rate. 
 
 * Gittlerus, " De renum vulnere, et qui huic euccedit, crueato mictu." 
 t Mem. de lAcadi'mie Royale de Chir., t. iii., p. 238, fol. ed., 1819.
 
 142 SURGERY OF THE KIDNEY AND URETER. 
 
 Injuries which involve the kidneys are of various kinds. They 
 may be conveniently considered under the following heads : 
 
 A. SUBPARIETAL INJURIES OF THE KIDNEY, or those in which no 
 open wound communicates with the injured organ. 
 
 B. INCISED AND PUNCTURED WOUNDS. 
 (a) Without prolapse of the kidney. 
 
 (6) With prolapse of the injured kidney through an external 
 
 wound, 
 (c) With prolapse of the uninjured kidney through an 
 
 external wound. 
 
 C. GUN-SHOT WOUNDS. 
 
 The relative frequency of these several forms of injury in civil 
 and in military life is suggested by the following records. It is very 
 different in the two classes, as might have been expected. Among 
 2,610 autopsies on persons dying from all causes at the Middlesex 
 Hospital between 1873 and 1883, there were thirteen instances of 
 injury to the kidney, twelve of these being subparietal and one 
 a penetrating wound. During fourteen years elapsing between 
 that time and the present, among 3,040 autopsies, there occurred 
 only three instances of injury to the kidney, all of which were 
 subparietal. In the " History of the War of the American Re- 
 bellion" only three cases of rupture without external wound are 
 given by Otis, who says that " but few fatal cases appear in the 
 reports." There was no instance whatever reported of incised 
 or punctured wound. There were twenty-six cases of recovery 
 from alleged gun-shot wounds of the kidney, most of them com- 
 plicated with wounds of other organs or of the ribs ; thirteen 
 involved the right kidney, and twelve the left ; and there were fifty- 
 nine cases of fatal gun-shot wounds of the kidney, most of them 
 complicated with injuries to other viscera and to the spine or ribs. 
 
 Edler, in 1887, collected 152 cases from various sources, and 
 compared the frequency of injury of the kidney with that of the 
 spleen, his results being as follows : 
 
 Kidney. Spleen. 
 
 Subcutaneous 90 83 
 
 Shot wounds 50 32 
 
 Incised and punctured 12 14 
 
 Between 1884 and 1893, inclusive, I collected thirty-one cases, 
 from English and American sources, of injuries of all kinds to
 
 COMPARATIVE FREQUENCY OF THE DIFFERENT INJURIES. 143 
 
 the kidney lacerations, ruptures, punctured and gun-shot wounds. 
 Of these, twenty-six were ruptures, two were gun-shot and three 
 stab wounds. Herzog, in 7,805 post-mortem examinations made 
 at Munich between 1877 and 1889, found seventeen cases of 
 kidney injury, of which sixteen were sub-parietal. Amongst 9,500 
 surgical patients admitted into St. George's Hospital between the 
 years 1874 and 1879, nine only, i.e. one per thousand, were cases 
 of lacerations and contusions of the kidney (Guterbock). 
 
 Of the twenty-six cases of rupture in the cases collected by me 
 
 14 died (three owing to simultaneous injuries to other organs). 
 12 recovered. 
 
 Of the three punctured wounds, all recovered. 
 
 Of the two gun-shot wounds, one recovered and one died after 
 abdominal iiephrectomy : the renal artery and vein had been 
 wounded and the diaphragm perforated, and the bullet lodged 
 against the aorta, the sheath of which was wounded. 
 
 In no case was there a rupture of both kidneys. 
 
 In a recent publication (1896), Keen of Philadelphia has tabu- 
 lated 155 cases, not including those of Maas (seventy-one in 
 number), but beginning where Maas left off, namely, in 1878. 
 The analysis is as follows : 
 
 Gun-shot wounds 19 
 
 Other penetrating wounds 8 
 
 Subparietal rupture 118 
 
 Partial nephrectomy for rupture 2 
 
 Traumatic hydro-nephrosis 6 
 
 Ruptured ureter (pelvis) 2 
 
 A. SUBPARIETAL INJURIES. 
 
 As shown by the above-quoted figures, subparietal injuries 
 are by far the most common. They vary much in severity, 
 from the slightest contusion attended with a little haematuria, 
 but without any obvious lesion of the renal tissue or pelvis, 
 to complete rupture of the organ into two or more separate parts. 
 They are as a rule unilateral, and only very occasionally bilateral. 
 Three cases have been recorded in which rupture of an unsym- 
 metrical kidney occurred, the other kidney being entirely absent.* 
 
 * Cock, Trans. Path. Soc. Lond., vol. i. ; Taylor, Brit. Med. Journ., 1870, 
 vol. ii., p. 485; and Johnson, Montreal Med. Journ., 1893-4, vol. xii.
 
 144 
 
 SURGERY OF THE KIDNEY AND URETER. 
 
 Rupture of the kidney is by no means an unfrequeiit accident, 
 despite the protected situation of the organ and its envelope 
 of fatty areolar tissue. Bloch, in 1873, collected forty cases. 
 
 In 1891 Obalinski made a still larger 
 collection, and finally we have the 
 118 of Keen's collected from reports 
 published since 1878. 
 
 Causes. The causes of subpa- 
 rietal injuries are generally crushes 
 and direct blows upon the abdomen, 
 loin, and lower part of the thorax, 
 muscular violence, falls from a 
 height, and the forcible flexion of 
 the trunk either antero-posteriorly 
 or laterally. 
 
 The passage of wheels (Fig. 23), 
 buffer accidents, shell contusions, 
 the falling in of earth upon the 
 body, the compression of the trunk 
 between two resisting surfaces, such 
 as a wall and the pole of a carriage, 
 or the platform and the footboard of 
 
 a railway carriage, and direct blows upon the loin or upon the ilio- 
 costal interspace in front, are the common kinds of accidents 
 which lead to them. Falls from a height cause injury to the 
 kidney in two ways at least, either by direct violence, the trunk 
 striking against some hard body in the act of falling, or by the 
 sudden and very forcible flexure of the trunk upon itself when 
 the person alights upon the ground. In some instances the first 
 effect of the violence seems to have been the fracture of one 
 or more ribs, the kidney being wounded by the end of a 
 fractured rib. 
 
 As examples of rupture of the kidney resulting from simple 
 muscular contraction may be cited (1) that of Clement Lucas : a man 
 of sixty-six was walking behind a waggon loaded with sacks, and 
 as one fell he endeavoured to catch it by gripping it suddenly 
 with both hands. He at once felt violent pain to the left of 
 the umbilicus, and after a short time passed blood in his urine. 
 (2) That of Campbell, a young girl of fourteen, who doubled 
 
 Fig. 23. Fissures in right Kidney, 
 caused by cart wheel. (St. 
 Thomas's Hospital Museum.)
 
 VARIOUS CAUSES OF INJURIES. 145 
 
 up her body forcibly to the left side in jumping a hedge, and 
 immediately experienced severe pain with collapse and the passage 
 of bloody urine. (3) Londsuth (1761) reported the case of a soldier, 
 who, while boxing with a comrade, was seized with sudden pain 
 and died of rupture of the kidney. 
 
 Giiterbock (1895), in a review of 985 autopsies held in inquest 
 cases, of which 326 were in persons in whom death resulted 
 from accidents, found thirty-six instances of ruptured kidney, repre- 
 senting 10 per cent of the injuries. His analysis is as follows : 
 
 Total number of accidents. 
 Male - - 262 
 
 Female 64 
 
 Number in which the kidney was injured. 
 
 Under 10 yrs. of age.. Between 11-70 yrs. 
 
 4 26 (total 30) 
 
 2 4 ( 6) 
 
 Fourteen of Gliter bock's cases concerned the right kidney, seven 
 the left kidney, and in fourteen both kidneys were damaged. 
 
 Turner records 198 cases of contusion of the kidney up to- 
 1899. Of these 136 are mentioned as occurring in males, and 
 17 in females. A rather larger number involved the right than 
 the left organ, and in six only were both kidneys injured. 
 
 As regards relative frequency of distribution of these several 
 causes Edler gives the following tabular statement of the ninety 
 cases in his list, including seventy-one collected by Maas. 
 
 Crushea 30 
 
 Falls 28 
 
 Run over 13 
 
 Blows 9 
 
 Shell contusions . . . . 4 
 Unknown 6 
 
 It is w r orthy of notice in connection with the obvious relation 
 of these injuries to dangerous occupations, and other exposure 
 to risk, that of these ninety cases only six occurred hi females, 
 and that the ages of the males were chiefly between twenty 
 and forty, that is, in the most active period of life. 
 
 The causes of the injury in twenty -two out of twenty-six 
 cases collected by me between 1884 and 1893, were as follows : 
 
 18 Falls and kicks on the loin or corresponding side of 
 
 the abdomen, chiefly on the loin. 
 4 Run over. 
 4 Not stated. 
 
 26 cases. 
 VOL. I. K.
 
 146 
 
 SURGERY OF THE KIDNEY AND URETER. 
 
 A man may meet with an accident when intoxicated, and 
 may be unconscious of having received any serious injury or 
 of having met with any accident, as in the case from which 
 the kidney represented in Fig. 24 was taken. 
 
 Iviister has collected notes of 300 cases, including most of 
 the preceding, up to 189G. 
 
 Of 272 in which the particulars are stated, 142 occurred on 
 
 the right and 118 on the left 
 side, 12 being bilateral. 
 
 The ages of the patients were 
 chiefly between ten and forty 
 years, and the influence of sex 
 was very marked, being indi- 
 cated by the occurrence of sub- 
 cutaneous renal injury 281 times 
 in males and only 18 times in 
 females, though in the children 
 this was not so decided, there 
 being 33 males to 8 females. 
 
 Kiister, who does not con- 
 sider that forcible antero-pos- 
 terior or lateral bending of the 
 trunk can cause rupture of the 
 kidney, advances other explana- 
 tion based on experiments on the 
 dead body. He says, " It must, 
 however, not remain unnoticed 
 that Morris was the first to as- 
 cribe to the lower ribs a certain 
 share in the production of the 
 injury as he believes the broken 
 bone may occasionally penetrate 
 the kidney. 
 
 "The writings of later Ger- 
 man authors, since ft. Simon, 
 show that no doubt exists as to 
 the lower ribs playing an im- 
 causing injury of the kidney. The effects 
 K'<Mi described as direct or indirect (contrecoup), 
 
 Fig. 24. Dee]) laceration on the internal 
 surface of left Kidney, which was 
 removed on account of persistent 
 hiemorrhage from an intemperate 
 linn, who fur five weeks had had a 
 larut! retro-peritoneal swelling and 
 hannaturia, (Author's case, reported 
 in tli- Cdith-it! Journal. An;.;-. 1. 1S91.) 
 
 portant part in 
 of injuries have
 
 THEORIES AS TO MODE OF OCCURRENCE. 147 
 
 but the mode of laceration of the organ has not been found 
 to correspond to the direction of application of the injuring force. 
 " The only theory which satisfactorily explains the lacerations 
 of the kidney found after abdominal injuries which do not cause 
 penetrating wounds, is that of hydraulic pressure acting through 
 the full vessels and pelvis, and causing the organ to burst along 
 lines for the most part radiating from the hilus towards the 
 point of maximum impact of the lower rib, the opposing resistance 
 being supplied by the vertebral column. 
 
 " Experiments performed on flaccid kidneys thrown with some 
 force against the floor, proved that only superficial grazing or 
 laceration was thus produced. 
 
 " On the other hand, when the pelvis and arteries were injected 
 :and ligatured after closure of the vein, and the organ then thrown 
 down, there ensued deep laceration of the kidney substance, the 
 chief tear always taking place between the point of impact and 
 the pelvis, which was not unfrequently opened ; other rents had 
 a radiating direction. A most important observation in these 
 experiments was that the edges of the rents were everted, and 
 in one case the pelvic fat was forced outwards between- the edges 
 of the fissured parenchyma. When the force was applied to 
 the convex border the fissures took a longitudinal direction." 
 
 In prosecuting these experiments further on the human body, 
 Klister found that it is easy to push forwards the lower ribs 
 until they touch the kidney, and even force it towards the verte- 
 bral column, though on the right side the liver offers some 
 resistance. 
 
 " When the kidney was distended with water and a heavy 
 blow delivered on the loin, with a mallet, the low r er ribs were 
 broken and a superficial graze inflicted on the adjacent part 
 of the kidney, but deep lacerations were produced on both back 
 and front aspects of the organ, their direction being towards 
 the hilus. 
 
 " This represents the effect of a blow vertical to the lower 
 ribs, but does not apply to one delivered in front, either by a 
 thrust or fall, but in such a case it is possible, as in the case 
 of sudden muscular effort, that forcible and rapid adduction of 
 the lower ribs takes place as a result of muscular contraction, 
 forcing the kidnev against the vertebral column.
 
 148 SURGERY OF THE KIDNEY AND URETER. 
 
 " A sudden force exerted tangentially by the rib against the 
 upper pole may tear or separate it without affecting the rest of 
 the organ ; or a slowly applied force from the front may tear 
 the pedicle or separate the poles without bursting the kidney." 
 
 Pathology. Injuries to the kidney are rarely quite un- 
 complicated. Either important parts, in relation with the organ, 
 participate in the damage, or remote regions of the body suffer 
 with the kidney when the body is exposed to great violence. 
 Our remarks, however, will be chiefly confined to a consideration 
 of the immediate and remote effects of traumatism on the kidney 
 itself, with its capsule, vessels and duct. The nature of the wound 
 of the kidney varies much. Of twelve cases of subparietal in- 
 juries of the kidney, the notes of which are before me, seven 
 were lacerations, i.e. partial ruptures, which extended through 
 half the thickness or less of the organ ; two were complete rup- 
 tures, the injured kidney being divided into two separate portions ; 
 in the tenth case the kidney was crushed to pieces, almost into 
 a pulp ; in the eleventh, there was simply subcapsular haemor- 
 rhage, that is, blood was extravasated beneath the fibrous capsule 
 of the kidney, but the renal substance was not ruptured ; and 
 hi the twelfth there was blood in the pelvis of the kidney, but 
 no rupture, and the source of the bleeding could not be found. 
 In this last case the abdomen had been run over by a carriage, 
 and death was caused by laceration of the liver. 
 
 In quite the majority of cases blood in considerable quantity 
 was extravasated into the circumrenal cellular tissue. This would 
 be expected as a matter of course in cases of complete rupture, 
 or when the kidney is very much crushed, but it is also found 
 in cases where there is no laceration whatever of the renal sub- 
 stance. Thus in a case in which blood was effused between the 
 capsule and the cortex of the kidney, and in another in which 
 the only change in the kidney was the presence of a little blood 
 in the renal pelvis, there was a considerable amount of blood 
 extravasated in the cellular tissue around the kidney. 
 
 1. Tearing of outer fat capsule. This may occur with or 
 without injury to the kidney. It is usually marked by an 
 effusion of blood, either infiltrating the fibro-adipose tissue, or 
 forming a distinct collection in some part of it, perhaps entirely 
 enclosing the gland. The haematoma so formed is not usually
 
 SUBCAPSULAR HAEMORRHAGE. 149 
 
 very extensive, and for the most part subsides rapidly, the blood 
 separating into a clear serous fluid tinged with yellow or brown 
 from the detritus of the coagulum. In. rare cases such a collection 
 remains as a cyst, with clear fluid and sediment derived in the 
 same way, which may subside slowly or remain chronic. 
 
 The peritoneum may be torn, and thus blood or urine may 
 escape into the peritoneal cavity. This is much more likely to 
 happen hi children than adults. Before the eighth or tenth year 
 the perinephric fat is not developed, and the peritoneum is separated 
 from the front surface of the kidney only by means of the an- 
 terior layer of the perinephric fascia. If therefore the anterior 
 surface of the kidney of a child under ten is ruptured the peritoneum 
 is nearly sure to suffer also. This adds greatly to the mortality, 
 not only because of the liability to septic infection and fatal 
 peritonitis when blood or urine have been poured into the peri- 
 toneal cavity, but because also of the greater freedom of haemor- 
 rhage through the rent of the peritoneum than into the resisting 
 perinephric tissue when the peritoneum is intact. Death occurred 
 in six cases out of seven in children under ten in Maas's list of 
 seventy-one cases. 
 
 2. Separation of fibrous capsule. Subcapsular haemorrhage. 
 Blood may be extravasated beneath the fibrous capsule or into the 
 pelvis of the kidney without any laceration or rupture of the 
 substance, and the pressure so excited may suffice to cause continued 
 pain and interference with function. Every surgeon who has 
 operated often upon the kidney must have witnessed the occurrence 
 of blood extravasated between the parenchyma and the capsule 
 of the kidney in the course of the manipulations requisite for 
 isolating the kidney before bringing it out upon the surface of 
 the loin, but in rare cases a subcapsular extravasation occurs 
 a,s the result of some strain or muscular effort leading to sudden 
 pain and other symptoms which are not relieved until the blood 
 is let out by division of the fibrous capsule. In the two cases, 
 of which brief reports are subjoined, the symptoms were very 
 severe and persisting, and gave rise to the opinion that a renal 
 calculus was possibly present and acting as the irritant to the 
 kidney. In one case fever, rigors, and delirium with renal pain 
 were the leading symptoms, but there was no hoematuria. In the 
 other case haematuria and pain, with shivering at the outset and
 
 150 SURGERY OF THE KIDNEY AND URETER. 
 
 occasional rise of temperature subsequently, were noticeable. In 
 both cases the condition was observed as soon as the kidney 
 was exposed and before any attempt was made to enucleate 
 the organ from its connections. In the elder woman the kidney 
 was movable and was extruded through the lumbar wound 
 without the need of more than the slightest manipulation. 
 
 In the first case there was a subcapsular extravasation 
 of blood whereby the greater part of the fibrous capsule of the 
 kidney had been detached. It is a very remarkable illustration of the 
 severe symptoms which may be caused by this form of injury, 
 and so far as I know it is in this respect quite unique. A 
 lady, aged sixty-six, was taken ill on September 4th, 1893, with 
 severe pain in the left loin, fever, and rigors, symptoms which 
 were attributed to the presence of a renal calculus, and which 
 were subsequently stated to have followed a strain in lifting 
 down a heavy box from a high shelf on the previous day. The 
 symptoms continued unabated for eleven days, when the fever 
 and rigors ceased ; but pain and tenderness in the renal region 
 persisted and were accompanied by sleeplessness and delirium. 
 The pain radiated along the course of the left ureter. On one 
 or two occasions some gravel was passed ; and there was undue 
 frequency of micturition. 
 
 These symptoms continued and were accompanied by wasting 
 aiicl sallowness, so it was decided to explore the left kidney. 
 
 On October 15th I made an incision in the left ilio-costal 
 space and the kidney was readily and at once exposed. It was 
 but loosely held by its connections, and with the greatest ease 
 was brought out 011 to the surface of the loin. On pressure 
 between the finger and thumb the kidney yielded a crackling 
 sensation over its whole surface, similar to that produced by 
 cutaneous emphysema. A small incision was made through 
 the capsule of the kidney and at once two or three teaspoonfuls 
 of bright blood escaped and left the renal capsule loose and flaccid 
 on the renal tissue. 
 
 Xo calculus was felt in the substance or pelvis of the kidney 
 or upper part of the ureter, and I did not think it necessary 
 to cut into the substance of the kidney, as I invariably do when 
 exploring for calculus. There was no rise of temperature above 
 O'.I'S after the operation. The stitches were removed on the
 
 SUBCAPSULAR HAEMORRHAGE. 151 
 
 seventh and ninth days, the wound being quite healed by October 
 24th. The secretion of urine was scanty for some days, but 
 recovery was speedy and complete. 
 
 In the second case a young married woman, aged twenty-two, 
 was admitted to hospital with a history of sudden acute pain in 
 the loins, radiating to the groins and thighs, which commenced 
 five months previously, accompanied by a shivering fit lasting half 
 an hour, and haematuria lasting a few hours only. This occurred 
 after considerable muscular effort in the course of house-work. 
 She remained in bed six weeks and then on attempting to get up 
 experienced renewal of the pain and hsematuria, wdiich subsided 
 when she returned to bed. This experience was repeated with 
 each of several attempts to resume her duties. Three weeks before 
 admission attacks of pain, sharp and shooting in character, but 
 sometimes dull and dragging, began to occur at night. 
 
 There was unusual frequency of micturition throughout, the 
 bladder being emptied eight or nine times a day, and three or 
 four times at night. The pain affected the dependent side 
 w r hen lying, the left more severely. One attack of pain and 
 hoematuria was accompanied by a rise of temperature to 
 102 F. A dull aching pain in the left side persisted, and 
 the patient appeared somewhat wasted and anaemic, and exhibited 
 tenderness in the loins, especially the left. The urine passed 
 immediately after admission was deeply stained with blood, but 
 was normal on the following day. During the ensuing ten days 
 there was no further manifestation beyond the dull aching pain, 
 worse in the left loin than the right. Xephrotomy was performed 
 on December 14th. On exposing the kidney a dark patch was 
 seen at its lower posterior part having a gritty feel and which 
 on incision proved to be softened kidney substance with effused 
 blood. The incision was carried through the kidney substance 
 into the pelvis in search of a calculus, but nothing of the kind 
 was found. The wounds in the kidney and tissues were then 
 sutured and the patient made an uninterrupted recovery and 
 was discharged three weeks later. 
 
 A careful perusal of numerous reports of cases of ruptured 
 kidney leads me to think that in a good number of instances 
 the injury had at first been confined to the parenchyma without 
 further involving the fibrous capsule of the kidney than to detach
 
 152 SURGERY OF THE KIDNEY AND URETER. 
 
 it from the parenchyma ; and that the capsule had subsequently 
 given way and the parenchyma had become disorganised by the 
 softening effect and the tension caused by the extravasated blood 
 within the capsule. In many cases the blood is extravasated 
 beneath the capsule and between it and the parenchyma, 
 separating the one from the other, just as blood effused from a 
 ruptured middle meningeal artery separates the brain and its 
 membranes from the skull-cap. In other cases the blood is 
 extravasated into the parenchyma, bulging the capsule and 
 encroaching on one or more of the calyces; in other cases again 
 a large branch of the renal artery within the capsule has been 
 ruptured and a traumatic aiieurysm has formed, as in cases quoted 
 in an article on " Aneurysm of the Renal Artery," which I 
 published in the Lancet in October, 1900 (vol. ii., p. 1002). This 
 form of injury explains the course of many of the symptoms, 
 as, for example, the remissions of hsematuria, the exacerbations 
 of pain, the irregular pyrexia, the intermittent anuria,* and more 
 frequent and more important than all, the long interval which 
 often elapses between the receipt of injury and the development 
 of a tumour caused by blood or blood and urine in the peri- 
 nephric tissue. 
 
 It is easily understood how the effused blood pent up within 
 the capsule compresses some parts of the parenchyma and 
 engorges the vessels of the rest of the organ so that blood escapes 
 into the calyces or renal pelvis from the congested vessels, even 
 though the rupture is quite superficial. After a time hours 
 or a day or two the parts adjust themselves to the pressure, 
 and the pressure is perhaps diminished by partial absorption 
 of some of the blood effused, and then the pain and the 
 hoematuria cease or are lessened, or the secretion of urine which 
 for a time has been suppressed is resumed again. After a while, 
 from some cause exercise, a more stimulating diet, straining 
 at stool, some mental disturbance, or what not fresh haemorrhage 
 is excited and the symptoms return, until at length the strain upon 
 the softened capsule of the parenchyma causes it to give way, 
 and blood or blood and urine are rapidly effused into the parts 
 around ; or without the occurrence of any further haemorrhage 
 the blood which is already effused beneath the capsule becomes 
 * tiec Case 8 in Ccrou's thesis, De VOligurie ct dc I'Anur ie Traumatique
 
 VARIATION IN LINES OF LACERATIONS. 
 
 153 
 
 septic and the capsule is perforated or the renal cavity opened 
 into by ulceration or sloughing. 
 
 Many cases might be quoted which, from the course of the 
 symptoms, and in fatal cases from the results of the autopsies, 
 lend powerful support to this view. 
 
 3. Laceration of the parenchyma of the kidney is met with hi 
 every degree of depth, direction, and number of fissures. Fissures 
 
 Fig. 25. Ruptured Kidney, with numer- Fig. 26. Longitudinal rent in Kidney 
 ous superficial transverse fissures. (St. of a boy run over by a cart. (St. 
 Thomas's Hospital Museum, No. 2055.) Thomas's Hospital Museum, No. 2056.) 
 
 may penetrate its substance centripetally from beneath the 
 capsule, or centrifugally from the calyces, or may completely open 
 up the latter. Laceration and rupture of the kidney may 
 take place in any direction, vertically, obliquely, or transversely, 
 or starred. It is more frequently transverse, or radiating from 
 the hilum to the convex border, the kidney substance giving 
 way in the direction of the tubules, not across them. Some- 
 times the laceration is superficial, and limited to one surface only. 
 Sometimes there are several lacerations of different length and depth 
 (Fig. 25). When the rupture is complete, one or the other end
 
 154- SURGERY OF THE KIDNEY AND URETER. 
 
 of the kidney may be broken off, or the rupture may run verti- 
 cally (Fig. 26), or transversely across the centre, extending through 
 renal substance and pelvis as well (Fig. 27). In one of my cases 
 the right kidney was ruptured right through its substance, the 
 rent commencing at its upper border and extending downwards 
 obliquely to its centre ; there were, besides, two small lacerations 
 in the lower part of the organ. Assistant-Surgeon Gunn* saw 
 a case in which death had been caused by hsemorrhage from the 
 right kidney, which had suffered complete longitudinal laceration 
 by the passage of a waggon wheel. 
 
 Sir J. Fayrer f found in a Hindoo, who died from tetanus 
 sixteen days after a fall from a height, an extensive rupture 
 of the left kidney, running from its upper end to the hilurru 
 and the areolar tissue surrounding the vessels at their entrance 
 into the hilum was densely infiltrated with blood. Besides com- 
 pound injuries to the fore-arms, both liver and spleen were also 
 ruptured. There was no peritonitis. 
 
 A man, aged twenty-nine, who had received a kick in. bis 
 back from a horse fifteen years before, without having haemat- 
 uria at the time, suffered a few days afterwards severe pain in 
 the loin, vomiting, and haematuria which occurred at intervals. 
 There was a well-defined, hard, smooth tumour in the right loin 
 which yielded egg-shell crackling on manipulation. A lumbar 
 incision exposed a well-defined mass the size of a large orange 
 involving the lower end of the kidney, calcified, and mistaken at 
 the time for an ossifying sarcoma. The pedicle was ligatured en 
 masse, and the kidney and tumour removed together. It proved 
 to be an encapsuled and calcified hoematoma, with a thin layer 
 of kidney substance spread over it. The patient died of severe 
 haemorrhage and collapse. * 
 
 To recapitulate: when the capsule is torn the principal effect 
 of the injury is an effusion of blood, giving rise to a haematoma. 
 The haemorrhage is not necessarily extensive, as small vessels in 
 the parenchyma are alone involved, and there is no effusion 
 of urine if the uriniferous tubes only are implicated. There- 
 is no tendency for the lips of the fissures to separate, and they 
 
 " Med. and Surg. History of War of Rebellion," vol. ii., part ii., p. 20. 
 t Fayrer, " Chir. and Path. Observations in India," p. 591. 
 I St. Thomas's Hospital Jlejwrts, 1* ( J:2, p. -2(51.
 
 RUPTURE THROUGH THE RENAL PELVIS. 
 
 155 
 
 unite readily by primary union, suppuration rarely taking place. 
 Rents may occur both on the anterior and posterior aspects 
 of the kidney, and more rarely at the outer or inner borders : as 
 alwve stated, they tend to take a radiating direction from the 
 hilum, but may be either oblique or longitudinal. At the poles 
 fissures are more irregular, and not infrequently sever one or other- 
 end completely. 
 
 More severe lesions in the centre of the kidney, separating 
 
 Fig. 27. Complete transverse laceration. (Westminster Hospital Museum, 
 
 No. 790n.) 
 
 it into two or more portions, necessarily open the calyces or pelvis, 
 and lead to extravasation of urine. These will be considered in 
 the next paragraph. 
 
 4. Rupture into the pelvis. Deeper rents into the centre of 
 the kidney, often separating it into two or more parts which 
 may remain attached only by the vessels at the hilum, necessarily 
 open the pelvis, and the body of the kidney may even be 
 entirely separated from its pelvis by a cross rent. When a por- 
 tion of the kidney is entirely freed from its connections, especially
 
 156 SURGERY OF THE KIDNEY AND URETER, 
 
 if the upper or lower extremity of the organ, it may lie at some 
 distance from its normal position. In Page's case (Clin. Journ., 
 Nov. 25, 1896), a boy, aged fifteen, fell from a cart, striking 
 the left side against the kerbstone. There was pain in the 
 loin and vomiting, he was collapsed when seen two hours after, 
 and there was tenderness over the left twelfth rib with hse- 
 maturia. Ergot was administered and an icebag applied. The 
 reaction was febrile and there was renewed vomiting. On the 
 fourth day there was fulness in the left side with pain and 
 tenderness and neuralgia of the last dorsal nerve. The loin was 
 therefore explored, blood-clot and urine were liberated and a rent 
 was discovered in the kidney. The subsequent discharge of urine 
 was copious. On the seventeenth day, owing to the occurrence of 
 blood and pus in the urine and high temperature, the wound was 
 reopened, more blood and urine \vith pus were released, and the 
 kidney found swollen and, as was thought at the moment, in too 
 septic a condition for removal. This, however, was effected a 
 week later, when it was found nearly divided into two pieces. 
 
 It is possible also for damage to occur around a calyx, giving 
 rise to the presence of blood and of kidney fragments in the 
 urine, without anything being apparent on the surface. 
 
 In any case of fissure blood is effused into the rent and 
 into the kidney substance in. the neighbourhood ; but when the 
 large vessels in or near the hilum are lacerated the effusion of 
 blooci is rapid and extensive, and the kidney itself may be buried 
 in an enormous blood effusion, which also invades the neighbour- 
 ing parts. It may separate the layers of the mesentery, extending 
 to the small intestine, and lift forward the colon, or extend to 
 the diaphragm or bony pelvis along the rectum, or distend the 
 nank, causing compression of the important veins in front of the 
 vertebral column. In some cases blood has followed the course 
 of the spermatic vessels along the inguinal canal, causing ecchy- 
 mosis at the external ring or in the scrotum. 
 
 When complete rupture occurs the haemorrhage is sometimes 
 very great, as in a case recorded in the Guy's Hospital Reports* 
 A young man fell against the edge of a cask whilst deeply intoxi- 
 cated, and died in twenty-seven hours in a state of collapse ; at the 
 autopsy the left kidney was found completely divided transversely 
 
 * Second series, vol. ii., p. 424 ; case 20.
 
 RUPTURE INTO THE PERITONEUM. 157 
 
 through its middle into an upper and lower half. There was. 
 extensive and general extravasation beneath the peritoneal coats 
 of all the viscera, excepting the liver, and an enormous coagulum 
 of blood was found in the left lumbar region, extending from 
 the diaphragm to Poupart's ligament, and also across the spine. 
 The viscera, more especially on the left side of the abdomen ,. 
 had been raised forward by the effused blood. 
 
 When the kidney is completely ruptured and the peritoneum 
 covering it is also torn (an accident likely to occur from very 
 great violence inflicted upon the front of the abdomen) the 
 haemorrhage may be great and suddenly fatal. In the Guy's Hos- 
 pital Reports* there is the record of a case of a lad, aged eight 
 and a half years, who was suddenly and forcibly struck on the 
 abdomen by the handle of a truck, and died within an hour. At 
 the post-mortem examination the upper extremity of the right 
 kidney was completely torn off, and about a quart of blood 
 was found diffused throughout the cavity of the peritoneum. 
 
 In other cases blood is effused behind the peritoneum from 
 ruptured kidney, and into the cavity of the peritoneum from 
 rupture of some other viscus. A man,f aged twenty-four, over 
 whose body a railway carriage probably passed, died five hours, 
 after the accident ; on examination, a pint and a half of blood 
 was found poured out behind the peritoneum, and the right 
 kidney was much torn, and cut nearly into two parts ; within 
 the peritoneal cavity were eight ounces of blood, and on the 
 convex surface of the right lobe of the liver was a rent three 
 or four inches in length, and penetrating deep into its structure. 
 
 In St. Bartholomew's Hospital Museum there is the right 
 kidney from a lad, aged nineteen, who was crushed by the pole 
 of a van against a wall. Bloody urine was drawn off by the 
 catheter during life. Death took place twelve hours after the 
 accident. The abdomen was found full of blood - clots ; the 
 lower portion of the kidney had been torn off ; the liver was 
 much lacerated ; the tenth rib was fractured. 
 
 The most characteristic effect, however, of rupture into the 
 pelvis of the kidney is extravasation of urine. This takes place 
 principally in the neighbourhood of the kidney, forming with 
 
 * Second series, vol. ii., p. 485 ; case 21 (1844). 
 t Ibid., case 22.
 
 158 SURGERY OF THE KIDNEY AND URETER. 
 
 the blood a large retro-peritoneal tumour, more especially where 
 a free passage along the ureter is interfered with ; under these 
 circumstances a large cyst may develop with a smooth inner wall 
 containing urine mingled with detritus of blood. 
 
 5. Rupture of renal artery and rein. Grawitz records the case 
 of a potter, aged twenty-seven, who fell, striking his right hypochon- 
 drium against the sharp edge of a chest. At once violent pain and 
 vomiting were experienced, and there was a dulness in the right 
 side of the abdomen and hsematuria. The patient died in twenty- 
 four hours. The autopsy revealed a rupture of the right kidney 
 and of the renal artery and vein. 
 
 Where a communication is established between the pelvis of the 
 kidney and the lacerated parenchyma or vessels, there is naturally 
 a tendency for the blood to escape with the urine into the bladder. 
 When this occurs the bladder may rapidly become distended 
 with blood, either liquid or clotted, mixed with the secretion 
 from the other kidney. 
 
 Thus in the case of a youth of sixteen (recorded by Blum), who 
 fell from an omnibus on to his left shoulder and lumbar region, 
 such a haemorrhage continued at intervals for over three weeks- 
 The patient Avas able to rise from the ground after the accident, 
 and after a short rest walked for half an hour to reach home, 
 but hfematuria with clots occurred immediately and continued 
 with other urgent symptoms, so that nephrotomy and tamponning 
 of the ruptured kidney were resorted to on the third day, and 
 ;H the}' proved ineffectual iiephrectomy was performed successfully 
 twenty-four days after. The bladder had been in the meantime 
 continually distended with urine, blood and blood-clot, causing 
 intense pain and difficulty in micturition. 
 
 In some cases it has been observed that the blood extravnsated 
 in the neighbourhood of the kidney remains perfectly fluid for 
 several days. If recovery takes place extra vasated blood may 
 remain in great part unabsorbed without giving rise to further 
 local change, as is proved by the case * of a man who died 
 eighteen months after he had been kicked by a horse on the right 
 side of the abdomen. Both kidneys were very granular and 
 full of cysts. The cellular tissue around the right kidney was 
 
 * See Catalogue of St. George's Hospital Museum : and Trans. Path. Sue., 
 vol. xi. p. l-li.i.
 
 NECROSIS OF KENAL TISSUE AFTER INJURY. 159 
 
 consolidated, a large clot of blood occupied the renal cavity, 
 and communicated also with the exterior, where a large quantity 
 of blood-clot was lying in the subperitoneal tissue. The line of 
 rupture could be faintly traced through the substance of the 
 gland. The ureter, where cut across (about one inch and a 
 half from the kidney), was found quite impervious. 
 
 This case shows also another important fact, namely, that 
 the ureter and renal pelvis may become quite plugged by ex- 
 tra vasated blood, and that in this way the channel from kidney 
 to bladder may be permanently obliterated. 
 
 The plugging of the renal pelvis with blood may be the only 
 visible change in the kidney. This was seen in the case of a 
 woman who had been run over, and whose death occurred from 
 rupture of the liver ; the left kidney was nowhere lacerated, but 
 the pelvis was occupied by blood, the source of which could not 
 be detected. 
 
 It appears to be in those cases in which, blood flows slowly 
 into the pelvis or ureter that the blood is apt to clot there, causing 
 obstruction and subsequent distension and wasting of the kidney. 
 
 6. Laceration of pelvis or vessels at the hilum. Without 
 damage to the kidney substance, the organ may be completely 
 detached from the structures at the hilum as a result of con- 
 tinuous severe pressure rather than of sudden violence. The 
 effect of separation from the ureter is extravasation of urine 
 without serious haemorrhage, giving superficially the appearance 
 of hydro-nephrosis, though investigation shows the kidney itself 
 to 1 be on the confines or at one end of the sac, usually in front. 
 
 7. Total destruction of the kidney. In some cases the kidney is 
 found literally " torn to pieces," or the parenchyma reduced to a mere 
 pulp within its capsule, either as the direct result of an injury 
 or of the inflammation to which an injury gives rise. In some 
 of these cases there is little or even no extravasation of blood 
 into the tissue around. Necrosis occurs at once in the separated 
 portions and in those in which the blood-vessels are thrombosed. 
 Haemorrhage is often not severe owing to the early occlusion 
 of vessels, and there may be no extravasation of urine, on account 
 of the complete destruction of the secreting structure. The danger 
 to the patient, apart from that due to loss of the kidney (which 
 is considerable when the other organ is diseased, injured or
 
 160 
 
 SURGERY OF THE KIDNEY AND URETER. 
 
 absent or even temporarily impaired in function), is in the septic 
 and suppurative changes which take place early in the damaged 
 area (Fig. 28) and readily extend to other parts in the neigh- 
 bourhood or to the other kidney by way of the bladder. 
 
 Detachment or thrombosis of vessels, whether of artery or vein 
 or both, necessarily results in necrosis of the kidney, either in 
 part or in its entirety, according to the area cut off from the 
 
 Upper end of Kidney. 
 
 Torn Ureter 
 
 Torn Renal Artery. 
 
 Torn Renal Vein. 
 Lower end of Kidney 
 
 Fig. 28. Lacerated Kidney and a Perinephric Abscess caused by the buffer of a 
 locomotive. (Guy's Hospital Museum, No. 1595.) 
 
 circulation. When a portion only is affected, one or other pole or 
 wedge-shaped area in the middle presents the several changes 
 occurring in an infarct, with sharply demarcated edges, being 
 first dark and congested and then pale and fibrinous before under- 
 going necrosis and suppuration, or cicatricial contraction. 
 
 When the main artery or vein is thrombosed or divided, 
 mortification attacks the kidney, which separates by suppuration. 
 The degree of haemorrhage in such cases depends on the nature 
 of the injury to the vessels and on the opportunity of escape 
 of blood into the peritoneum or other large cavity. In some 
 at least the loss has been comparatively trifling.
 
 INJURIES TO OTHER ORGANS FREQUENT. 161 
 
 Pissary and Gurnard record an instance of rupture of the 
 renal vein in a man who died thirteen hours after being crushed 
 between two waggons, the force being expended between the left 
 hypochondrium and the right loin. The man suffered from shock 
 and signs of internal haemorrhage, with severe pain in the right 
 renal region. Xo urine was passed and no blood escaped. In 
 the collapsed state of the patient only a tentative exploration 
 was ventured upon, disclosing extensive laceration of the omentum ; 
 but on post-mortem examination the left renal vein was found torn 
 nearly through its whole circumference several centimetres from 
 the hilum, the effused blood extending to the bifurcation of the 
 aorta and into the left hypochondrium. 
 
 The thrombus which forms in the lacerated artery and vein 
 does not extend far towards the main trunk; it is short and is 
 apt to become displaced, giving rise to secondary haemorrhage. 
 The formation of a traumatic aneurysm is a very rare complication, 
 cases of which will be referred to further on (p. 238 et seq.). 
 
 8. Septic infection. Septic organisms probably reach the seat 
 of injury from the lower urinary passages, from the colon, or even 
 by way of the circulation ; setting up suppurative changes in the 
 effused blood or blood and urine, and the damaged or separated 
 portions of kidney, or giving rise to an abscess, which, as in an 
 observation of Kade, quoted by Kiister, may open into the perito- 
 neal cavity. In more favourable cases the pus may escape by the 
 ureter, but in such instances, and in those where clots in the 
 bladder break down, usually in the second week, there is often 
 ascending pyelitis and pyelo-nephritis (bilateral), with death from 
 uraemia. 
 
 9. Associated injuries may be either independent, or extensions 
 of the local damage, in which the kidney itself is involved. Among 
 the former ma}* be mentioned fracture and dislocation of the 
 spine, fracture of the skull or of the extremities, and -such other 
 complications as might be expected to accompany the exposure 
 of the body to the effects of severe force. Rupture of the bladder is. 
 usually associated with fracture of the pelvis. 
 
 Of the twelve cases of subparietal injuries in my own list, the 
 
 right kidney alone was involved in eight, the left alone in one 
 
 only, and in three there were lesions of both kidneys. In ten 
 
 instances the liver was ruptured as well as the kidney, and in 
 
 VOL. i. L
 
 ]62 SURGERY OF THE KIDNEY AND URETER. 
 
 some of these there was rupture of the spleen, or lungs, or both, 
 as well as of the kidney. Of the ten cases in which the liver 
 was ruptured it was the right kidney alone which suffered in 
 six ; and both kidneys in three, the left being most injured 
 in one of the latter. Many recorded cases also show that when 
 the right kidney is injured the liver is very commonly damaged 
 also. The right kidney is, however, sometimes the only organ 
 injured. This was the case in a lad, aged fifteen, who was run 
 over by a cart and died very shortly after from extravasation 
 of blood into the subperitoneal tissue.* 
 
 When a fall has been the cause of the injury, fractured ribs, 
 fractured pelvis, or fractured skull may complicate the rupture 
 of viscera. In four out of ten cases in which the liver as well 
 as the kidney was ruptured the ribs were fractured also, and 
 in two other cases there was fracture of the skull. 
 
 . Despite' the protected situation of the kidney, it may be in- 
 jured in persons of all ages or either sex. Of twelve fatal cases 
 seven were in men, two in women, and in two the sex was 
 not stated. 
 
 Among those injuries with which kidney lesions are more closely 
 involved, may be mentioned rupture of the pleura, diaphragm, or 
 lung, accompanied by pneumothorax, and not unfrequently with 
 fracture of the lower ribs. Kiister estimates that this latter accident 
 is met with as often as fourteen times in 251 cases of subcutaneous 
 renal injury. The same author mentions fourteen among 251 
 cases in which rupture of the peritoneum occurred with extra- 
 vasation of blood or urine or both into its cavity, and points 
 out that this is more liable to occur in children, owing to this 
 membrane being more tightly stretched. The rents were mostly 
 associated with damage to the anterior surface of the kidney, 
 but were sometimes remote from it. The liver, spleen, pancreas. 
 duodenum, and colon are also occasionally injured, especially 
 the first named. 
 
 T. H. Manley reported in 1897 an instance of rupture of a horse- 
 shoe kidney as the result of a kick from a horse in the left lumbo-iliac 
 region, with impact of the patient's back against the corner of a corn- 
 bin. There was immediate collapse with intense pallor, and pain in 
 the abdomen. The rirst urine was passed sixty-four hours later and 
 * See St. George'-* Hospital Museum Catalogue.
 
 SEQUELS OF KIDNEY LACERATIONS. 
 
 163 
 
 contained only a few blood corpuscles. On the sixth day, as feculent 
 vomiting and tympanitis had occurred after getting up during 
 the night, an incision eight inches in length was made along the 
 outer edge of the left rectus and a portion of gangrenous intestine 
 removed. There was also rupture, of the renal substance and 
 probably of one of the veins of the horse-shoe kidney. Sudden 
 vomiting and haemorrhage ended the case. 
 
 When life is prolonged for some weeks or months, pyo-nephrosis 
 and renal abscess are by no means rare sequelae of an injury 
 (either contusion or laceration) of 
 the kidney. Mr. Pollock recorded 
 such a case in his article in the 
 " System of Surgery," * Perinephric 
 abscess and complete tumefaction of 
 the renal substance are also occasional 
 consequences of a blow in the loin. 
 These changes are more likely to 
 follow if a calculus is contained within 
 the injured organ. I recorded such 
 a case of perinephric abscess in my 
 " Surgical Diseases of the Kidney " 
 (1885), pp. 220, 221 (see Fig. 29). 
 Other sequelae are chronic nephri- 
 tis, calculus or cyst formation, 
 and aneurysm of the renal artery. 
 
 A strain or slight laceration of the renal pelvis may be followed 
 by adhesive inflammation and obliteration of the urinary duct. 
 Hydro-nephrosis may ensue within a few weeks after injury to 
 the renal pelvis, and lead to a tumour in the loin ; and this, 
 after a succession of tappings, may cease to refill, owing to the 
 complete destruction of the secreting substance of the injured 
 kidney. An illustrative case of this sort is described by 
 Croft.t Stanley's J case was, perhaps, a similar one to Croft's ; 
 or it may have been a case of torn pelvis of kidney ; it was not 
 one of ruptured ureter, as it is so often quoted as being. In 
 other cases of lacerated pelvis of kidney, the organ in the course 
 
 * Holmes, " System of Surgery," vol. i., p. 882 (3rd edition). 
 t Trans. Clin. Soc.. vol. xiv., p. 107. 
 t Med.-Chir. Trans., vol. xxvii. 
 
 Fig. 29. Calculus tightly fitting the 
 Kidney, and leading to Peri- 
 nephric Abscess after an Injury. 
 (Middlesex Hospital Museum.)
 
 164 SURGERY OF THE KIDNEY AND URETER. 
 
 of months or years becomes converted into a number of abscess 
 sacs owing to pyo-nephrotic distension of the calyces, and the 
 ureter may atrophy after becoming quite impervious. Haviland 
 has recorded such a case.* 
 
 Symptoms. The symptoms of injury to the kidney are 
 compounded of those common to all injuries of abdominal organs, 
 such as (1) collapse and severe vomiting or retelling, the manifesta- 
 tions of internal haemorrhage, and later of peritonitis, (2) local 
 indications, such as lumbar pain, ecchymosis, and swelling both 
 pain and swelling extending in directions radiating from the site of 
 the organ injured, and being attended in some cases with definite 
 attacks of renal or ureteral spasm ; and lastly, disturbance of 
 the normal functions of the kidneys, as evidenced by alteration 
 in the character or quantity of the urine, which shows itself 
 principally in haematuria and diminution or actual suppression 
 of the secretion. The symptoms do not, always supervene at once, 
 even when the kidney has been badly ruptured or a good half 
 of it even pulped. Many cases might be quoted in proof of 
 this. In one instance known to me, a young man was kicked 
 in the loin early in a game of football, yet he played the game 
 through, walked over a mile after changing his clothes and drink- 
 ing some beer, and it was only on discovering later that he was 
 passing blood that he began to feel faint and ill. Mynter describes 
 a case where a man went on with his work as a brakeman to a 
 freight train and rode thirty miles before he began to have faint- 
 ness, pain, and vomiting, yet half his kidney was completely 
 pulped. t On the other hand, patients have been killed off quite 
 suddenly in two hours or less.J 
 
 Collapse. The first effects of contusion of the kidney, even 
 when not associated with extreme violence or widespread injury, 
 are faintness and loss of consciousness; these may be of short 
 duration, or possibly not sufficiently profound to prevent the 
 patient staggering to a place of safety or his home. On the 
 other hand, the collapse may be deep and of long duration, ex- 
 tending from some hours to as long as five days. The face 
 is pale and drawn and covered with sweat, the temperature sub- 
 normal, the pulse quick and small. The injured person may 
 
 * Path. Soc. Trans., vol. x., p. -209. t Ann. Surgery, 1891, No. 14. 
 
 I See Dunlop's cases, iMncet, 1880, vol. i., p. 91.
 
 LOCAL SYMPTOMS OF INJURY. 165 
 
 'either lie quietly without expression of pain, and though un- 
 willing to speak, exclaim when moved or examined ; or 
 may be groaning or crying out with agony. Attacks of 
 vomiting usually supervene, and may be frequently repeated 
 during the next few days. When continued beyond the period 
 of collapse and reaction, the vomiting may be attributed to irri- 
 tation of the peritoneum by blood effused into its cavity or behind 
 it and pushing it forward ; or by extension of clot into the neigh- 
 bourhood of the coeliac axis and sympathetic nerves and ganglia, 
 or between the attachments of the mesentery. 
 
 The aspect of the patient immediately, and for some hours or 
 days after the accident is in some cases discouraging in the extreme, 
 so that to the inexperienced recovery might appear impossible, 
 though the course of these cases shows that in the absence of pro- 
 gressive anaemia this is not really of such grave import. In other 
 cases, even though death be imminent, the appearance of the patient 
 does not arouse serious concern. He may apparently recover, 
 and rising, at once continue on his way or at his work, and only 
 after some minutes or perhaps hours manifest signs of collapse. 
 This may be the result of slowly developing haemorrhage or may 
 1)6 associated with injuries to other organs, for, as Kiister points 
 out, these variations are not met with in uncomplicated punctured 
 wounds of the kidney, whereas they are quite usual as representing 
 the effect of abdominal injury on the central nervous system. 
 
 Ecchymosis. Local indications of renal injury may be abrasion, 
 ecchymosis, or the appearance of blebs in the kidney region, 
 either in front or behind; they are, of course, by no means con- 
 clusive. There is not usually any ecchymosis of the loin or renal 
 area of the front of the abdomen, though sometimes, when the 
 injury has been caused by the kick of a horse or the transit of 
 a carriage wheel, some bruising of the surface may co-exist with, 
 but be quite independent of, the extravasation of blood from 
 the torn kidney. Of more importance are the evidences of ex- 
 tension of deep haemorrhages which show themselves on the 
 surface ; thus the appearance of ecchymosis or bruise-like dis- 
 coloration of the skin in the region of the external abdominal 
 ring, apart from local injury, indicates effusion of blood along the 
 connective tissue around the spermatic vessels, or possibly by way 
 of the circumflex iliac arterv.
 
 166 SURGERY OF THE KIDNEY AND URETER. 
 
 In Gerard Marchaiit and Aldibert's case* a man, aged thirty- 
 seven, was thrown from a vehicle, striking his left false ribs. 
 Shock, pain and haematuria, with oliguria followed, and subse- 
 quently polyuria, peritonitis, renal swelling, and ecchymosis ap- 
 peared at the root of the penis and over the external orifice 
 of the inguinal canal, with oedematous infiltration of the 
 epididymis and spermatic cord. There was vigilant resistance .of 
 the abdominal muscles. Through a lumbar incision a litre of 
 blood was forcibly ejected, the kidney was found in two parts, the 
 lower encapsuled and an inch and a half away from the rest. 
 Both portions were removed and bleeding from the hilum con- 
 trolled. The quantity of urine increased from 760 to 1,450 grms. 
 in six days and the patient recovered. The rent in the kidney 
 was from above downwards and from without inwards. 
 
 Pain. Pain in the side may be simply the result of superficial 
 injury, in which case it lasts but a day or two; or it is only 
 elicited by pressure ; or it may be due to fractured ribs. 
 
 Pain actually due to the kidney injury may occur at the 
 moment of the accident, with a painful sense of crackling in the 
 body apparent to the patient ; it may continue as a boring 
 or shooting sensation deep in the loin or back, and ma}' radiate 
 in various directions from that point but especially towards the 
 groin, testicle, and thigh, being attended with painful contraction 
 of the cremaster. The pain is increased with change of position 
 and pressure 011 the loin, so that the patient shrinks from ex- 
 amination and assumes some posture of comparative ease from 
 which he refuses to be disturbed. 
 
 Later there may be a feeling of severe tension due to the 
 effusion of blood or urine or both. The occurrence of testicular 
 pain and retraction is usually associated with severe hsematuria, and 
 is due to the spasm of the ureter excited \>y the passage of clots. 
 
 In a case t of injured kidney, owing to a severe contusion 
 of the left side of the abdomen from a fragment of shell, " the 
 shock was great and of long continuance ; there were a bruise 
 in the left Hank, excessive tenderness and pain, anuria, and 
 
 "Diagnosis and Surgical Interference in Lacerations of the Kidney," 
 1889. 
 
 t " Medical and Surgical History of the War of the American 
 Rebellion," vol. ii., p. -20.
 
 TUMOUR AND H.EMATURIA. 107 
 
 retraction of the left testicle.'' In another case,*" which recovered, 
 the injury was caused by a fragment of shell ; there was pain 
 along the ureter, retraction of testicle, smarting at the orifice 
 of the urethra, difficulty in micturition, and occasionally tubular 
 clots of blood in the urine. The hsematuria continued for three 
 weeks after the injury, and then the patient gradually convalesced. 
 
 Other pains of a neuralgic character arise from the involve- 
 ment of nerves in the injury, and follow the course of their 
 distribution : pain on inspiration indicates interference with the 
 diaphragm often associated with restrained thoracic respiration and 
 contraction of the abdominal muscles ; and the patient perhaps 
 speaks unwillingly, with effort, and in a low whisper. 
 
 Tumour. The development of a swelling, from extravasation 
 within or without the kidney, sometimes occurs so rapidly as to 
 be immediately apparent to the eye, and sometimes its appear- 
 ance is postponed for several weeks, or it may not occur at all. 
 The effusion of blood outside the kidney is often augmented by 
 extravasation of urine, and in cases where the pelvis only is 
 injured, urine may be the principal or sole constituent. 
 
 Such a tumour, whether a hsemato-nephrosis or a circumrenal 
 extravasation, is rounded in form and slightly movable both 
 from side to side and in the antero-posterior direction. The 
 percussion note over it is dull, the colon being pushed inwards 
 towards the middle line, though it may in rare instances be found 
 in the loin or even in the hypochoiidrium. Fluctuation may 
 sometimes be felt, but usually at a late stage. 
 
 The appearance of meteorism, seldom intense, like hiccup, 
 regurgitant vomiting, and melaena, are rather indications of 
 concomitant injury to the intestine ; . and similarly, effusion in 
 the peritoneal cavity, whether serum, blood, or urine, is evidence 
 of extension of injury to that membrane, which generally gives 
 rise to fatal peritonitis. 
 
 Hwmaturia. Haematuria is a very common symptom. It 
 occurred in sixty-five out of seventy -one cases collected by 
 Maas. It may be stated at once that the hsematuria following 
 an injury to the loin, or the front of the ilio-costal area of the 
 abdomen, is not necessarily due to ruptured or lacerated kidney ; 
 and, on the other hand, that hipmaturia is not always present 
 
 * u Med. and Surg. Hist, of the War of the American Rebellion," vol. ii., p. 21.
 
 168 SURGERY OF THE KIDNEY AND URETER. 
 
 when the kidney is severely lacerated or completely ruptured. 
 If the ureter becomes plugged by clot, so that neither blood 
 nor urine can get down to the bladder from the injured organ, 
 haematuria cannot occur, and the kidney may be ultimately lost 
 as an excreting organ. If the cortical substance of the kidney 
 is only superficially lacerated there need not be even the smallest 
 drop of blood passed with the urine. 
 
 1. Hsematuria may denote simply contusion of the kidney. 
 This, I believe, was proved by two cases, in each of which 
 a boy was run over by a carriage. In each case there were 
 collapse and praecordial pain, as well as pain in the affected 
 loin. In one case there was no difficulty or pain in micturating 
 throughout ; in the other the catheter had to be used at first. 
 In each case the urine was mixed with a large quantity of blood ; 
 in one the haematuria continued for three days, and in the other 
 for four days. In. neither case was there any contusion of the 
 surface, or any swelling in the loin. Both patients were well 
 within a fortnight, though slight localised peritonitis had occurred 
 in one. 
 
 2. Haematuria may occur by transudation from the tem- 
 porarily congested cavity of the kidney, and without any 
 appreciable breach of surface, just as bleeding may occur from 
 the nose or from the vascular lining membrane of any other 
 cavity of the body. Toxic haematuria and the bleeding excited 
 by irritants, such as cantharides and turpentine, is unattended 
 by any definite lesion of tissue. It is more than probable, when 
 haematuria follows some muscular strain, that the blood is derived 
 by transudation from suddenly congested vessels in some part 
 or other of the urinary tract, not necessarily from the kidney 
 at all. In some cases after death the interior of the kidney 
 has been filled with blood, though no lesion of the tissues could 
 be discovered. In other cases a sudden strain has displaced a 
 small calculus which previously had been encysted within the 
 kidney. Haemorrhage caused in this manner may be severe 
 and of long continuance. 
 
 3. Haematuria of a temporary character may be caused by 
 an embolus or thrombus within the renal vessels, and this may 
 be associated with some sudden muscular strain. 
 
 4. When hoematuria is not an immediate or a verv earlv
 
 ILEMATURIA FROM OTHER CAUSES. 169 
 
 symptom of an injury, but appears at a later period, i.e. a day 
 or two afterwards, it may be the consequence of inflammation 
 extending from the damaged circumrenal cellular tissue to the 
 kidney, which has not itself been injured. 
 
 5. Simple shaking of the kidney, as in horse exercise, seems 
 in certain individuals always to excite slight hsematuria. The 
 mere change from one pace to another, as well as the prolonged 
 fatigue of riding, have been said to cause in some men bloody 
 urine accompanied by lumbar pain. 
 
 6. The results of shaking of the kidneys are more marked 
 in persons who are afflicted with renal calculus or gravel. Con- 
 versely, traumatic lesions of the kidney predispose to the formation 
 of renal calculus or gravel. 
 
 7. Hsematuria which is due to a pre-existing cause may be 
 noticed after an injury, as in a boy, aged fifteen, who after 
 striking his side had persistent hsematuria, which on inquiry 
 was found to have occurred on previous occasions, and to be 
 due to a villous growth in the bladder (Newman, p. 312). 
 
 8. Dr. Tiffany cautions American surgeons against concluding 
 that all are cases of injured kidney in which haematuria follows 
 violence, by reminding them that in the region from Washington 
 to the Capes of Chesapeke, hsematuria is not uncommon after 
 injuries, but that it is due to malarial causes, not to the injury, 
 and that an examination of the blood* in these cases will prove 
 the malarial origin of the bleeding. 
 
 9. Kenal hsematuria of an intermittent character occurs from 
 many causes, from Bright's disease, calculus, renal angeioma, 
 and from excess of uric acid in urine. 
 
 When the kidney has been contused or deeply lacerated, the 
 quantity of blood passed with the urine during the first few 
 hours sometimes amounts to many ounces ; as a rule there is 
 a small quantity at least during the first few acts of micturi- 
 tion. In some cases blood may be passed immediately after the 
 accident, continue for a day or so, and then disappear, to 
 recur, perhaps, in a few days, or not until fifteen or sixteen days 
 later, on going to stool or making some other strong muscular 
 effort.* Such haemorrhages may recur two or three times, or 
 more. 
 
 * See Guys Hospital Reports, p. 470 (1844).
 
 170 SURGERY OF THE KIDNEY AND URETER. 
 
 M. Gelley* has recorded a striking case of recovery after 
 injury to the right kidney, followed by immediate haematuria 
 which lasted five days, and later on by recurrent attacks of 
 hsematuria. The recurrences happened on the twelfth day after 
 the injury and lasted nine days ; and on the twenty-ninth day, 
 and lasted three days. The patient was a man, aged sixty-two, 
 who was injured by the wheel of a passing carriage. 
 
 In other cases the haematuria may be slight at first, and 
 increase exceedingly later on. Mr. Keeves has published t the 
 case of a lad, aged nineteen, who fell from a cart and sustained 
 a very severe contusion of the right kidney. For nine days 
 there was only very slight haematuria, but on the tenth and 
 three succeeding days large quantities of nearly pure blood were 
 discharged. The patient died at the end of the fourth week, 
 and at the autopsy most of the right kidney was a broken-down 
 pulp, situated in a large retro-peritoneal space filled with blood 
 and blood-clot. There was a false aneurysm of a branch of 
 the renal artery. The bladder was distended with blood-clot 
 and much inflamed. (This is one of the nineteen cases referred 
 to by the author in an article on "Renal Aneurysm" in the 
 Lancet, October 6th, 1900.) 
 
 In other cases the appearance of blood with the mine has been 
 delayed altogether until the eleventh day (Raver) or even much 
 longer. In complete rupture, when the kidney is divided into 
 two parts, blood is frequently absent from the urine. J It is also 
 quite certain that the cortical substance may be severely contused, 
 even lacerated in one or more places, without the urine being 
 charged with any blood whatever. Erichseii records two cases, 
 in neither of which was there any blood in the urine. Hnematuria 
 may be absent, owing (1) to the ureter or renal pelvis being 
 temporarily or permanently plugged by blood-clot, (2) to throm- 
 bosis of the renal vessels, (3) to complete separation of the kidney 
 from the ureter. 
 
 Several cases of severe damage to the kidney in which no haema- 
 
 * Revue Medicate de VEst; Annales des Maladies des Organes G&rito- 
 urinaires. 
 
 t Lancet, October 4th, 1884. 
 
 J See cases quoted above from Guy's Hospital -[Reports. 
 " Science and Art of Surgery," vol. i., p. 850. 8th ed.
 
 H.-EMATUKIA AX UXCERTAIX SYMPTOM. 171 
 
 turia lias been present might te quoted. Charteris (Lancet, 1880, 
 vol. i., p. 90) recorded a case in which the ureter was impervious 
 from the pelvic brim onwards. The patient struck his right side 
 against the corner of a table ; there was no hnematuria, vomiting 
 being the principal symptom, and death occurred from exhaustion 
 from this cause on the thirtieth day. The right kidney was large 
 and weighed seven and a half ounces, and was completely ruptured, 
 the peritoneum was not torn, but a periiiephric abscess containing 
 twenty-six ounces of pus had been formed. The ureter was very 
 much dilated in its upper part, and tilled with a large quantity 
 of white purulent fluid much thicker in consistence than that 
 in the perinephric abscess ; below the brim of the pelvis the 
 ureter was impervious to the pus. C. A. Power (Trans. New York 
 Acad. of Mecl., 1887) published a case of a woman, aged fifty-two, 
 who died three days after a deep transvei-se rupture on the pos- 
 terior surface, together with several smaller ruptures of the left 
 kidney. There was 110 haematuria throughout in this case. 
 
 Raver states that haematuria, more or less considerable, in- 
 dicates without doubt that the kidney has been shaken or other- 
 wise injured, either in consequence of a general shaking of the 
 body ; or in a violent effort during which the muscles of the 
 parietes of the abdomen were suddenly and forcibly contracted ; 
 or in consequence of a contusion of the lumbar region. But 
 he thinks it is impossible to say, in the majority of cases, what 
 is the precise nature of the renal injury. 
 
 It is unnecessary to attach great importance to this uncer- 
 tainty of diagnosis between the several subparietal lesions of the 
 kidney, viz. contusion, laceration, and rupture, except from the 
 point of view of prognosis. The contusions and superficial lacera- 
 tions are very amenable to recovery, whereas complete ruptures 
 are almost certain to cause death from haemorrhage or peritonitis. 
 
 Hsematuria may continue for weeks or till death, the 
 bladder being distended with blood-clot and extensive haemorrhage 
 existing around the kidney. In Butlin's case (St. Earth. Hosp. 
 Rep., 1896), J. X., twenty -one, a butcher, fell from a height of 
 twelve feet, striking the left hip ; he was able to rise, but felt sick, 
 and staggered on rising to his feet ; there was tenderness in the 
 right iliac region and loin, and almost immediately he passed four 
 ounces of bright blood. There was marked collapse after the
 
 172 SURGERY OF THE KIDNEY AND URETER. 
 
 accident, but no other symptoms or complications. The haema- 
 turia persisted for five weeks and was followed by pyuria, though 
 the urine remained acid throughout. 
 
 The haematuria may intermit for days or weeks, recurring 
 in varying degrees or being absent altogether for a time. The 
 recurrences may coincide with the displacement of a thrombus 
 owing to movement, rough handling of the hsematoma, as 
 in Nickel's case, or disintegration of clot through the action 
 of urine ; or may be due to emptying of a blood-sac by way 
 of a rent in the pelvis, as cited by Kiister. 
 
 Blood may appear in the urine derived from other injured 
 parts of the urinary apparatus, such as the bladder, mostly 
 in cases of fractured pelvis, though in these cases other signs 
 are added which make its origin sufficiently obvious. 
 
 If the laceration is a severe one, or if complete rupture has 
 occurred, haemorrhage into the subperitoneal tissue or into the 
 peritoneal cavity will in all probability be great, and then faint- 
 ness, collapse, pallor, coldness of the extremities, intense anxiety, 
 thirst, cold sweats, and increased pain in the abdomen will be 
 caused. In the urine, which may either be passed off voluntarily 
 or retained in the bladder till withdrawn bv the catheter, there mav 
 
 4 * 
 
 be blood, blood-clots, blood-casts, and even broken renal tubules. 
 
 After injury to the kidney, clots may be passed in the urine 
 as long worm-like casts of the ureter. Microscopic blood-casts 
 of the uriniferous tubes are also occasionally found. A case is 
 reported in the " History of the War of the American Rebellion," 
 of haematuria persisting for three weeks, and of clots moulded 
 to the form of the ureter being occasionally passed in the urine, 
 which remained albuminous up to the time of death, two months 
 after the injury. 
 
 Analysis of Symptoms in twenty-six cases. Out of twenty-six 
 cases of rupture of the kidney collected without selection from 
 English, Irish, Scotch, and American journals over a period of 
 ten years (1884 to 1893), heematuria was a symptom in eighteen, 
 in three very severe, in two remittent, and in two associated 
 with difficult micturition and retention of urine for a period 
 of one week. The heematuria lasted three weeks in two cases, 
 and for eight days, seven days, "several" days in others. 
 
 A tumour in the loin occurred in twelve of the twentv-six
 
 BLOOD RETAINED IN THE BLADDER. 173 
 
 cases. In one it was evident within an hour, in another it 
 appeared on the fifth day, in others it was delayed for ten days, 
 fourteen days, and in two cases for three weeks and rather more. 
 
 In nine of the cases pain was a pronounced symptom, in 
 two it was described as intensely severe. 
 
 In some cases after the hsematuria ceases the urine may 
 continue to be albuminous for a long time. Kiister has collected 
 eighteen cases from published records in which albuminuria 
 persisted after the cessation of hsematuria. In some cases after 
 traumatism without hsematuria this symptom has existed. 
 
 Sometimes, after intense and urgent pain in the abdomen, 
 the next symptom is frequent and painful micturition, the urine 
 voided being highly mixed with blood. In other cases there is 
 no blood in the urine, or there may be entire suppression of 
 urine. The absence [of hsematuria, with a marked diminution 
 in the quantity of urine secreted, is suggestive of plugging of 
 the ureter with blood-clot. 
 
 When the ureter is plugged there may be severe renal colic ; 
 but this is more likely to occur when comparatively small clots 
 are passing along to the bladder, than when a large coagulum 
 fills the renal pelvis or completely stops the upper end of the 
 ureter. 
 
 Coagulum formed in the pelvis of the kidney or ureter is 
 usually passed piecemeal into the bladder. Sometimes, however, 
 it remains either adherent, or entrapped above the narrow upper 
 end of the ureter, leading to hydro-nephrosis. In a case recorded 
 by Holmes such a clot was found post-mortem eighteen months 
 after an injury in the kidney region. 
 
 Blood rapidly effused in the kidney or renal pelvis finds its 
 way directly to the bladder and produces an urgent desire to 
 micturate, pure liquid blood being apparently passed without 
 difficulty in most cases ; in others, however, the effort is fruitless. 
 This inability may be due in some cases to reflex inhibition and 
 in others possibly to incompetence of the abdominal muscles, 
 a-5 a result of injury ; but sometimes it is due to clotting of the 
 blood within the bladder and the valve-like action of a portion 
 of clot at its neck, or to the worm-like clots from the ureter tem- 
 porarily stopping the passage of the urethra. ' 
 
 The retention causes great distress and also gives rise to pain
 
 174 SURGERY OF THE KIDNEY AND URETER. 
 
 at the end of the penis resembling that of vesical calculus. It 
 is, however, relieved by the passage of a catheter, and the 
 escape of the clots. 
 
 When the blood flowing slowly into an empty bladder clots 
 there in mass, it may produce a coagulum around which the 
 bladder contracts without chance of relief even by the catheter. 
 This state of things is attended by most urgent symptoms, and 
 by the development of a tumour which can be felt above the pubes. 
 Blood which has remained long in contact with urine, in the 
 bladder, or elsewhere, assumes a brown hue, and the corpuscles 
 lose their form and colouring matter, and become unrecognisable. 
 
 Later symptoms. After the effect of shock or loss of blood 
 has passed oft', the local pain may continue, and be increased by 
 deep inspiration ; the pulse will perhaps become sharp and rapid, 
 the skin hot and feverish, the tongue furred,, and nausea and 
 vomiting may arise. 
 
 If the injury has been inflicted from the front of the body, 
 tympanitis, abdominal pain and tenderness, and other signs of 
 traumatic peritonitis may set in. 
 
 When the case is going to terminate favourably, the urine, 
 which shortly after the accident appeared perhaps to be almost 
 pure blood, may within two or three days become entirely clear, 
 first in colour, and then by degrees of every trace of albumen ; 
 the pain may become less and less ; the pulse decline from 160 
 beats or more to 80 or less ; nausea and vomiting will cease ; 
 the bowels will act naturally, and the patient slowly or even 
 rapidly return, to usual health. 
 
 In certain cases, presumably of contused if not slightly lace- 
 rated kidney, the whole of the above phases have been passed 
 through in the course of a week or ten days.* 
 
 In other cases inflammation occurs in the kidney, the 
 urine then becomes mixed with mucus, renal epithelium, or pus ; 
 and the cure may be effected only after the lapse of many months. 
 Traumatic nephritis is often preceded by the appearance of hyaline 
 casts and of polyuria. One-sided oedema has been observed (Potain) 
 and attributed to disturbance of the sympathetic system. 
 
 * See cases by Lewis, Campbell, Harrison ("Lectures on Diseases of 
 the Urinary Organs," p. 333), St. George's Hospital Records, and others 
 referred to in the text.
 
 ALTERATIONS IX THE SECRETION OF URINE. 175 
 
 The urinary symptoms. Variations in the quantity of urine 
 secreted are common after injury to the kidney, and the normal 
 standard may not be re-established for some days or even weeks. 
 Oliguria may indicate the loss of function of one kidney or tem- 
 porary inhibition in both. Yeret cites twelve cases of polyuria, 
 the quantity varying from 2 to 10 litres in twenty -four hours 
 over a period of from two to five days. Most of the cases were 
 combined with albumiiiuria, but in two there was none. 
 
 Complete anuria. Cerou, in his Thesis on Oliguria and 
 Anuria due to Traumatism,* has collected six cases of more or 
 less complete anuria after injury to one kidney alone, the other 
 organ, as proved by him in five cases, being uninterfered with 
 and normal. Only one of the six cases recovered. 
 
 In Butler's case (Lancet, vol. i., p. 79, 1890) anuria existed 
 for thirteen days and was due to atrophy of the opposite kidney, 
 which weighed only 120 grs., and to permanent impaction in the 
 ureter of the damaged organ of a mass of hard gritty thrombus 
 (see Part II., Vol. II., p. 476). 
 
 The entire suppression of urine indicates injury to an un- 
 symmetrical, an atrophied, or a solitary kidney, or to both 
 kidneys, attended possibly with plugging of the renal vessels, 
 as in a case reported by Moxon ; or it may be due to an in- 
 hibiting nervous influence, such as occasionally seems to arise after 
 severe operations,! or to the collapse produced .by the injury, 
 or to the general failure of function which may precede death. 
 
 Retention of urine may result from the impaction of 
 blood-clot in the urethra or neck of the bladder, from rupture 
 of that viscus, or from paralysis of the abdominal muscles as a 
 result of injury. 
 
 Abdominal swelling in certain instances has come on rapidly, 
 and been attended with fluctuation. 
 
 To recapitulate : After the first onset of the symptoms, 
 which are those of intense localised pain, and possibly of collapse 
 with loss of blood, there are six chief dangers to anticipate : 
 
 (1) continuous and excessive extravasation of blood leading to 
 death by .syncope within a few hours or a day or two ; 
 
 (2) peritonitis, either as the direct effect of the violence, or of the 
 
 * " De rOHgurie et de 1'Anurie," Paris, 1877.1 
 
 t Dickinson, " Renal and Urinary Affections," vol. iii., p. 1299.
 
 176 SURGERY OF THE KIDNEY AND URETER. 
 
 tension and ulceratioii of the peritoneum due to the accumula- 
 tion of blood and urine which has been extravasated behind it; 
 (3) inflammation and suppuration of the perinephric tissue ; (4) 
 occlusion of the ureter by blood-clot, and the retention of urine 
 within the cavity of the kidney, and its attendant effects of 
 hydro-nephrosis, pyo-nephrosis, pyelo-nephritis, renal abscess or 
 renal atrophy ; (5) simple traumatic nephritis ; (6) when the 
 renal pelvis or calyces are opened so as to allow of the escape 
 of urine, secreted by the damaged organ, into the perinephric 
 tissue, a vast tumour may be formed by the accumulation of the 
 extravasated urine, or urine and blood; and, if both blood and 
 urine are extravasated, they will undergo septic changes if not 
 soon evacuated by lumbar incision. 
 
 When injury to the kidney is associated with other visceral 
 lesions, such as rupture of the liver, spleen, lungs, or heart, or 
 with fracture of the skull, spine, or pelvis, the symptoms may 
 be so serious, complicated, and rapidly fatal as to mask all signs 
 of rupture of the kidney, except perhaps the presence of blood 
 in the urine. 
 
 When there is an absence of blood in the urine, injury to 
 the kidney must nevertheless be suspected if there is pain in 
 the renal region, together with collapse or the appearances of 
 internal haemorrhage. There will, too, sometimes be fulness and 
 duliiess of the injured loin, and the abdominal muscles on the 
 affected side will be rigidly contracted and hard. Unless the 
 pelvis of the kidney is torn, there will be 110 great amount of 
 urinary extravasation. It would appear from certain cases of 
 iiephro-lithotomy, as well as from other operations on and lacera- 
 tions of the kidney, that the torn surface of the renal parenchyma 
 does not secrete any urine, and that for any considerable urinary 
 extravasation to occur it is necessary to have a wound communi- 
 cating directly or indirectly with the pelvis of the kidney. The 
 late Sir Spencer Wells * published an extraordinary case which 
 tends to support this view. 
 
 Prognosis. Owing to the depth at which the kidneys 
 are situated, for the most part under shelter of the costal arches 
 and in close proximity to the vertebral column, injuries to these 
 organs must necessarily seldom be uncomplicated. In falls and 
 
 * British Medical Journal. April 19, 1884.
 
 RECOVERY AFfER LACERATIONS. 177 
 
 crushes and such widespread traumatism, which are for the most 
 part associated with lesions of one or both kidneys, the general 
 shock and damage to other important and remote parts of 
 the body tell conspicuously in prognosis ; and in gunshot and 
 penetrating wounds, as well as in more localised contusions 
 caused by the thrust of blunt objects, the degree and nature 
 of injuries to intervening parts and organs cannot be left out 
 of account. 
 
 That even deep lacerations and severe contusions are not 
 necessarily fatal is admirably shown by museum specimens. 
 
 In the pathological cabinet of the Xew York Hospital is a 
 specimen which shows the repair of a rupture of the kidney 
 that almost completely divided the organ horizontally near the 
 centre ; " lymph is copiously effused between the separated sur- 
 faces and upon the exterior." 
 
 Recovery may even follow laceration of the kidney and ob- 
 literation of the corresponding ureter. Such a case is recorded 
 in the London Pathological Society's Transactions* the patient 
 subsequently dying of granular disorganisation of the other kidney. 
 The specimen is in St. George's Hospital Museum. 
 
 There are many cases published of recovery after injury, 
 in which there is reason to believe that the kidney has been lace- 
 rated ; t and others in which it has been positively ascertained 
 that healing had taken place prior to death from other causes. 
 
 The pi-oof of the cicatrisation of wounds of the kidney is 
 found hi persons who have lived for some weeks, or longer, after 
 laceration of the organ, and have died from some other cause. 
 Such was the case reported by Athol Johnsoii,^ of a man, aged 
 thirty -eight, who ruptured his liver and right kidney, and fractured 
 his seventh cervical vertebra. He died from the effects of the 
 injury to the spine three weeks afterwards, and at the post-mortem 
 there were found, besides an extensive rupture of the right lobe 
 of the liver, 'several ruptures, all beautifully united on the anterior 
 surface of the right kidney. The preparation in St. George's 
 
 * Vol. xi., p. 140. 
 
 t Dr. M. Campbell, Brit. Med. Journ., p. 225 ; Feb. 2, 1884. W. 
 B. Lewis's case of ruptured kidney, recovery, Med. Times and Gazette, 
 p. 228, Aug. 20,. 1870. Harrison, op. cit., p. 333. " Medical and Surgical 
 History of the American War of the Rebellion," vol. ii., p. 20. 
 
 I Med.-Chir. Trans., vol. xxxv., p. 55. 
 VOL. I. M
 
 178 SURGERY OF THE KIDN T EY AND URETER. 
 
 Hospital Museum* shows how completely repair may take place 
 in a kidney, even when both organs are small, granular and 
 cystic. The inference is that in this case the renal disease existed 
 long before the injury occurred to the kidney. The man lived 
 and was well, with only one kidney, and that one small, granular, 
 and cystic, the function of the other being completely suppressed 
 by the clot in the ureter. Although it is now common knowledge 
 that accidental injury to a kidney followed by recovery must have 
 been very common, yet in 1860 Holmes was unable to find an 
 account of the dissection of such an organ. 
 
 Lacerations affecting only the cortical substance are often 
 healed by the effusion into them of coagulable lymph or by the 
 organisation of blood-clot, which temporarily checks the further 
 extravasation of blood and of urine, and ultimately forms the 
 cicatrix. 
 
 A fatal result may be brought about by collapse, haemorrhage, 
 or peritonitis, or at a later date by pyaemia, cystitis, hectic fever, 
 or exhaustion from abscesses excited by urinary extravasation, 
 or by -broken-down tissues, or blood-clot ; or death may occur 
 from peritonitis or collapse, set up by the bursting of the con- 
 tents into the peritoneal cavity, through a sloughing of the limit- 
 ing membrane of the abscess. If the ureter become permanently 
 obliterated after, injury, the kidney becomes atrophied, or death 
 may be caused by suppuration of the organ. 
 
 In the ninety instances of subcutaneous injury collected 
 by Edler the number of fatal cases was exactly equal to that 
 of recoveries, seventeen dying within forty-eight hours and the 
 remainder three weeks or more later. An. analysis of the cases 
 shows the prognosis of uncomplicated subcutaneous injuries of 
 the kidney to be fairly good, fatalities being due to primary 
 haemorrhage or to subsequent suppuration and peritonitis, and 
 constituting about one-third of the number. 
 
 In complicated kidney injuries the prognosis is very bad, but 
 not necessarily fatal. 
 
 In a series of 306 cases collected by K ster, there were 162 
 recoveries and 144 deaths (a mortality of 47 per cent.). Among 
 222 uncomplicated cases there were only sixty-seven deaths (a 
 mortality of 30 per cent.) : whilst eighty-four cases complicated 
 
 ' r Trans. Path. Sac., vol. xi., p. 140.
 
 THE MORTALITY OF SUBPARIETAL INJURIES. 179 
 
 with injury to the brain, spinal cord, bladder, or other abdominal 
 organ, peritoneum, pleura, or lung, or involving damage to both 
 kidneys or to a "fused" or an " unsymmetrical " kidney, yielded 
 seventy-seven deaths. 
 
 Death occurred in 10 instances in 24 hours 
 
 13 ,,6 days 
 
 21 ,,3 weeks 
 
 9 2 months 
 
 6 10 months 
 
 6 20 years 
 
 2 ., unstated. 
 
 C7 
 
 The causes of death were : shock in 5 ; haemorrhage in 30 ; 
 suppuration in 27 ; chronic nephritis in 3 ; and calculus and 
 osdema of the lungs in 2. 
 
 Death from haemorrhage was most common, bleeding being 
 immediate, recurrent, or continuous. There were four instances 
 of traumatic aneurysm. Only one case in which the kidney was 
 ruptured into the peritoneal cavity recovered, and that only 
 after immediate operation- (Kehr). 
 
 Keen gives sixty-seven recoveries in 117 cases, but deducting 
 seventeen cases in which either the opposite kidney was injured 
 or absent, or the patients died from other injuries, he finds 100 
 cases with sixty-seven recoveries, i.e. a mortality of 33 per cent. 
 But from his analysis of these cases he thinks the mortality 
 might have been reduced to 23 per cent, had nephrectomy, 
 primary or secondary, been practised in some of the fatal cases. 
 Out of twenty-two cases in which nephrectomy was performed there 
 were eight deaths, i.e. a mortality of 36.4 per cent. ; whereas 
 the percentage mortality of the remaining seventy-eight cases, in 
 a large number of which the injuries were very slight, was 34.5. 
 
 Out of thirty-four fatal cases (excluding cases with one kidney 
 arid in which death was due to other injuries), Keen found that 
 death was due to haemorrhage and shock in fourteen ; to sup- 
 puration, including peritonitis, in sixteen, leaving coma, anuria, 
 and nephritis the causes of four deaths. These figures confirm 
 what I have before stated, namely, that the two chief dangers of 
 rupture of the kidney are haemorrhage, primary or secondary, and 
 suppuration, either in the perinephric tissue or in the kidney itself.
 
 180 SURGERY OF THE KIDNEY AND URETER. 
 
 The causes of death in fourteen fatal cases out of the 
 total of twenty-six subparietal injuries which I collected from 
 American and English sources, from 1884 to 1893, both years 
 inclusive, were as follows : 
 
 Seven were from haemorrhage. In five the haemorrhage was 
 into the retro-peritoneal tissue, and death occurred in twenty-four 
 hours, sixty hours, four clays, six days, and nine days respectively. 
 In two the haemorrhage was into the peritoneal cavity, and 
 derived probably from other ruptured organs ; one of these died 
 twenty-nine hours after the injury, and nine hours after the 
 spleen and left kidney had been simultaneously removed by ab- 
 dominal laparotomy ; the other, a woman, aged fifty-two, fell 
 from a second-floor window and ruptured the left kidney, the 
 liver and spleen ; at the autopsy the abdominal cavity was full 
 of clotted blood and serum ; the left kidney had a deep transverse 
 rupture on its posterior surface and several other smaller ruptures. 
 The patient died on the third day. No hsematuria throughout. 
 
 Two deaths were due to peritonitis, one month after the injury. 
 
 One patient died, after nephrectomy, from ascending pyelo- 
 nephritis and cystitis due to retained blood-clot. 
 
 One died from perinephric extravasation of blood and urine 
 twenty-one days after the injury. The lumbar swelling did not 
 appear until the fourteenth day, and was opened six days later 
 (the day before death). There was a rupture along the middle 
 of the anterior surface and complete detachment of the lower 
 one-third of the kidney. 
 
 One died from uraemia of four days' standing and a perinephric 
 abscess, following on a suppurating sinus which had existed 
 since three weeks after an injury three years before. The opposite 
 kidney was in a state of acute pyelo-nephritis, and two-thirds 
 of the injured kidney was quite destroyed ; only the upper third 
 existed, and this could not be found at the time of the lumbar 
 incision. 
 
 One death was due to uraemia of thirteen days' standing, 
 commencing four days after the injury, owing to permanent 
 occlusion of ureter with blood-clot. The opposite kidney was 
 cystic and atrophic. Death occurred on the seventeenth day. 
 
 One death occurred on the eighteenth day from injuries to other
 
 CAUSES WHICH INFLUENCE THE MORTALITY. 181 
 
 The mortality is considerable because injuries of the kidney, or 
 its pelvis, are likely to be complicated with injury to the peritoneum, 
 or to be themselves complications of various kinds of fractures of 
 the adjacent vertebrae or ribs. When the liver or spleen is 
 ruptured as well as the kidney, the prognosis is very unfavourable. 
 
 When the injury is limited to one kidney, and death occurs 
 within a few days, the cause of death is usually collapse from 
 haemorrhage ; but in by far the larger number of rapidly fatal 
 cases there are lesions of other viscera besides. Thus, of twelve 
 fatal cases from the Middlesex Hospital post-mortem records 
 there were ten in which the liver was ruptured, and in 
 some of these the spleen or lungs, or both, were ruptured 
 as well. In one case there was rupture of the heart and 
 fractured ribs, with partial rupture (deep laceration) of the 
 left kidney. Usually in the fatal cases death occurs from 
 shock or syncope within a period varying from an hour or less 
 to twenty-four or thirty -six hours. When life is prolonged beyond 
 two or three days death may occur in a week from pleuro-pneumonia 
 if the ribs are fractured and the lungs contused. This was the 
 cause of death on the fourth day in one of my cases ; and on 
 the second day in one of the cases recorded in St. George's Hos- 
 pital Catalogue. In a case under the care of Mr. Erichsen, pneu- 
 monia was the cause of death nine weeks after laceration of 
 the left kidney by a buffer injury. Experience shows the neces- 
 sity of being guarded in our prognosis, because some cases which 
 at the outset looked very serious, and even alarming, have quickly 
 recovered ; whereas others, apparently far less serious, have 
 terminated almost suddenly in death. 
 
 In rupture of the kidney, its pelvis, or ureter, the prognosis 
 as far as life is concerned is less unfavourable than in rupture 
 of the other abdominal organs. 
 
 It is largely due to the plugging of the renal blood-vessels, 
 and to the capacity of the other kidney, if healthy, for doing 
 compensatory work, that so many recoveries from contusion, 
 laceration, rupture, and puncture of the kidney take place ; but 
 the two chief conditions upon which recovery depends are, the 
 escape of the peritoneum, and of the large branches of the renal 
 artery and vein. If a large branch of the renal artery be torn, 
 and death does not quickly follow from bleeding, the gradually
 
 182 SURGERY OF THE KIDNEY AND URETER. 
 
 increasing haemorrhage is likely to lead by pressure to sloughing 
 of the peritoneum, even though that membrane may have escaped 
 the original injury. 
 
 Diagnosis. Except in the case of very slight injury, the local 
 indications of pain, tenderness and swelling in the kidney region 
 and the occurrence of haematuria, with possibly fibrinous casts of 
 the tubules and broken-down corpuscles, or of albumiiiuria per- 
 sisting after the accident, are sufficient indications of the nature of 
 the injury. It is more than probable that some of the cases which 
 have been regarded as examples of recovery from ruptured kidney 
 were not really cases of rupture. For example, a lad, aged fifteen 
 years, had been run over, and for three days suffered pain in 
 the hypochondrium, and vomited at intervals. There was blood 
 in the urine on and after the day of the accident, and on the 
 fifth day a quantity of granular matter with uric acid crystals, 
 a little blood, and some casts, were voided in the urine. On 
 the seventh day the urine was clear, and on the tenth the boy 
 seemed well and continued so afterwards. In this case, though 
 the organ was all in probability contused, one cannot but suppose 
 that recovery w T ould have been less rapid if the kidney had been 
 ruptured. In some cases of haematuria after a blow on the 
 abdomen, the injury was probably a contusion of the bladder, 
 not a lesion of the kidney at all. This possibility has to be borne 
 in mind, especially when pain and other local symptoms are absent. 
 
 After injury to the kidney or ureter, the symptoms are some- 
 times too obscure, or insufficient, for accurate diagnosis. When 
 there is no hsematuria it is impossible, at first, to say whether 
 the pains in the loin are due to injury to the muscles, to extrava* 
 sation of blood in the circumrenal tissues, or to a lesion of the 
 kidney itself. If a very acute pain is felt in the loin, without 
 any noticeable alteration in the composition and quantity of the 
 urine, there is a strong probability that the injury is not of 
 the kidney. This, however, cannot always be relied upon. In 
 Stanley's two cases,* the urine was passed naturally and freely, 
 and there were no symptoms leading to a suspicion of injury 
 to either ureter or kidney, until a large tumour, from which 
 fluid containing urea was drawn away, formed in the right 
 hypochondrium of one, and in the lumbar region of the other- 
 
 * Med.-Chir. Trans., vol. xxvii.
 
 DIAGNOSIS OF SUBPARIETAL INJURIES. 183 
 
 In Poland's valuable case,* which I had the opportunity of 
 watching when house surgeon at Guy's Hospital, the precise 
 nature of the injury remained doubtful up to the time of death, 
 owing to the almost entire absence of urine during the six days 
 the patient lived. The absence of urine was due to thrombosis 
 of the renal vessels of one kidney, and the rupture of the pelvis 
 of, and extravasation of urine from, the other kidney. Throm- 
 tosis of the renal vessels, as a result of violence to the 
 lumbar region of the spinal column, is a possible occurrence, 
 and should be remembered in relation to renal injuries, and 
 to suppression of urine after injury to the back. Moxon f has 
 described a typical example of nearly complete obstruction of 
 the vessels of both kidneys, in a man, aged twenty-two, who 
 was struck in the back by an engine. 
 
 If, when the collapse from an abdominal injury has passed 
 off, pain in the hypochondriac or lumbar region continues, and 
 there is vomiting and anxiety of countenance ; if, moreover, 
 the urine contains blood and blood-casts, gradually diminishing 
 in quantity during three, four, six, or seven days, or longer ; 
 and if convalescence is slow, the suspicion that some contusion 
 or laceration has occurred is justly aroused. 
 
 If after the abdomen has been run over, or the patient has 
 fallen, or been struck on the abdomen or loin, faintness, coldness, 
 vomiting, and abdominal pain follow ; if on the day of, or the 
 day after the accident, and whether the . catheter be required 
 or not, the urine is found to contain a quantity of blood and 
 blood-clot ; and if after several days blood-clots continue to pass, 
 or pus as w r ell as blood is voided in the urine ; if, moreover, 
 there is pain along the course of the ureter, with retraction of 
 the testis, or a rigid and prominent state of some of the muscles 
 of one side of the abdomen, with frequent desire to micturate ; 
 or, finally, if a tumour, dull 011 percussion, forms in the loin 
 or lumbar or hypochondriac region of the abdomen, accom- 
 panied or not with signs of local peritonitis, there are safe 
 grounds for believing that either the kidney or its pelvis has 
 been ruptured. The passage of blood-clot along the ureter 
 into the bladder is sometimes a source of great suffering, and 
 
 * Guy's Hospital Reports, 3rd series, vol. xiv. 
 t Ibid.
 
 184 SURGERY OF THE KIDNEY AND URETER. 
 
 of cystitis. A typical and instructive case which was under 
 Hilton was made the subject of a valuable clinical lecture* 
 by that philosophic surgeon. The clots frequently assume the 
 shape of the pelvis of the kidney ; sometimes they are long, 
 worm-like casts which have been moulded in the ureter, and 
 sometimes they are blood-casts of the uriniferous tubes. The 
 latter may be seen, if looked for, after even slight injuries such 
 as contusions of the kidneys. If the bleeding is not profuse, 
 the clots cease to pass after a few days. 
 
 Mr. Cock recorded f a case of rupture of a single kidney, 
 in a lad eighteen years old, who fell from a height on to some 
 rafters. The patient died comatose on the eleventh day. The 
 left kidney was completely divided through its pelvis, and the 
 two halves were widely separated by a large collection of blood 
 and urine, which had been extra vasated very widely into the 
 cellular tissue behind the peritoneum. The kidney and ureter 
 were nearly twice the normal size, owing to the rudimentary state 
 of the right kidney. There was congenital absence of the upper 
 part of the right ureter, vein, and artery. 
 
 In other cases also, referred to in this chapter, there were dul- 
 ness and swelling in the lumbar and iliac regions, caused by the 
 extravasation of blood when the kidney was completely ruptured, 
 and by the effusion of blood and urine when the pelvis of the 
 kidney Avas torn. It is sometimes difficult to diagnose such 
 swellings from tumours due to distension of the cavity of the 
 kidney with blood-clot (haemato-nephrosis). Raver J has recorded 
 a case of this kind, and has made remarks upon it to the 
 following effect : 
 
 Hoematuria, more or less considerable, is the most constant 
 result of contusions of the kidney ; but it is exceedingly rare 
 that blood, after having coagulated in the ureter or pelvis of 
 the kidney, accumulates to such an extent as to distend the 
 kidney and to transform it into a large sac which extends 
 from the hypochondriuni to the iliac fossa. Renal tumours 
 of this dimension are usually the consequence of pyelitis, of a 
 hydro-nephrosivS, or of a cancerous, tuberculous, cystic, or hydatid 
 
 * Guy's Hospital Reports, 3rd series, vol. xiii., p. 9. 
 
 t Twins. Path. Soc. Loud., vol. i., p. -2 ( .r.'>. 
 
 I '' Traite des Maladies des Reins," vol. i., p. 280.
 
 TREATMENT DURING SHOCK. 185 
 
 degeneration. One can recognise, or at least suspect, that the 
 distension of the kidney is a sequence of an internal haemorrhage 
 by the nature of the case, and the rapidity of the development 
 of the tumour. Undoubtedly it will be difficult to distinguish 
 during life a tumour formed by an extravasation of blood around 
 the kidney and outside the peritoneum, from a tumour caused by 
 the dilatation of the kidney by blood accumulated within its 
 cavity, let, in extra-renal haemorrhages the tumour generally 
 appears soon after the accident, and is not circumscribed like 
 renal tumours. A tumour due to blood effused within the cavity 
 of the renal pelvis (haemato-nephrosis) is formed later, and more 
 slowly, than an infiltration of blood into the retroperitoneal 
 cellular tissue, as the kidney is distended with more difficulty 
 than the peritoneum can be detached from its connections. 
 
 Alounier has reported (Gaz. des Hopitaux, 1849, p. 148) a 
 case somewhat similar to the one referred to by Eayer. 
 
 The figure given in a later chapter (Fig. 70, p. 475) illustrates 
 a hsemato-nephrosis, and shows the condition of the renal cavity 
 after the pyramidal parts have been greatly destroyed. It is from 
 the body of a man, aged twenty -five, who died of purpura ; there 
 is no account of his having received an injury. 
 
 Treatment. The first requisite in the treatment of a case of 
 renal injury is commonly the combating of shock, which is often 
 prolonged and profound. Professor Kuster considers the hypo- 
 dermic injection of a solution of camphor highly efficacious in 
 rousing the patient from the state of collapse, in addition to the 
 ordinary treatment by warmth. In all cases in which contusion 
 or rupture of the kidney is suspected or known to have occurred, 
 absolute rest in bed must be observed ; stimulants and solid food 
 must be avoided, and pain and restlessness must be allayed by the 
 subcutaneous injection of anodynes. The internal use of gallic 
 acid, infusion of matico, ergot of rye, and the preparations of iron 
 have been recommended to check haemorrhage, and may be tried ; 
 acetate of lead, combined with opium, has been employed for the 
 same purpose. The liquid extract of ergot in drachm doses every 
 two hours until four doses have been taken, or in half-drachm 
 doses every three hours, and repeated as long as circumstances 
 require it, is, I consider, the most certain and most rapidly effica- 
 cious remedy of this sort ; or three grains of ergotin may be
 
 186 SURGERY OF THE KIDNEY AND URETER. 
 
 subcutaneously injected, instead of giving the liquid extract by 
 mouth or rectum. Internal remedies, however, are slow in action 
 and not very efficacious in effect. Certainty no time ought to be 
 wasted by trying them in cases in which operative treatment 
 seems indicated. Thirst should be slaked and sickness checked 
 by sucking ice. Ice given by the mouth assists in checking sick- 
 ness and lowering the temperature of internal parts and thereby 
 tends to stop internal haemorrhage. 
 
 Pain should be met by an injection of morphia, which will 
 also allay peristalsis in the colon overlying the injured kidney. 
 Pain will be sometimes assuaged by strapping the affected side ; 
 a practice which assists in keeping all the parts about the 
 injured organ quiet, and which by gentle compression helps to 
 limit and check haemorrhage. If the large bowels be full of solid 
 faecal matter they must be relieved by enemata of oil and water, 
 otherwise they ought not to be disturbed for several days. I 
 have seen sharp haematuria from an injured kidney brought on 
 unexpectedly more than a fortnight after the infliction of the 
 wound, and when the patient appeared to be quite convalescent, 
 by the passage of hardened faecal matter along the colon, and thus 
 across the surface of the kidney. This occurred in a case of 
 iiephro-lithotomy in a young man, which I reported to the Clinical 
 Society in 1885. To assist in keeping' the intestines free of faecal 
 matter until sound healing has occurred, and otherwise to avoid 
 undue stimulation of the circulation, only very light articles of 
 diet, and those only in small quantities at a time, should be 
 allowed for two or three weeks at least. It is especially important 
 that the quantity of fluids should be limited as far as possible, 
 because any increase in the activity of the kidneys, under the 
 circumstances, is very disadvantageous. 
 
 In cases of injured kidney of every description the diet must 
 be bland in character, chiefly liquid, and limited in quantity. 
 
 In Hilton's case, to which I have already referred, the patient, 
 at his own earnest request, was allowed a little solid food on the 
 eighth day after the accident, and from that time fresh haemorrhage 
 ensued, and the case went rapidly from bad to worse. To quote 
 Hilton's own words, " T7p to this time the case seemed to 
 promise a good result. The blood in the urine was daily di- 
 minishing ; the vomiting, pain, and other general symptoms
 
 TREATMENT OF INTERNAL HEMORRHAGE, 187 
 
 were abating in severity. On the seventh day he had a craving 
 for solid food ; this was allowed him, and from the period that 
 his diet was improved he retrograded. His urine again became 
 more bloody. The solid food was, of course, at once discontinued ; 
 but it had already induced some mischief. It necessarily produced 
 an increase of the vermicular motion in the intestines, and also 
 caused the heart to pulsate more forcibly ; and now that we 
 are familial' with the post-mortem evidence we can see how an 
 increased force of the circulation might, and probably did, dislocate 
 a clot which was closing the 'mouth of a torn artery." 
 
 Every precaution should be taken against exciting irritability 
 of the stomach ; and if vomiting occurs the patient should be 
 fed entirely by nutritive enemata. Fresh haemorrhage is apt 
 to be excited by the detachment of clots, and the reopening 
 of plugged vessels by straining efforts. Vomiting, therefore, as 
 well as defaecation and the peristaltic action of the intestines, are 
 to be prevented if possible. In all abdominal injuries in which 
 haemorrhage is to be feared, intestinal and gastric activity is 
 undesirable, and therefore solid food and aperients of every sort 
 are to be forbidden. To solid food there is a twofold objection : it 
 stimulates the action of the heart, and also the involuntary 
 muscular fibres of the viscera. 
 
 When there is reason for thinking that haemorrhage is going 
 on, either from the continuing collapse of the patient ; the quan- 
 tity of blood voided by the urethra ; the diffused dulness and 
 swelling of the loin and renal region of the abdomen, which 
 indicate extravasation into the retro-peritoneal cellular tissue ; 
 or from the formation of a circumscribed renal swelling, which 
 is the mark of haemorrhage into the cavity of the kidney itself ; 
 ice bags, or Leiter's tubes through which a stream of iced water 
 is kept running, applied to the loin and ilio-costal area of the 
 abdomen, may be tried, unless immediate operation is indicated. 
 The ice, or iced water, may be applied with advantage outside 
 the strips of strapping, which should reach from the spine to 
 the linea alba. 
 
 When the blood-clots are of small size, and the haemorrhage 
 less considerable, 110 instruments are required, or should be used, 
 for their removal ; they will be voided through the urethra with- 
 out undergoing decomposition or setting up vesical inflammation.
 
 188 SURGERY OF THE KIDNEY AND URETER. 
 
 The urine itself lias a solvent effect upon the clots, and this will 
 suffice to get rid of even a considerable amount of blood. But 
 when the blood-clot leads to retention of urine, associated with 
 spasmodic contractions of the bladder, a full-sized catheter with 
 two large eyes must be introduced, and the bladder injected 
 with some antiseptic solution, so as to break up the clot 
 and assist its removal. And if little or nothing escapes through 
 the catheter, Clover's or Bigelow's evacuating syringe should be 
 tried. The error of injecting styptics into the bladder should 
 not be committed. 
 
 These methods failing, the last resource will be cystotomy. 
 Although it is needless to say that such an operation should 
 not be contemplated except in obstinate and severe cases, yet 
 where the bladder is more or less distended with blood, and 
 frequent, fruitless, and painful efforts at micturition torment 
 the patient, it is well to bear in mind that a much better prospect 
 of recovery will be afforded by not postponing the operation 
 until the patient is exhausted by haemorrhage or spasms of the 
 bladder ; or until cystitis has been set up, and the clots within 
 the bladder have decomposed, thereby exposing the patient to the 
 risks of suppurative pyelo-nephritis. 
 
 If clots of blood accumulate in the bladder, or are forced 
 into the urethra, and there give rise to such pain and distress 
 as was suffered by Hilton's patient, supra-pubic cystotomy should 
 be performed. The bladder would readily be emptied of clots 
 through the wound above the pubes, and could be kept 
 aseptic by covering the wound lightly with iodoform cotton-wool, 
 through which the urine would percolate. I well remember 
 the CRiestioii of cystotomy being discussed in the case referred 
 to, and feel sure that it would have saved much suffering had 
 it been performed. 
 
 Mr. Rawdon, of Liverpool has put on record * a case in which 
 he adopted this treatment, but unfortunately at too late a period. 
 His patient was a lx>y, aged twelve years, who was admitted 
 into the Liverpool Infirmary on the day after he had fallen into 
 a stone basement, a height of about eight feet. He was passing 
 blood in his urine, and suffering pain in the right side, and 
 there was a small bruise over the crest of the ilium. For the 
 
 * Brit. .Med. Journ. : and Lancet, May 26th, 1883.
 
 TREATMENT OF ACTIVE ARTERIAL HAEMORRHAGE. 189 
 
 first few days the haematuria diminished, but it subsequently 
 increased, and acute cystitis followed. The diagnosis was rupture 
 of the right kidney ; and with the object of preventing blood 
 from entering the bladder, the injured kidney was removed by 
 lumbar nephrectomy on the seventeenth day. This was the 
 first case of nephrectomy for ruptured kidney. The kidney 
 was found to have been torn nearly completely across. Eelief 
 followed the operation, but, acute cystitis continuing,, lateral cys- 
 totomy was performed four days after the nephrectomy, and 
 on the twenty -first day after the injury. Fostid clots were re- 
 moved from the bladder through the wound. Relief from the 
 bladder symptoms was obtained, but death followed on the fortieth 
 day after the injury, from pyelitis and suppuration of the substance 
 of the left kidney, due probably to extension upwards from the 
 bladder of the inflammation which had been excited by the pre- 
 sence of decomposing blood-clots there, and by the retention 
 of urine to which they had given rise. 
 
 When arterial blood escapes into the pelvis of the kidney, 
 it traverses the urinary passages rapidly, and is quickly expelled 
 by the bladder, which is excited to frequent spasmodic contractions 
 to expel it ; and if this form of haemorrhage continues, and 
 threatens the life of the patient, despite all the efforts which have 
 been mentioned to check it, an exploratory incision into the loin, 
 followed (if the extent of injury to the kidney indicates it, or 
 the haemorrhage cannot be checked without it) by nephrectomy, 
 should be resorted to. G. Simon recommends the application 
 of a tampon or the cautery to laceration of the parenchyma, 
 and if this fails or is inapplicable, nephrectomy. Kuster's teaching, 
 the general lines of which agree with my own, may be sum- 
 marised as follows : 
 
 In severe haemorrhage make an exploratory incision in the 
 loin. If the kidney is ruptured but the fragments are still 
 attached to the hilum, stuff the interstices with gauze. 
 
 Suture with superficial stitches the two portions of a kidney 
 if they are attached by the pelvis and hilum (Fig. 30). 
 
 If vessels are found bleeding outside the hilum, apply forceps 
 and ligature; if within' the pelvis, stuff with gauze. 
 
 The main artery is very seldom damaged, and death of the 
 part involved does not necessarily follow occlusion of a branch.
 
 190 
 
 SURGERY OF THE KIDNEY AND URETER. 
 
 When the pelvis is hard and distended with blood it should 
 be opened and stuffed with gauze after turning out the clot. 
 Stitching the edges of the pelvis to the parietes will facilitate the 
 removal and renewal of the plug, which may be required during 
 two or three days. 
 
 More extensive injuries require immediate nephrectomy, but the 
 application of a tampon or clamp may give time to wait for 
 
 an improved condition of the 
 patient before further procedure. 
 Effusion of blood or urine into 
 the peritoneum requires abdominal 
 section. The incision is best made 
 along the outer edge of the rectus. 
 After removal of the kidney and 
 suturing of the peritoneum, the 
 space should be drained through 
 the loin. 
 
 The best plan is to make an 
 oblique incision in the loin to 
 examine the kidney, and to carry 
 this towards the front of the 
 abdomen, if necessary even to the 
 outer edge of the rectus ; the rent 
 in the peritoneum can then be 
 closed, and lacerations of the spleen 
 Fig. so. Kidney of a boy run over or ]{ ver attended to, and the cavity 
 
 bv a cart (pelvic aspect). It is al- 11 -,i r i i' 
 
 washed out with saline solution. 
 
 Collections of blood and extra- 
 vasated urine, causing at a later 
 stage an increasing tumour with 
 
 pain and fever, demand treatment by lumbar incision. Though 
 Bennett May, Marshall, Croft, and Delabort have reported 
 cases cured by repeated puncture, aspiration ought to be aban- 
 doned. It is not requisite for purposes of diagnosis ; it is slow 
 and uncertain in all, and actively harmful in some cases in its 
 effects. Such cases should be treated by a free opening. They 
 should not be allowed to open spontaneously, but should be 
 incised and drained before they suppurate, and the wound in 
 the kidney closed, if possible, by sutures. 
 
 most split into two longitudinally. 
 and one pole is nearly detached. 
 (St. Thomas's, No. 2056.)
 
 USE OF THE TAMPOX. 191 
 
 When a portion of the kidney is found detached it should be 
 removed ; partial nephrectomies of this kind have been done by 
 Keetley (Lancet, 1890, vol. i.), Bardenheur (Arch. Klin. Chir., 1891, 
 xlii., 371), and John B. Nash (Australian Medical Gazette, Nov. 
 20th, 1897, and private communication), and E. Owen (private 
 communication). 
 
 The following case, reported from the Marburg Klinik, shows 
 the value of the tampon and drainage : H. F., aged seven, 
 fell on June 7th, 1891, from a staircase on to. sand, striking 
 the right hip. Soon after there was epistaxis, vomiting and 
 abdominal pain. The right renal region was harder than the 
 left, there was no pain on pressure. Five hundred cm. of 
 urine were passed containing blood and albumen. By June 14th 
 there was pain in the right side, pus in the urine, which when 
 removed by catheter, contained blood and granular casts ; and 
 there was increasing anaemia. On the 19th June a lumbar 
 incision was made and a rent discovered in the right kidney. 
 The renal pelvis was opened and cleared of clot with the 
 finger. It was then stuffed with iodoform gauze, and the 
 edges attached to the skin. The tampon was removed after 
 three days, and the fistula closed in seventeen days, the patient 
 being well by July 7th. 
 
 In Kolliker's case (1895) arrest of haemorrhage was effected by 
 tampon in a boy, aged twelve, who after a fall was unconscious 
 and exhibited heematuria. On the ninth day there was oedema of 
 the left side of the body, and on the tenth fever and anuria. An 
 incision disclosed blood and urine in the outer capsule, and the 
 kidney loose and rent between the middle and upper thirds, the 
 fissure running forwards and outwards. Both the kidney and 
 loin wounds were stuffed with iodoform gauze. They healed in 
 five and a half and seven weeks respectively. 
 
 The kidney should be removed if the tissues are infiltrated 
 or the organ greatly damaged, or extensively suppurating, but 
 not on account of a single abscess merely. 
 
 Experience has shown that lives which otherwise would have 
 been lost may be saved by the timely and well-judged employment 
 of lumbar iiephrectomy. 
 
 Nothing short of iiephrectomy was possible in Kehr's case of a 
 boy, aged nine, who fell (December 17th, 1893) from the sixteenth
 
 192 SURGERY OF THE KIDNEY AND URETER. 
 
 rung of a ladder, striking the left side of the abdomen against 
 an iron object, on his way into a shallow cellar. There was no 
 fracture of ribs, pelvis or extremities, but evidence of contusion 
 of organs with internal haemorrhage, accompanied by severe ab- 
 dominal pain and hsematuria. 
 
 After being conveyed some way by train he was received in 
 a state of profound collapse, with an increasing tumour producing 
 dulness over the entire left side of the abdomen. Bloody urine was 
 withdrawn by catheter. Considering the possibility of intestinal 
 injury an incision was made under ether from the navel to the 
 pubes. It was almost bloodless, but half a litre of sanguineous fluid 
 spurted out of the blue-looking peritoneum as it was opened. 
 A large hsematoma was discovered extending from the diaphragm 
 to the pelvis; in it the lower third of the kidney was involved 
 and the colon, though itself uninjured, steeped. A cross incision 
 was made from the umbilicus to the eleventh rib. There was 
 a sudden rush of blood through a rent in the posterior layer 
 of the peritoneum, which was controlled by pressure, while the 
 kidney was ligatured and removed. A second ligature was placed 
 on the stump and the hiematoma cleared and washed out, the 
 operation lasting a few minutes only. The quantity of urine excreted 
 increased in five days from 200 to 900 grammes. The patient 
 got up on January 9th, and left cured on the 20th. The kidney 
 had been torn across between its middle and lower thirds, the vein 
 and ureter being also torn, the latter two inches from the renal pelvis. 
 
 Bei'navs reports the case of a man, aged twenty-three, who 
 fell from a vehicle, striking the left lumbar region against the 
 wheel. For the first twenty-four hours he was in a state of 
 acute alcoholism with vomiting and purging. There was hsema- 
 turia, and a swelling dull on percussion appeared in the right 
 abdominal and lumbar regions. A lumbar incision disclosed a 
 haematoma as large as a child's head, the kidney was torn in 
 several places up to the pelvis, and was practically detached ; 
 though the artery wan torn it did not bleed at the operation. 
 The urine exceeded \ ,500 c.c. during the following two days, 
 and the patient was well in fifty days. 
 
 Wallis, in the Clinical Society's Transaction* (vol. xxx.), cites 
 fourteen instances of nephrectomy for subcutaneous lacerations of 
 the kidney with severe haemorrhage, of which nine recovered and
 
 H^MATURIA NECESSITATING NEPHRECTOMY. 193 
 
 five died. It is best to interfere early in cases of serious haemor- 
 rhage, as waiting is productive of a high mortality. 
 
 Keen gives twenty-two nephrectomies for subcutaneous ruptures, 
 with eight deaths. Five of these were primary nephrectomies 
 with one death, i.e. a mortality of 20 per cent. ; and thirteen 
 were secondary nephrectomies with five deaths, a mortality of 
 3 8" 5 per cent., showing that secondary nephrectomy is nearly 
 twice as fatal as primary. Only three of the cases in which the 
 form of operation is stated were abdominal nephrectomies; and 
 of these one died. 
 
 Nephrectomy should be entertained in cases of profuse and 
 continuous hsematuria, especially if the bleeding is rapid and 
 arterial ; in cases of delayed dangerous haemorrhage occurring days 
 or months after an injury, and which is probably due to trau- 
 matic aneurysms ; * and also in cases in which, though haematuria 
 may be slight or altogether wanting, there is a strong presump- 
 tion from the increasing collapse, pallor, dulness and swelling 
 of the loin, that the kidney has been severely injured. In such 
 cases an exploratory incision should be made down upon the 
 kidney through the loin, and it will be more than probable that, 
 just as in Mr. Rawdon's and Mr. Hilton's cases, the kidney will 
 be found in great part or entirely torn across. 
 
 Peritonitis. When the abdomen has become distended, but 
 without being entirely tympanitic, a course of calomel and opium 
 has been adopted as the treatment, under the idea that the 
 injury has set up traumatic peritonitis. In certain cases the 
 result has been satisfactory.! But, as Athol Johnson long ago 
 pointed out, the distended state of the belly and the pain which 
 is usually so much complained of in the first instance, are not 
 caused by inflammation, but are due rather to the stretching of the 
 peritoneum and its numerous nerves, w r hich are derived both 
 from the cerebro-spinal and sympathetic systems. If, however, 
 traumatic peritonitis should be excited and there has not been much 
 loss of blood, it must be treated in the early stages by the appli- 
 cation of twenty or thirty leeches, followed by cold compresses, 
 flannels wrung out of iced cold water, or Leiter s tubes, to the abdo- 
 men. In the later stages, cold applications and leeches are out of 
 
 * See Nasse, Berliner klin. }Yochenschrift, August 22, 1898. 
 t See St. George's Hospital Catalogue, series xi.. case 4. 
 VOL. I. X
 
 194 SURGERY OF THE KIDNEY AND URETER. 
 
 the question, and hot fomentations applied over conium, belladonna, 
 or opium ointment, or turpentine stupes, should be substituted. 
 At a still later period, blisters, iodine applications, or mercurial 
 preparations are sometimes useful in promoting the absorption of 
 inflammatory products. Opium is the sheet-anchor in these cases, 
 and should be given in half- or one-grain doses every three or four 
 hours to an adult. In young subjects, and where the peritonitis 
 is of the sthenic form, calomel in one-grain doses, combined with 
 opium, should be given until the system is brought under its 
 influence ; in some cases it affords great relief from meteorism- 
 
 Constipation should be left untreated for some days ; enemata 
 are the best means of affording relief. The same great care 
 should be employed with regard to diet as is requisite in all 
 forms of peritonitis, so as to avoid any undue action of the in- 
 testinal muscular coats and abdominal muscles. 
 
 Anuria, when due to the shock of the accident, will pass off 
 as soon as reaction is established. It should therefore for a 
 time be treated 011 the expectant plan by warmth, gentle re* 
 storatives, and hot saline drinks. If it persists the kiclney should 
 l)e exposed through the loin and incised, unless the calyces 
 or renal pelvis are already open. As anuria may be due to 
 a ruptured single kidney or to the opposite kidney being also 
 injured or previously diseased, it is a very unfavourable symptom. 
 Schroeder, in a case of anuria in which the upper third of the 
 kidney was detached, simply plugged the lumbar wound and the 
 patient recovered. 
 
 Perinephric suppuration and nephrectasis. If a renal or 
 perinephric abscess, or nephrectasis whether the distension of 
 the renal cavity is by urine, pus, or blood follows as a late result 
 of an injury to the kidney, it should be treated on the principles 
 laid down under those headings in other parts of this work. 
 These are the cases in which aspiration was formerly tried. 
 
 The late Mr. J. F. West * of Birmingham removed by lumbar 
 tiephrectomy from a lx>y, fifteen years old, who had four months 
 before received an abdominal injury, a suppurating kidney, which 
 weighed sixteen ounces. Haematuria; a lumbar tumour, pus in 
 the urine, and pyrexia, soon followed the injury. The aspirator 
 was used a month afterwards, and fifty-five ounces of purulent fluid 
 
 * Brit. lied. Jonrn., p. 669 (April 7th, 1883).
 
 ASPIRATION OF THE LUMBAR SWELLING. 195 
 
 were removed from the interior of the kidney ; this operation was 
 repeated a week later, and was followed up by lumbar nephrotomy 
 and drainage. As purulent ammoniacal fluid daily passed through 
 the drain tube, and the patient was rapidly emaciating, nephrec- 
 tomy was performed ; but the patient died (as I learnt from 
 Mr. Jordan Lloyd) between two and three weeks afterwards 
 from exhaustion and purulent infiltration into the retro-peritoneal 
 connective tissue. 
 
 Another case in which aspiration was followed by lumbar 
 incision, and at a still later period by lumbar nephrectomy, has 
 been recorded by Mr. A. E. Barker in the Lancet (January 17th, 
 1885). A male child, aged three years and eight months, had 
 been run over by a hansom. It would seem that the pelvis of 
 the kidney had been lacerated by the transit of the cab wheel, 
 and that urine had escaped into the circumrenal tissue, and there 
 formed an encysted collection of urine and pus. 
 
 A case very similar in character to the above, which yielded 
 to aspiration and to the treatment of simple perinephritis, had 
 been previously published by Mr. Bennett May, in the British 
 Medical Journal (January 20th, 1883). 
 
 In Marshall's case, reported in 1883,* aspiration and drainage 
 through a cannula was followed by the patient's recovery, but 
 whether with a permanent fistula, or not, is not recorded. A 
 girl of thirteen was knocked down and run over; a swelling 
 which occupied the left lumbar region and left half of the 
 abdomen was aspirated and five ounces of a yellow-brown 
 odourless fluid were drawn off, w T hich when heated emitted a 
 strong urinous odour and yielded a heavy flocculent albu- 
 minous precipitate. It contained *55 per cent, of, urea. Sub- 
 sequently a large trocar and cannula were introduced and 
 thirty -six fluid ounces of chocolate-coloured fluid, similar in 
 character to that before obtained, were withdrawn. A drainage 
 tube was inserted, and a profuse discharge of a similar fluid, 
 and later the escape of pus and once a gush of clear 
 urine-like fluid, occurred. The patient left the hospital with 
 a superficial wound thirteen months after the accident and 
 five months after her admission. It is pretty certain that 
 
 * Lancet ; and Brit. Med. Journ., May 26th, 1883 ; and Roy. Med.- 
 Chir. Trans., vol. Ixvi., p. 311.
 
 196 SURGERY OF THE KIDN T EY AND URETER. 
 
 in this case as it is in others where urine escapes into the 
 cellular tissue either the renal pelvis was ruptured or a calyx 
 is laid open, and that the extravasated urine comes from the 
 cavity of the kidney, not from the torn renal substance. It 
 would seem from Sir Spencer Wells' case already referred to, 
 as well as from operation wounds and numerous instances of 
 lacerated kidney, that the torn renal surface is not capable of 
 secreting urine at all, or, at any rate, not in sufficient quantity 
 to give any of the characters of urine to the fluid contents of a 
 tumour in contact with the kidney. 
 
 Mr. Croft * describes a case diagnosed as traumatic hydro- 
 nephrosis in a boy, aged twelve years, who, on June 3rd, 1880, 
 fell and hurt his left side and loin. The tumour was tapped 
 eight times. Between three and four pints of much the same 
 kind of fluid were drawn off each time, except that on the 
 last occasion it contained a very large amount of albumen. From 
 this time no swelling recurred, and ten months afterwards the boy 
 remained in a " cured " condition. Mr. Croft explains the case 
 by supposing that at the time of the accident a lesion (but not 
 a complete rupture) of the pelvis of the kidney near its junction 
 with the ureter occurred, and that adhesive inflammation, and, 
 as a consequence, complete obliteration of the lumen of the upper 
 end of the ureter, followed. The cure was obtained, he thinks, 
 by the entire atrophy of the kidney and the contraction of the 
 hydro-nephrotic cyst. 
 
 In one of the two well-known cases recorded by Mr. Stanley f 
 the injury may have been (probably was) of the same character 
 as that in Barker's, Bennett May's, and Marshall's cases. This 
 patient also .was a boy, who developed a large swelling in the right 
 side six weeks after an injury. No symptoms of drowsiness or 
 uraemia were observed. Upwards of fifty ounces of uriiious fluid 
 were drawn off through a cannula ; and at intervals, ranging from 
 eleven clays to three months, the tapping was repeated, and the same 
 kind of fluid was withdrawn. At the last tapping only six ounces 
 came away ; the tumour slowly diminished, and at the end of 
 nine months the patient left the hospital with a swelling which 
 
 * Clin. Soc. Trans., vol. xiv., p. 107. 
 
 t Trans. Med.-Chir. Society, vol. xxvii. See also the chapters on 
 Injuries of Ureter, Vol. II., p. 330 et seq.
 
 SPONTANEOUS RECOVERY AFTER KIDNEY INJURY. 197 
 
 still fluctuated. The final termination of the case is not 
 known. Bennett May's and Marshall's, and Croft's, cases show 
 that an accumulation of urine in the loin, either outside or inside 
 the cavity of the kidney, in consequence of an injury, may be en- 
 tirely and permanently got rid of by the use of the aspirator. 
 
 Dr. K. F. Weir* reported a case of injury to the kidney 
 followed by an abscess within the substance of the organ, which 
 was treated successfully by nephrotomy and drainage. 
 
 The following case shows that recovery may sometimes occur 
 spontaneously after injury to the kidney attended with severe 
 hsematuria.f What the ultimate result to the kidney is after such 
 an injury it is, of course, impossible to say. A cavalry soldier 
 whilst dressing his horse received a kick in the lumbar region ; 
 some time afterwards he fainted, and only rallied after he 
 was carried to his room. Very soon afterwards there was a large 
 ecchymosis where he was kicked ; there was little manifest pain ; 
 the respirations were impeded, and the pulse was small, hard, and 
 frequent. He was bled immediately. Within four hours from 
 the accident his condition was much worse, the abdomen was 
 tympanitic, tender, and very painful, his respirations were very 
 difficult, fever had commenced, and no urine had been passed. 
 He was bled a second time, and more freely than the first. 
 During the night he was horribly tormented by a desire to urinate, 
 but without capacity to do so. The next morning the bladder 
 was found considerably distended ; a catheter was introduced 
 and a large quantity of urine, at first of natural colour, but 
 quickly becoming bloody, was evacuated. He was at once much 
 relieved ; but a quarter of an hour after the use of the catheter 
 he perceived a trickling of blood, which lasted during an entire 
 hour, and gave him much comfort. The fever, pain, and 
 tumour of the abdomen entirely disappeared, the respirations be- 
 came easy, and two hours afterwards the urine was discharged 
 naturally. Haematuria persisted during three consecutive days 
 at intervals more or less prolonged ; on the sixth day there only 
 remained a slight pain in the lumbar region. On the fifteenth 
 day he was able to walk about, and on the twenty -fifth day he 
 was discharged. 
 
 * New York Med. Journ., Dec. 27, 1884. 
 
 t Aran/'Essai sur 1'Hematurie," 1811. Quoted by Eayer, vol. i., p. 278.
 
 198 SURGERY OF THE KIDNEY AND URETER. 
 
 Operative and non- operative treatment of subparietal in- 
 juries contrasted. As showing the different results in reference to 
 operative treatment the following figures are of value : 
 
 Of twenty-six cases collected from English and American 
 sources in the ten years 1884 to 1893 inclusive, fourteen were 
 treated palliatively, of whom ten died and four recovered, i.e. 
 70*7 per cent. died. Eleven were treated by operation of some 
 kind, of whom eight recovered and three died, i.e. 27"2 per cent, 
 died. The nature of the operations performed in the eleven 
 cases were, three nephrectomies (one alxlominal, two lumbar), 
 with two deaths, one of the lumbar operations being successful ; 
 six cases of lumbar incision for extravasated blood and urine (one 
 not until six months after the injury, and in this case a small 
 fistula remained), with five recoveries and one death ; one partial 
 nephreetomy with recovery ; one lumbar iiephrectomy after a 
 preliminary exploratory laparotomy, with recovery. One patient, 
 whose case I have not included in the above analysis, died 
 after cystotomy performed on a wrong diagnosis. 
 
 It is pretty clear from a perusal of the reports of cases, that 
 more lives might be saved if timely operations were judiciously 
 performed. It is to be feared that besides the cases which 
 might have been saved, some of those which were operated 
 upon ended fatally because the operation was too long delayed. 
 On the other hand, whilst some of the injuries for which no 
 operation is performed are, no doubt, very slight ones, we 
 must not lose sight of the fact that others are among the 
 most severe, the patients dying within a few hours of the in- 
 jury from shock and haemorrhage, and being too ill from the 
 first to allow of any surgical operation being undertaken with 
 any reasonable prospect of success. 
 
 The argument is, I think, fallacious which assumes that the 
 cases which have been, operated upon are the most severe, and 
 those not operated upon are the slighter injuries ; and so also is 
 the conclusion that if many of those treated palliatively had been 
 operated upon, the mortality would have been very materially further 
 reduced. It must be admitted that the expectant plan is of 
 necessity adopted in some of the very severest as well as in the 
 verv slightest cases.
 
 199 
 
 CHAPTEE VI. 
 
 INJURIES OF THE KIDNEY (Continued). 
 
 * 
 
 B. INCISED AND PUNCTURED WOUNDS OF THE KIDNEY. 
 
 1. WITHOUT PROTRUSION OF THE ORGAN. 
 
 Causes. Wounds of the kidney in civil practice at least 
 are very rare ; and in warfare uncomplicated wounds of the 
 kidney are not less so. Otis tells us that no instance was reported 
 during the American War, 180 1-1865. Of forty-three cases 
 collected by Klister,* six only occurred in females, and two resulted 
 from lance and bayonet wounds in warfare. Keen tabulated 
 eight cases of wounds of the kidney inflicted by other weapons 
 than firearms : of these, five were stabs made by a knife, one by 
 a pair of shears, one by a fall upon a pair of scissors, and one by 
 a fall upon a pointed stick. 
 
 Edler f gives twelve cases, in five of which the wounds were pro- 
 duced by knife thrust, one by a dagger, and the others by rapier, 
 yataghan, lance, sword and scythe. In two other cases recorded 
 below (pp. 212, 213)the wound was caused by a fall upon railings and 
 the consequent impaling of the loin. They differ widely from one 
 another, according to the nature of the weapon with which they 
 are inflicted ; as to whether they involve the cortex only, or 
 penetrate to the tubular or pelvic portions of the organ ; and, 
 again, as to whether they do or do not implicate the peritoneum 
 or large blood-vessels of the kidney. From the anatomical position 
 of the kidney, penetrating wounds like subparietal ruptures of 
 this viscus may be of two chief classes : (1) those inflicted upon 
 the posterior surface and in which the peritoneum is not involved ; 
 and (2) those affecting the front surface and involving the 
 peritoneum and very probably some of the other viscera as well. 
 
 * Deutsche Chirurgie, 1896. 
 t Arch. f. klin. Chir., 1887.
 
 200 SURGERY OF THE KIDNEY AND URETER. 
 
 Symptoms. A wound of the kidney will be indicated by 
 the situation, direction, depth, and immediate consequences of 
 the injury; except in such a rare case as that recorded by 
 Murphy, where a man fell on the handle of a hay-fork, which 
 entered the rectum and, penetrating the colon, crushed the upper 
 pole of the left kidney. 
 
 Pain. As a rule injury is followed at once by more or less 
 iicute pain in the renal region. This is frequently due to the 
 injury of the skin and soft parts rather than of the kidney. 
 In most cases the pain is severe ; in some it has been de- 
 scribed as excruciating ; while in a few it seems to have been 
 slight, or altogether wanting. Hence Hunter speaks of the 
 " sensation " as being " trifling " ; and John Bell says, " The patient 
 will be easy and his belly soft for some days, till the blood, 
 coagulating, excites inflammation." The pain is not always con- 
 fined to the renal region, but extends frequently along the ureter, 
 to the testicle, and even to the corresponding thigh. This is 
 especially the case when blood-clots are being passed along the 
 ureter. Occasionally there is retraction of the testicle, or spas- 
 modic contractions of the scrotum may be noticed. 
 
 Escape of urine. Another early symptom is the escape of blood, 
 or blood and urine, from the wound when the injury is behind 
 the peritoneum. If the kidney is wounded superficially and the 
 cortical substance alone affected, blood may appear externally ; or 
 be poured out into the circumrenal cellular tissue ; or escape into 
 the peritoneal cavity if the injury has been inflicted from the front, 
 or the peritoneum has been reached and transfixed from behind. If 
 the wound of the kidney is deep and the calyces or renal pelvis 
 opened, urine as well as blood ma}' escape from the external 
 opening ; or be extravasated into the retro-peritoneal tissue, or 
 peritoneal cavity. Urine is not likely to issue forth unless a 
 calyx or tlie renal pelvis has been penetrated. 
 
 Hcematuria may or may not lie an early symptom. If the cortex 
 only is wounded, hsematuria will not necessarily occur at all. In 
 the following fatal case* no haematuria occurred. A woman, aged 
 twenty-eight, on December 27th, 1894, fell on a butchers knife 
 and subsequently wandered about for four days before coming under 
 
 * Gaylord, Medical Xeu's, Philadelphia, 1895, vol. Ixvi., pp. 402-4: "A 
 Case of Incised Wound of the Peritoneal Surface of the Kidnev."
 
 HyEMATURIA INCONSTANT, AND VARIABLE IN DEGREE. 201 
 
 observation. A wound two and a half inches long was situated close 
 to the eleventh rib on the right, and this side of the alxlomen w?ls 
 dull on percussion, as far as the pelvis and to within two inches of 
 the umbilicus, the rest being tympanitic. The urine contained 
 20 per cent, of albumen. There was general anasarca, and 
 also some pneumonia at the base of the right lung. Next 
 day she aborted of a five months' foetus. On January 6th the 
 dulness had extended to the fourth rib and centrally to the 
 umbilicus, a mass occupying the right iliac fossa. Death occurred 
 suddenly. There was a lacerated wound on the anterior surface 
 of the right kidney 5 cm. long, extending downwards and out- 
 wards, with a large haematoma. No hsematuria occurred, and 
 there was no sign of repair in the kidney. 
 
 When the cavity of the kidney has been opened it is most 
 likely that the fact will be declared very quickly after the injury, 
 as urine more or less stained with blood, or even pure blood, 
 may be passed freely within a few minutes per urethram. On 
 the other hand, dysuria, or urgent and frequent desire to mic- 
 turate without the ability to do so, may be a leading feature ; 
 the discharge of urine along the ureter into the bladder, or along 
 the urethra from the bladder, being prevented or rendered difficult 
 by the impactioii of blood-clot either in the ureter, the urethra, 
 or at the neck of the bladder. 
 
 When hgematuria occurs, it may set in at any time from 
 a few minutes to a few days, though usually it commences within 
 a few hours ; it may last for only a day or two or extend over 
 several days ; it may be slight, and sufficient merely to stain 
 the urine, or it may be profuse and rapidly fatal. 
 
 In some cases so much blood is effused into the surrounding 
 tissues and peritoneum, arid is thus drawn aw r ay from the kidney 
 so rapidly, that none traverses the ureter to the bladder, even 
 though the wound opens the renal cavity. This was proved 
 to have been the case in an instance given by Morgagni.* A 
 man, aged twenty, was stabbed on March 24th, 1742, and rapidly 
 died from internal haemorrhage. The knife had entered the 
 right cavity of the thorax between the ninth and tenth ribs, 
 and after piercing the diaphragm close by these ribs and 
 penetrating the adjacent part of the liver, it passed through 
 
 * Morgagni, Letter liii., s. 40. 
 
 t-l-i 
 
 _ t-C . A i,
 
 202 SURGERY OF THE KIDNEY AND URETER. 
 
 the right kidney obliquely from the anterior to the posterior 
 surface and wounded the muscles by the side of the spinal column 
 beyond. No very large blood-vessel was wounded, but an 
 enormous quantity of blood was poured out into the peritoneal 
 cavity. The bladder contained a small quantity of urine unstained 
 by blood. 
 
 To the above symptoms others must be added -as occurring 
 shortly after the infliction of a severe wound. Nausea and 
 vomiting, pain in the epigastrium, muscular spasms, and rigidity 
 of the abdominal parietes on the side injured ; fainting fits ; 
 a small pulse, rapidly becoming feebler, irregular, and more and 
 more rapid ; coldness of the skin ; restlessness ; and intense 
 anxiety of features, all indicate considerable shock and more or 
 less loss of blood. If the peritoneum is wounded and urine 
 escapes into its cavity, traumatic peritonitis will soon declare 
 itself. If the wound does not involve the peritoneum, peritonitis 
 may come on at a later period by extension of inflammation 
 from the retro-peritoneal cellular tissue. When a penetrating 
 wound is not fatal within a few days, inflammation more or 
 less severe and widespread must be looked for ; in the old- 
 fashioned gun-shot wounds it was inevitable, with the modern 
 bullet and in clean punctured or incised wounds it may 
 possibly be escaped. During the course of the inflammation 
 there is abdominal distension and pain, a dry hot skin, a parched 
 tongue, red at its edges and furred in the centre, and a high 
 temperature with a rapid pulse. lligors sometimes mark the 
 commencement and continuance of suppuration. Should the 
 inflammation involve the kidney itself, the symptoms of nephritis 
 or pyelitis will arise, and pus in the urine from inflammation 
 of the renal pelvis will then most likely be found. 
 
 When, the inflammation commences in the retro-peritoneal 
 cellular tissue, perinephritis and perinephric abscess present them- 
 selves in the various aspects and with the several tendencies described 
 under those heads. There may form outside the peritoneum f 
 after some hours or days, a dull swelling due to the accumulation 
 of blood, or of blood and urine ; and at a still later period retro- 
 peritoneal suppuration may give rise to just the same kind of 
 hardness and swelling as extravasated blood or urine. Subse- 
 quently in each case the peritoneum may become inflamed owing
 
 DIFFICULTY OF DIAGNOSIS. 203 
 
 to its being stretched and irritated ; and death from peritonitis 
 in this way sometimes occurs. 
 
 Retention of urine, which has been known to last for four, 
 five, or six days and longer, and then to be followed by the 
 passage of bloody urine and blood-clots, has in some cases of 
 punctured wounds been a striking feature. 
 
 There is the utmost uncertainty as to whether, after an injury 
 to the kidney, there will be simple retention of urine, or dysuria 
 with frequency of micturition, or retention with frequent painful 
 and fruitless efforts to micturate. 
 
 When lumbar pain and swelling are accompanied by fever, 
 and followed by vomiting, abdominal distension, restlessness, 
 anxiety, and hiccup, then there are what John Bell called "the 
 torments of the miserere mei" and death is not far off. 
 
 Diagnosis. In some cases the evidence of a wound of the 
 kidney has been full and complete from the first ; in others 
 it has only been obtained after some of the remoter effects of 
 such wounds have had time to show themselves ; in others, 
 again, the diagnosis has remained uncertain throughout ; and, 
 lastly, in some fatal cases of abdominal wounds the injury to 
 the kidney has only been thought of when actually seen on the 
 post-mortem table. 
 
 When urine, or a fluid having a strongly urinous odour, 
 escapes by the external wound, the diagnosis cannot be uncertain. 
 Hiematuria and pain in the renal region coming on at once after 
 a wound in the loin, are very strong reasons for diagnosing 
 wound of the kidney. If the haematuria follows almost im- 
 mediately after the injury, and especially if there is a considerable 
 quantity of blood voided per urethram, the evidence amounts 
 almost to proof. Haematuria has been noted in the larger pro- 
 portion of cases, and is so fairly constant a symptom that it 
 ought to cause suspicion in cases where there is neither dysuria 
 nor escape of urine by the wound, nor any evidence of urinary 
 extravasation. 
 
 When traumatic peritonitis occurs, and haematuria exists or 
 has just previously existed, attention should be at once directed 
 to the kidney. 
 
 It must be borne in mind, however, that the kidney may be 
 wounded, and its pelvis actually transfixed, without haeinaturia
 
 204 SURGERY OF THE KIDNEY AND URETER. 
 
 occurring ; whilst hsematuria may follow a wound which does 
 not implicate the kidney. 
 
 Probably, did the patient live, some amount of hsematuria 
 would, sooner or later, be seen in every case in which a calyx 
 or the renal pelvis was entered, provided the ureter did not 
 become blocked by clot or foreign body. As a consequence of 
 traumatic perinephritis, the loin may be the seat of pain, the 
 kidney may become inflamed, and the urine may be charged 
 with blood ; so that pain and haematuria conjoined, when coming 
 on a day or two after a wound in the renal region, are by no 
 means absolute signs of a wound of the kidney. In other words, 
 inflammation of the kidney, attended by pain and hsematuria, 
 may occur as a result of a wound in the renal region which, 
 however, does not directly involve the kidney itself. 
 
 The situation, direction, and depth of the wound ; a com- 
 parison of the wound with the weapon ; and the respective 
 attitudes of the patient and of the assailant at the moment when 
 the wound was inflicted, may assist in guiding to a right diagnosis. 
 Taken by themselves, apart from the symptoms, they cannot, 
 however, be relied upon. 
 
 A digital exploration of the wound will, in some cases, make 
 the diagnosis quite clear as to whether the kidney is or is not 
 wounded. 
 
 To repeat ; it may be stated (1) that a wound in the renal 
 region followed by the escape of urine through the wound is 
 conclusive of injury of the kidney ; (2) that such a wound 
 quickly followed by the discharge per urethram of urine heavily 
 mixed with blood, or of pure blood, is almost conclusive, if not 
 quite so ; (3) that such a Around followed by retention of urine 
 or lumbar or abdominal pain and dysuria, even without hsema- 
 turia, is highly suggestive of a superficial wound of the kidney, 
 or of a deeper wound and the blockage of the ureter ; (4) that 
 haematuria followed by traumatic peritonitis is strong evidence of 
 an injured kidney. 
 
 Pathology. The lesions which have been found after death 
 in cases of wounded kidney have varied with the length of time 
 the person has lived after being wounded, and with the nature 
 of the weapon wherewith the wound has been inflicted. 
 
 Only one kidney is as a rule implicated. Foreign bodies are
 
 RENAL OBSTRUCTION, FISTULA, AND OTHER SEQUELAE. 205 
 
 not apt to be carried into the wound, as is the case in gunshot 
 wounds, nor are other organs involved unless the wound is in- 
 flicted from the front or side of the body, which is rare, or in 
 such an accident as that of Murphy's (p. 200), which is altogether 
 exceptional. The wound may involve the renal substance only, 
 or the renal pelvis, or the vessels at the hilum. The edges 
 of an incised wound may be smooth and sharp; if inflicted with 
 a blunt instrument, they will be lacerated; and all gradations 
 in size are met with, from a fine puncture to a cut as wide 
 as the hand. 
 
 Wounds reaching the kidney from the loin may open the 
 pelvis of the organ, but do not commonly penetrate to the peri- 
 toneum. 
 
 When the external wound is large and direct, blood and urine 
 escape freely; on the other hand, when there is only a small 
 opening and the soft parts are penetrated obliquely, they fall 
 .together, and internal extravasation may occur, much as in sub- 
 parietal injury. 
 
 Narrow aseptic wounds of the kidney close by organisation 
 of blood-clot, and leave only a fine pigmented scar ; larger ones 
 close more slowly and with granulation, leaving a larger scar. 
 If the abdominal cavity is penetrated a fistula may possibly ensue, 
 the walls of which will be formed by adhesions of the abdominal 
 viscera. Septic injuries of the kidney through the lung and 
 pleura result in empyema, whilst aseptic penetration may cause 
 only limited adhesion. 
 
 Garengeot and Dumont the younger report cases fatal from 
 incised penetrating wounds involving the renal vein. 
 
 When the patient has lived several days a perinephric abscess 
 may form ; and the kidney has been found more or less dis- 
 integrated, with merely a semi-liquid pulp in the midst of the 
 inflammatory or suppurating changes of perinephritis. The 
 kidney in some cases has been reduced to a mere abscess sac ; 
 or part of it has been suppurating, and the rest has had a pale 
 pink colour, and a granular, softened, and flabby consistence. 
 
 The renal pelvis is not very unfrequently the seat of active 
 suppurative changes, and may present greenish, sloughy, or 
 ulcerated patches ; blood may be mixed with the pus, and the 
 vessels of the mucous membrane may be much distended,
 
 206 SURGERY OF THE KIDNEY AND URETER. 
 
 When the ureter has become permanently blocked by blood- 
 clot, foreign body, or adhesive inflammatory changes, the kidney 
 undergoes those pathological changes which are productive of 
 either hydro-nephrosis, pyo-nephrosis, or granular degeneration 
 and atrophy. 
 
 Death from causes unconnected with the kidney has rendered 
 it possible to prove the complete cicatrisation of wounds of the 
 kidney. 
 
 The length of time required for the repair of a wound of 
 this organ varies, no doubt, with the character of the wound. 
 Probably some few days pass before repair commences. In the 
 New York Hospital Museum is a specimen (No. 749) showing a 
 deep punctured wound of the convex border of the kidney, not 
 involving the pelvis. The patient died five days after the lesion 
 from other injuries. There had been no attempt at repair. 
 
 Prognosis. " Servari 11011 potest cui renes vulnerati sunt," 
 sa}*s Celsus ; but this is far too sweeping ; for though serious, wounds 
 of the kidney are by no means necessarily mortal. Hemien says : 
 " The slightest reflection 011 the situation and structure of the 
 kidney, and 011 its various sympathies, will at once show the 
 desperate nature of wounds inflicted 011 it, even with all the 
 caution of a curative intention. The instances that I have ob- 
 served where recovery has been established are very few indeed. 
 If the patient has survived the first haemorrhage, the fever and 
 peritoneal inflammation with incessant hiccough and vomiting, 
 and sympathy of the diaphragm and stomach, have generally cut 
 him off ; and if he has for a time escaped, excruciating pains, 
 profuse suppuration from fistulous sores, hectic, and emaciation 
 have terminated his existence. Where the cure has been effected, 
 there is reason to think that the ureter has been but slightly 
 bruised, and the body of the kidney itself left untouched." 
 1 ' At the present day, however, we know, from the success that 
 has attended recent surgical operations upon the kidney, that 
 this estimate of the danger of renal wounds is altogether too 
 unfavourable. 
 
 The prognosis in cases of incised and punctured wounds, involving 
 the kidney only, is more favourable than if the peritoneum or some 
 other organ as well as the kidney is implicated. Among twelve cases 
 reported by Edler death ensued in five, the fatal issue being due
 
 SEPSIS AND HEMORRHAGE. 207 
 
 in two to primary and in two to secondary haemorrhage, whilst 
 the fifth succumbed after nephrectomy. 
 
 The post-mortem investigation in the fatal cases shows that 
 injuries to the parenchyma are of comparatively trifling import- 
 ance, being accompanied by only slight loss of blood and no 
 extravasation of urine; wounds of the pelvis, on the other hand, 
 are associated with both in a very considerable degree, the main 
 vessels in some cases being opened or entirely severed. 
 
 Persistent suppression of urine, whether due to severe damage 
 to both kidneys or their vessels or to the destruction of a " soli- 
 tary " or an "unsymmetrical" kidney, or merely to reflex inhibition 
 of the renal function, is necessarily fatal. 
 
 Of the eight cases of punctured wounds tabulated by Keen, 
 six recovered and two died, one of coma from suppression of urine 
 on the second day after the injury, and one of abdominal 
 sepsis and abscesses of the liver a month after the accident. In 
 four of the cases nephrectomy was performed and all of them 
 recovered ; in two of the four the nephrectomy was secondary 
 after previous lumbar incision. 
 
 Kiister records ten fatal cases out of forty-three such injuries, 
 many with serious complications a mortality of 23' 25 per cent. 
 The results in simple cases were still more favourable, as shown 
 by the record of four deaths among thirty-one uncomplicated 
 injuries, i.e. a percentage of 12'9, the causes of death being sepsis 
 and haemorrhage. 
 
 As evidence of the utility of surgical interference in these 
 cases he quotes ten operations, including two primary and six 
 secondary nephrectomies, one secondary loin incision, and one 
 operation for the removal of a cyst, all of which were followed 
 by recovery. 
 
 Moreover, several cases of recovery from accidental wounds 
 were on record at dates long prior to modern surgery. Haller, 
 Bourienne, Borthwick,* Fallopius, Yalleriola, Schenckius, Heister, La 
 Motte, Forest, and other old writers, have given instances of 
 recovery from incised and punctured wounds. 
 
 The following cases of incised and penetrating wounds have also 
 
 * Hennen (op. cit., p. 435) refers to the cases of these three observers. 
 References to them and to others are given in the " History of the War of 
 the American Rebellion," and by Rayer.
 
 208 SURGERY OF THE KIDNEY AND URETER. 
 
 l^een reported as ending in recovery. The case of a butcher's 
 boy, aged fourteen, is related by Knox, of Edinburgh, and by 
 Schuster * He had received a stab wound three inches deep, on 
 the right side, immediately below the twelfth rib, three inches 
 from the spine ; considerable haemorrhage followed ; urine mixed 
 with blood was passed for three days ; on the seventh day there 
 was slight icteric coloration of the skin ; a copious light brown 
 fluid, which proved to be urine, escaped from the wound ; recovery 
 in fifty days. 
 
 Bouriennef recites a case of bayonet wound in the side, pene- 
 trating the kidney ; severe pain, vomiting, distension of the 
 abdomen, and convulsive retraction of the testicle followed ; on 
 the second day blood passed per urethram ; recovery ensued in 
 twenty-four days. 
 
 Purmann's case. A soldier received a stab wound of the left 
 kidney ; retention of urine, finally bloody urine, which escaped 
 with great force on the fifth day ; complete recovery in six weeks. 
 
 Forest's case. A youth of twenty, stabbed in the right kidney, 
 had retention for six days ; after hot fomentations he passed a 
 quantity of bloody urine, with clots, and had a rapid convalescence. 
 
 Dupuy's case. A man stabbed with a sharpened foil in the 
 right lumbar region ; had acute pain, and voided nearly pure 
 blood from the urethra ; acute circumscribed peritonitis and 
 nephritis followed ; he recovered under an energetic antiphlogistic 
 treatment. 
 
 Sir A. Cooper mentions having seen a boy who was struck 
 in the back with a penknife, and almost immediately wished to 
 make water ; on doing so, he passed a large quantity of blood. 
 Haematuria continued for several clays, but subsided on his re- 
 maining quiet in bed. 
 
 Mr. Ackerly, J of Liverpool, relates the case of a man, aged 
 thirty, who was wounded in two places by the open blades of 
 a pair of tailor's shears, the one entering the abdomen about 
 two inches above the anterior superior spinous process of the 
 
 " History of the War of the American Rebellion," vol. ii., part ii., p. 162. 
 
 t Journal de Med.- Chir. Phar., etc., Juillet a Decembre, 1774 ; vol. i., 
 part xlii. 
 
 J " Observations on Wounds of the Abdomen," Lond. Med. Gazette, vol. xx., 
 p. 549 (1837).
 
 SPONTANEOUS RECOVERY AFTER PENETRATING WOUNDS. 209 
 
 ilium, on the left side (from which wound about four inches 
 of omentura protruded), the other entering near the spine, on 
 the same side, just beneath the last rib. There were copious 
 discharges of urine from the latter wound for two days. The 
 omentum was cut away, and the bleeding vessels secured by 
 ligatures. Recovery ensued in fourteen days. 
 
 Mr. J. Johnston* recorded a case of recovery, after an incised 
 wound of the kidney, in a man aged thirty-two. The wound 
 was inflicted with a large table-knife, with a blade of eight and 
 a half inches, the whole of which penetrated the tissues. The 
 peritoneal cavity was opened. Painful spasmodic retraction of 
 the testicle was the prominent symptom, and led the man to 
 suppose that he had been stabbed in the groin. There was 
 much haemorrhage from the wound, and within an hour after 
 its infliction a pint of blood was passed by the urethra. Symp- 
 toms of peritonitis followed, and a perinephritic abscess had to 
 be opened ; quantities of urine escaped through the abscess 
 opening. The patient made a good recovery in about six weeks, 
 and it is to be inferred, though it is not stated, that a permanent 
 urinary fistula was escaped. 
 
 Fourteen cases of recovery after incised or punctured wounds 
 of the kidney were collected from various sources, and are referred 
 to by the editor, Dr. Otis.f No instance of punctured or incised 
 wound of the kidney was, however, known to have occurred 
 in the War of the Rebellion. 
 
 The sources of danger from penetrating renal wounds are (1) 
 haemorrhage, if the great vessels of the organ are injured ; (2) 
 peritonitis, if the front surface of the organ or any of the 
 adjacent viscera are penetrated ; and (3) perinephritis and 
 perinephric abscess, and effusions of blood or blood and urine 
 behind the peritoneum. If the wound is inflicted upon the 
 posterior surface, and neither peritoneum nor the great vessels 
 at the hilum are wounded, recovery may be looked for. Indeed, 
 it is not too much to say that whilst the kidney may recover 
 from very considerable lesions, mere punctures or incisions of its. 
 substance are attended with a very small amount of risk. 
 
 * Brit. Med. Journ., April 4th, 1857, p. 275. 
 
 t "Medical and Surgical History of the War of the American Rebel- 
 lion," vol. ii., part ii. 
 VOL. I. O
 
 210 SURGERY OF THE KIDNEY AND URETER. 
 
 Convalescence is in some cases prompt, in some it is completed 
 only at the end of many months. A bad prognosis must be 
 given when there is much extravasation, if a foreign body remains 
 in the wound, or if the peritoneum has been lacerated. Wounds 
 of the trunks of the renal vessels are rapidly fatal. When shiver- 
 ing, fever, swelling, and the other signs of purulent infiltration 
 into the cellular tissue, set in, the prognosis is bad, unless early 
 and efficient vent can be given to the matter. Abscesses behind 
 the peritoneum, if not opened and thoroughly drained, cause 
 continued fever, sepsis, and death, after a long and exhausting 
 illness. Nephritis, cystitis, and peritonitis are other causes of death. 
 
 Rayer, whose estimate on the whole of the dangers of renal 
 wounds is by no means an exaggerated one, clearly attaches more 
 importance to wounds of the calyces and pelvis of the kidney than 
 to wounds of the surface of the organ. Though agreeing with 
 Rayer in this opinion, yet I do not think experience justifies 
 us in regarding the prognosis of simple wounds penetrating to 
 the cavity of the kidney as unfavourable ; certainly they are 
 not to be classed in the same category of risk as wounds of 
 the renal artery or vein. 
 
 Treatment. Mild purgatives and emollient enemata are 
 indicated if the towels, especially the large bowels, are loaded, 
 but after these have been once freed of their contents, the quieter 
 they are kept the better. It is, however, very undesirable that 
 a mass of hardened faeces should rest in the colon and act as 
 a source of irritation to the neighbouring injured kidney. 
 
 The treatment of the wound cannot be too simple. It should 
 be left open for drainage, unless it be a very large incised wound, 
 in which case one or more deep sutures may be introduced 
 to bring the edges together. Some antiseptic gauze, or a 
 piece of lint soaked in carbolised oil, and over this a layer of 
 absorbent cotton- wool, are the only dressings needed after 
 the parts around, and the wound track, have been carefully 
 cleansed and disinfected. If the wound is not aseptic, a drainage 
 tube should be retained. 
 
 Unless its course be very oblique, it will rarely be necessary 
 to enlarge the wound for the purpose of preventing infiltration 
 of urine. If the opening externally is very small and its edges 
 subsequently become oedematous, blood or urine may not be
 
 TREATMENT OF COMPLICATIONS OF PENETRATING WOUNDS. 211 
 
 able to escape readily from the tissues, and in such cases it is 
 imperative to widen the wound as soon as possible. It may 
 be needful, in order to arrest haemorrhage or suture the kidney, 
 to enlarge the wound. If this is done the kidney should be 
 brought well into view for the purpose of examination, and the 
 subsequent procedure will depend on the condition found. If 
 the parenchyma is simply incised it should be sutured ; if the 
 renal pelvis, and not the parenchyma, is opened by a clean cut 
 wound it should be sutured as after the operation of pyelotomy. 
 If the parenchyma is contused as well as punctured or incised, 
 suturing the wounded surfaces together will be contra-indicated, 
 and would not, in all probability, succeed even in controlling haemor- 
 rhage ; under these circumstances, the wound should be packed 
 with iodoform gauze, with the object of staying the bleeding and 
 with the expectation that repair will take place in the wounded 
 kidney. If a portion of the kidney has been cut completely 
 off from the rest, it should be removed, and the cut surface 
 of the main portion of the organ carefully examined for any 
 large bleeding vessel. If there be any such it should be ligatured, 
 or clamped by forceps which might be left in situ; but the 
 ligature cut off short is the best. If a large branch of the 
 main vessels of the kidney is divided or the kidney substance 
 much lacerated, primary nephrectomy should be performed. If 
 the peritoneum has been opened and blood or urine has escaped 
 into the peritoneal cavity, laparotomy and antiseptic cleansing, 
 and the removal of the clots and urine, may be requisite; but 
 it should be remembered that neither blood nor urine, if aseptic, 
 causes trouble to the peritoneum. 
 
 A wound of the peritoneum with severe contusion or lacera- 
 tion, as well as a punctured or incised wound of the renal 
 parenchyma, would be an additional reason, for primary neph- 
 rectomy. If, however, the peritoneum has been opened but 
 no blood or urine has escaped into it, the rent in the mem- 
 brane should be sutured, and the damaged kidney treated on 
 its merits as if the peritoneum had remained intact. Instead 
 of suturing the peritoneum the wound has been plugged 
 with iodoform gauze, as in the following case, recorded by F- 
 Hartley in the Xew York Clinical Society, 1887. A man, aged 
 twenty-rive, was stabbed in the right side, the knife entering
 
 212 SURGERY OF THE KIDNEY AND URETER. 
 
 between the ninth and tenth ribs, midway between the mam- 
 mary and axillary ' lines, opened the peritoneum and traversed 
 the right kidney from the outer to the inner margin. Haemor- 
 rhage was profuse, and it was necessary to enlarge the wound 
 to arrest it. The peritoneal wound was plugged with iodoform 
 gauze and free exit given to the urinary discharge. Kecovery 
 occurred with a small urinary fistula, which persisted for six 
 months while the patient was under observation. 
 
 If after some days there should be any indication of peri- 
 nephritis and if the original wound, being small, has not already 
 been enlarged, this should be done without waiting for the 
 formation of pus. If a perinephric abscess has formed it should 
 of course be laid freely open and drained ; and if the kidney 
 itself has shared in the inflammation of the surrounding tissue 
 or become necrosed, or has independently of perinephritis become 
 the seat of acute pyelitis or pyelo-nephritis, secondary nephrectomy 
 should be performed. Wallis gives seven cases of nephrectomy for 
 perforated or incised wounds, of which six recovered and one died. 
 Keen quotes four cases (out of eight punctured wounds tabulated by 
 him), in which nephrectomy was performed, twice as a primary, and 
 twice as a secondary operation, and all the patients recovered. 
 
 The following are brief abstracts of some of the published 
 cases of incised and punctured wounds two of which (Cheever's 
 and Gage's cases) are included in Keen's list which have been 
 treated by nephrectomy : 
 
 In the Medical Society's Reports for 1896, F. S. Edwards 
 narrates the case of a man, J. M., aged fifty-five, who fell from a 
 third floor on to some railings, one of which penetrated his side, 
 broke off, and was extracted by a policeman. When seen he was 
 suffering from shock and haemorrhage from a wound in the left 
 loin, \vith haematuria. There was a deep contused and lacerated 
 wound extending from the lowest two ribs, which were com- 
 minuted, to the anterior superior iliac spine, and haemorrhage 
 was proceeding from the kidney, which was exposed at the 
 bottom of the wound, the organ being lacerated both longi- 
 tudinally and transversely into the hilum. Nephrectomy was 
 performed and was followed by suppuration and fever, but with 
 ultimate recovery. The amount of urine increased regularly in five 
 days from 22 to 50 ounces, the urea being estimated at 473 grains.
 
 SUCCESS OF PRIMARY NEPHRECTOMY. 213 
 
 111 the Clinical Society's Reports for the following year, 1897 
 (vol. xxx., p. 44), Wallis reports the case of a man, twenty-two years 
 of age, who met with a similar accident, falling from a ladder and 
 being impaled on spiked railings. The wound was situated below the 
 tenth costal cartilage on the right side, and was 1^ inches long. 
 A pint of blood was passed by the urethra. The kidney, which 
 was torn nearly in two, was at once removed, and the peritoneal 
 cavity cleansed. Healing occurred at once and recovery was 
 rapid. The author gives a summary of twenty-one cases of 
 iiephrectomy for injury of the kidney, fourteen being subcutaneous 
 lacerations, with nine recoveries and five deaths; and seven 
 perforated or incised wounds, with six recoveries. In one recorded 
 by West in the British Medical Journal (1883), the result was not 
 stated. 
 
 In Cheever's case a man, G. C., aged twenty-five, was stabbed 
 in the right loin with a pair of shears. Haemorrhage from the 
 Avound with heematuria, accompanied by clots and pain at the 
 neck of the bladder and end of the penis, occurred. Lumbar 
 nephrectomy was performed ten days afterwards, and a large 
 amount of coagulum was removed from the outer capsule. The 
 kidney wound was stellate, li cm. in diameter, and, penetrating 
 the nearest calyx and the pelvis, passed completely through the 
 organ. The patient was discharged thirty-two days after the 
 operation. 
 
 H. Gage, in the Boston Medical and Surgical Journal (vol. i., 
 1891) records the case of a girl, aged twelve, who received a 
 wound in the right lumbar region from a small pair of shears 
 while stooping. The wound was 1 inch long and situated just 
 below the twelfth rib. Hsematuria occurred the same evening 
 and continued with intermissions for sixteen days, being very 
 profuse and attended with the discharge of clots. During the 
 thirteen or fourteen days while the urine was clear there was 
 pain, with the development of a tumour in the loin, which dis- 
 appeared with the recurrence of hsematuria 011 the fifteenth day. 
 The tumour was due to the plugging of the ureter with clot 
 and to the extravasation of blood into the circumrenal tissues, the 
 patient suffering at this time from anaemia with frequency of 
 micturition and tenesmus. Lumbar nephrectomy was performed. 
 The tissues were found infiltrated with blood and urine, and
 
 214 SURGERY OF THE KIDNEY AND URETER. 
 
 the ureter was distended and blocked with clot. The shears had 
 passed completely through the kidney a little below the centre, 
 crossing the pelvis and severing a large branch of the renal 
 artery before emerging through the capsule on the anterior aspect. 
 
 A remarkable case of recovery after left lumbar nephrectomy 
 and resection of a prolapsed portion of the left lung is recorded 
 by Demons.* A mechanic, forty-nine years of age, was wounded by 
 a knife in a fight ; the wound was 4 cm. long in the left side 
 of the thorax, between the ninth and tenth ribs, through which 
 protruded a piece of the lung as large as a fist ; there were 
 other symptoms pointing to wound of the left kidney, hsematuria, 
 vomiting, and pain and swelling in the left side. The prolapsed 
 portion of lung was resected at the end of a week, but no im- 
 provement followed, and pus and urine exuded from the wound 
 in the thoracic wall. Abscesses formed around the wound, and 
 the patient continued to get worse till lumbar nephrectomy was 
 performed, after which he at once began to improve, and 
 ultimately got quite well. 
 
 Cases are recorded in the British Medical Journal of 
 November 18th and November 25th, 1899, by Bland -Sutton, 
 Turner, and Swinford Edwards, in which primary abdominal neph- 
 rectomy was performed for ruptured kidney. Though this method 
 is recommended by these surgeons, it ought, in my own opinion, 
 only to be followed in cases in which there is doubt as to the 
 organ injured, or as to whether there is an injury to some other 
 abdominal organ as well, or where there is reason to think blood 
 is escaping into the peritoneal cavity. 
 
 B. INCISED AND PUNCTURED WOUNDS (continued). 
 
 2. WITH PROLAPSE OF THE INJURED OR UNINJURED KIDNEY 
 THROUGH THE EXTERNAL WOUND. 
 
 The kidney may be prolapsed through a wound either in the 
 back or on the front of the abdomen. When through a posterior 
 wound the peritoneum is not necessarily injured. 
 
 The prolapsed kidney may be either injured or uninjured. 
 The prolapse may take place primarily, that is, at the time of the 
 infliction of the parietal wound ; or secondarily, that is, some time 
 
 * Bull, ft Mem. Soc. de Chirurgie de Paris, 1886, n.s. xii., pp. 450-455.
 
 PROLONGED PROLAPSE A CAUSE OF NECROSIS OF KIDNEY. 215 
 
 after the infliction of the wound as the consequence of coughing, 
 sneezing, or some other sudden or considerable muscular effort. 
 It may be caused by a deep spasmodic inspiration accompanying a 
 violent or unexpected injury, or by the withdrawal of the weapon, or 
 it may even be due to the effort of rising. The forcible contrac- 
 tion of the diaphragm and abdominal muscles may very easily 
 displace the kidney from its loose attachments and cause it to 
 protrude as soon as the resistance of the lumbar muscles is 
 withdrawn. 
 
 The wound through which the prolapsed organ appears may 
 be inflicted by any cutting, lacerating, or penetrating instrument, 
 or it may be a result of gun-shot injury. 
 
 Symptoms. Besides the evidence of the protruded organ, 
 there may be haematuria whether the kidney is wounded or 
 not, and there may be discharge of blood or urine, or both, from 
 the protruded organ if it be wounded as well as protruded. 
 
 Haemorrhage naturally occurs from a wounded kidney whilst 
 it is prolapsed unless the vessels are twisted or compressed by 
 the lips of the parietal wound (see case 2, p. 218). Compression 
 of the emulgent vein causes congestion and swelling of the kidney, 
 as is constantly seen in the operating theatre, if the renal artery 
 is not under control. If the protruded kidney is not soon 
 returned into the body, and the congestion thereby relieved, 
 haemorrhagic infarction and necrosis will follow, as in Cartwright's 
 case (see p. 218). 
 
 Otis gives the case of a man who fell backwards upon a 
 scythe, which caused an incision 44 inches long, through which 
 the right kidney, slightly wounded, protruded. The kidney 
 was returned, and ice applied ; bloody urine was passed per 
 urethram during eight days ; the patient recovered completely .* 
 
 The prolapse may be only partial, i.e. only one end of the 
 kidney may protrude. Mr. Venionf recorded the case of W. M., 
 aged fourteen, who fell from a height of forty feet and received 
 a wound of the soft parts immediately above the right iliac crest, 
 through which protruded the lower end of the right kidney ; 
 a piece of its substance had been chipped out, leaving a gap 
 which would admit the finger end ; tenderness of the abdomen, 
 
 * Beck, Ckirurgie der Sckussverletzungen, s. 543 (1872). 
 St. Bart's Hasp. Reports, p. 124 (1866).
 
 216 SURGERY OF THE KIDNEY AND URETER 
 
 discharge of small quantities of blood-stained urine by the urethra, 
 and free discharge of urine from the wound were followed by 
 recovery in eight weeks. 
 
 In such a case as Mr. Yemen's it is to be expected that the 
 quantity of urine discharged through the wound would be very 
 profuse and extend over a considerable number of days. The 
 gap in the kidney in question, which admitted the end of the 
 finger, extended, there can be no doubt, into the cavity of the 
 organ, and this is the condition which, as was stated in the 
 last chapter, is favourable to urinary extravasation ; whereas 
 a rent or actual rupture, which does not open up the calyces 
 or pelvis of the kidney, will give issue to but a small amount, 
 if any, of urine. 
 
 The older surgeons, I think, knew this ; and, perhaps, John 
 Bell* had it in his mind when he wrote : " If an intestine be 
 wounded it pours out its faeces into the abdomen ; if the liver, 
 spleen, or kidney be wounded, these pour out blood ; if the bladder, 
 then urine niters into the cavity of the belly." 
 
 A kidney which has once been protruded may readily protrude 
 again before the wound is closed, and it has been said it may 
 become movable, but from my experience of renal explorations, 
 in nearly every one of which I take the kidney out on to the 
 loin and replace it, I should say that there is nothing more 
 unlikely to happen to it. 
 
 Treatment. This consists in 
 
 (1) The replacement of the kidney after arresting haemor- 
 rhage and cleansing and closing rents in its substance, if it 
 l)e not injured beyond repair. 
 
 (2) Fixing the kidney in its place by silk sutures has been 
 recommended, but can hardly ever be requisite, and would 
 be likely to cause a temporary fistula if the wound were 
 not throughout absolutely aseptic. 
 
 { .'>) The closure of the parietal wound, if recent, by deep silk 
 stitches, if it is aseptic or can be made so. If not, the 
 Avound should be in great part closed and a free opening 
 maintained for drainage. In an old Avound it may be 
 better to tampon till the kidney is adherent and then 
 close with deep sutures. 
 
 * "On Wounds," p. 311 (3rd ed.).
 
 CONSERVATIVE TREATMENT OF PROLAPSED INJURED KIDNEY. 217 
 
 In any case, if the protruding kidney is not completely broken 
 up or too severely contused, and if the source of the haemorrhage 
 is not a large branch of the renal artery or vein, and the bleeding 
 can be controlled without securing either of the main trunks, the 
 organ ought to be replaced, after it has been cleansed, in a 
 person of young or middle age and of good constitution. 
 
 The repeated successes of nephro-lithotomy have proved that 
 recovery without a urinary fistula readily takes place after 
 wounds of the kidney, whether the secreting substance of the 
 organ is but slightly wounded and the calculus removed from 
 an encysted space within it ; or is deliberately broken into with 
 the finger-tip so as to open up a calyx ; or is left altogether 
 untouched, and the renal pelvis instead of the secreting tissue is 
 the part opened. The only difference seems to be, not in the 
 certainty of recovery, but in the greater or less quantity of urine 
 which escapes from the wound, and the longer or shorter duration 
 of the urinary discharge. The smaller the opening into the 
 cavity of the kidney, whether that opening be made directly into 
 the renal pelvis or through the secreting substance into a calyx, 
 the less the amount and the shorter the duration of the flow 
 of the urine by the wound. 
 
 Even if a portion of the prolapsed kidney should be entirely 
 broken off, the bulk of the organ provided it is not much bruised, 
 that it is still connected with its pelvis and ureter, and that the 
 main blood-vessels are uninjured should be replaced with the 
 fair expectation that the patient will recover and that the remnant 
 of the kidney will be of great future use. 
 
 Nephrectomy has been successfully performed in at least three 
 cases. Two cases of stab wound, with hernial protrusion of a kidney 
 through the wound, and its subsequent extirpation, are quoted 
 by Dr. L. S. Pilcher.* Briefly stated, they are as follows : (1) 
 Stephen P., aged twenty-five years, was stabbed with a bread- 
 knife half an inch wide in the left hypochondrium on June 3rd, 
 1873 ; two or three hours after cough set in, which caused 
 the kidney to protrude through the wound. At the end of 
 twenty-four hours he presented himself at the clinic of Professor 
 
 * Pilcher : Annals of tlie Anatomical and Surgical Society, vol. i., p. 51 
 1878-9. Barker, in Medico-Chir. Trans., vol. IxiiL, p. 185, also gives 
 abstracts of this and the next case.
 
 218 SURGERY OF THE KIDNEY AND URETER. 
 
 Brandt,* in Klausenberg, having a pulse of eighty, a temperature 
 nearly normal, and able to walk to a gallery to be photographed. 
 On the fourth day after being wounded the kidney was drawn 
 out and severed from its connections, after its pedicle had been 
 igated. Rapid recovery resulted. At no time did the patient 
 show symptoms of uraemia or peritonitis. The quantity of urine 
 secreted increased daily while he was under observation. Twenty 
 days after the injury the patient left the hospital, and was able 
 to work as before. 
 
 (2) In January, 1875, an Arab girl,f of about fifteen years of 
 age, was stabbed with a knife in the loin ; the right kidney 
 was wounded, and was forced out of the abdomen between the 
 lips of the wound, by which it was partially strangulated ; a 
 ligature was thrown round the pedicle formed by the vessels and 
 ureter, and gradually tightened ; at the end of six weeks the 
 very slight pedicle still remaining was cut through and the organ 
 was removed. The girl made a rapid recovery, and subsequently 
 remained in perfect health. 
 
 In the third case, Cartwright's,^: a Chinaman had received a 
 stab wound in the loin from which the kidney protruded. It 
 had been treated with bird dung and saliva and was in a state 
 of putrefaction when seen by the surgeon, who applied a liga- 
 ture to the pedicle and removed the kidney. The patient 
 smoked two pipes of opium during the operation and then 
 walked away. He returned in two weeks well. 
 
 * See, for fuller account, Wiener Med. Wochenschrift, 1873. 
 t Marvaud, Recueil de Mem. de Med., de Chirurg., etc., vol. xxxi. 
 p. 502 (1875). 
 
 I Lancet, 1880, vol. i., p. 403.
 
 219 
 
 CHAPTER VII. 
 
 INJURIES OF THE KIDNEY (Continued). 
 C. GUN-SHOT WOUNDS. 
 
 OWING to the penetrating character of gun-ehot wounds it 
 seldom happens that in these injuries the kidney suffers alone. 
 Either the projectile reaches the kidney from the front after 
 first damaging the intervening abdominal organs, or else, being 
 discharged from behind or laterally, it traverses the kidney 
 and passes on to penetrate the abdomen or spine. This is 
 especially true of the projectiles of comparatively large size and 
 high velocity employed in modern warfare. Exception may be 
 claimed for the injuries caused by small arms which occur for 
 the most part in civil practice. 
 
 The frequency of gun-shot wounds of the kidney as compared 
 with similar injuries to other parts of the body, in military prac- 
 tice, is represented by Edler* as '12 per cent.; this estimate 
 exactly corresponding with that of Klister| for injuries of the 
 kidney from all causes in civil life, as compared with accidental 
 injury, also from all causes, to other parts. 
 
 From observations on kidney injuries in various campaigns 
 by Demme, Serrier, Fischer, and Barnes and Otis, since 1859, 
 it is estimated that these organs suffer in about 7'3 per cent, 
 of penetrating abdominal pounds, and in 3'6 per cent, of all 
 abdominal wounds. Abdominal gun-shot injuries in which the 
 cavity is opened constitute just about 50 per cent, of all wounds 
 of the abdomen due to this cause. 
 
 The cases on which our knowledge is chiefly based are eighty- 
 five described by Otis in the American Civil War, fifteen in 
 the Health Report on the Franco-German War, and fifty collected 
 from older wars and various sources, and quoted by Edler in. 
 
 * Edler, L. Arch. f. Klin. Chir., Bd. xxxiv., s. 379. 
 t Kiister, Deutsche Chirurgie, Lieferung, 526. 1 Halfte, Stuttgar, 
 (1896).
 
 220 SURGERY OF THE KIDXEY AND URETER. 
 
 his "Dissertation on Injuries of the Kidney," 1887. In addition to 
 these, nineteen cases have been collected and published by Keen 
 of Philadelphia in the Annals of Surgery, 1896. 
 
 With regard to the distribution of this form of injury as to 
 sex, only three cases are on record in women, two accidental and 
 one suicidal. They are reported by Bardeleben, Keen and Price. 
 
 Pathology. When a bullet strikes the kidney, according 
 to the degree of penetrating power it possesses, it either remains 
 in the parenchyma, opens up the cavity of the pelvis, or passes 
 right through the organ. As to the degree of injury inflicted, 
 there may be more or less damage to the renal substance; an 
 end may be separated; or there may be a clean perforation, the 
 walls of which are lined with a blackened eschar ; or the organ 
 may be divided into two, as in Bloch's case ; or it may be 
 converted into a mere pulp. 
 
 The passage of a bullet causes contusion and laceration for 
 some little distance around its line of transit. It has been shown 
 experimentally that a flaccid kidney presents a stellate laceration, 
 while one in which the vessels or pelvis are distended bursts 
 or splits widely when struck by a bullet. 
 
 Communication between the track of the bullet and the tissues 
 is shut off at first by the eschar, which intervenes ; this separates 
 in from five to twelve days, accompanied by suppuration and 
 sometimes by the escape of urine, gas, or blood, due to the injuries 
 of other organs. Severe haemorrhage is unusual at first, but 
 there may be considerable infiltration of blood into the outer 
 capsule and surrounding tissues. The pelvis or ureter is rarely 
 occluded by clot. Adhesion of the organ to its capsule may be 
 very tough. 
 
 The bullet, or a piece of bone or other foreign body carried in 
 with the bullet may remain in the kidney, and either become 
 encysted or set up septic inflammation ; or may pass out by the 
 ureter or the wound with the urine. 
 
 It ma}' l>e the cause of a persistent fistula or become the 
 nucleus of a calculus, as recorded by Stromeyer ; or it may cause 
 suppurative nephritis and perinephritis. 
 
 We learn from the History of the American Civil War*" that 
 yun-skot wounds of the kidney, are often associated with wounds 
 
 * "War of the American Rebellion," part ii., vol. ii.
 
 REPORTED RECOVERIES NOT ENTIRELY UNEQUIVOCAL. 221 
 
 of the stomach, spleen, liver, diaphragm, intestines, or spine. Such 
 cases are usually speedily fatal from shock, or shock and haemor- 
 rhage conjoined. The least complicated cases are observed when 
 a ball enters the lumbar region and penetrates the cortical substance ; 
 whereas if the peritoneum is also wounded urine escapes into the 
 cavity of the belly, and fatal peritonitis is almost inevitable. 
 
 The experience of that war seems to justify the view that 
 for the escape of urine from the kidney into the parts around, 
 the pyramidal structure at least, if not also the calyces or the 
 renal pelvis, must be wounded. Urinary infiltration into the 
 retro-peritoneal tissue does not seem to be a common consequence 
 of shot wounds of the kidney. 
 
 During the war, a total of seventy-eight cases of gun-shot 
 wounds of the kidney were recorded. Of these, fifteen cases 
 of wound of the right organ were associated with wound of the 
 liver ; six of the left kidney with wound of the spleen ; seven 
 oases of wound of one or other kidney were complicated by 
 wounds of the intestine, and five by wounds of the spinal 
 column. Fractures of the lower ribs were frequently associated 
 with renal injuries. In six out of nineteen other cases, the renal 
 wounds caused death in the first few days from shock or haemor- 
 rhage ; and two men lingered for seven and nine months respec- 
 tively, and died of exhausion from suppuration. Of twenty -six 
 cases of recovery, thirteen were wounds of the right and twelve 
 of the left kidney ; in one case the side is not stated. Fifteen 
 were pensioners, and appeared to have been alive ten years at 
 least after receiving their wounds. In six of the successful cases 
 the liver also w r as wounded. All the six cases in which the 
 spleen was wounded were fatal. 
 
 But it is stated that though the instances of recovery from 
 shot wounds of the kidney reported during the war were not 
 unfrequent, they are generally wanting in such details as would 
 establish them as unequivocal. 
 
 A case* is given of quite miraculous recovery after a gun- 
 shot wound. The injury was followed by considerable haemor- 
 rhage, six days of neglect of treatment, repeated journeys of 
 many miles, a convalescence complicated by typhoid fever, and a 
 
 * "War of the American Rebellion," part ii., vol. ii., p. 164. Quoted 
 from the Confederate States Medical and Surgical Journal.
 
 222 SURGERY OF THE KIDNEY AND URETER. 
 
 renal abscess, which discharged externally and resulted in a 
 urinary fistula, but which subsequently closed. This case teaches 
 the important lesson that a surgeon should never abandon as 
 hopeless any case of injury, however unpromising it may at 
 first sight appear. 
 
 Twenty-one additional instances of recovery from gun-shot 
 wounds are collected from various sources and referred to by 
 the editor, Dr. Otis. In some of these cases parts of the organ 
 have been torn off and carried away by the missile, so that 
 one or other end has been wanting ; in other cases the bullet has 
 transfixed the organ, leaving a lacerated hole right through it. 
 
 Secondary haemorrhage may occur when the sloughs separate, 
 &nd cause sudden death. 
 
 The healing of a gun-shot wound of the kidney takes place, 
 after separation of the eschar and a period of more or less sup- 
 puration, by the development of granulations which fill the track of 
 the bullet, and subsequently organise into cicatricial tissue. Thus, in 
 an instance recorded by Legouest, a kidney, which had been pene- 
 trated by a ball from lief ore backwards near its centre, had upon 
 each face a depressed solid fibrous cicatrix, with fibrous rays 
 branching from it. The man (a Eussian soldier), at the battle 
 of Inkermann, had sustained two gun-shot wounds, one in the 
 loin and one in the Jeft knee. He died from the consequences 
 of the wound of the knee-joint, and thus the repair of the ex- 
 tensive injuries to the kidney was proved in this case. 
 
 Professor Sociii reports the case of a man who received a shot 
 wound in August, 1870. The patient was alive in March, 1871, 
 but died shortly afterwards, from a cause not stated. After 
 death the shot was found encysted in the kidney. 
 
 Several cases in which death has not taken place until a 
 long time after the infliction of the wound have shown clear 
 evidence of perfect cicatrisation. 
 
 Jules Luys records a case of unquestionable gun-shot wound 
 of the kidney in a man who died nine years afterwards ; a mass 
 of fibrous tissue was found filling the wound in the substance 
 of the kidney. 
 
 Klebs, however, states that in two cases of gun-shot wound, 
 fatal on the fourteenth and eighteenth days respectively, no 
 interstitial new formations were found in either kidnev.
 
 SEQUELS OF GUN-SHOT WOUNDS OF THE KIDNEY. 223 
 
 Urinary fistula of long duration is not a common result, even 
 after gun-shot wounds, for it is only reported in one out of the 
 twenty-six recoveries during the American Civil War. There were 
 but few instances of urinary abscesses, and no examples of per- 
 sistent urinary fistula. The duration of life in the fatal cases 
 has varied from a day or two to eight or nine months or more; 
 the early deaths having been due to shock or haemorrhage, the 
 later ones to protracted suppuration. 
 
 Sometimes the bladder is highly inflamed by extension of the 
 inflammation along the ureter from the renal pelvis ; in Von 
 Brim's case the opposite kidney was the seat of numerous miliary 
 abscesses, and the probability is that the septic infection spread 
 from the bladder by ascending ureteritis on the opposite side. 
 
 When wasting or paralysis of the muscles of the spine or 
 lower limb has followed wounds of the kidney (and these sequelae 
 have been noted in several instances of gun-shot wound) there 
 has been division or laceration of the nerves supplying those 
 muscles. 
 
 Dr. W. S. Bird* describes a case of gun-shot wound of the 
 kidney in a man, aged forty. The bullet entered, leaving a small 
 wound on the right side, below the margin of the false ribs. In 
 the back was a similar wound occupying the same relative position. 
 He was shot by a man some ten or twenty feet in front of him. 
 He walked to a physician's office and then home. He did not 
 vomit, but during the first four hours he several times discharged 
 liquid blood by the bowel. Laparotomy next da}- revealed no 
 wound of the peritoneum, but an extravasation behind the peri- 
 toneum around the right kidney. Xothing more was done and the 
 wound was closed. He died suddenly twelve hours after the oper- 
 ation. A post-mortem examination disclosed a penetrating wound 
 of the middle of the anterior surface of the right kidney, the 
 bullet had destroyed that part of the organ and laid it open to 
 its outer or right border. The renal pelvis was not opened. 
 
 The case is remarkable because of the anterior surface being 
 penetrated from the front without injury to the peritoneum ; 
 and secondly, because only clear urine was drawn oft' during 
 life, or was present in the bladder after death. Xo doubt the 
 vessels of the parenchyma were at once plugged or thrombosed, and 
 * Med. Rec., April 10th, 1897
 
 224 SURGERY OF THE KIDNEY AND URETER. 
 
 as the renal pelvis was not opened, no blood escaped into it or 
 into the ureter or bladder. 
 
 Bernays records a case in which a negro, forty-two years of 
 age, was shot in the lumbar region, the ball entering 1J inches 
 from the spine below the twelfth rib, passing straight through 
 the loin and lodging near the gall-bladder 2 inches from the 
 middle line and the same distance below the costal margin, whence 
 it was extracted. There was profound shock, and one hour after 
 the injury there was intense and continuous hsematuria; on this 
 account the loin was explored : .a large haematoma was found, 
 and on reaching the kidney the ball was seen to have passed 
 completely through the organ opening the pelvis, ureter, and renal 
 vein. The kidney was therefore removed. The bullet was ex- 
 tracted from the front and the wound packed with gauze. The 
 nephrectomy incision healed by first intention and the packing 
 was removed from the front in eight days, the patient being 
 discharged cured in sixty days. 
 
 Operative interference is more" satisfactory at the time of 
 the injury than after the supervention of suppuration or 
 uraemia, when the kidney is destroyed and the operation prac- 
 tically amounts to the mere opening of a lumbar abscess. An 
 early nephrotomy enables the surgeon to ascertain the extent of 
 injury and either to simply drain the region or perform partial 
 or total nephrectomy. Since Gustav Simon first removed the 
 kidney at Heidelberg in 1868, the operation has been repeated 
 several hundreds of times, but only on five occasions on account 
 of bullet wound. 
 
 Keen of Philadelphia in 1896 collected nineteen cases of 
 gun-shot wound. Of these, ten recovered and nine died, four 
 dying after nephrectomy and five without the operation having 
 been performed. In only five of the nineteen cases was nephrec- 
 tomy done, In the successful operation there was also injury to 
 the liver followed by multiple abscesses. Of the fatal operations 
 the result was due in one case (Keen's) to gangrene of the 
 intestine fifteen days after the operation ; in another (Willard's), 
 to severe haemorrhage, the renal artery and vein having been 
 divided by the ball, which finally lodged in the wall of the 
 aorta; while in the other two (Von Brim's and Richardson's) 
 death resulted from subsequent suppuration or nephritis in the
 
 RECOVERIES AFTER LAPAROTOMY AND DRAINAGE. 225 
 
 other kidney. In the five fatal cases not nephrectomised, three 
 died of peritonitis and two of haemorrhage. 
 
 Of the ten which recovered, five teach especially important lessons. 
 In Mayo's case there were two perforations of the intestine, a wound 
 of the omentum and perforation of the pleura, the kidney being 
 perforated and blood present in the abdominal cavity. Lapar- 
 otomy and lumbar drainage saved both the kidney and the patient. 
 In Dalton's two cases, though the abdomen in one and the 
 abdomen and pleura in the other had been traversed by the 
 ball, yet, there being no evidence of serious internal haemorrhage 
 and none of wound of the intestine (the liver dulness not having 
 disappeared), abdominal section was not done and conservative 
 surgery was justified by the happy result in each. In Richard- 
 son's case the liver and kidney were both perforated, the latter 
 seriously, and there w r as free infra-peritoneal haemorrhage, yet 
 abdominal section, removal of the clots, and drainage of the 
 renal wound were followed by cure. In Tiffany's case both the 
 spleen and kidney were perforated, yet ligation of the spleen 
 tissue, and gauze tamponnade and drainage of the kidney, were 
 followed by a good result. 
 
 Dr. E. Adenot* records a case of a boy of seventeen being shot 
 in the left side : the ball of a revolver penetrated the antero- 
 lateral wall of the belly and wounded the kidney after passing 
 through the parietal peritoneum. Laparotomy was at once per- 
 formed, a quantity of blood-clot removed, and the starred and 
 fissured wound of the kidney detected ; the ball was not extracted. 
 Subsequently the projectile was located by the radiograph and 
 removed through the lumbar incision. Secondary infection 
 took place and the lumbar wound had to be reopened for more 
 effective circumrenal drainage. The patient ultimately recovered, 
 after a somewhat tedious illness, with the preservation of the 
 wounded organ. 
 
 Symptoms. The immediate effect of gun-shot wound of 
 the kidney, as of any other abdominal organ, is collapse, at- 
 tended by the usual manifestations of that condition : blanching 
 of the surface, cold sweats, small rapid pulse, cold extremities 
 and complete muscular prostration. Not unfrequently, when 
 
 * Lyon M< j d., Juin 5, 1898; Annexes des Mai. des Organes Ge'nito-urin- 
 aires, Avril, 1899, p. 395. 
 VOL I. P
 
 226 SURGERY OF THE KIDNEY AXD URETER. 
 
 reaction sets in vomiting occurs, there is severe pain in the 
 injured region often extending to the entire side, and especially 
 involving the testicle which may be retracted. 
 
 The pain appears to be more severe in those cases in which 
 the kidney is crushed or torn, and is comparatively slight when 
 the organ is simply perforated. Severe pain of a colicky char- 
 acter referred to the testicle, scrotum, or groin may indicate 
 the presence of blood-clot in the ureter. 
 
 Escape of urine occurs from the wound, and is a certain sign 
 not only of renal injury but that the pelvis of the organ has 
 been penetrated. The rapidity with which it occurs depends on 
 the shortness of the channel to the kidney and the supervention of 
 reaction after collapse, and also upon the length of time taken 
 in the separation of the eschar or sloughs. 
 
 Haemorrhage from the wound is usually slight, owing to the 
 formation of an eschar along the track of the projectile ; it may, 
 however, be considerable, especially where large vessels are lacerated ; 
 it may take place either immediately, or with the separation of 
 the eschar in from five to twelve days. It is a nearly constant 
 sign in the earl}' stage, and also after separation of the eschar. 
 As inflammation develops, a sanguineous discharge is commonly 
 followed by the escape of pus both by the wound and along the 
 ureter. This occurs earlier and with greater intensity when foreign 
 bodies accompany the bullet, particularly when such foreign sub- 
 stance is of a septic nature like portions of clothing. 
 
 The presence of a foreign body is indicated in addition by 
 rigors and intermittent fever, an unhealthy appearance of the 
 wound and breaking down of granulation tissue, with septic 
 peritonitis or metastatic pyoemic abscesses if the condition is 
 not relieved. 
 
 Besides these direct manifestations of the renal injury, there 
 may be indications of the effusion of gas, blood, or urine, and later 
 of pus around the kidney, or in the peritoneum in the case of an 
 abdominal wound, or into the pleura if the thorax is penetrated, 
 which may cause the kidney injury to be overlooked till urgent 
 straining and the passing of bloody urine draw attention to it. 
 
 On the other hand, though the evidence of wound of the 
 kidney lie indisputable, and the bullet pass completely through 
 the trunk, penetrating the peritoneal cavity, there may be 110
 
 HAEMORRHAGE AND SEPSIS THE CHIEF DANGERS. 227 
 
 serious injury of important organs, and the patient may recover 
 completely without operative interference. Thus in a case re- 
 ported by Surgeon-Major A. Hayes in the British Medical Journal 
 (i., 1886, p. 150), a man received a perforating gun-shot wound 
 of the abdomen by a Martini ball, implicating the right kidney 
 and producing profuse secondary haematuria. The ball entered 
 just to the right of the umbilicus and made its exit over the pos- 
 terior region of the right kidney, the probe showing that the 
 bullet had gone straight across and not round the abdominal 
 wall. The urine was smoky directly after the accident, and on 
 the seventh day large quantities of blood were passed per urethram, 
 which continued for five days and had a bright arterial colour. 
 The patient recovered completely without operative interference. 
 
 Grawitz* quotes six similar cases, five of which recovered 
 without operation, the sixth dying some time after the injured 
 left organ had been removed, from suppurative nephritis, or, as 
 Grawitz writes, " nephritis apostematosa," of the remaining kidney. 
 
 It would appear from these cases that the principal danger 
 in uncomplicated renal injury is septic infection, while that from 
 haemorrhage is by comparison slight. The most careful aseptic 
 measures should therefore be observed in the treatment of such 
 cases, and the use of the catheter as far as possible should be avoided. 
 
 An analysis of thirty-seven of the fifty cases referred to by 
 Edler, of which twenty-two proved fatal, showed that haematuria 
 was the most constant symptom, being noted in twenty-six in- 
 stances ; pyuria occurred in nine ; ten were marked by escape 
 of urine from the wound ; seven by paraplegia, and an equal 
 number by neuralgia and other nervous manifestations ; four 
 showed symptoms of nephritis, and three disturbance of the 
 function of the opposite kidney. 
 
 Analysis of the symptoms of gun-shot wounds of kidney during 
 the American Civil War. Of twenty-six cases of reported recovery 
 from, wounds of the kidney, during the American Civil War, 
 haematuria occurred in fifteen. Various forms of dysuria are 
 referred to, and lumbar pains, muscular rigidity, partial paralysis, 
 and other disabilities are mentioned. Abstracts of fourteen of 
 these cases are published in the " History," and as many of them 
 lived for several years they supply some important information 
 
 * Arch. f. klin. Chir., 1889, bd. xxxviii., pp. 438-9.
 
 228 SURGERY OF THE KIDNEY AND URETER. 
 
 as to symptoms and ultimate results. From such facts concerning 
 these fourteen cases as are supplied I find that seven had haema- 
 turia, two pus in the urine, three pain on micturition, two re- 
 tention of urine, one for ten days, the other only until the day 
 after the injury. One had retraction of, and one acute pain in, 
 the testis. Four had paralysis of the muscles of the leg of the 
 same side as the injured kidney, and three had some weakness 
 of the muscles of the spine and were unable to stoop or lift 
 any weight, or were bent and could not straighten the back 
 without pain in the region of the kidney. In one case, in which 
 the wound of the kidney was complicated with wound of the 
 intestine, the patient passed a musket ball, weighing an ounce, 
 with the stool ten days after he was shot ; this man was alive 
 ten years afterwards, but was totally disabled by incomplete 
 paralysis of the right side and constant pain in the back and 
 neck, sometimes so severe as to confine him to bed for several 
 days. In another case in which the descending colon, as well 
 as the left kidney, was injured, there was a permanent faecal 
 fistula ; this man was alive nine years after the infliction of 
 the wound. 
 
 The editor of the " History " remarks that in a few cases 
 pus and phosphatic deposits in the urine were observed for con- 
 siderable periods. 
 
 After haematuria has ceased, blood in microscopic quantity, as 
 well as pus and tube casts, may be found in the urine. 
 
 In a very remarkable case (No. 513)* the ball entered over the 
 outer part of the left clavicle whilst the soldier was stooping, 
 and having passed through the lung it lodged in the region of 
 the left kidney, and was extracted on the tenth day, together 
 with fragments of fractured Ixme. Haematuria continued for 
 eight or ten days after the injury. Nearly five months afterwards 
 the urine contained albumen, granular uriniferous tube casts, 
 and blood and pus corpuscles. This man was alive ten years 
 and a month after receiving the wound, but had frequent pain 
 in the shoulder, and his left arm was partially paralysed. 
 
 Secondary haemorrhage is common after the separation of 
 eschars or sloughs. When haematuria comes 011 six, seven, eight 
 days, or later, after a gun-shot wound, it is generally caused 
 
 * "History of the War of the American Rebellion."
 
 CAUSES OF DEATH. 229 
 
 by the separation of sloughs. Herein rests a great distinction 
 between gun-shot wounds and incised wounds. The latter may 
 heal rapidly and without suppuration ; the gun-shot wounds 
 are followed by more or less sloughing and suppuration and 
 all the risks to which those processes expose the patient. 
 
 There may be second haemorrhage from the bowel without 
 hsematuria if the colon as well as the kidney is damaged ; or 
 a retro-peritoneal abscess may be a secondary consequence, as 
 in the following fatal case, recorded by Lidell.* 
 
 A man, aged twenty -nine, was shot in the right hypochondriac 
 region just below the margin of the ribs. Pain, tympanitis 
 and hsematuria were quickly exhibited. On the following day the 
 haematuria continued, but after this it appears to have ceased. 
 On the fifth day the abdominal pain and tympanitis had in- 
 creased, and blood had been seen hi the stools. The patient died on 
 the thirteenth day from the bursting of a retro-peritoneal abscess 
 into the right pleura. The right kidney had been pierced at 
 its .lower end ; the bullet w r as found against the sacrum. 
 
 Lidell f gives an instance of gun-shot wound of the right 
 kidney, in which the patient died of peritonitis fifteen days after 
 he was wounded. The right kidney had been pierced by the ball, 
 which was found lying loose in the cellular tissue near the spinal 
 column ; the kidney was for the most part disintegrated, the blad- 
 der highly inflamed and filled with bloody pus, and the peritoneum 
 everywhere inflamed. The ball entered about two inches to the left 
 of the third lumbar vertebra, and passing obliquely forwards, 
 upwards, and to the right, traversed the bodies of the second 
 and third lumbar vertebrae to reach the right kidney. 
 
 When the injury to the kidney is associated with wounds of 
 the stomach, liver, spleen, or other important structures, such as 
 the intestines, diaphragm, or thorax, an almost certain and 
 generally a very speedy death from shock, or shock and haemor- 
 rhage combined, must be anticipated. When the spinal column 
 is involved symptoms due to that lesion will be present. Thus, 
 in Lidell's case just quoted there was partial paralysis of the 
 lower extremities w r ith diarrhrea and inability to void urine from 
 
 * Amer. Journ. Med. Sciences, April, 1867, p. 356: "Injuries of the 
 Abdominal Viscera by Firearms." 
 
 t Amer. Journ. Med. Sciences, Oct., 1864, p. 134 : " Injuries of the Spine."
 
 230 SURGERY OF THE KIDNEY AND URETER. 
 
 the first ; on the ninth day peritonitis and ischuria renalis, and 
 on the thirteenth complete paralysis of the lower limbs and 
 enuresis in place of retention of urine, occurred. 
 
 If foreign substances have been carried into the wound and 
 become lodged in the ulterior of the kidney, much pain and even 
 very violent suffering may be caused by the transit of the foreign 
 body along the ureter and urethra. 
 
 Portions of clothing carried in by a bullet may possibly be 
 detected and removed through the external wound. 
 
 Sometimes as the result of ulceration air may gain admission 
 to the renal pelvis. Sometimes a fragment of bone may either 
 be driven into the kidney by the weapon, or find its way there 
 after a time by pressure or ulceration. 
 
 In two remarkable gun-shot cases, pieces of cloth from the soldiers' 
 uniforms (in one instance accompanied by " epithelial detritus," and 
 in the other coated with phosphates) were passed by the urethra. 
 One of these is mentioned by Demme,* who says, " One of my 
 colleagues at the Ospedale, San Francisco, observed a case of -shot 
 wound of the kidney in which a piece of cloth from the soldier's 
 uniform passed by the urethra ; examination proved the cloth 
 to be impregnated with epithelial detritus." 
 
 The other, probably the most singular case on record, as 
 illustrating nearly the whole series of symptoms of injuries of 
 the kidney, is recorded by Hennen.j 
 
 An officer was wounded by a musket-ball, which entered 
 Ijetween the ninth and tenth ribs, and about midway between 
 the sternum and the spine, and was cut out from near the 
 point of the transverse process of the lowermost dorsal vertebra, 
 on the day after the receipt of the wound. Within an hour he 
 voided a quantity of bloody urine. He was in extreme pain, which 
 was aggravated by his being moved a distance of three leagues 
 the same night. Soon the pain spread from his wound over 
 his Ixnvels, and delirium supervened ; he was then bled several times, 
 and blisters were applied to his abdomen. Then followed intense 
 pain in his right shoulder, and the wound in his back nearly 
 mortified from his lying so long, but in seven weeks he was 
 well enough to be sent to England. The journey excited fever, 
 
 * Mcd.-Chir. Studien, bd. ii., s. 151 (1SG1). 
 t Op. cit., pp. 442 et seq.
 
 DIAGNOSIS OF GUN-SHOT WOUNDS. 231 
 
 and a recurrence of peritonitis ; and a tumour formed in the site 
 of the posterior wound, which was punctured at the end of a 
 fortnight, and six ounces of pus having a urinous smell were 
 evacuated. The discharge continued for some time, and another 
 abscess formed lower down, which was punctured in about three 
 weeks, and a large quantity of pus of the same kind escaped. 
 The abscess healed and burst again and again. Pain, emaciation, 
 and frequent micturition followed, but with actual diminution 
 of the quantity of urine voided, together with the symptoms 
 of renal colic. And then, at the expiration of seven months 
 from the infliction of the wound, he passed per urethram some- 
 thing having the shape of a short thick shrimp, w r hich upon 
 examination proved to be a piece of cloth, covered with black 
 grit. After this he rapidly convalesced. 
 
 Stromeyer relates the case of a Danish officer who was shot 
 in the right side under the short ribs, and who soon after passed 
 urine through the wound, and had haematuria. A concrement 
 of the size of an orange pip was voided per urethram two 
 months after. 
 
 Diagnosis. The diagnosis of gun-shot wounds must be 
 made with reference to the situation and direction of the track 
 of the wound, the presence of blood in the urine, and the escape 
 of urine by the external wound. The situation of the pain, 
 the suppression or partial suppression of urine combined with 
 haematuria or the discharge of a .little urine from the wound 
 are also most important indications. Allowing for the difference 
 in the character of the wound inflicted by firearms and by 
 penetrating weapons other than firearms, and for the fact that 
 whilst firearms contuse the tissues, which therefore are less 
 prone to primary haemorrhage than wounds inflicted by cutting 
 instruments, the points of diagnosis of the one class are the same 
 as those of the other. The reader therefore is referred to the 
 description given of the diagnosis of Incised and Punctured 
 Wounds on previous pages. 
 
 Prognosis. In the fifty instances of gun-shot wounds of 
 the kidney cited by Edler the fatalities were twenty-two, of 
 which eight were due to complications, six to pyaemia after 
 three months, and eight to peritonitis or haemorrhage within 
 eight days.
 
 232 SURGERY OF THE KIDNEY AND URETER. 
 
 Of extra-peritoneal shot wounds, about one-fourth appear to 
 end fa tall}\ The difference in prognosis between complicated and 
 uncomplicated shot wounds of the kidney in the above series is 
 clearly indicated in the following table : 
 
 Recovered. Died. Total. Per cent. 
 
 Uncomplicated . . 15 5 20 85 
 
 Complicated . . . . 3 15 18 80 
 
 Not stated . . 10 2 12 16'8 
 
 In a larger series, quoted by Kiister in 1896, we find the 
 
 following results : 
 
 Recovered. Died. Total. Per cent. 
 
 American War . . 26 59 85 69'41 
 
 Franco-German War . . 7 8 15 53 "33 
 
 Other cases, chiefly in civil life 37 13 50 26 
 
 The difference in mortality in military practice is attributed 
 to the circumstances of war and the greater size and velocity of 
 the projectile. The prognosis is also very much worse when the 
 spinal cord or the thoracic or abdominal cavities are injured, or 
 when foreign bodies are carried into the wound. 
 
 In the series of nineteen cases collected by Keen between the 
 years 1884 and 1896 ten recovered, and nine died, and an analy- 
 sis of the injuries shows the same preponderance of mortality in 
 the complicated over the uncomplicated cases. 
 
 Complications, such as wounds of the spinal column, diaphragm 
 and intestines, bring their own results, so that actual recovery from 
 n wound of the kidney may be followed by death due to such com- 
 plications. In some of these fatal cases the kidney was repaired 
 and had been performing a large share of the work of excretion. 
 
 Treatment. The first measures must be directed to the relief 
 of the state of shock, which occurs immediately 011 receipt of the 
 wound. 
 
 Complete rest, warmth and stimulants are needed in this stage, 
 and should be followed shortly by the administration of morphia 
 to relieve pain and restlessness. Any interference with the wound 
 is prohibited, and it is best merely to cleanse and cover it with 
 a loose absorbent dressing such as a pad made of double cyanide 
 gauze tissue or some other absorbent and antiseptic material. Plug- 
 ging is undesirable as it leads to internal accumulation of blood and 
 urine or to inflammatory exudation. When reaction occurs, a wound 
 in the thorax or abdomen may be closed, provided the bullet
 
 PRIMARY OPERATIONS NOT MUCH EMPLOYED. 233 
 
 has passed out and there is no indication of haemorrhage or in- 
 jury to organs that requires immediate interference. Such a 
 favourable state of things is necessarily very rare and must not 
 be hastily assumed to exist. 
 
 If the bullet remains in the body it should be carefully sought 
 for and, if possible, removed, with any foreign bodies such as 
 portions of clothing or splinters of bone that may have been 
 carried in with it. 
 
 We learn from the History of the American Civil War that 
 " urinous infiltration in the lumbar cellular tissue does not appear 
 to be common after shot wounds of the kidney. The reason 
 probably is, that the eschars lining the track protect the parts 
 until a limiting wall of inflammatory exudation has formed. 
 Hence it seems unwise to enlarge the exit wounds at first ; but 
 later on, the free incision of the phlegmonous accumulations likely 
 to form in the loin constitutes a most important part of the 
 treatment." 
 
 During this War of the American Rebellion we are told that 
 the practice which Larrey and Dupuj'tren enjoined, of freely 
 enlarging the lumbar orifices of wounds of the kidney to prevent 
 the infiltration of urine internally, or amongst the muscles of the 
 back, does not appear to have been at all followed. Thus we read : 
 " Nephrotomy was not practised. Though there were several in- 
 stances of lodgment of balls in the kidney, and cases of lacera- 
 tion, without communication with the peritoneal sac, there appear 
 to have been none in which the attendant circumstances were 
 thought to require nephrotomy, or to warrant the operation 
 of extirpation of the kidney." It must, however, be observed 
 that this statement was published in 1876, and refers to a 
 period of from eleven to thirteen years before, and that the 
 first nephrectomy was not performed till 1869 ; and one cannot 
 but feel that with our present experience of renal operations, 
 several of the recorded cases of gun-shot injuries might with 
 advantage have been submitted to one or other of them. 
 
 It is probable, however, that when the Surgical History of 
 the South African War comes to be written the same absence 
 of operative treatment for wounds of the kidney will have to 
 l)e recorded, but that the reasons assigned for not operating 
 will be different.
 
 234 SURGERY OF THE KIDNEY AND URETER. 
 
 Already we have heard enough to know that penetrating 
 wounds of the kidney caused by small-bore bullets do not 
 necessarily set up fatal mischief, even when other organs the 
 liver, the spleen, or the intestines are also penetrated : that 
 even if large blood-vessels within a solid organ are partially divided 
 haemorrhage need not be serious ; and that the kidney or the 
 liver may be traversed from before backwards or from side to 
 side without any symptoms of importance following. A shrapnel 
 bullet has been known to pass through both liver and kidney 
 and yet cause only slight collapse and some temporary tympan- 
 ites and hasmaturia. Mauser bullets have traversed the abdomen 
 in all kinds of directions, and yet the wounded men have made 
 good recoveries without requiring operation. 
 
 It is the contused and lacerated wound, and the wound 
 made septic by the introduction of other foreign bodies, such 
 as pieces of clothing and fragments of bone, as well as the 
 bullet, which give rise to grave consequences at the time and 
 serious complications at a later date. Small-bore bullets make 
 exceedingly small wounds and do not lacerate ; hence in many 
 instances there are practically no immediate symptoms and no 
 after ill-effects whatever. 
 
 The question of surgical interference will be settled by the 
 nature and extent of the injury. So far as the kidney itself 
 is concerned, a superficial wound of the cortex leads to no extra- 
 vasation of urine, to but trifling haemorrhage, and to practically 
 no risk of auto-infection, owing to the fact that only capillary 
 vessels and tubes are laid open and rapidly close, allowing of no 
 communication with the bladder, and supplying but little clot 
 or exudation in which wandering germs can develop. In such 
 cases careful aseptic dressing of the wound may be all that is 
 necessary. 
 
 When the bullet lays open the ureter, renal pelvis, or vessels 
 of the hilum, there ensues extravasation of blood or urine or 
 both together. The immediate danger from haemorrhage, either 
 into the abdominal cavity if the peritoneum is rent, into the 
 bladder by way of the renal pelvis and ureter, or, if these are closed, 
 into the parts surrounding the kidney, is very great ; and the 
 risk of subsequent infection of large blood or urinous effusions, 
 especially where there is free communication with the bladder
 
 TRANS-PERITONEAL OPERATIONS BEST FOR SOME CASES. 235 
 
 through the ureter, makes the prospect of saving the kidney or 
 the life of the patient almost hopeless. Taking these matters into 
 consideration, and also the fact that an injury at the hilum of the 
 kidney, producing these conditions, necessarily involves loss of 
 function, if not actual death of the organ, nothing remains but 
 to explore the kidney and, if necessary, to remove it. 
 
 In cases where the main vessels are divided, haemorrhage is 
 generally so severe and continuous that immediate operation is the 
 only means of arresting it in time to save life. An instance of 
 this is recorded by Willard.* Both artery and vein were divided 
 and the ball lodged in the wall of the aorta : abdominal iiephrec- 
 tomy was performed immediately and the patient survived four 
 days, but ultimately died of haemorrhage. 
 
 . Besides these extremes, as regards severity of the injury, 
 there are perhaps a greater number of intermediate cases which 
 must be treated each on its merits; they call in most instances 
 for exploration, but on examination the kidney need not in 
 every one be sacrificed. 
 
 Except in those cases where the bullet has entered from the 
 back or side, and the damage is presumably retro-peritoneal, it 
 is for the most part best to make an abdominal incision so as 
 to be able to deal with haemorrhage into the peritoneum and 
 injuries to other abdominal viscera, besides having a wider view 
 of the ureter and vessels. 
 
 The opening is usually made in the middle line, but Langen- 
 buch's incision along the side of the rectus may be preferable 
 when the injury is believed to be limited to one side. 
 
 The first necessity is to stop bleeding and clear out blood and 
 clot from the peritoneal cavity. Nephrectomy is required when 
 the vessels or renal pelvis are so damaged as to interfere with 
 the vitality or excretory function of the organ, but should one pole 
 only be injured a partial excision may suffice. Keenf was the 
 first to publish a case of nephrectomy for gun-shot wound of 
 the kidney. The stomach, liver and ileum, were involved, as 
 well as the mesenteric artery. The patient died 011 the fifteenth 
 day from peritonitis due to gangrene of the bowel. The nephrec- 
 tomy was by the abdominal method. 
 
 * Trans. Amer. Surg. Assoc., 1888, vol. vi., p. 516. 
 t Trans. Amer. Surg. Assoc., 1887, vol. v., p. 193.
 
 236 SURGERY OF THE KIDNEY AND URETER. 
 
 The removal of clots from the bladder is of the utmost im- 
 portance, not only on account of the pain and discomfort they 
 produce and the obstruction they cause to urination, but because 
 of their tendency to septic infection and suppuration, with the 
 consequent changes in the kidneys and in the environment of the 
 
 wound. 
 
 
 
 In Willard's case, the bladder being found full of clots when 
 it was examined at the time of the abdominal nephrectomy, and 
 its walls being intact, he simply removed all the clotted blood 
 in the bladder by squeezing it with his hands. 
 
 If no abdominal opening has been made, the clots may be 
 broken up and removed by means of a large catheter or Bige- 
 low's evacuator ; and should the bleeding be continuous and severe 
 the kidney must be removed, or a free incision made into the 
 bladder to ensure its remaining free of subsequently formed clot. 
 
 The importance of removing clots of blood from the bladder 
 has been mentioned in describing the treatment of ruptured 
 kidney, and it cannot be too fully emphasised. The aseptic 
 catheterisatioii and irrigation should be first tried, but if these 
 means fail, the bladder should be cleared by cystotomy. 
 
 It matters but little whether the bladder be reached by a 
 perineal or suprapubic incision, so long as there is a free exit 
 for the escape of the clots, but on the whole, the suprapubic 
 opening is to be preferred as being more easily kept aseptic. 
 Foreign bodies introduced into the kidney and escaping along 
 the ureter into the bladder require removal. It is impossible 
 to read the account of Hennen's celebrated case, or to have 
 witnessed the sufferings of Hilton's patient, to whom I have 
 before referred (p. 184), without feeling convinced that both 
 would have been saved a world of pain had cystotomy been 
 performed. In Hennen's case, moreover, the operation would 
 doubtless have led to the early detection and removal of the 
 foreign body in the bladder, to the expulsion of which, along 
 the urethra, the agony of the latter period of the case was due. 
 
 That Hennen's patient at length recovered by nature's efforts 
 without an operation is no argument whatever against nephrotomy 
 and cystotomy in similar cases. Miraculous recoveries must not 
 make us lose sight of general principles, nor extraordinary cures 
 cause us to forget ordinary dangers.
 
 SECONDARY NEPHRECTOMY IMPRACTICABLE FROM ADHESIONS. 237 
 
 Haemorrhage should be checked by the internal administration 
 of large and quickly repeated doses of ergot, by the local appli- 
 cation of ice, and by well-directed pressure upon the loin ; care 
 must meanwhile be taken to secure good drainage of the wound. 
 
 If life be threatened by haemorrhage or suppuration, the 
 kidney ought to be removed by lumbar nephrectomy. 
 
 Simon gave it as his opinion " that it might be advantageous 
 in uncomplicated cases of injury to the kidney, where the kidney 
 suppurated (cases almost invariably fatal), to extirpate the injured 
 kidney." Billroth (in 1870 1872), quoting this remark of Simon's, 
 added, " I would not hesitate to perform this operation, should 
 an opportunity offer." At the present day nephrectomy, or 
 nephrotomy with drainage, according to the circumstances of the 
 case, is acknowledged to be the right treatment for this condition. 
 
 The persistence of a urinary fistula in a case which has other- 
 wise ended favourably calls for a plastic operation to close the 
 false channel. 
 
 If phlegmonous inflammation or extravasation occurs, free 
 incisions should not be delayed, and if a circumscribed collection 
 of urine or blood is formed, though repeated aspirations might 
 possibly bring about a cure, yet they ought not to be relied 
 upon a free incision and drainage being not only more certain 
 but also much quicker in its effect. 
 
 Professor von Brun published a case, in 1871, of a man with 
 urinary fistula, following a shot wound received in December, 
 1870 ; a portion of the left kidney \vas extirpated March 23rd, 
 1871, and death resulted ten hours afterwards. The organ was 
 so adherent that its complete removal was impracticable. It was 
 converted into a large abscess. The right kidney was also dotted 
 with small abscesses, an indication, probably, that the nephrectomy 
 was too long delayed.
 
 238 
 
 CHAPTER VIII. 
 ANEURYSM OF THE RENAL ARTERY. 
 
 REFERENCE has already been made (p. 161) to traumatic aneurysm 
 as one of the consequences of subparietal injury, but aneurysms of 
 the renal artery and its branches occur also from other causes 
 than injury. Whether traumatic or spontaneous, they are among 
 the rarest of all aneurysms. 
 
 Two varieties are found after injuries : (1) small sacci- 
 form aneurysms, the walls of which are formed by some or all 
 the coats of the artery ; and (2) large false aneurysms, the walls 
 of which become more or less firmly matted to the surrounding 
 organs and tissues. 
 
 A false aneurysm may go on growing for years, and ultimately 
 attain an enormous size. It can develop in three ways, namely : 
 (a) by the giving way of a small true aneurysm ; (b) by the 
 yielding of a thrombus which temporarily closes a ruptured artery ; 
 and (c) by the immediate outpouring of blood from a ruptured artery. 
 
 A true or sacciform aneurysm always, apparently, of small 
 size if of traumatic origin, may be associated with an extravasation 
 of blood or urine, or of blood and urine ; both being the conse- 
 quences of the same accident. One such case, at least, is on 
 record (Reeves's or Turner's). In this case the swelling detected 
 during life was a false hydro-haemato-nephrosis. The small 
 aneurysm was a post-mortem discovery, and had no bearing on 
 the cause of death ; but none the less it was a very interesting 
 and rare result of injury. 
 
 A true aneurysm may be associated with a false aneurysm, 
 and both may be the direct result of the same accident : thus 
 a small sacciform aneurysm may be situated on the renal artery, 
 and the artery or one of its branches may be torn across or 
 lacerated further on, and there open, into the false aneurysmal 
 sac. Such was the condition in Hilton's case. 
 
 In an article published in the Lancet of October (th, 1900, I 
 have given brief abstracts of nineteen cases of renal aneurysm, 
 and these are all which up to the present are known to -have
 
 ANEURYSM A LATE CONSEQUENCE OF INJURY. 239 
 
 occurred. The cases fall into different groups as follow : (1) True 
 aneurysm of traumatic origin associated with false hydro-hsemato- 
 iiephrosis, one case ; (2) true aneurysm of traumatic origin 
 associated with false aneurysm due to rupture of the artery and 
 not of the sacciform aneurysm, one case; (3) false aneurysm due 
 to the bursting of a sacciform aneurysm, three cases; (4) false 
 aneurysm due to yielding of a thrombus in a ruptured artery, 
 one case ; (5) false aneurysm following immediately on the wound 
 of the artery, six cases; (6) aneurysm of the renal artery not 
 of traumatic origin, seven cases. 
 
 Although the cases there collected are the only instances of 
 aneurysm of the renal artery or its branches with which I 
 am acquainted, it is probable that many others of the kind 
 have been overlooked at post-mortem examinations, or, if de- 
 tected, have remained unrecorded. Now that attention has 
 been drawn to their occurrence, there will, I anticipate, be 
 other examples forthcoming in the near future. As a result 
 of injury, aneurysm, whether of the sacciform or diffused type, 
 is of great practical importance. If of the sacciform type, it 
 would seem to be usually either associated with some other 
 injury to the kidney or renal pelvis giving rise to haematuria or 
 a large tumour consisting of blood and urine ; or the sacciform 
 aneurysm after a time ruptures and a false aneurysm is formed. 
 
 A false aneurysm, whether caused by the rupture of a sacci- 
 
 ' form aneurysm or by the direct rupture of the walls of the 
 
 artery, gives rise to a tumour of great clinical interest puzzling 
 
 to diagnose, difficult and dangerous to treat, and hitherto, if not 
 
 operated upon, invariably fatal. 
 
 The knowledge that an aneurvsmal tumour is occasionally a 
 late and not an immediate consequence of injury ; that it may 
 be caused by an accident which either slightly or extensively 
 damages the kidney ; that it often ultimately leads to absolute 
 destruction by atrophy or inflammation of the whole or a con- 
 siderable part of the organ ; and, finally, that there is great risk 
 attached to operative treatment, and certain death if such treat- 
 ment is not adopted such knowledge ought to be an additional 
 inducement to surgeons, if other conditions do not contra-indicate 
 the operation, to explore early every kidney which is seriously 
 damaged by an accident.
 
 240 . SURGERY OF THE KIDNEY AND URETER. 
 
 Etiology. Of the nineteen cases of renal aiieurysm which 
 I have collected (the number of cases I collected is twenty-one, 
 but two are omitted from the analysis for reasons given in the 
 article referred to), twelve were traumatic and seven spontaneous. 
 Of the traumatic cases two \vere sacciform when discovered after 
 death, nine were false, and one doubtful. Of the nine false 
 aneurysms two occurred from the bursting of a sacciform aiieu- 
 rysm; one followed after a time from the yielding of a thrombus 
 in the ruptured artery, without having been preceded by a sacci- 
 form aneurysm; five were the immediate consequence of rupture 
 of the artery ; and in one the nature of the aneurysm is riot 
 mentioned. 
 
 Of the seven spontaneous aneurysms, three were sacciform. 
 One of these was described as being of the size of an apple, and 
 two of the size of a haricot bean and of a hazel nut respectively. 
 One was a false aneurysm in the form of a true ha?mato-nephrosis. 
 
 In one case no description of the aneurysm is given beyond 
 the fact that it ruptured into the renal pelvis. The sixth was 
 probably sacciform originally, but ruptured and became a false 
 aneurysm, forming an intra-capsular tumour surrounding the 
 kidney. The seventh seems to have been a false aneurysm from 
 the beginning. 
 
 Sex. Of the twelve traumatic cases, ten were in men, two 
 were in women. In the case of one of the women there might 
 be some doubt as to whether the sacciform aneurysm w T hich 
 subsequently ruptured was really of traumatic origin, because 
 though she had a fall 011 a staircase, she had apoplexy from a 
 haemorrhage into the left optic thalamus, and was the subject of end- 
 arteritis her aorta and other arteries being affected. The branches 
 of the renal artery next the clot were markedly dilated and tortuous. 
 
 Of the seven spontaneous aneurysms, four were in males, three 
 in females. 
 
 Age. Of the traumatic cases the age is stated in ten. 
 One was fifteen, one nineteen, one twenty-one, one twenty-five 
 years, one thirty-six, another thirty -nine, and four were between 
 the ages of forty-nine and fifty-one. Of those whose ages are not 
 given, both were men in active life; one is described as a "young 
 boatman," the other as a " doctor," whose aneurysm resulted from 
 a fall from a horse four years before his death.
 
 NO CHANGES IN KIDNEY FROM TRUE ANEURYSM. 241 
 
 Of the spontaneous cases the ages of six are stated : they 
 were all over fort}' ; the youngest was forty-three, the eldest 
 sixty-six. The seventh was described as " a young man." 
 
 Nature of injury or disease. Of the traumatic cases, one 
 patient was thrown out of a cart ; another was struck by the 
 buffer of an engine ; a third was thrown from a horse ; two 
 fell from a height, striking the loin on the side of the injured 
 kidney ; one slipped and struck his loin on the gunwale of his 
 boat ; one fell against a counter and contused his side ; one fell 
 against a box ; another slipped and fell against the edge of a 
 low wall ; two fell against steps or a staircase ; and one was 
 run over by a handcart. 
 
 Of the spontaneous cases, malignant endocarditis with multiple 
 emboli was present in one case ; calcareous degeneration of the 
 coats of the arteries was found in two others; another died of 
 nephritis ; the fifth died comatose with destruction of one kidney 
 from the aneurysm and chronic nephritis of the opposite kidney. 
 In the sixth the patient had what must have been erroneously 
 called an attack of " rheumatic fever," for it passed off in five 
 days. It seems probable that an embolus or a thrombus led 
 to the development of the aneurysm. In the seventh case there 
 was absolutely no assignable cause. Leudet, following Corvisart, 
 Griithrie, and Berard, thought these small aneurysms were de- 
 veloped in the substance of the wall of the vessel and subsequently 
 opened into the lumen of the artery. 
 
 Pathological consequences. As long as a sacciform aneurysm 
 remains unruptured it seems not to produce an}* distinct changes 
 in the kidney or parts around. If situated within the kidney 
 capsule the little tumour may press aside and more or less flatten 
 some of the tubules, as in Armstrong's case, but without de- 
 stroying them. If a sacciform aneurysm bursts into the renal 
 pelvis profuse haemorrhage is the result ; the bladder may become 
 distended with blood and blood-clot, and blood may flow away 
 from the urethra as in Gossett's and Oestreiclvs cases. The 
 patient thus dies from sheer loss of blood, or from this cause 
 combined with the pain and other effects of blood-clots distending 
 and decomposing within the bladder. 
 
 When a false aneurysm is formed whether as the effect of 
 injury or disease, and whether indirectly by the rupture of a 
 
 VOL. i. Q
 
 242 SURGERY OF THE KIDNEY AND URETER. 
 
 sacciform aneurysm, or directly by the giving way of the artery 
 matters not serious damage is generally done to the kidney, 
 and extensive pressure changes and displacements are wrought 
 in the surrounding tissues and organs. The blood may distend 
 the pelvis and calyces, and, producing complete absorption of the 
 renal parenchyma, create a true hsemato-nephrosis ; or it may be 
 extravasated entirely within the capsule, between it and the 
 renal parenchyma ; or it may be extravasated partly within the 
 renal capsule and partly into the perinephric tissue ; or it may be 
 entirely outside the renal capsule completely or partially surrounding 
 it. The kidney may have undergone complete or partial atrophy ; 
 
 Cajisul 
 
 White laminated 
 clot. 
 
 Cavity. 
 
 Kidnev. 
 
 Fig. 31. Aneurysm of Renal Artery with Kidney. Removed during life by 
 Albert of Vienna. (Reproduced from Hochenegg's paper.) 
 
 or the kidney, if any remains of it, may be spread out in the wall 
 of the sac, as it was in the case under my own care, in which the 
 kidney had almost, and its adrenal had completely, disappeared. 
 
 When part of the kidney has been flattened out or absorbed 
 the rest of the organ may appear to be covered by the same 
 capsule. Even when the aneurysm has been stated to be entirely 
 separate from the kidney it is yet described as being in the same 
 capsule (Hahn). This condition of the capsule is, I have no 
 doubt, in some cases only apparent, not real. The matting 
 together of the sac of the aneurysm and the structures ad- 
 jacent becomes so intimate and firm that it is impossible to say 
 where renal capsule ends and sac begins. It is the same with 
 the capsule of an adrenal tumour, as is pointed out in Chapter 
 XXIII. , when describing " Tumours of the Adrenal " (Vol. II., p. 1 ( .).
 
 RUPTURE OF THE RENAL CAPSULE BY FALSE ANEURYSM. 243 
 
 The blood may tiller along the course of the vessels and thus 
 get within the capsule of the kidney and thence break into the 
 calyces. It will be seen from Fig. L, Plate I., in Chapter L, that the 
 relation of the small branches of the Venal artery to the calyces 
 readily explains their rupturing into the renal cavity and the 
 escape of fluid blood thence along the infundibulum and ureter. 
 If the blood is really extravasated within the renal capsule it 
 may either break down and disintegrate the parenchyma and 
 
 A 
 
 Fig. 32. Dr. W. \V. Keen's case of Aneurysm of the Renal Artery. 
 Right and left are the two halves of the kidney ; the whole central mass is the aneurysm, filled chiefly 
 with laminated clot. A, Probe, showing where the renal artery communicates with the sac of 
 the aneurysm ; B, probe in the pelvis of the kidney and the ureter. (Reproduced from the Phil, 
 Journ., May 5, 1900.) 
 
 rupture the capsule, or spread between the parenchyma and the 
 capsule (Armstrong's and Eouppe's). 
 
 If the capsule is stripped up from the parenchyma the latter 
 may be undamaged except that its outer surface will be slightly 
 roughened, or eroded ; but the capsule may be greatly distended and 
 even ruptured, and thus blood may escape into the peritoneal cavity 
 (Armstrong's case) as well as into the retro-peritoneal tissue. 
 
 The tumour may displace and become extensively adherent 
 to neighbouring structures. The colon is commonly displaced 
 towards the median line ; the liver and spleen are pressed up- 
 wards and the diaphragm may be raised. Some of the adhesions 
 of the sac wall may be loose and easily separated ; others may 
 be so dense and strong that they are aljsolutely inseparable as
 
 244 SURGERY OF THE KIDNEY AND URETER. 
 
 was the case between the sac and the diaphragm, and the sac 
 and some parts of the peritoneum, in my own patient. 
 
 The contents of the sac are for the most part blood-clot ; 
 there is sometimes only a Very little fluid blood or blood serum, 
 so that not more than a drachm or two can be drawn off when 
 the tumour is tapped in the course of exploring it. 
 
 The clot in the sac is of different ages, colour, and con- 
 sistence. In some cases it has been found nearly all laminated ; 
 in others chiefly passive ;. in others again disintegrated. 
 
 When a sacciform aneurysm and a blood tumour co-exist 
 the source of the blood which forms the tumour is not always 
 the vessel upon which the small sacciform aneurysm is situated. 
 The blood may be derived from a ruptured vein or from torn 
 vessels in the parenchyma (Reeves's) ; neither the artery on 
 which the aneurysm is situated nor the small aneurysm itself 
 being lacerated ; they are therefore not in communication with the 
 perinephric blood tumour, and not the source of the haematuria. 
 
 The blood may be derived from the vessel on which a small 
 aneurysm is situated, and not from the aiieurysm itself (Hilton's 
 case). When this is so, two aneurysmal conditions really co-exist 
 in connection with the same vessel, namely, a small sacciform 
 aneurysm and a large false aneurysm. 
 
 The perinephric tumour co-existing with the small sacciform 
 aneurysm may be composed partly of blood and partly of urine, 
 the blood being derived either from the aneurysm or from the 
 artery on which it is placed, or from a different source altogether; 
 the urine comes from a lacerated renal pelvis or calyx (Reeves's 
 and Hilton's cases), or from the ureter. 
 
 Either a spontaneous (Gossett's) or a traumatic (Oestreich's) 
 aneurysm may burst into the renal pelvis. In Daniel Nebel's 
 case, as well as in Armstrong's, death was caused by the rupture 
 of the aneurysm into the peritoneal cavity. 
 
 Both local and general peritonitis have been caused by the 
 aneurysm ; and in Hilton's case there was a slough with a per- 
 foration in the peritoneum over the tumour. 
 
 Symptoms. An unruptured sacciform aneurysm gives rise to 
 no clinical symptoms, and is only discovered at the post-mortem 
 examination of a person who has died of some other disease, or from 
 some other effect of the same accident which caused the aneurvsm.
 
 TUMOUR AND HEMORRHAGE CAUSED BY FALSE ANEURYSM. 245 
 
 If it is possible that a small uiiruptured aneurysm no larger 
 than a haricot bean may assist in producing atrophy of the kidney 
 (Leudet's and Banner's cases), this nevertheless would be unat- 
 tended with any clinical signs. 
 
 A false aneurysm, no matter how formed, whether traumatic 
 or spontaneous, probably always causes sooner or later a tumour, 
 and nearly always gives rise to haematuria. There are no symptoms 
 other than these, which are commonly due to the rupture of a 
 sacciform renal aneurysm, or of the wall of the renal artery itself. 
 
 Tumour. A tumour was detected during life in fourteen out of 
 nineteen cases, and in one other it is quite certain that some en- 
 largement must have been present. The size of the tumour varies 
 from that of a double fist to a swelling which fills half the ab- 
 dominal cavity, reaching vertically from the false pelvis to the 
 dome of the diaphragm, which it pushes upwards, and laterally 
 from the side of the flank inwards as far as or beyond the median 
 line, forcing the loin backwards and outwards and the abdominal 
 parietes forwards. 
 
 The date of its appearance and the rate of its growth vary 
 according to the degree of resistance of the tissues into which 
 the blood is infused, and the extent and firmness of the 
 coagulum which for a time may close the rent in the vessel or 
 the aneurysmal wall. In one case (Rouppe's) which ended 
 fatally and suddenly on the tenth day no doubt from the 
 rupture of the false aneurysmal sac which was formed by the 
 capsule of the kidney the tumour was only detected a few hours 
 before death. When the extravasation is into the perinephric 
 tissue, it does not follow that the tumour appears earlier and 
 grows more rapidly than when it is within the capsule of the 
 kidney. If the first effect of the injury is the formation of a 
 small sacciform aneurysm or of a rent in. the vessel wall which 
 becomes plugged by coagulum, all the immediate clinical symptoms 
 due to the accident may pass off, and the patient may be dis- 
 missed as quite well, and a long or short interval may elapse 
 before any signs whatever of a tumour are detected. On the other 
 hand, the presence of a swelling may be detected at once, or 
 within a few days after the injury, as in Halm's case and my own. 
 
 It is possible that a small aneurysm might rupture into the renal 
 pelvis or a calyx, and cause death by haemorrhage without giving
 
 246 SURGERY OF THE KIDNEY AND URETER. 
 
 rise to a tumour : unfortunately, in one case in which death was 
 brought about in this way, no description of the aneurysm, is 
 supplied (Gossett's). In Oestreich's case of traumatic aneurysm, 
 where haemorrhage into the renal pelvis occurred, there was a 
 large tumour in communication with the renal pelvis. 
 
 The tumour, on bedside examination, is generally neither 
 irregular nor nodulated on the surface, and no case is related 
 where the kidney formed a projection upon the tumour, as it 
 does sometimes in perinephric extravasations * and hi some new 
 growths of the kidney or adrenal. The tumour is but slightly 
 movable if it is not actually fixed ; it rarely, if ever, moves 
 with ordinary respiration, or with change of posture, though in 
 several of the cases there has been some antero-posterior mobility 
 on bimanual examination (ballottemeni). The abdominal parietes 
 may be tightly stretched over the tumour, but have no appear- 
 ance of being adherent to it or infiltrated by it. No enlarged 
 veins in the parietes, no recently developed varicocele such as 
 is seen in some cases of new growth of the kidney and adrenal, 
 no oedema (except a slight degree in Dourlin's case) and no 
 marked redness have been observed in any of the recorded cases. 
 
 Pain. The tumour is not generally tender on pressure or 
 the seat of acute pain. On the other hand, it may give rise to 
 insupportable pain, as in Dourlin's and other cases. If it attains 
 to a great size it may cause some discomfort or a dull aching. 
 In one case pain in the loin occurred for three months before a 
 tumour was detected : in another there was severe pain in the 
 sacral region from time to time, especially on sitting. Pain and 
 tenderness may exist if localised peritonitis is present. In Gossett's 
 case the tenderness over the kidney of the affected side was so 
 great that the patient could scarcely bear the pressure of her 
 clothes. In most of the cases there was severe pain immediately 
 after the injury which caused the aneurysm. In Dourlin's case 
 retraction of the testes on the side of the aneurysm was a 
 marked symptom. 
 
 Hccmaturia. This is a very common symptom, and the next 
 
 * This was a feature in a case of perinephric abscess referred to further 
 on in this work ; and also in a case of ruptured abdominal aneurysm reported 
 by the author in the twenty-second volume of the Pathological Society's 
 Transactions, p. 105
 
 HiEMATURIA OFTEX THE EARLIEST SYMPTOM. 247 
 
 most important to tumour. Indeed it may be the most impor- 
 tant symptom, and may possibly be fatal before any tumour has 
 been formed. 
 
 More frequently than tumour, haematuria is the earliest symp- 
 tom, and may precede a tumour by mam 7 months or even a year 
 or two. It may commence immediately and go on for months 
 after the injury, or to the end of life ; or, beginning at the 
 outset of the case, it may cease after a day or two, and remain 
 absent for months ; in my case it commenced immediately after 
 the injury, continued for five months, then ceased and did not 
 reappear, though the patient survived for four and a half years 
 longer. It may not commence, however, till long after a tumour 
 has been known to exist, as in Keen's case of spontaneous false 
 aneurysm, and then it was but a trace, and only noticed on one 
 occasion. A small sacciform aneurysm may rupture immediately 
 into the renal pelvis, or a false aneurysm may open by ulceration 
 into it, and then the haemorrhage may be profuse and fatal. 
 There may be haematuria, without any direct communication 
 between the renal pelvis and the aneurysm, by the extravasated 
 blood burrowing inwards from the hilum and breaking into a 
 calyx or disintegrating the parenchyma. Haematuria may be 
 coincidental and not directly connected with the aneurysm, but 
 may arise from other injuries to the kidney, as probably was the 
 case in Reeves's patient. 
 
 When the haemorrhage is very profuse the blood may flow 
 away freely through the bladder and out of the external urethra! 
 meatus, or long clots may be extruded from the urethra ; if 
 this happens in the female it may be mistaken for uterine 
 haemorrhage or bleeding from the genitalia (as in Gossett's and 
 Oestreich's cases) unless a careful examination is made. 
 
 Pulsation. This symptom, so characteristic of most other 
 aneurysms, is remarkable by its absence in renal aneurysm. In 
 one case (Daniel Nebel's) pulsation was detected and the case was 
 diagnosed as an aneurysm. In only two other cases (Hahn's and 
 my own) was it at all suspected to exist, and in each of these 
 it was very indistinct, if present; in neither instance could it be 
 made out on most careful palpation of the tumour just before 
 and during the operation. In Gruber's case it is stated there 
 was no pulsation, neither were there any auscultatory signs.
 
 248 SURGERY OF THE KIDNEY AND URETER. 
 
 As Keen has remarked, "the chief reason why the diagnosis 
 has not been made is that the artery is relatively small and 
 the sac very large, hence the impulse of the blood is not 
 sufficient to distend the large sac and produce pulsation." 
 
 Auscultation. Observation on this point seems only to 
 have been made in one case besides my own, and in that case 
 no bruit was detected. In my patient's tumour there was no 
 thrill, but there was a loud systolic bruit over the tumour, best 
 heard ill front, but which did not extend along the vessels 
 towards the groins. 
 
 The urine. Except for the presence of blood, or of a little 
 albumen in the intervals between the attacks of heematuria, the 
 urine is normal. If some independent disease affects the kidney, 
 or if pyelitis follows a laceration of the kidney caused by the 
 same accident which produced the aneurysm (Eeeves's case), then 
 albumen, renal casts, or pus may be passed. Dysuria and fre- 
 quent micturition have been noted when blood-clots were passing 
 or when the bladder was filled with blood or decomposing blood- 
 clot, and also in Dourliii's case, in which hsematuria is not 
 mentioned as having occurred. 
 
 The general symptoms. These are only such as would 
 be expected from the loss of blood and the pressure effects of the 
 tumour. 
 
 Loss of strength, loss of flesh, pallor, nausea, with or without 
 vomiting, and gastro-iiitestinal disturbances, such as loss of appetite, 
 indigestion, flatulent distension and constipation, have been com- 
 plained of by some, but by no means all the patients. Rigors, 
 fever, and rapid emaciation do not occur, unless indeed the so- 
 called " bilious attacks " with high temperature described in Keen's 
 case can be ascribed to the aneurysm, which is most improbable. 
 
 Diagnosis. As a small sacciform aneurysm, so far as is at 
 present known, causes no symptoms whatever, the question of 
 diagnosis in such cases does not arise. I should not be surprised, 
 however, if, as time goes on, the symptoms attributed to renal 
 calculus prove on exploration to be in very exceptional cases due 
 to a small aneurysm of the renal trunk or one of its branches. 
 
 It is the tumour caused by a false aneurysm which gives rise 
 to the difficulty of diagnosis. The affections with which it is 
 most apt to be confused are renal and adrenal new growths, true
 
 DIAGNOSIS OF RENAL ANEURYSM FROM NEPHRECTASIS. 249 
 
 and false hydro- or haemato-nephrosis, and ruptured kidney. The 
 history of an injury is of but little help when the tumour occurs 
 a few months after a fall unless there has been continuous haema- 
 turia or frequent recurrences of haematuria ever since the accident, 
 liecause malignant growths are also apt to follow injury. Neither 
 is haemorrhage, no matter how profuse or how bright the blood 
 which flows, in favour of aneurysm as distinct from renal new 
 growths, especially new growths in the renal pelvis (see case, 
 Chapter XXII., on Tumours of Kenal Pelvis (Vol. II. p. 9). Nor 
 does the rate of increase of the swelling render much assistance in 
 distinguishing the one from the other. Pain and tenderness, rapid 
 emaciation, large veins on the abdominal parietes, varicocele recently 
 developed, and the presence or suspicion of a malignant growth 
 in some other part or organ would point to malignant renal or 
 adrenal tumour. Hydro-nephrosis is usually more elastic if not 
 fluctuating, often intermits contemporaneously with marked vari- 
 ations in the quantity of urine passed, is in many cases very 
 painful or even agonising at the times of great distension of the 
 kidney, is seldom, if ever, accompanied by haematuria, and is never 
 attended by profuse haemorrhage; and more frequently than not 
 it is unassociated with any history of injury. 
 
 H cemato-nephrosis develops quickly or even suddenly, and, it 
 may be, quite independently of any injury; gives rise to intense 
 pain and much constitutional disturbance, and has most likely 
 been preceded by the symptoms of some other renal affection, 
 such as tumour, calculus, or ureteral obstruction; but the true 
 hsemato-nephrosis, it should be remembered, may be really a false 
 aneurysm, either of traumatic or spontaneous origin. The follow- 
 ing case is an example of a traumatic aneurysm, confined entirely 
 within the renal capsule and really constituting a haemato-neph- 
 rosis. It was communicated by M. Danyau, and commented on 
 by Raver * (see p. 184 ante). 
 
 A young workman, aged fifteen, was taken to the Hotel de 
 Dieu in the early part of October, 1835 ; the anterior region of the 
 left kidney had been contused against a counter ; after this he 
 passed blood with his urine. Some time afterwards, the haema- 
 turia for a while having ceased, he suddenly voided from three 
 to four " palettes " of pure and bright blood. On the 19th of 
 
 * Rayer's " Traite des Maladies des Reins," vol. i., p. 280.
 
 250 SURGERY OF THE KIDNEY AND URETER. 
 
 November a remittent tumour was felt in the hypogastrium 
 and left flank, and seemed to be elongated in the direction of 
 the ureter. The bladder contained clots of blood ; there was 
 retention of urine, and catheterisation was very painful ; and the 
 tumour, without becoming more painful, was more prominent 
 and larger. He died on the 26th of November. At the post- 
 mortem the tumour consisted of the kidney, its pelvis, and the 
 commencement of the ureter, greatly distended and filled with 
 a mass of black coagulum which had already commenced to 
 decompose. There was no trace of either pyramidal or cortical 
 substance of the kidney left ; they had both disappeared as the 
 result of intrarenal pressure caused by the effused blood. On 
 examining the interior of the sac with care, the orifice of a renal 
 artery, plugged by a clot, was discovered. The walls of the 
 tumour were formed by the fibrous tunic of the kidney and the 
 condensed layers of the surrounding cellular tissue. The lower 
 end of the left ureter, and the kidney and ureter of the right 
 side, were healthy ; the bladder was healthy, and moderately 
 distended with clear urine. In the Gazette des Hopitaux* 1849, 
 p. 148, Mounier reports a similar case, which he describes as a 
 " hgemato-iiephrosis." 
 
 In false hydro- or hydro-hcemato-nephrosis following ruptured 
 kidney, the tumour, as in true haemato-nephrosis, is generally deve- 
 loped very rapidly, is attended with great pain, and if the renal 
 cavity is opened there is a diminished amount of urine passed 
 naturally ; the urine at a later stage will probabh- contain pus 
 if the patient survives. There is too, in these cases, generally much 
 more shock at the time of the injury and a great deal of consti- 
 tutional disturbance, with rigors, high temperature, and suppuration 
 when the condition has advanced. 
 
 It must be borne in mind, however, that perinephric extra- 
 vasation due to injured kidney or ureter is sometimes delayed 
 for weeks after the accident ; and, 011 the other hand, a haema- 
 toma from a ruptured renal artery (that is, a false aneurysm) 
 may commence to form from the moment of the accident. 
 
 In the absence of pulsation in the tumour, there is absolutely 
 no way that I know of, except by an exploratory operation, 
 to distinguish a simple luematoma or a true hremato-nephrosis 
 
 * See also Bloch's " Thesid," p. 85.
 
 OPERATION ESSENTIAL FOR FALSE ANEURYSM. 251 
 
 due to a ruptured vein or ruptured renal parenchyma, from a 
 haematoma or a haemato-nephrosis due to a ruptured artery; i.e. 
 a primary false aneurysm. A cancer of the kidney may pulsate 
 (see post, p. 537). 
 
 If some weeks or months after an injury, and perhaps after 
 a period of apparent health, a tumour develops having the char- 
 acters above described, a suspicion of renal aneurysm ought to 
 be aroused, and the treatment ought to be directed accordingly. 
 
 Prognosis. This is most unfavourable in false aneurysm : 
 all the cases hitherto reported which have not been operated 
 upon have died. Only four have been operated upon, and three 
 out of the four recovered. 
 
 The three successful cases are Albert's, Hahn's, and Keen's. 
 The two former were of traumatic origin. Keen's was a spon- 
 taneous false aneurysm. In the unsuccessful case the operation 
 was rapidly followed by a fatal result. This may have been 
 in part attributable to the nature of the operation employed, but 
 the enormous size, and the firm adhesions, and the other con- 
 ditions of the tumour, would, I think, have made any opera- 
 tion unsuccessful. 
 
 All the patients with aneurvsmal tumours not operated upon 
 died from their aneurysms. Another case (Reeves's), where a 
 small aneurysm was associated with a tumour caused by peri- 
 nephric extravasation of blood and urine from laceration of the 
 kidney, was also fatal, but not from the aneurysm. One patient 
 in whom no tumour existed died from haemorrhage, due to the 
 rupture of the aneurysm into the renal pelvis. 
 
 In the remaining three out of the total of nineteen cases, 
 the aneurysms were quite small, and were found in persons 
 who died from causes other than the aneurysm. 
 
 The causes of death of the cases not operated upon have 
 been : profuse haemorrhage from rupture into the renal pelvis 
 (three cases) ; haemorrhage into the peritoneal cavity ; haemorrhage 
 into the retro-peritoneal tissue from rupture of the false sac ; 
 and peritonitis. In the case in which the patient died after 
 operation, death was due to shock and loss of blood ; but had 
 the man not been operated upon, his life could not have been much 
 prolonged, as the contents of the sac were beginning to break down. 
 
 Some of the aneurysms had existed a long time before death
 
 252 SURGERY OF THE KIDNEY AND URETER. 
 
 occurred, or before the operation was performed. In Keen's 
 case and my own five years had elapsed ; in the case of the 
 medical man who fell from his horse, four years ; and in 
 Hocheiiegg's case, two years. In Gruber's case the patient lived 
 only ten months after the accident, and but two months after the 
 detection of the tumour. 
 
 The most rapidly fatal cases were those in which the aneurysm 
 burst into the renal pelvis ; in one of them a case of spontaneous 
 aneurysm the first symptoms referable to the kidney were pain 
 and tenderness, and death from haemorrhage followed 011 the 
 ninth day. 
 
 In another a case of traumatic aneurysm the injury hap- 
 pened three months before death, but the tumour was detected 
 only three days before : haematuria commenced about a month 
 after the fall, rapidly became worse, then excessive, and continued 
 to the end of life. In Halm's case, two months elapsed after 
 the accident before a tumour was found, and the operation was 
 performed a week later ; there seems to have been no hsematuria 
 and no albuminuria throughout, and their absence no doubt was 
 a reason why the tumour was diagnosed as being hydro-iiephrosis. 
 
 In Rouppe's case, a tumour suddenly developed with violent 
 pain, faiiitness, and thirst nine days after the accident, and the 
 patient was dead in ten hours. Haematuria in this case, at first 
 considerable, had ceased some days before the tumour appeared. 
 In Mourner's case the accident occurred on January 20th, and 
 death followed on February 14th. In Danyau's the accident 
 occurred in the early part of October and death took place on 
 November 20th. 
 
 Treatment. When a tumour due to a renal aneurysm exists, 
 the only prospect of saving life is by nephrectomy and the 
 removal of the whole or the greater part of the aneurysmal 
 swelling. 
 
 The operation will in most instances have to be commenced as 
 an exploratory proceeding, for though the surgeon may suspect an 
 aneurysm he cannot diagnose it from a haematoma due to a ruptured 
 vein or lacerated kidney unless there be pulsation, which, as 
 we have seen, then- rarely if ever is. In other cases the tumour 
 will be mistaken for a new growth or a hydro-iiephrosis. 
 
 The course to pursue is to commence by making an oblique
 
 IMPORTANCE OF SECURING THE PEDICLE EARLY IN OPERATION. 253 
 
 incision in the loin. As soon, however, as the nature of the 
 tumour is ascertained either the lumbar incision should be pro- 
 longed considerably forwards and the renal pedicle reached and 
 cleared by reflecting the peritoneum inwards from off the 
 tumour, or, what is even better if the tumour is very large, the 
 patient should be turned over and a trans-peritoneal operation 
 performed by opening the abdomen in front, along the linea 
 semilunaris of the same side as the tumour, then the peritoneum 
 should be divided along the outer side of the colon, and reflected 
 inwards, clearing the pedicle of the kidney. The whole of the 
 pedicle should be secured or, at any rate, the renal artery 
 should be ligatured, before attempting to empty or remove 
 the sac. 
 
 The nature of the tumour will not at once be revealed on 
 exposing the sac from the loin, but it will soon be if a small 
 incision is made through the sac wall and the contents are found 
 to consist of laminated blood-clot. There may be very little 
 fluid in the sac, and that of a thin pinkish or pinkish-yellow or dirty 
 light-brown colour, which will not at all assist the diagnosis, 
 so that a mere puncture of the sac wall with a trocar and cannula 
 is not sufficient. If, when the sac is incised and a little of its 
 solid contents are removed for examination, haemorrhage occurs, 
 the small opening should be immediately plugged with gauze 
 and the pedicle secured in the manner just described. 
 
 It is undesirable and dangerous to proceed to remove much 
 of the clot. All that is necessary or safe to be done is, to make 
 a small incision through the sac wall sufficient to remove enough 
 of the contents for diagnostic purposes, and as soon as the lami- 
 nated nature of the clot is detected to cease from further dis- 
 turbing the sac contents till the vessels of the pedicle are securely 
 tied. 
 
 It was by not following this course (but by adopting the 
 plan which John Bell employed and so graphically described in a 
 case of gluteal aneurysm, and which I once employed successfully 
 in a large aneurysm near the bifurcation of the carotid) that the 
 alarming character and some of the difficulties of the operation 
 in my case of renal aneurysm were due ; and I thus specially 
 refer to it as a warning to others. It is the first and only case 
 of renal aneurysm I have had to operate upon, and should it
 
 254 SURGERY OF THE KIDNEY AND URETER. 
 
 fall to my lot to operate again in a similar case, I shall do so by 
 the method and with the precautions I now inculcate. 
 
 The plan adopted by Albert was a nearly transverse incision 
 from a point a little inside the mammary line outwards for about 
 20 cm. and passing about two fingers' breadth below the arch 
 of the ribs on the right side posteriori}-. The peritoneum was not 
 opened, but was reflected inwards so as to expose the tumour 
 in the hinder part of the wound. The patient was placed during 
 the operation on his left side. Keen's operation was an ordinary 
 anterior or trans-peritoneal one. Halm combined the lumbar and 
 trans-peritoneal methods. 
 
 The risks necessarily attending the operation are haemorrhage 
 and shock. Albert met with severe haemorrhage from laceration 
 of the renal artery on separating the loose adhesions. This 
 was arrested by iodoform gauze packing and a pair of haemostatic 
 forceps which were left in place for five days. 
 
 Halm on puncturing the tumour through a lumbar incision 
 drew blood, and 011 attempting to loosen the inferior pole of the 
 tumour a sudden profuse haemorrhage occurred which he checked 
 by packing the wound : he then proceeded by the anterior 
 incision. 
 
 In Keen's case, which was commenced and completed through 
 an anterior incision, the patient, in spite of the injection of the 
 saline solution into the veins of the arm, and also of the fact 
 that not more than four ounces of blood were lost, was " very pro- 
 foundly shocked." The pedicle in Keen's case also gave some 
 trouble, being "so broad that it had to be secured in seven dif- 
 ferent sections, the arteries being numerous and large and the 
 veins especially enormously distended." 
 
 Another risk is the adhesions which may unite the wall of 
 the aneurysm with the peritoneum and bowel, with the dia- 
 phragm, solid viscera and praevertebr^l vessels. If the adhesions 
 are tough and firm, as they were in my patient, it may be 
 impossible to remove the whole of the sac wall. When such 
 tough connections are present, entire separation of the cyst should 
 not be attempted. As much of its wall as possible should be 
 removed and the rest left and drained.
 
 255 
 
 CHAPTER IX. 
 
 FERINE PHRIC EXTKAVASATIONS, TRAUMATIC 
 AND NON-TRAUMATIC. 
 
 THE cellular tissue surrounding the kidneys not unfrequently 
 becomes the seat of very extensive extravasations of air, blood, 
 urine, faeces, or pus ; and great care is sometimes needed to 
 form an accurate diagnosis as to the nature of the swelling and 
 the precise locality of the effused fluid. In the case of air, a 
 distended colon may be supposed to exist ; in the case of blood, 
 urine, or pus, it is sometimes very difficult, if not quite impossible, 
 to say whether the swelling is intra- or extra-renal. This is still 
 more difficult when the extravasated fluid is fairly circumscribed 
 or positively encysted. 
 
 In these extravasations the kidney is often greatly involved, 
 if it be not the original source of the fluid. A ruptured or 
 lacerated kidney may be the cause of a blood tumour in the 
 surrounding tissue ; a ruptured renal pelvis may be the cause of 
 circumscribed or diffused swelling due to the escape of urine ; 
 a renal abscess or suppurative pyelitis may lead to diffused sup- 
 puration or an abscess in the circumrenal tissue. On the other 
 hand, air, blood, pus, or faecal matter may be derived from the 
 caecum, colon, or other source, and give rise to a tumour in 
 the loin or renal area of the abdomen, the kidney itself remaining 
 uninvolved, though during life some doubt may exist as to 
 whether it is so or not. 
 
 Am. 
 
 Air is occasionally found in considerable quantity around the 
 kidney after injury. In a case which was admitted into the 
 Middlesex Hospital, the left kidney was bruised throughout and 
 its upper pole lacerated either by the spike of some railings on 
 which the man had fallen or by the end of a fractured rib. 
 A very extensive emphysema involved the subperitoneal tissues
 
 256 SURGERY OF THE KIDNEY AND URETER. 
 
 of the loin, the air having entered through a wound in the ilio- 
 costal space. 
 
 The source of the air is not always traceable, but its distri- 
 bution is often very extensive. In a case admitted into the 
 hospital, with fractured pelvis and rupture of the ileum just 
 where it entered a hernial sac, there was a large quantity of 
 air behind the peritoneum in the pelvis and in both loins: 
 it had also diffused itself along the vertebrae behind the dia- 
 phragm, into the posterior mediastinum and thence to the neck, 
 from which it spread, guided by the cervical fascia, to the 
 shoulders, arms, and pectoral regions. All these parts were 
 distinctly crepitant to the touch. There was no injury to the 
 lungs, and no rent in the peritoneum, and the only external 
 wound was a perineal incision, which had been made on account 
 of a rupture of the urethra complicating the fracture of the 
 pelvis. 
 
 Extensive emphysema of the cellular tissue of the right loin 
 followed the application of the abdominal tourniquet in the treat- 
 ment of a case of aiieurysm involving the coeliac axis and superior 
 mesenteric artery. The small intestines were ecchymosed and 
 their submucous coat emphysematous in places ; and at one 
 part the intestinal walls were very much thinned out by the 
 pressure. It is quite possible that the air in this case had simply 
 transuded into the retro-peritoneal tissues through the thinned 
 wall of the ileum. 
 
 Wounds of the loin, groin, and perineum, whether complicated 
 by wounds of the Ixnvel or not, and fractures of the lower ribs 
 with injury to the lung, may be the cause of this form of extra- 
 vasation. Retro-peritoneal abscess opening into the bowel may 
 give rise to emphysema about the kidney. Decomposition may 
 also lead to the formation of gas in cases of retro-peritoneal 
 suppuration. 
 
 BLOOD. 
 
 Blood may be effused around the kidney from a ruptured renal 
 artery or vein ; or from other wounded vessels, without the kidney 
 or the renal vessels themselves being injured. Violence inflicted 
 upon the loin is very likely to be followed by extensive extra- 
 vasation of blood into and far bevond the region of the kidnev.
 
 PERIXEPHRIC H.EMATOMA. 257 
 
 When the kidney is injured, a. Subcapsular hccmorrliage. 
 It must not be forgotten that injuries to the loin are some- 
 limes followed by extravasation of blood beneath the fibrous 
 capsule of the kidney, i.e. between the capsule and the glandular 
 substance, as well as into the abundant circumrenal cellulo-fattv 
 tissue, without the occurrence of any rupture of the renal capsule 
 itself. In a case reported by Mr. Poland,"* and referred to in the 
 chapter on subparietal injuries of the kidney, this state of things 
 was found. I have mentioned cases under my own care of sub- 
 capsular extravasation of blood giving rise to pain and other 
 symptoms, though not to tumour, in the chapter on subparietal 
 injuries (see p. 150). 
 
 b. Intra-renal hcenwrrhage. It must also be borne in mind 
 that large extravasations of blood may take place into, and 
 be limited to, the renal cavity, either as the result of injury or 
 not, and form a tumour of large size a veritable haemato- 
 nephrosis. 
 
 Neither of these forms of blood extravasation is, however, at 
 present under consideration. 
 
 c. Perinephric extravasation. It is to this condition that atten- 
 tion has now to be drawn. 
 
 In one of the cases in the Middlesex Hospital series, a con- 
 siderable quantity of effused blood was found around the kidney, 
 but the only evidence of injury to the kidney itself was the 
 presence of a little blood in the renal pelvis. 
 
 In other cases in which the renal substance is lacerated, or 
 the kidney is actually ruptured into two or more pieces, great 
 quantities of blood are rapidly poured out into the retro-peritoneal 
 tissues. Instances of this kind are mentioned in the chapter 
 on subparietal injuries. 
 
 One of the most desperate operations I have ever performed 
 was for a large, rapidly-increasing lumbar and abdominal tumour 
 which followed an injury to the kidney, and consisted of an 
 enormous mass of old, laminated, discoloured blood-clot in con- 
 nection with a torn renal artery, which had formed a large 
 false aneurysm, and caused almost complete absorption of the 
 kidney. The accident had occurred five years before the tumour 
 began, to increase, but was followed immediately by marked 
 
 * Guys Hospital Reports, vol. xiv., p. 86 ; third series. 
 VOL. I. R
 
 258 SURGERY OF THE KIDNEY AND URETER. 
 
 haematuria, lumbar swelling and ecchymosis.* Gradually all 
 symptoms cleared up except that a certain amount of fulness 
 always remained in the renal region, and for over four years 
 the patient worked on his farm. At length the haemorrhage into 
 the tissues recurred and a large hard swelling began to show 
 itself, which at the tune when the patient came under my obser- 
 vation was thought to have a slight expansive pulsation and 
 certainly had a loud general bruit. 
 
 When the kidney and its vessels are uninjured. It would 
 be possible to refer to many cases in which most extensive retro- 
 peritoneal haemorrhage has followed fracture of the pelvis or 
 lumbar spine. 
 
 Everywhere the retro-peritoneal tissues are rich in blood- 
 vessels, and the anastomoses between the vessels of the parietes 
 and those of the viscera are numerous and important, both in 
 the loins and pelvis : these vessels are not unfrequently the sole 
 source of considerable blood extravasations. 
 
 The rupture of muscles, such as the psoas and quadratus 
 lumborum, is sometimes the cause of most extensive haemorrhage 
 around and beyond the kidney. So also is the rupture of an 
 aneurysm of the abdominal aorta or one of its large branches. 
 
 The extent of the effusion in cases of ruptured aneurysm is 
 sometimes astounding, for the blood by degrees dissects up the 
 peritoneum, and permeates the cellular tissue in every direction, 
 causing the ribs and loins to bulge outwards ; it may also carry 
 forwards the posterior and lateral layer of peritoneum and the 
 abdominal viscera, so that the abdomen protrudes in front ; and 
 the blood may, moreover, descend along the psoas and iliacus 
 until a fluctuating tumour is formed in each groin, even below 
 the level of Poupart's ligament. There usually is not the least 
 pulsation in such swellings, and unless the clinical history of the 
 case is known, the diagnosis is very difficult, if not actually 
 impossible. In some cases there has been an attack of syncope 
 to mark the bursting of the aneurysm ; but life may continue 
 long after the rupture, and the slow course of the disease, with 
 the absence of every characteristic sign of aneurysm, will probably 
 lead to the supposition that the swelling is malignant. 
 
 * The case is reported at length in an article on "Aneurysm of the 
 Kenal Artery," in the Ismcet for October 6th, 1900.
 
 PER1NEPHRIC H.EMATOMA. 259 
 
 Erosion of the vertebrae from pressure of the aneurysm may 
 give rise to more or less pain, or even to some degree of flexion 
 of the thigh, and then there is a risk that the swelling in the 
 loin and groin or iliac region may lead to the mistaken diagnosis 
 of perinephric abscess, or lumbar caries with abscess. To open 
 such a swelling with the view of evacuating pus would be a very 
 serious, and might prove even a fatal mistake. Cases of ruptured 
 abdominal aneurysm leading to retro-peritoneal haemorrhage are 
 recorded in the Transactions* of the Pathological Society of London. 
 
 In a caset which I reported to this society an enormous 
 tumour, adherent over a large surface to the peritoneum lining 
 the front and lateral wall of the abdomen, had everywhere pul- 
 sated ; nothing but skin and condensed cellular tissue formed 
 its posterior limit ; and finally it ruptured into the peritoneum, 
 just above the caecum and the right kidney. The kidney and 
 the vena cava were pushed far forwards, so as to form part 
 of the front limit of the tumour. 
 
 Another case in which the kidney was raised so completely 
 by the extravasated blood from a ruptured sacculated aneurysm 
 of the aorta as to present a tumour anteriorly in the hypo- 
 chondrium, is described by Silcock.* 
 
 A somewhat similar case of a ruptured aortic aneurysm giving 
 rise to an extensive retro-peritoneal extravasation of blood is 
 recorded in vol. i., p. 80, of the Pathological Society's Transac- 
 tions. In this case there had been long-standing pain in the 
 left loin, the urine was albuminous, and a fluctuating, pulsating 
 tumour expanded the false ribs ; the left lumbar region also 
 was occupied by the tumour, and the left kidney was displaced 
 forwards in front of the extravasated blood. 
 
 Retro-peritoneal haemorrhage is sometimes produced by ulcera- 
 tion into a vessel due to pressure of an abscess or a tumour. 
 I have recorded a case in which a stricture of the oesophagus 
 set up suppuration behind the diaphragm, and death resulted 
 from haemorrhage from the aorta, the coats of which were ul- 
 cerated through just above the coeliac axis. 
 
 * See especially vols. i., iv., xix., xxi., xxii., and.xxxiv. 
 t Trans. Path. Soc., vol. xxii., p. 104. 
 J Trans. Path. Soc., vol. xxxiv. 
 
 >$ " The International Encyclopaedia of Surgery," vol. v., p. 952 (New 
 York, 1884).
 
 260 SURGERY OF THE KIDNEY AND URETER. 
 
 Sometimes the cause of the haemorrhage is not cleared up at 
 the post-mortem examination, as in the case of a woman, aged 
 thirty-eight, who died in the Middlesex Hospital of cancer of the 
 vagina and uterus and secondary deposits in the pelvic glands 
 and the lungs, who had a ha?matoma the size of a foetal head 
 in the left renal region. 
 
 Symptoms. The symptoms vary with the cause and extent 
 of the extravasation. When the blood occupies the cellular 
 tissue of one loin, chiefly or entirely, it causes a tumour some- 
 times difficult to diagnose from a distended kidney. When the 
 xtravasated blood, coming from an aneurysm of the aorta, crosses 
 the spinal column and occupies the whole space between the 
 outer edge of one quadratus lumborum and the outer edge of 
 the other, the whole of the back part of the peritoneum, and 
 with it the viscera and prevertebral large vessels, are raised 
 forwards, the whole abdomen becomes distended, and prominent 
 in front, and one or both kidneys may project and form a 
 tumour on the anterior aspect. 
 
 There may be no symptom to indicate the onset of the ex- 
 travasation. Even when the source of the haemorrhage was a 
 ruptured aneurysm, there has been in some cases nothing to 
 mark the giving way of the sac. In other cases there has been 
 an attack of syncope at the moment of rupture, but soon recovered 
 from ; and subsequently the blood had been effused gradually 
 and over a period of man}' weeks, or perhaps months, before 
 death. * 
 
 Sometimes the character of the pulsation is decisive, although 
 the position and outline of the tumour resemble very much a 
 true haemato-nephrosis. Such a case is described by Sir Henry 
 Thompson in the fourth volume of the Pathological Society's 
 Transaction* (p. 110, case 22). 
 
 The amount of blood extravasatecl has been greatest in cases 
 in which the aneurysm has been seated at, or at some spot above, 
 the origin of the renal arteries. 
 
 The 1>1 ood extravasated is of course as really lost to the in- 
 dividual as if it had escaped through an open wound, but as 
 the effusion is gradual the downward tendency of the patient is 
 gradual also ; or the primary haemorrhage may be followed by 
 
 * Trans. Path. Sac., vol. i., p. So.
 
 SYMFTOMS OF PERINEPHRIC ILEMATOMA. 261 
 
 a long period without further extravasation, and then a sudden 
 or gradual increase in the tumour may commence. If the in- 
 crease be gradual, it may steadily continue, until the life and 
 strength are slowly worn away. The lamination and characters, 
 of the clot found in the tissues after death in several of these 
 eases show that the blood must have been effused gradually, and 
 for many weeks or months, before life terminated. 
 
 In some cases symptoms of acute or chronic peritonitis have 
 been excited.* 
 
 When the extravasation is the result of a blow upon the loin 
 the symptoms will depend upon the rapidity and extent of the 
 haemorrhage. If the source of the bleeding is a superficial lacer- 
 ation of the kidney, or a rupture of a lumbar artery,- or of one 
 or more of the anastomosing branches in the circumrenal cellular 
 tissue, some days or weeks may be required before the effusion 
 is sufficient to give rise to any swelling or increased dulness in. 
 the loin, and no syncope or any sign of faintness is noticed at 
 any time ; then after some days the effused blood becomes more 
 solid, and the tumour more' irregular, and by degrees perhaps, 
 it is absorbed. 
 
 In other instances, after becoming harder, partly from coagu- 
 lation and partly from inflammatory effusion around, the blood 
 and clot may disintegrate and be even softer than at any previous 
 time. Under these circumstances the symptoms of suppuration will 
 arise. 
 
 When the pelvis of the kidney or one of the calyces is opened > 
 and urine mingles with the extravasated blood, the swelling and 
 dulness of the loin are much more likely to be rapidly developed,, 
 and suppuration sooner or later is very likely to occur. 
 
 Marshall f recorded a typical case of suppurating haematoma > 
 in which probably the renal pelvis was ruptured, as there was 
 urine mixed with the blood. Though the tumour in this case was 
 due to injury, the symptoms were much the same as in cases 
 in which the extravasation was due to a ruptured aortic aneurysm > 
 namely, severe pain in the flank passing inwards towards the 
 umbilicus, and also affecting the lumbar spine ; pain increased 
 by movement, improved somewhat by rest, but not disappearing 
 
 * See case by Murchison, Path. Soc. Trans., vol. xxi., p. 136. 
 t Trans, of the Roy. Med. and Chir. Soc., vol. Ixvi., p. 311.
 
 262 SURGERY OF THE KIDNEY AND URETER. 
 
 entirely ; capacity, withal, of getting about ; absence of haematuria, 
 or other urinary trouble, from first to last ; great exacerbation 
 of pain after many months ; swelling and tenderness in the left 
 lumbar region and left half of the abdomen ; fluctuation across 
 the tumour, which was dull on percussion ; pain along the thigh, 
 increased by extension of the limb ; pallor ; anxiety of features ; 
 emaciation, and tendency to death by anaemia. There is this most 
 important difference, however, that in the traumatic case life was 
 saved, and a satisfactory result ultimately obtained, by surgical 
 treatment. 
 
 When the kidney is completely ruptured and the haemorrhage 
 is both rapid and extensive, there are all the signs of great loss 
 of blood, collapse, syncope, pallor, cold sweats, restlessness, blueness 
 of the extremities, anxiety, vomiting, thirst, feeble, rapid, and 
 irregular pulse, unconsciousness, and death. 
 
 Diagnosis. It is sometimes difficult, if not impossible, to 
 distinguish during life a tumour formed by an effusion of blood 
 behind the peritoneum and in connection with the kidney, from 
 a swelling caused by the kidney itself when dilated with blood 
 or urine and blood. Though extrarenal haemorrhages frequently 
 give rise to a swelling soon after the accident, which is generally 
 not circumscribed ; and though the tumour, caused by effusion 
 of blood, or by retention of urine within the cavity of the 
 kidney, is circumscribed, and is generally formed slowly and after 
 a somewhat prolonged period ; yet the extrarenal haemorrhages 
 are sometimes quite circumscribed, and do not present any 
 noticeable swelling for many months after the onset of the ex- 
 travasation ; and, on the other hand, a hsemato-nephrotic tumour 
 may be very rapidly developed.* 
 
 The diagnosis has also to be made first as to the nature of 
 the fluid extravasated whether blood or urine ; and secondly, 
 if blood, whether its source is an injured kidney or a renal 
 vessel 011 the one hand, or, 011 the other hand, some vessel 
 altogether independent of the kidney. This second point is 
 important because of the difference in treatment of the cases 
 in which the kidney is ruptured, and of those in which the 
 haemorrhage is caused by the giving way of an aneurysm of the 
 aorta, the coeliac axis or one of the mesenteric arteries. 
 
 * See article on "Renal Aneurysm,'' Lancet, October Gth, 1900.
 
 NATURE AND SOURCE OF EXTRAVASATION. 263 
 
 The nature of the fluid. The extravasated fluid will probably be 
 urine; and the renal pelvis or ureter will probably be lacerated 
 if after an injury there is little or no haematuria and the 
 quantity of urine voided naturally continues to be much below 
 the normal. After any severe injury attended with shock the 
 secretion of urine may be temporarily suppressed or reduced ; 
 but after this stage has passed, the amount of urine reaching 
 the bladder may be reduced nearly one-half if there is a free 
 escape for it through a rent in the renal pelvis or ureter. 
 
 The rate of increase in size of the lumbar tumour under these 
 circumstances may be to a degree in proportion to the reduction 
 in the quantity of urine passed naturally ; and this may be the 
 case whether the urine begins to escape into the tissues im- 
 mediately after the injury, or, owing to the wall of the renal 
 pelvis or ureter being but partially torn through in the first 
 instance, or to temporary blocking of the rent in them, the 
 escape of urine does not begin until some days or weeks after 
 the accident (see author's case, Part II., Vol. II., p. 348). 
 
 It is probable that the extravasated fluid will be blood, and the 
 renal parenchyma or a branch of one of the renal vessels will probably 
 be ruptured if after an injury profuse or marked hsematuria occurs, 
 especially if the passing of blood continues for several days hi 
 succession, or recurs after a period of rest, on the patient making 
 any physical effort ; if immediately after the accident the symptoms 
 are those of shock with internal haemorrhage; or if after a day 
 or two ecchymoses are seen in the lumbar or lateral abdominal 
 region. 
 
 Tlie source of the hcemorrhage, whether from the kidney or 
 a ruptured aneurysm. Should faint expansile pulsation be detected 
 no matter how faintly marked, and no matter how long after 
 an accident in a tumour following an injury which caused 
 a hsematoma at once or soon after the accident in the situation 
 of the kidney, the inference to be drawn is that the trunk of 
 the renal artery or one of its main branches has been partially 
 or completely torn across, and that a false renal aneurysm has 
 resulted. 
 
 A haematoma, whether it pulsates or not, will probably be 
 due to the rupture of an aneurysm of the aorta or of one of 
 its large branches (other than the renal artery) if in the entire
 
 SURGERY OF THE KIDNEY AND URETER. 
 
 absence of history of injury the extravasation occurs in a person who 
 lias been previously failing in health, and who has been complaining 
 of gastro-intestinal disturbances, or nerve and pressure symptoms 
 referred to the abdomen ; or if an aneurysm is known to have 
 existed and a sudden attack of abdominal pain, attended or not 
 by syncope, is followed by a retro-peritoneal swelling. It is a 
 very noteworthy fact that ruptured aortic aneurysms seem as a 
 rule to give rise to pulsation in the extravasated retro-peritoneal 
 blood mass ; w r hereas false aneurysms of the renal artery do not. 
 Also that the former raise the kidney forwards and cause it 
 to present as an obvious tumour or swelling in front of the 
 main swelling ; whereas this condition has not been observed in 
 any one of the recorded cases of renal aneurysm (see p. 246, and 
 the article in the Lancet, October 6th, 1900). 
 
 Prognosis. Eecovery may take place after very extensive trau- 
 matic haemorrhage ; but retro-peritoneal haemorrhages due to rup- 
 tured aortic aneurysm are certainly fatal in course of time, though 
 death may supervene very slowly, as the cases recorded above prove. 
 
 Eecovery, or what may seem like recovery, may take place, 
 the extravasated blood remaining unabsorbed, but more or less 
 consolidated, but there is always the risk that some complica- 
 tion may arise. Eecovery may occur after suppuration and 
 the discharge of the matter through a spontaneous opening or 
 an incision through the loin. 
 
 If the haemorrhage increases, or if suppuration follows and 
 surgical aid is not invoked, death will occur from peritonitis 
 due to tension upon or rupture of the peritoneum ; or the colon 
 may be penetrated and faeces and flatus may enter the blood 
 tumour and give rise to decomposition, septic absorption, and 
 death from septicaemia. 
 
 Treatment. When the haemorrhage is due to ruptured 
 aortic aneurysm, little or nothing in the way of treatment will 
 avail. When due to injury to the kidney the treatment must 
 be based upon the principles stated in the chapters on injuries, 
 to this organ. When due to a false aneurysm of the renal 
 artery or one of its main branches, an operation is urgently 
 indicated, and the involved arterial branch should be ligatured 
 if it can be isolated. If the trunk of the renal artery is involved, 
 or if the kidney be much damaged either by the original injury,
 
 TREATMENT OF PERINEPHRIC HJEMATOMA. 265 
 
 or as the result of pressure by the blood-clot, the kidney 
 should be removed after ligaturing the renal pedicle (see 
 p. 253). The kidney will very likely be flattened and spread 
 out on the wall of the aneurysmal sac and may not be 
 recognisable, and in that case it will not be removed unless 
 the false aneurysmal sac be practically or completely dissected 
 out. Such a dissection it may not be desirable to attempt owing 
 to the adhesions of the sac to the diaphragm and to neighbouring 
 organs. If 'owing to the history and the presence of pulsation 
 or other symptoms a renal aneurysm is suspected, it would be 
 safer to commence the operation with an abdominal incision, 
 through which the aorta might be compressed by an assistant, 
 or the renal artery ligatured before the removal of the blood- 
 clot through a lumbar incision is attempted. 
 
 If the tumour is so large as to overspread the front of the 
 vertebral column and to render the compression of the abdo- 
 minal aorta impossible ; or if the exact nature of the case 
 is not suspected or ascertained until the tumour is cut into, 
 some of the clot must be removed and a way thus made for 
 the hand of the surgeon to be pushed towards the renal pedicle, 
 or towards the opening of communication with the renal artery ; 
 and in this manner the haemorrhage must be controlled until the 
 clot has been cleared out and a ligature can be applied to the 
 artery (see author's case in the Lancet, October 6th, 1900). Such 
 an operation, however, will tax the skill and resources of the 
 surgeon, and is one of the most desperate which he is likely to 
 be called upon to undertake. 
 
 Repeated aspiration or aspiration and drainage through a 
 punctured opening has been successful even in suppurating 
 traumatic haematoma connected with lacerated kidney (Marshall's 
 case) ; but it is not a mode of treatment to be recommended in 
 any case, and should the blood cyst communicate directly with an 
 aneurysmal sac it can but hasten the fatal termination. 
 
 URINE. 
 
 Urine is extravasated into the loin behind the peritoneum 
 from rupture involving the calyces or pelvis of the kidney, 
 or the ureter ; or from a direct penetrating wound of the renal 
 cavity ; or as a consequence of ulceration through the kidney.
 
 266 SURGERY OF THE KIDNEY AND URETER. 
 
 Ulceration of the ureter, whether as a sequel of injun* or of 
 the pressure of a tumour, may also cause urinary extravasation 
 into the loin, or iliac region. I have related a case in which a 
 large retro-peritoneal sarcoma between the rectum and bladder, 
 the size of a cocoa-nut, caused complete ulceration of the right 
 ureter,* about two inches and a half above its lower end, and thus 
 led to extravasation of urine into the iliac and lumbar regions. 
 
 Symptoms. When urine escapes from the pelvis of the 
 kidney or the ureter it diffuses itself sometimes very rapidly 
 in the loin and parts beyond, and may displace forwards the 
 liver, spleen, stomach, and intestines in the same manner as 
 blood has been described above as doing. The inflammation 
 excited in the cellular tissue may run on to suppuration, and 
 this may be followed by pointing of the matter in the loin or 
 groin ; or, if no infection takes place, the cellulitis will stop short 
 of suppuration, and, becoming chronic in character, may spread 
 slowly towards the iliac fossa and the brim of the pelvis, and cause 
 contraction of the ilio-psoas muscle. Under these last-named 
 circumstances a firm hard swelling will remain in the iliac or 
 lumbar region for many months, but ultimately may clear up, 
 and the contraction of the iliacus and psoas and of the muscles 
 of the anterior wall of the abdomen on the affected side will 
 yield to gentle use and massage, or to one of the many modes of 
 making extension. 
 
 In some instances the effused urine becomes encapsuled within 
 a thick- walled cyst of inflammatory formation, and with the 
 cavity of this cyst, which may contain pus as well as urine, 
 the kidney communicates at the point of rupture or ulceration. 
 This was the condition in one of Mr. Stanley's cases.t 
 
 Many cases of extravasation of urine into the perinephric 
 tissue, especially when encysted, have been erroneously regarded 
 as cases of hydro-nephrosis arising from traumatism, and the con- 
 dition has therefore been designated " pseudo-hydro-nephrosis." That 
 true hydro-nephrosis can follow traumatism is well proved, but 
 it is decidedly a rare condition, J and when it does thus occur 
 
 * See an article on Injuries and Diseases of the Abdomen, in the fifth 
 volume of the " International Encyclopaedia of Surgery," p. 948 (1884); edited 
 by Ashhurst. 
 
 \Med.-Chir. Trans., vol. xxvii. 
 
 I See Part II., Vol. II., p. 333.
 
 PERINEPHR1C EXTRAVASATION OF URINE. 267 
 
 is usually consequent upon some narrowing of the ureter, 
 and therefore does not generally give rise to symptoms until 
 some time after the injury. A retro-peritoneal extravasation or 
 pseudo-hydro-nephrosis, on the other hand, usually comes on soon 
 sometimes immediately after the injury, as would be expected, 
 since it depends upon an injury to the renal pelvis or ureter, 
 through which the urine escapes ; the time which elapses before 
 a tumour can 'be definitely recognised varies considerably in 
 different cases, and no doubt depends upon the nature of the 
 aperture in the pelvis or ureter and the ease or otherwise w r ith 
 which urine can pass through it. 
 
 The presence of a tumour which depends upon injury to the 
 kidney or ureter, is frequently preceded by haematuria, which 
 continues for a variable time, and may be either slight or severe. 
 
 The extravasation is a cause of pain, and there is often great 
 tenderness on palpation ; all degrees of swelling occur, from 
 that which merely gives rise to an obscure sense of resistance to 
 a tumour of enormous dimensions. In a typical case a well-marked 
 tumour can be felt, lacking the definite outline of the kidney 
 which is obscured by it; or the kidney may be well defined and 
 felt as a prominence in front of the tumour. 
 
 If tapped, urine, or urine and blood, will be drawn off; but 
 the condition frequently recurs, and repeated aspirations are 
 necessary. Finally, after weeks or months, the tumour may 
 cease to recur owing to atrophy of the renal substance; or, as 
 occasionally happens, it disappears spontaneously if the free passage 
 to the bladder is re-established. 
 
 A very large quantity of fluid is often drawn off on aspirating 
 these cases. Thus, for instance, in a case recorded by Hicks * 
 of a boy in whom the condition rapidly followed an injury, aspira- 
 tion was performed three times, namely, on August 1st, 5th, and 
 8th ; two pints were drawn off on the first occasion, and two quarts 
 on each of the others ; after the third operation there was no 
 recurrence, and a good recovery resulted. This case illustrates also 
 the rapidity with which recurrence can occur. The urine is naturally, 
 in the majority of cases, aseptic at the time the extravasation takes 
 place, and therefore, unless septic infection subsequently spreads 
 from the bowel or elsewhere, suppuration will not supervene. 
 
 * The Medical Record, April 17th, 1880.
 
 2G8 SURGERY OF THE KIDNEY AND URETER. 
 
 One feature which is sometimes noticed in cases of urinary 
 extravasation from the kidney must be mentioned, because when 
 it occurs it forms a serious complication in the treatment by 
 lumbar incision, and sometimes has seemed to necessitate neph- 
 rectomy. This is the deposition of phosphates from the urine in 
 large amounts on the walls of the cavity into which the urine is 
 effused. These deposits are large enough to block drain tubes, 
 and have occasionally to be removed in masses as large as beans 
 or hazel-nuts in order to maintain a free discharge of pus and 
 urine through the opening which has been made by the surgeon. 
 Barker's case* affords an illustration of this : the pelvis of 
 the kidney had been ruptured, and the lower end of the kidney 
 formed part of the wall of the urinary abscess, and w*as covered 
 with lymph and phosphates ; frequent blockages of the drain 
 tubes by masses of phosphates had occurred prior to the 
 nephrectomy which was ultimately performed. The same kind 
 of accumulation of phosphatic concretions in and around the 
 drain tubes has been noticed many times after nephrotomy for 
 pyo-nephrosis. 
 
 Treatment. The proper treatment of urinary extravasation 
 when once the diagnosis is clear consists an making a free lumbar 
 incision, and draining. In cases in which the diagnosis was uncertain, 
 but from the fulness and dulness of the loin there was reason 
 to think that urine was escaping behind the peritoneum, the 
 aspirator needle has been used by inserting it at the spot where 
 the fluid was suspected to be present. A single introduction of the 
 needle has in some cases withdrawn all the fluid, and convalescence 
 has forthwith commenced. In other cases, where the escape 
 continued and the swelling in the side again and again reformed, 
 a lumbar incision and drainage has succeeded ; but this treatment 
 by the aspirator is tedious and uncertain, and is not to be recom- 
 mended. A free incision and drainage is always to be preferred; 
 and if the kidney is found torn across, the detached fragment 
 should be either sutured to the broken surface of the mass of 
 the organ, or be removed, or the whole kidney, if greatly 
 damaged, should be taken away. A lumbar incision becomes 
 imperative when suppuration has been allowed to occur before 
 operating ; in this condition the formation of a free opening 
 
 * Lancet, January 17th, 1885.
 
 NEPHRECTOMY REQUIRED IN CERTAIN CASES. 269 
 
 ought not to be delayed. Nephrectomy will be requisite if 
 the kidney is greatly damaged by the original injury, or ex- 
 tensively destroyed by subsequent suppuration ; it may also be 
 advisable in certain cases in which the fistulous opening into 
 the kidney or its pelvis does not close after drainage, and where 
 the continuous escape of urine and pus from the loin is exhausting 
 the patient's strength by fever, or exposing him to the risks 
 of blood poisoning or albuminoid changes in the viscera. When 
 incision and drainage are long delayed the retro-peritoneal cellular 
 tissue may become widely affected, and chronic suppuration 
 may become established. But when an early incision down to the 
 kidney is made from the loin, the kidney injured by accident 
 (provided the injuries are not very extensive) is put into the 
 same position for recovering as a kidney which has been opened 
 for the extraction of a calculus. 
 
 Pus. 
 
 Pus may be extravasated into the perinephric tissue by the 
 ulceration or rupture of a pyo-nephrosis or of an abscess in the 
 renal parenchyma ; or by the giving way of an abscess in 
 some organ or tissue in the neighbourhood of the kidney. Pus 
 may also burrow into the tissues around the kidney from the 
 cellular tissue of the broad ligament, of the iliac fossa, or the true 
 or false pelvis. These forms of extravasation Avill be considered 
 in the next chapter. 
 
 Faecal extravasation requires no special description in a work 
 on the kidney. For an account of this condition the reader 
 may be referred to an article by the author in the fifth volume 
 of Ashhurst's "International Encyclopaedia of Surgery."
 
 270 
 
 CHAPTER X. 
 PERINEPHRITIS AND PERINEPHRIC ABSCESS. 
 
 BY perinephritis is meant an inflammation of the cellular and 
 adipose tissue surrounding the kidney. 
 
 Three distinct varieties have been recognised, namely : (1) 
 Sclerosing, (2) Lipomatous, and (3) Suppurating Perinephritis. 
 
 The Sclerosing form is a fibrosis of the renal capsule and the 
 fatty tissue around. In its slighter forms it may merely give 
 rise to an unnatural adhesion between the capsule and the kidney 
 tissue ; but when more severe the kidney may lie in a shell of 
 connective tissue, which contracts firm adhesions to neighbouring 
 organs and gives rise to great trouble and danger if nephrectomy 
 is attempted. 
 
 In advanced cases the surgeon may be misled concerning the 
 size of the kidney, which on palpation often gives an impression 
 of being considerably larger than it really is. Such kidneys 
 may frequently be correctly diagnosed by the fact that their 
 apparent increase in size is unaccompanied by that particular kind 
 of mobility on palpation which the French surgeons speak of as 
 ballottement, i.e. the bobbing of the kidney forwards and back- 
 wards between the hands, when it is palpated with one hand on 
 the loin and the other on the abdominal wall in front a move- 
 ment which can be made so freely in the case of some simple 
 enlargements of the organ. 
 
 This form of perinephritis is apt to cause, as a late result, 
 misplacement of the kidney. This was first pointed out in 
 connection with a case reported to the Pathological Society of 
 London by Durham in 1861.* The right kidney weighed only two 
 and a half ounces, was healthy in structure, but was curiously mis- 
 placed, being situated altogether above the last rib, and firmly 
 connected with the diaphragm by dense fibrous tissue, the effect, it 
 was supposed, of perinephritis occurring at a very early period 
 
 of life. 
 
 * Trans., Case 5, p. 135.
 
 PERINEPHRIC ABSCESS. 
 
 271 
 
 The Lipomatous variety (Figs. 33 and 34) is especially apt to 
 follow some affections of the kidney itself ; a large increase of the 
 fatty tissues results, which after enveloping the kidney penetrates it, 
 along with the vessels at the hilum, an(J may in extreme cases 
 transform the whole organ into a fatty mass (see Fig. 117, Vol. II., 
 p. 73). 
 
 There is no sharp line of demarcation between the sclerosing 
 
 Fig. 33. Hilum of a Cystic Kidney packed with tough fibro-lipomatous tissue, the 
 
 result of lipomatous perinephritis. (Middlesex Hospital Museum.) 
 
 (This is the same kidney laid open as that illustrated in Fig. 85, p. 562.) 
 
 and lipomatous varieties, and an intermediate form is often met 
 with in which the excess of perirenal tissue is composed of fibro- 
 fatty material. 
 
 Suppurating Perinephritis. The third variety is characterised 
 by the presence of pus, and it is to this form that the term 
 Perinephritic Abscess is applied, whether the suppuration be 
 diffused or localised. 
 
 Perinephritis has been met with at all ages, from five weeks 
 old upwards. Perinephric abscess occurs more commonly in 
 adults ; but as the result of injury it may arise at any age.
 
 272 
 
 SURGERY OF THE KIDNEY AND URETER. 
 
 Though perhaps more frequent in men, the abscesses are often 
 met with in women. In some few instances they are idiopathic 
 in origin, and quite simple in their course and termination. In 
 many they are symptomatic, and after running a complicated 
 course terminate fatally. 
 
 From very ancient times renal abscess, pyo-nephrosis, and 
 
 Fiif. o4. Lipomatous Perinephritis. Suppurating Kidney firmly embedded in the 
 cellulo-fatty tissue of the Loin. 
 
 calculous pyelitis have been known to end in suppuration around 
 the kidney, necessitating the evacuation of pus by an incision 
 in the loin. But it was only at and since the time of Raver 
 that special attention was paid to abscesses situated outside the 
 kidney, and due to causes independent of the kidney. 
 
 It was Raver who gave the first systematic account of peri- 
 nephric or extrarenal abscesses. He classified them into three 
 groups, according to their etiology, thus : (1) Primary extrarenal 
 abscesses, or those which are independent of any fistulous opening
 
 CAUSES OF SUPPURATIVE PERINEPHRITIS. 273 
 
 into or other disease of the kidney ; (2) consecutive extrarenal 
 abscesses, comprising cases in which the abscesses are secondary 
 to an inflammation of the kidney, i.e. in which the inflammation 
 has spread to the cellulo-adipose tissue by contiguity, but without 
 urinary infiltration ; (3) consecutive extrarenal abscesses formed 
 in consequence of a fistula communicating between the renal 
 cavity or renal substance and the surrounding cellulo-adipose 
 tissue, and generally, though not invariably, due to calculus in 
 the kidney. 
 
 Etiology. The causes of perinephritis may be divided into 
 two classes : 
 
 (a) Primary. 
 
 (6) Secondary to the kidney or (c) to some other organ. 
 
 (a) Among the primary cases many are traumatic in origin. 
 The various injuries to which the loins are liable, such as blows, 
 strains, punctured and incised wounds, whether they involve 
 the kidney or not, and whether urine is extravasated or not, 
 are prone to excite perinephritis. 
 
 A sudden chill, especially after exposure to great heat, and 
 after sweating, is an exciting cause. Raver quotes two cases 
 typical of this cause. In a case under my own care the exciting 
 cause was a chill after prolonged rowing. 
 
 Perinephritis may also occur as a complication or sequela of 
 general diseases, as tuberculosis and the exanthemata. A case 
 of much interest, which has been quoted by many subsequent 
 writers, was described by Dr. Butler* as due to a peculiar irri- 
 tative fever, commonly called the Plymouth Dockyard disease. 
 This seems to have been a particular form of septicaemic cellulitis. 
 
 (6) Perinephritis most frequently originates in suppurative 
 pyelitis, nephritis, or pyelo-nephritis, by extension through or 
 actual perforation of the capsule. Albarran has shown that the 
 infection passes through the capsule by way of the lymphatics. 
 In some cases the kidney affection is secondary to inflammation 
 of the bladder ; in others it is due to tubercle, cancel', cystic 
 or hydatid disease of the kidney itself ; in others, again, and 
 much more frequently, to calculus within the kidney. 
 
 Urethra! stricture, vesical calculus, and prostatic disease may 
 each lead to acute or chronic perinephritis by first exciting pyelitis, 
 
 * Edin. Med. and Surg. Journ., vol. xxvi., p. 106. 
 VOL. I. s
 
 274 SURGERY OF THE KIDNEY AND URETER. 
 
 pyelonephritis, or pyo-nephrosis. Evidence of chronic perinephritis 
 is often seen in the post-mortem examination of such diseases 
 of the lower urinary tract as those just named, and is furnished 
 by the induration of the circumrenal cellular tissue, and by the 
 thickened and firmly fixed renal capsule which is left behind on 
 attempting to remove the kidney. In acute cases of this kind 
 the capsule is found to be very vascular, and' numerous abscesses 
 are formed in the inflamed cellular tissue around the capsule. 
 In time these small abscesses coalesce and burrow far and wide, 
 if they do not soon open into the colon or in. some other direction. 
 
 In certain cases the spread of the inflammation has been by 
 direct contiguity, as when numerous miliary abscesses are formed 
 at the outer surface of the kidney* in pyelo-nephritis. In others 
 abscess in the circumrenal cellular tissue has followed repeated 
 attacks of the gravel or of renal colic, without there being any 
 perforation of the renal capsule. Andral f records a case of 
 perinephric abscess which followed chronic inflammation and 
 atrophy of the kidney ; and Raver (p. 264) gives the particulars 
 of the case of a woman, aged sixty-five, who suffered from ex- 
 trarenal abscess excited by a tumour of the kidney. In another 
 case of Raver's a perinephric abscess of the left loin followed 
 dilatation and suppuration of the left ureter, due to a fungous 
 cancer of the bladder. 
 
 Perinephritis, when induced by simple extension of inflamma- 
 tion from within the kidney, and not by extravasation following 
 perforation, is preceded by inflammation of the fibrous capsule of 
 the kidney. 
 
 The cases of perinephric abscess consecutive to renal fistula 
 are chiefly due to calculous pyelitis. These are very numerous. 
 Lafitte, in 1734, recorded three such in his article on cases in 
 which nephrotom.y is practised with success.* Others arise from 
 tubercle, cancer, hydatid, penetrating or lacerating wounds, etc. 
 
 A renal calculus, after destroying to a greater or less extent 
 the renal structures, may ulcerate through the capsule and lie 
 loose in a suppurating space behind the kidney. Tuberculous 
 matter may lead to ulceration of the capsule, and sprout, fungus- 
 
 * BM. de la Socii-te Anatomique, tome i., p. G9 ; 1835. 
 t Andral, " Clinique Medicale," tome iv., p. 188; -211(1 edition. 
 I Memoires de I' Acad'mie Royal e dc Chirurrjie, tome ii., pp. 233-237. 
 In 4to.
 
 CAUSES OF PERINEPHRIC ABSCESS. 275 
 
 like, into the tissue around the kidney ; or perinephric abscess 
 may be induced by the presence of tubercle in the kidney, without 
 the renal capsule being previously perforated. 
 
 (c) Perinephritis is often a consequence of the extension of 
 inflammation from distant parts, such as the pelvis, colon, appen- 
 dix, testicle, spermatic cord, spleen, liver, gall-bladder, or vertebrae. 
 So easily can inflammation which begins in the pelvic or iliac 
 regions spread upwards to the loins, along the ureter or the veins 
 or the retroperitoneal connective tissue, and there give rise to an 
 abscess around the kidney, that diseases of, or operations upon 
 the rectum, urinary bladder, testicle, or the uterus, and cellulitis 
 arising during the puerperal state, are well-known causes. 
 
 Perforation of the gall-bladder by a gall-stone (Trousseau), 
 of the colon by a pin (Raver, p. 247), or of the diaphragm by 
 an empygema or a pneumonic abscess have been recorded as 
 causes of perinephritis. Perforation of the ileum by a typhoid or 
 scrofulous ulcer has been thought to be an occasional cause (Trous- 
 seau) ; so also is appendicitis. Castration, excision of the rectum, 
 lithotomy, the injection of a hydrocele, incision of heematocele, 
 the various operative methods of treating varicocele, internal 
 urethrotomy (Roberts), and other operations on the urethra ; 
 and diseases of the prostate, urethra, bladder, and seminal vesicles, 
 and even the retention of a catheter in the urethra (Nieden), 
 have each been followed by perinephritis. The inflammation 
 extends by continuity along the retroperitoneal tissue or veins, 
 without the kidney itself being involved. 
 
 Poland tabulated twenty-eight cases of primary abscess, the 
 causes of which are given as follow : Falls and contusions, three ; 
 jolting of carriage, one ; fatigue in walking, one ; muscular effort 
 (digging), three ; debility, one ; uncertain and insidious, four 
 110 cause assignable, six ; cause not stated in six cases. In three 
 cases there is a doubt as to whether the abscesses were strictly 
 primary or were not rather consecutive ; in one of the doubtful 
 cases the abscess occurred thirty-two days after the removal of 
 a testicle of the same side (Chopart) ; in another, fifteen days 
 after an abscess of the broad ligament had burst into the bladder 
 and vagina ; and in the third, calculi had been passed four years 
 before, and the patient had latterly suffered from pyelo-nephritis. 
 
 In twenty -six instances collected bv Dr. Duffin, two were the
 
 276 SURGERY OF THE KIDNEY AND URETER. 
 
 result of severe injury to the loin ; two had a puerperal origin ; 
 one followed a renal abscess secondary to lithotrity ; one was 
 excited by irritability of the bladder ; eight were caused by kidney 
 disease ; and in twelve the abscess appeared to be independent of 
 any affection of the urinary organs. In five of these twelve a 
 sprain in the loin may have been the exciting cause ; in three, 
 exposure to cold ; in one, ulceration of the gall-bladder. 
 
 Symptoms. The symptoms of perinephritis are not always 
 the same, nor are they always well pronounced, especially in the 
 early stages of the inflammation. They vary with the cause, as 
 well as with the acuteness of the disease. When the inflammation 
 is secondary to some distant disease, such as puerperal peri- 
 metritis, or pelvic cellulitis, the symptoms of the primary affection 
 may disguise those of the perinephritis. Even when perinephritis 
 is the primary disease, the symptoms are sometimes of a most 
 insidious, obscure, or ill-defined character, so that typhoid fever, 
 appendicitis, hip joint disease, rheumatism, or spinal caries may 
 be suspected rather than perinephric abscess. 
 
 It is necessary, therefore, to bear in mind that, whereas in 
 some cases the symptoms of perinephritis are both locally and 
 constitutionally very pronounced, and the disease is so rapid in 
 its course that a large and fluctuating tumour in the flank may 
 be developed in from ten days to a fortnight, in others the 
 beginning and early part of the progress of perinephric abscess 
 is ill-defined and slightly marked, the local pain being either 
 absent, or neglected in consequence of a more severe pain else- 
 where, or owing to the severity of the constitutional symptoms 
 diverting observation from the local (Trousseau). It is pretty 
 certain that sometimes cases of perinephritis which do not go on 
 to suppuration, but recover under rest and suitable treatment, 
 are diagnosed wrongly as incipient hip joint or spinal disease or 
 disease of the sacro-iliac joint. 
 
 Symptoms of perinephritis without suppuration. The 
 experience gained by a close study of perinephric abscesses, as 
 Gibney points out, has enabled us to recognise the symptoms of 
 perinephritis before the inflammation has reached the stage of 
 suppuration. When, after an injury or otherwise, there is 
 tenderness on pressure in the renal region, and the patient whilst 
 standing, or sitting, inclines over to the tender side, perinephritis
 
 PERINEPHRITIS SIMULATING HIP JOINT DISEASE. 277 
 
 should be suspected. The diagnosis will be made by attention to 
 the following symptoms. 
 
 The spinal column is preternaturally stiff, and curved in the 
 antero-posterior direction, though without angular curvature ; 
 possibly it will deviate a little from the affected side. There is 
 stiffness in walking, and the body is inclined over to the affected 
 side ; so much so, in some cases, that the crest of the ilium 
 is in contact with the lower ribs. 
 
 Whilst standing, the body will be flexed upon the thigh of 
 the affected side, and the hand of the same side will rest supporting 
 the trunk on the corresponding thigh. The continued flexion of 
 the thigh causes some lordosis in walking. If an effort is made to 
 stand, without support, on the affected side, the body is thrown 
 far over towards that side, and the opposite thigh and leg are 
 strongly flexed. Stooping will be difficult. Whilst lying on his 
 back the patient will not extend the thigh beyond 160, and in 
 more severe cases not beyond 130. There is pain in every 
 movement of the trunk in severe cases, so that the patient may 
 not be able to turn over in bed. Flexion of the thigh will not 
 give pain, but complete extension will not be possible, and its 
 attempt will cause discomfort, if not pain. Abduction and ad- 
 duction will probably be uninterfered \vith, but there may be 
 some difficulty in adduction. The patient will be able to stand 
 on the affected limb alone, in the manner described above. In 
 mild cases the limb may look straight whilst standing, but when 
 lying or sitting on a hard mattress the ham cannot be made 
 to touch the surface. Occasionally the thigh is rotated out- 
 wards ; when this is so, the heel of the affected side during 
 standing rests upon the dorsum of the other foot. In this state 
 the second stage of hip joint disease is simulated. 
 
 When knee joint pain is complained of, as it sometimes is, 
 we must beware of mistaking perinephritis for morbus coxae. 
 With pain in the knee, lameness, and muscular rigidity about the 
 hip joint, it is too often concluded that we have sufficiently strong 
 evidence of morbus coxae ; but one of the cases reported by 
 Gibney and another which has passed under my ow r n observa- 
 tion should convince us of tjie necessity of cautious examination 
 before we commit ourselves to this diagnosis on these symptoms 
 alone.
 
 278 SURGERY OF THE KIDNEY AND URETER. 
 
 Gibney further points out that pain at the hip joint in such 
 acts as pulling on a boot, and resistance to complete flexion, 
 whilst strongly in favour of hip joint disease, are not incompatible 
 with periiiephritis. 
 
 In perinephritis there is no atrophy of the muscles of the 
 thigh, no shortening of the limb, no fulness or tenderness on 
 pressure about the head or trochanter of the femur ; no tender- 
 ness or pain, on succussion or passive motion of the hip joint ; 
 no tenderness over the sacro-iliac joint, and none on percussing 
 the spinous processes or succussion of the spinal column. The 
 tenderness in the loin will be above the crest of the ilium, and 
 one or two inches at least to the side of the spines of the lumbar 
 vertebrae. The tongue will be coated, the temperature raised 
 commonly to 103, often to 104 or higher, and the urine 
 will be acid and without blood or pus, though there will be 
 abundance of lithates, and there may be some albumen. 
 
 Thus, with feverishness without tenderness over the spinal 
 column, and with symptoms pointing to an inflammatory affection 
 011 one side of the column, there is an absence of the character- 
 istic signs of disease of the hip or sacro-iliac joint ; though a 
 very similar alteration in the attitude, and much the same limi- 
 tation of muscular mobility of the affected side, exist as in those 
 diseases. 
 
 In iioii-suppurative periiiephritis there is no tumefaction in the 
 loin or around the kidney, as in periiiephric abscess. 
 
 If recovery by resolution occurs, the tenderness in the loin 
 subsides, the temperature declines gradually to 100 and then to 
 normal, sitting is less uncomfortable, and walking more easy, 
 flexion of the thigh is no longer maintained, and extension in 
 dorsal decubitus can be fully and easily accomplished. The 
 tongue gradually cleans, and the bowels act with regularity. 
 At length all inclination of the trunk to the affected side is 
 discontinued. 
 
 Symptoms of perinephric suppuration. Periiiephric abscess 
 generally declares its presence by symptoms unmistakable. The 
 constitutional indications are the same as those excited by 
 deep - seated suppuration elsewhere : rigors, high temperature, 
 sweating, furred tongue, thirst, loss of appetite, perhaps vomit- 
 ing, and delirium in the acute cases ; constipation, foul
 
 PAIN A LEADING SYMPTOM IN PERINEPHRIC ABSCESS. 279 
 
 tongue, loss of appetite, slight elevation of temperature in the 
 chronic. In other words, the symptoms will be more or less 
 severe according to the acuteness of the inflammation. In old 
 and weakly persons, and when the inflammation is chronic, the 
 symptoms may be altogether masked until the abscess, by its 
 size and pressure upon surrounding structures, forces itself upon 
 attention. In some subacute cases the only symptom for several 
 weeks before pus was discovered, or even suspected, has been 
 lameness, wrongly attributed to morbus coxee or to rheumatism. 
 
 The febrile temperature does not always take the same course; 
 in some cases it is like the course of typhoid, running continuously 
 high ; in others it is intermittent, and suggestive of malaria 
 or pyaemia. The obstinate constipation, which Trousseau remarks 
 always exists, is certainly a very frequent symptom, and is doubt- 
 less due to the loss of, or the dread on the part of the patient 
 of employing, muscular effort. 
 
 Of the local symptoms, those due to pressure are more marked 
 in periiiephric abscess than in perinephritis. Pam is one of the 
 earliest and most prominent indications. Deep-seated and often 
 paroxysmal, it frequently ushers in the disease. The common seat 
 of the pain is the loin and side of the abdomen, but it some- 
 times shoots down the thigh or into the hypogastrium, scrotum, 
 penis, testes, or groin. Its wide diffusion is explained by the 
 anatomical distribution of the nerves of the lumbar plexus which 
 traverse the renal region. 
 
 It is in one case of a dull aching character, in another darting 
 or pricking. Occasionally it may be felt in the knee, as in 
 coxalgia (Gibney). In most cases the pain which sets in at the 
 beginning continues and increases throughout the progress of 
 the inflammation and until the pus is evacuated ; but in 
 other cases its severity diminishes temporarily, and in chronic 
 cases it may disappear entirely for weeks, or even months, 
 encouraging a delusive hope that recovery has taken place 
 (Trousseau and Ebstein). Invariably the pain is increased on 
 pressure, and if the loin be compressed between the hands 
 the suffering caused is, in some instances, very acute. For a 
 period varying from a few days to several weeks no other local 
 symptom except pain or tenderness on pressure over the kidney 
 and in the loin may be present ; whilst the constitutional disturbance
 
 280 SURGERY OF THE KIDNEY AND URETER. 
 
 may or may not indicate that the pain has its origin in a grave 
 and organic disease. 
 
 The affected side will often give to the surgeon the sense of 
 increased resistance and weight long before pus has formed or 
 the abscess is large enough to cause any alteration in the outline 
 of the flank or abdomen. This condition will be best detected 
 by lifting, as it were, each lorn with the flat hands placed behind, 
 on each ilio-costal interspace ; thus simultaneously comparing 
 the resistance offered by the two sides. A feeling of weight 
 in the side is sometimes experienced by the patient, who will, 
 perhaps, for days together complain of a sensation of fulness 
 and pufnness in the flank. Later on there will be dulness in 
 the ilio-costal interspace, swelling in the region of the kidney, 
 at first hard and resisting, and if the parietes be thick and fat, 
 indistinct and ill-defined ; later in the case the ilio-costal curve will 
 be quite effaced, and obscure fluctuation may be felt. The skin 
 in the loin is often waxen and cedematous, unless the matter 
 makes its way to the surface, and then it becomes congested. 
 After a time deep-seated fluctuation may be detected in place 
 of the hard resistance previously felt ; but this will depend much 
 upon the thickness of the abdominal parietes. I have known 
 as many as six pints of pus pent up, presumably for several 
 weeks, in a perinephric abscess, and yet 110 fluctuation could be 
 made out, owing to the enormous thickness of the subcutaneous 
 fat. In this case the patient had suffered and recovered from 
 an acute abscess in the test is of the same side, before the com- 
 mencement of the perinephritis ; both abscesses were caused by 
 calculous pyelitis. 
 
 Retraction of the test is has been noticed in some cases ; it 
 is most likely to occur when perinephric abscess is caused by 
 calculous pyelitis, but is not restricted to such cases. 
 
 I have seen oedema of the foot and ankle precede for many 
 weeks every other sign of perinephric abscess. Pyelitis had existed 
 for a long time, and shown itself by a small quantity of pus 
 in acid urine, frequency of micturition, constipation, flatulence, 
 debility, and anorexia ; then followed oedema of the limb, with- 
 out pain ; and then, after a long railway journey, came pain 
 in the loin and in the same side of the abdomen ; the pain rapidly 
 increased, and was followed bv fulness, hardness, and dulness,
 
 LAMENESS, AND CONSTRAINED ATTITUDE. 281 
 
 and at last by redness and oedema in the loin. Niedeii gives 
 one case in which oedema of the lower extremity was noted. 
 
 Lameness and flexion of the thigh. A peculiar lameness is 
 often an early symptom, and is due to the flexed position in 
 which the thigh of the affected side is retained in order to 
 relieve pressure upon the inflamed tissue. Sometimes the patient 
 walks with the body bent forwards and inclined to the affected 
 side, with the hand of the same side resting on the middle 
 of the thigh. The sitting attitude is also, and for the same 
 reason, characteristic ; the patient sits on one ischial tuberosity, so 
 as to relax the psoas muscle of the other side. Dr. Duffiii, in his 
 excellent summary of twenty -six cases, has drawn particular at- 
 tention to this lameness as a diagnostic sign, and points out its 
 association with another symptom of perinephric abscesses namely, 
 their tendency to implicate the pleura and lung. The pus 
 sometimes follows the track of the psoas muscle downwards 
 towards the groin ; but it may also pass upwards along the 
 psoas beneath the ligamentum arcuatum internum, and thus 
 empyema or pulmonary fistula may be caused. 
 
 Sometimes the symptoms of pleurisy or pneumonia on the 
 affected side mask those of perinephritis, and the patient appears 
 at first to be suffering exclusively from disease within the chest 
 (Bowditch). 
 
 An inability to extend the thigh of the affected side has also 
 been an early sign in my experience. I will refer later on to 
 a typical case, in which the flexion of the thigh was a very 
 striking, but, as it happened, a very misleading symptom. It 
 was observed in twenty-seven out of one hundred and sixty-six 
 cases collected by Nieden. It may be only just sufficient to 
 prevent complete extension of the thigh, or so extreme that 
 the thigh is drawn up close to the abdomen. As long as the 
 limb is kept flexed the patient may be easy, but any attempt 
 to extend it causes pain. Sometimes other movements of the 
 thigh as well as extension give pain. Gibney mentions difficulty 
 in voluntary adduction, and in one case towards the end of the 
 disease there was resistance to complete passive flexion. In 
 Nieden's list there is one case in which convulsive movement* 
 of the leg was a symptom of perinephric abscess ; one in which 
 perinephritis (not abscess) was followed by paralysis of both
 
 282 SURGERY OF THE KIDNEY AND URETER. 
 
 legs ; another in which an abscess oil the left side was com- 
 plicated with pleurisy of the same side and paralysis of the 
 right arm and both legs. Altogether, in eight cases out of the 
 hundred and sixty-six there was some temporary anaesthesia or 
 more or less paralysis of the thigh of the affected side. 
 
 This bent position of the thigh, like the lameness and the 
 sitting 011 one side, is doubtless due to a relaxation of the 
 psoas muscle, whereby pressure and tension 011 the post-renal 
 cellular tissue are lessened and pain is thus relieved. The nerves 
 of the lumbar plexus pass outwards in very intimate relation 
 with the psoas muscle and post-renal cellular tissue, and in all 
 probability suffer some inflammatory thickening, and the relaxa- 
 tion of this muscle by flexion of the thigh tends to put these 
 nerves at ease. To the same end a stooping attitude is assumed, 
 the shoulders are elevated, and the trunk is inclined to the 
 affected side, so as to fix the spine and relax the upper end of 
 the psoas muscle. 
 
 The urine. The urine affords but a very imperfect aid to 
 diagnosis, because, in the first place, it may have been long ago 
 changed by antecedent vesical or renal disease ; and because, in 
 the second place, if the cause of the perinephric inflammation does 
 not reside in the urinary organs the urine itself may be quite 
 normal, except for the changes due to febrile action ; or at most 
 there may be a diminution in the quantity excreted. It may, how- 
 ever, contain albumen, as a result of pressure on the renal vein. 
 When perinephric abscess follows an injury to the kidney region 
 the urine may be at first blood-stained, and afterwards contain 
 pus. Frequent or painful micturition and incontinence of urine 
 have been observed. 
 
 The frequency of urinary complications in the twenty -six cases 
 analysed by Dr. Duffiii was as follows : Two patients had blood and 
 six had pus in their urine ; two suffered from vesical irritation ; 
 five had renal disease without bladder signs ; twelve were without 
 urinary trouble of any sort. In the two in which blood was 
 voided with the urine the perinephric abscess was caused by 
 injury to the loin. 
 
 Characters of the pun. The pus contained in some perinephric 
 abscesses is quite odourless, in others foetid ; in a few it has quite 
 a fecal odour, though no fistulous communication exists between
 
 ABSCESS WALL MAY BE GANGRENOUS. 283 
 
 the abscess and the bowel. Raver pointed this out as occurring 
 in one of his cases in which there was an entire absence of faecal 
 matter in the discharges, as well as of gas on pressing the 
 anterior abdominal walls, and, indeed, of all signs suggestive of 
 intestinal fistula. 
 
 As soon as the pus is evacuated the temperature falls, the 
 pain vanishes, the appetite returns, and the flatulence and con- 
 stipation disappear. The patient rapidly recovers, provided the 
 incision of the abscess has been made before the pus has burrowed 
 too widely or the inflammation has set up some dangerous 
 complication. 
 
 Pathology. The area of the cellulo-adipose tissue affected 
 may be very small or very extensive. A purulent collection may 
 be so small that it may be missed by an exploratory incision 
 extending from the last rib to the iliac crest ; whilst, on the 
 other hand, pus, if not provided with an opening, may burrow 
 upwards to the diaphragm, downwards to the groin, and inwards 
 across the middle line to the opposite loin. In acute cases the 
 fibrous capsule of the kidney may be very vascular and red, and 
 the cellular tissue surrounding it may be infiltrated with serous 
 fluid ; or numerous minute abscesses' may form in the inflamed 
 cellular tissue ; or the inflammation may be lighted up in the 
 whole of the surrounding tissue at once, and suppuration be 
 diffused throughout it. 
 
 In some cases the tissue is injected, and oedema tous with 
 serum or sero-pus ; in others one or several pints of pus may 
 have formed, and the kidney (little or not at all affected) may 
 be detached everywhere from its cellular and adipose sur- 
 roundings ; in others, again, besides pus, stringy, flocculent, and 
 gangrenous masses of the tissue have been found mixed with 
 the pus. In Dr. T. Turner's case the tissue surrounding both 
 kidneys was gangrenous and converted into a black pulpy mass, 
 and the fibrous capsule of each kidney was inflamed, whilst that 
 of the right was partly gangrenous, though the secreting sub- 
 stance of the kidneys was but slightly affected. The pathological 
 changes observed in the kidney are frequently those to which 
 the periiiephritis was due ; in other cases the renal changes are 
 secondary to the inflammation in the perinephric structures. 
 In some cases there has been found general softening of the
 
 284 SURGERY OF THE KIDNEY AND URETER. 
 
 kidney, but without any purulent deposits in the secreting sub- 
 stance, or suppuration in the pelvis, or calyces of the organ. 
 Sometimes the whole or a part of the kidney has been quite 
 liquefied by the solvent action of the surrounding pus and the 
 softening influence of the inflammation. 
 
 In a medico-legal case of some importance which arose several 
 years ago in Edinburgh, a calculus (from Avhich Fig. 29, p. 163, 
 is taken) had tightly fitted the cavity of the kidney of a 
 woman who was kicked in the loin by her husband. Acute 
 inflammation, followed by an enormous perinephric abscess, 
 occurred, and soon ended fatally. At the post-mortem examina- 
 tion the lower half of the kidney was quite liquefied ; it had 
 entirely lost all the characters of a solid structure, but the calculus 
 had literally to be cut out of the remainder of the organ, to 
 which it accurately and tightly fitted. 
 
 This abscess had burrowed upwards to the diaphragm, through 
 which it had partially ulcerated over an area equal to a penny- 
 piece ; and the base of the lung was firmly adherent to the 
 upper surface of the diaphragm over this area. Had the muscle 
 been completely ulcerated through, the pus would have entered 
 a bronchus, and not the pleural cavity. In this case the large 
 branched stone, weighing 337 grains, was the predisposing, and 
 the kick the exciting, cause of the suppuration ; and thus this 
 unsuspected and previously quiescent calculus at length destroyed 
 the life of its bearer. 
 
 As previously stated, blood is occasionally effused beneath, as 
 well as upon the outer surface of, the fibrous covering of the 
 kidney, and sometimes a number of small ecchymoses are seen 
 in the tissue around ; so, in some cases pus is found beneath the 
 fibrous tunic of the kidney, as well as in the cellular tissue out- 
 side, and the fibrous capsule may be perforated here and there, 
 thickened, and intimately adherent to the surrounding tissue 
 at points where there is no pus. Such a condition is usually 
 the result of some cause which has led to more or less dis- 
 organisation of the kidney prior to the perinephritis. Pyelitis 
 and pyelo-nephritis are usually associated with this condition. 
 
 The pus contained in a perinephric abscess ma}" be dark in colour 
 from extravasated blood, or fivcal matter; but owing to the prox- 
 imity of the colon, even a fiscal odour may be present without any
 
 VARIOUS DIRECTIONS TAKEN BY THE PUS. 285 
 
 fistulous communication with the bowel existing. Occasionally 
 a urinous odour has been noticed. Among the micro-organisms 
 which have been most frequently found in connection with these 
 abscesses are bacillus coli and the pyogenic cocci, w T hile in many 
 cases there is a mixed infection. 
 
 The seat of the pus, when the suppuration is not due to 
 extravasation from the kidney, is nearly always in the cellular 
 tissue behind, between the kidney and the muscles of the loin, 
 and with the kidney between it and the peritoneum. 
 
 When the perinephritis is the consequence of a renal fistula, 
 the pus will generally be posterior to the kidney. But it may 
 be in front of it, and, burrowing along behind the peritoneum 
 push that membrane forwards, as in the case of Sarah S., aged 
 thirty (Middlesex Hospital, No. 183, 1882), who died of scrofulous 
 pyo-nephrosis and cystitis. The left kidney was large, its capsule 
 very thick, and foci of pus were seen in places beneath the capsule, 
 The greater part of the kidney substance indeed, was suppurating. 
 A perinephric abscess, situated chiefly in front of the kidney, 
 had burrowed down to the anterior superior spine of the ilium 
 and the brim of the pelvis. 
 
 Or the abscess may ulcerate through the peritoneum, and 
 cause death by fatal peritonitis, as in a case recorded by Gardien ; * 
 or it may form an intraperitoneal abscess circumscribed by 
 adhesions. 
 
 A perinephric abscess may extend from the posterior border 
 of the liver or spleen to as low as the brim of the true pelvis ; 
 posteriorly, it is limited by the aponeurotic and muscular tissues 
 of the loin, which it bulges backwards and outwards, and may 
 destroy more or less by ulceration ; and, anteriorly, it may push 
 forwards the peritoneum, until it forms an enormous tumour, 
 readily detected by looking at the front of the abdomen. On 
 the other hand, in not a few instances the abscess has been so 
 small that after an exploratory incision no pus has escaped, and 
 the diagnosis has been for a moment called in question ; but 
 within a few days the matter has found its way into the opening. 
 
 In some instances, though the peritoneum may be much 
 bulged forwards, and the pus only retained posteriorly by the 
 skin, the abscess cavity is limited above and below by a tough 
 
 * See Rayer, p. 252.
 
 286 SURGERY OF THE K1D1S 7 EY AXD URETER, 
 
 thick cellular tissue, which shuts off the liver or spleen above, 
 and the iliac fossa below. Andral describes such a case.* 
 Occasionally an abscess in the liver or spleen, according to the 
 side affected, is excited by the inflammation in the perinephric 
 tissues. 
 
 In chronic inflammation or suppuration in the perinephric 
 tissue, very firm and tough adhesions are formed between it 
 and the fibrous capsule of the kidney, and between the latter 
 and the cortical substance. Indeed, one sometimes finds the 
 kidney " set," as it were, in a thick frame of cellular adipose 
 tissue, as an anatomical preparation is " set " in plaster of Paris. 
 In such a state it is impossible to separate the kidney without 
 tearing it out of its fibrous capsule. A specimen which I placed 
 in the Museum of the Middlesex Hospital shows this condition 
 well (Fig. 34, p. 272) ; and Durham reported a similar case in 
 February, 1885. Sometimes the fibrous capsule of the kidney 
 undergoes in places marked cartilaginous or bony thickening. In 
 one instance, in which I laid open a chronic purulent fistula 
 in the loin, I picked from off the capsule a small plate of 
 plastic lymph infiltrated with urinary salts, and which, for the 
 moment, felt like a calculus projecting on the surface of the 
 kidne}*. 
 
 When incision, the only proper treatment in cases of sup- 
 puration, has been neglected, the pus may burst in one or more 
 of several directions. In one case it will be into the colon, small 
 intestine, or stomach ; in another, into the pleural sac or the 
 lung ; in a third, into the ureter ; in a fourth, into the sheath 
 of the psoas muscle, and thus make its way to the groin ; or 
 it may reach the groin by travelling across the iliac fossa without 
 entering the psoas sheath ; similarly, after burrowing through 
 the pelvis it has appeared in the buttock by finding its way 
 through the sacro-sciatic notch ; more frequently it reaches the 
 surface at the loin or at some spot posterior to a line drawn 
 from the crest of the ilium upwards to a point one inch in front 
 of the tip of the eleventh rib. Compared with the frequency with 
 which perinephric abscesses perforate the colon, the pleura, or the 
 lung, the other forms of spontaneous opening are rare. Probably 
 it is not any exaggeration to say that of every twelve cases 
 
 * Clinique M>'dicale.
 
 SPONTANEOUS OPENING OF PERINEPHRIC ABSCESS. 287 
 
 which pursue their own course, four or five open into the 
 pleural cavity or lung. 
 
 Duffin gives six cases out of twenty -six in which the abscess 
 opened into the colon, one in which it opened into the peritoneum, 
 and one only in which it opened externally at the loin. Of 
 the twenty-eight cases of primary abscesses tabulated by Poland, 
 sixteen were uncomplicated, five burst into the colon, one into 
 the peritoneum, two into the vagina and bladder, three into 
 the lungs, and three probably into the kidney. In a case recorded 
 by Rolleston an abscess arising from tuberculous disease of the 
 kidney opened into the third part of the duodenum. 
 
 Liclell, in an article on rupture of the abdominal and pelvic 
 viscera,* cites a case of gun-shot wound of the right kidney 
 and third lumbar vertebra, where an abscess was formed in the 
 cellular tissue behind the caput coli, which burrowed along the 
 psoas magnus and among the muscles of the abdominal wall 
 and the back, and passing up beneath the right crus of 
 the diaphragm, burst into the right pleural cavity, and in 
 this way caused death. The case is worth quoting, because of 
 the emphasis the author lays upon its being " a matter of the 
 highest importance to secure the early discharge of the contents 
 of the abscess through an external opening, since from the 
 looseness of the cellular tissue the pus is apt to burrow widely." 
 Quain and Dickinson have each recorded a case in which the 
 abscess opened at the groin, and in two cases of my own, one 
 of which will be referred to further on, the same thing occurred. 
 Dr. F. Lange has reported a case where empyema and a sinus 
 on the front of the thigh were both apparently due to a peri- 
 nephric abscess. Bowditch gives a case of a young man supposed 
 to be dying of phthisis, and who was expectorating large quantities 
 of pus, which from time to time used to pour out of his mouth ; 
 but he had also the perinephric posture and lameness, and these 
 led Dr. Bowditch to incise the loin. Matter was reached, and 
 the patient recovered. This is a most striking example of the 
 value of incision. 
 
 Of the twenty-eight cases of primary abscesses recorded 
 by Trousseau and Bowditch, eighteen recovered, eight died, 
 and in two the result is not mentioned. Of the eight 
 
 * Amer. Journ. Med. Sciences, p. 356 (April, 1867).
 
 288 SURGERY OF THE KIDNEY AND URETER. 
 
 deaths, six were in cases in which no operation was performed, 
 and death was mainly attributed to this fact. Of the only two 
 fatal cases in which the abscesses had been opened, one died 
 of peritonitis, quite independent of the disease, and one from 
 prolonged suppuration and diarrhoaa. 
 
 A case in several ways unusual came under the care of Dr. 
 Coupland and Mr. Lawson in the Middlesex Hospital, on January 
 Gth, 1883. A boy, aged thirteen, had suffered for a month 
 from pain in the right renal region, and obstruction in the lower 
 end of the right ureter, probably due to impacted calculus. Pyo- 
 nephrosis followed, a tumour formed in the right renal region, 
 which was opened on February 14th by a lumbar incision, and 
 a fistulous opening was established in the loin. Suppuration 
 afterwards complete!}* surrounded the kidney and extended down- 
 wards, so that an opening was made in the groin on February 
 27th. This opening communicated with that in the loin ; but 
 at the post-mortem, no communication existed between the peri- 
 nephric abscess and the interior of the kidney, nor did the sinuous 
 fistula, which led from the pyo-nephrotic cavity to the surface 
 of the loin just below the last rib, communicate with the abscess 
 space around the kidney. During life a fragment of calculus 
 had been impacted in and removed from the urethra. As pus 
 had been freely discharged through the fistula in the loin, the 
 sacculatecl kidney had become somewhat shrivelled. The kidney 
 (the right) was devoid of its capsule, but the lining membrane 
 of its cavity was thickened, and suppurating foci were seen 
 in what remained of the pyramids. The calyces and pelvis 
 were filled with caseous pus. The ureter, which was double 
 to within three inches of the bladder, was enormously dilated 
 throughout its whole extent, but its vesical orifice was much 
 constricted. The dilated ureter was filled with the same kind 
 of material as the cavity of the kidney. The perinephric abscess 
 was full of semi-solid caseous material and green fluid pus. There 
 was empyema of the right side, and pus occupied a space between 
 the diaphragm and the under surface of the right lung, but 
 there was no communication between this empyema and the 
 perinephric abscess (Fig. 35). The left kidney was hypertrophied. 
 
 The course of events in this lad had been, no. doubt, first ob- 
 struction in the vesical orifice of the right ureter, and then
 
 PROGNOSIS DEPENDENT ON EARLY INCISION. 
 
 289 
 
 pyo-nephrosis ; the pyo-nephrosis gave rise to general suppurative 
 perinephritis ; lastly, empyema was set up by the contiguity of 
 the pleura to the perinephric abscess, which was pressing upwards 
 the right side of the diaphragm. The immediate cause of death 
 was septicaemic pericarditis. 
 
 The fact that the ureter was double throughout the greater 
 part of its course ; that the 
 lumbar fistula had, at the 
 time of death, no communica- 
 tion with the perinephric ab- 
 scess, but opened directly into 
 the sacculated kidney ; and 
 that the abscesses connected 
 with the kidney had no direct 
 communication with the em- 
 pyema, are striking features 
 in this case. F-'' 
 
 Prognosis. The prognosis A _ 
 is always grave. In 230 cases 
 collected by Ktister the mor- 
 tality was 34 per cent. The 
 duration of the disease varies 
 from two or three weeks to 
 many months. In a few cases 
 perinephritis ends in resolu- 
 tion before the suppurating 
 stage has been reached. Gib- 
 ney mentions one such case 
 of six months' duration. When 
 
 Fig. 35. Diagram showing Perinephric 
 
 Abscess. 
 suppuration occurs the prog- A> Sinus opeuing U p 0n the 8Urface and into the kidney 
 
 cavity ; B, periueplirie abscess space ; c, abscess 
 cavity within kidney ; D, septum in ureter ; E, em- 
 pycniic space ; F, diaphragm ; c, lung. 
 
 nosis depends chiefly on two 
 things, the early and free 
 evacuation of the pus, and the 
 
 cause of the disease. Incision not only saves life, but also hastens 
 recovery ; and in uncomplicated cases the recovery is complete. 
 The tendency to open spontaneously in the loin is not great in 
 perinephric abscess ; the pus is more likely to take some less 
 favourable direction ; but even if the abscess bursts externally, 
 it is too often not until after extensive burrowing has occurred, 
 
 VOL. I. T
 
 290 SURGERY OF THE KIDNEY AND URETER. 
 
 and through, an opening not free enough to permit of thorough 
 drainage. Prolonged suffering, hectic, and death, are too generally 
 the results in cases where incision is either delayed or neglected. 
 When the abscess is primary, i.e. not dependent upon renal or other 
 visceral or spinal disease, an opening into it is not only followed 
 immediately by great relief, but convalescence is soon completed. 
 
 An incision into the loin, by diminishing the tension of the 
 inflamed tissues and allowing of the escape therefrom of blood 
 and serum, has sometimes cut short the inflammation ; whilst in 
 other cases it has hastened the evacuation of the pus of a small 
 abscess, the precise locality of which was not entered by the 
 incision. When the perinephric abscess is secondary to 
 calculous pyelitis, and where there is distension of the pelvis 
 and calyces of the kidney, the lumbar incision is followed by a 
 fistula which may remain open permanently or for a very long 
 time. Sometimes the cure is only completed after the dis- 
 charge of several calculi, or after nephrectomy. 
 
 If the abscess burst into the lung, colon, or ureter, recovery may 
 ensue unless the cause of the abscess is incurable ; and, at any rate, 
 immediate relief from the local symptoms will in all probability 
 be experienced. On the other hand, fresh suppuration may 
 be excited by the escape of air and mucus, or by the extra- 
 vasation of faeces (as in a case reported by Bowditch) or urine 
 into the abscess ; and then death may occur from pyaemia, septi- 
 caemia, sapraemia, exhaustion, or gangrene of the lung. Even in 
 cases communicating with the intestine, kidney, or lung, relief, 
 and even permanent and complete cure, might be obtained by 
 lumbar incision. Hufeland* describes a case in which a pin, 
 swallowed by mistake, perforated the ascending colon and led 
 to the escape of faecal matter and gas, and thus to a considerable 
 abscess in the right lumbar region. The patient died in spite of 
 a lumbar incision. But, Hufeland adds, these abscesses do not always 
 terminate so ; and he then describes a similar case of faecal ab- 
 scess in the left loin of a man aged forty, which entirely healed 
 after it was opened and drained. Nieden mentions a case of cure 
 after an abscess of the perinephric tissue had burst into the lung 
 and eighteen ounces of pus had been expectorated. 
 
 If the abscess bursts into the peritoneum, death from peri- 
 
 * Vide Rayer, p. 247.
 
 DIAGNOSIS OF PERINEPHRITIS AND PERINEPHRIC ABSCESS. 291 
 
 tonitis will in all probability quickly follow ; if the abscess bursts 
 into the pleura! cavity, empyema will carry off the patient. 
 Death sometimes is caused by the pressure effects of the abscess 
 before it is opened or has ruptured. Syncope, apnoea and other 
 chest complications are very common in perinephric abscesses, 
 as well as in subdiaphragmatic abscesses within the peritoneal 
 cavity. When scrofulous disease or complete disorganisation 
 from calculous affection of the kidney is the exciting cause, 
 nephrectomy may afford the only chance. 
 
 In cases in which complete cure is impossible, and a per- 
 manent pus-discharging fistula remains, nephrectomy may be the 
 only chance of warding off lardaceous disease ; but, of course, 
 this operation applies only to cases in which the cause of the 
 abscess is in the kidney itself. 
 
 Diagnosis. In examining a case of probable perinephritis 
 or perinephric abscess, we have to ask ourselves first, how to 
 recognise it as such ; secondly, whether the perinephritis or 
 abscess is primary, or secondary to renal or some other organic 
 disease ; and thirdly, in cases where the inflammation or abscess 
 is very limited in extent, by what signs can we precisely localise 
 the seat of disease ? 
 
 1. The affections which may be mistaken for perinephritis 
 or perinephric abscess are lumbago, nephralgia, various organic 
 diseases of the kidney, spinal caries, appendicitis, splenic and 
 hepatic tumours, faecal accumulations in the colon, empyema, 
 pneumonia and abscess of the lung, typhoid fever, morbus coxae, 
 sacro-iliac disease, and psoas abscess. In the early stages and 
 in mild cases an exact diagnosis is not always possible. The 
 following indications will, however, assist us in most cases. 
 
 Lumbago is unaccompanied by fever, local swelling, or marked 
 tenderness on pressure ; the pain is felt on both sides of the 
 spinal column, does not extend around to the front of the renal 
 region, nor shoot along to the groin or testis, and though it is 
 aggravated by movements of the back, it does not cause spasmodic 
 contraction of the psoas muscle ; there is tenderness of the 
 muscles and fascia on pinching those structures. Though the 
 patient walks with a stoop and with a rigidity of the spine, there 
 are not the flexed thigh and lateral inclination . of the trunk 
 which are seen in perinephric abscess and perinephritis.
 
 292 SURGERY OF THE KIDNEY AND URETER. 
 
 In nephralgia the pain is periodic, paroxysmal and variable 
 in degree, sometimes being almost or entirely absent, and some- 
 times intense ; it is generally increased by fatigue or nervous 
 depression, and in women during menstruation ; it is unattended 
 by alteration in the urine, and does not often shoot along in the 
 direction of the ureter. There are spots in the loin which 
 are tender on pressure ; and there may be irritability of the 
 bladder ; and neuralgic pains similar to those in the region 
 of the kidney may be felt in the testis, in the opposite loin, or 
 in any other part commonly affected by neuralgia. The fulness, 
 hardness, and widespread tenderness, the continuous and daily 
 increasing pain, the sensation of tightness and puffiness felt by 
 the patient, and the flexion of the thigh so common in sharp 
 attacks of perinephritis, are all wanting in neuralgia. 
 
 Organic diseases of the kidney, such as cancer, tubercle, calculus, 
 pyo-nephrosis, and the various cystic diseases of the kidney, may 
 co-exist with (may have, in fact, given rise to) perinephritis. The 
 diagnostic characters of each of these are described under their 
 separate headings or in the chapters on renal tumours, and 
 need not be repeated here. It will be sufficient to state that 
 pyo-nephrosis and renal cysts, though they may give rise to 
 elevation of the general temperature of the body, do not cause 
 an increase in the local surface heat, nor oedema of the super- 
 ficial tissues of the loin; nor is the tumour in these cases so 
 ill-defined in outline as it usually is in perinephric abscess, and 
 fluctuation, when it can be detected, is deeper than when the 
 pus is outside the kidney. 
 
 Disease of the spinal column. The similarity between some 
 cases of perinephric abscess and disease of the vertebral column 
 is very striking, and Dr. Gibney records a case in which the 
 spinal brace had been ordered for a patient with perinephritis 
 running on to perinephric abscess. In spinal caries the pain 
 extends round the trunk, and is often most felt over the pit 
 of the stomach ; it is relieved by suspending the patient ; there 
 is a sense of weakness in the centre of the back corresponding 1 
 to the seat of affection ; and there is increased sensibility to 
 heat, so that the patient winces on the application of a hot sponge 
 t:> the spine. The body is held stiff, with the spinal column 
 straight, and the shoulders raised ; there is no inclination or
 
 DIAGNOSIS FROM MORBUS COXA\ 293 
 
 rotation of the trunk to one side as in perinephritis. The flexi- 
 bility and mobility of the spinal column is lost, and the spine 
 moves as a whole upon the hips. 
 
 As the disease progresses the patient cannot stand upright 
 unsupported, the body is bent directly forwards, and is in fact 
 supported by both hands resting on the thighs or on a chair 
 or table ; not by the hand of the affected side resting on the 
 thigh of the same side as in perinephric disease. There is diffi- 
 culty in standing on one leg. The walk is shuffling and tottering, 
 and the toes are more or less turned in. After a time one or 
 two of the spinous processes may become a little prominent ; 
 tenderness or pain will be elicited by pressure or percussion 
 over this part of the column ; and often, too, by pressing on 
 the head or shoulders whilst the patient is sitting on a firm 
 seat. When the disease has advanced to distinct deformity of 
 the spine, with great weakness and more or less palsy of the 
 muscles of the lower limbs, of the sphincter ani, and the detrusor 
 fibres of the bladder, there is or ought to be no possibility of 
 mistaking spinal disease for perinephritis. 
 
 Morbus coxcc. Perinephritis ought to be distinguished from 
 disease of the hip by two classes of symptoms, positive and nega- 
 tive. The positive signs of perinephritis are the higher situation 
 of the pain ; the tenderness, if not fulness, and other changes 
 in the loin ; the fact that passive flexion of the thigh upon the 
 trunk is no only painless of itself but often relieves existing pain, 
 and is effected without any movement of the pelvis ; and further, 
 the free and painless mobility of the hip joint in the direction 
 of rotation outwards and abduction whilst the limb is flexed. 
 
 The negative symptoms are the absence of fulness about the 
 hip joint, and of tenderness 011 pressure over the head and tro- 
 chanter of the femur , the absence of pain on percussion of the 
 thigh and less rigidity and spasm of the adductor and rotator 
 muscles of the thigh. 
 
 The symptoms of permephritis which suggest hip-joint disease 
 are the pain in the thigh and occasionally in the knee, the flexion 
 of the thigh on the trunk and of the knee on the thigh, the 
 inability to completely extend the thigh without causing pain 
 and tilting of the pelvis, the peculiar inclination of the trunk and 
 the limping walk. In cases in which the pus burrows downwards
 
 294 SURGERY OF THE KIDNEY AND URETER. 
 
 and opens below Poupart's ligament the simulation is even 
 more complete. A typical case is recorded in my earlier work, 
 "Surgical Diseases of the Kidney" (pp. 235-37). 
 
 Though caution is required to arrive at a right diagnosis ; 
 and though Gibney may be right in thinking that many re- 
 ported cases of hip disease followed by recovery with perfect 
 mobility of the joint, are in reality cases of cured periiiephritis, 
 yet such a mistake ought not to be made, and will not be, if due 
 attention is paid to the positive and negative signs mentioned above. 
 
 Sacro-iliac joint disease. The preceding statements respecting 
 the distinction between perinephritis and hip-joint disease apply 
 cccteris paribus to this affection. 
 
 Inflammation and abscess of the psoas simulate perinephritis 
 in the following points : pain, inability to stand upright, and lat- 
 eral inclination of the trunk to relax the muscle and to extend 
 the leg. If, however, there be suppuration due to caries of the 
 vertebrae, there will probably, though not always, be the symptoms 
 of disease of the spinal column, and an examination of the evac- 
 uated pus may show evidence of disintegrated bone. Further, the 
 situation of the pain and swelling in inflammation of the psoas will 
 be much nearer the middle line than in perinephritis. In peri- 
 nephritis the local symptoms show themselves in the loin and on the 
 side of the abdomen posterior to a line drawn from the front border 
 of the axilla to the crest of the ilium. If the psoas abscess 
 is large, it will descend below Poupart's ligament in the line of 
 the psoas muscle. Psoas abscess is not always due to spinal 
 caries, but the course and determination of the pus will be in- 
 dependent of the cause of the abscess. 
 
 The case of the boy above referred to, who was under my 
 care, shows that a perinephric abscess may burrow into the 
 thigh and present a swelling in the groin ; but in that case 
 the matter did not pass along the psoas muscle and beneath 
 Poupart's ligament, but took another course and reached the 
 thigh below the horizontal ramus of the pubis. 
 
 A perinephric or a renal abscess may, however, ulcerate into 
 the sheath of the psoas, and then the matter follows the course 
 of that muscle ; conversely, a psoas abscess may break into the 
 ureter and discharge itself with the urine.' 34 ' Thus a perinephric 
 
 * Dickinson's " Renal and Urinary Affections," vol. iii., p. 070.
 
 DIAGNOSIS FROM APPENDICITIS. 295 
 
 abscess may be the cause of a psoas abscess, or a psoas 
 abscess may either give rise to purulent urine or burrow into the 
 perinephric cellular tissue of the same side. 
 
 In a case under the author's care, a psoas abscess 011 the 
 left side was followed by a perinephric abscess on the opposite 
 side ; both were due to caries of the lumbar vertebrae, of the 
 existence of which there was not the slightest evidence before 
 the diseased bone was actually touched by the finger introduced 
 at the lumbar incision. 
 
 Blood extravasation. Alter a contusion or other injury blood 
 may be extravasated into the circumrenal cellular tissue in suffi- 
 cient quantity to give rise to swelling and pain. The diagnosis 
 would be made by the swelling coming on soon after an injury, 
 by the presence of ecchymosis or other evidence of violence, 
 and by the absence of local or general signs of inflammation ; 
 there may have been shock or collapse at first, and later on 
 haematuria from haemorrhage into the pelvis or calyces of the 
 kidney. Extravasated blood, if not quickly absorbed, may give 
 rise to periiiephritis, and, if it becomes infected, break down, 
 forming a suppurating swelling ; in this event the symptoms of 
 perinephric abscess would succeed those of extravasation of blood. 
 Appendicitis. The characteristic symptoms are pain, tenderness 
 and swelling in the right iliac fossa. There is the same insidious 
 onset in some cases, the same severity of onset in others, as in 
 perinephritis. There is the same description of pain, aggravated 
 by coughing and movements as in periiiephritis. There is the 
 same inclination of the trunk to the affected side, and the same 
 flexion of the thigh of that side, both with the same object, 
 namely, to relax tension and pressure upon the inflamed structures. 
 There is the same tendency for the pain to shoot downwards 
 into the thigh, and the same occasional numbness of the thigh, 
 as in periiiephritis. There is the same gradual iiicrease t of 
 swelling, hardness, redness, and at last, perhaps, a positive tumour, 
 sometimes apparently excited by similar causes, and often terminating 
 in similar ways ; and whereas perinephric suppuration is prone 
 to spread downwards into the iliac region, suppuration from appen- 
 dicitis is nearly equally prone to burrow upwards into the loin. 
 They may each give rise to oedema of the lower limb. 
 
 * See the author's "Surgical Diseases of the Kidney," 1885, pp. 238, 239.
 
 296 SURGERY OF THE KIDNEY AND URETER. 
 
 The great and distinctive difference is that in perinephritis 
 the pain, tenderness, and swelling are first and chiefly in the 
 ilio-costal interspace behind ; whereas in appendicitis they are 
 in the iliac fossa. In both alike there may be marked constipa- 
 tion, or alternations of constipation and diarrhoea ; but con- 
 stipation is usually more obstinate in appendicitis, and may be 
 associated with stercoral vomiting. When peritonitis is an early 
 symptom, and comes on without collapse and before pus has 
 had time to form in the cellular tissue, the probability is all 
 in favour of appendicitis. 
 
 When all the symptoms are referrible to the left side, appen- 
 dicitis is of course excluded ; but the same inflammatory changes 
 occur in and around the sigmoid flexure as around the caecum, and 
 occasionally those around the sigmoid are secondary to appendicitis. 
 This should be borne in mind when the left side is affected. 
 
 FcBcal accumulations give rise to pain, constipation, neuralgic 
 affections of the thigh, and hardness and swelling of the abdomen ; 
 but they are removable by aperients and enemata, are rarely 
 associated with fever, though the temperature may rise from 
 time to time ; and are unattended by the flexion of the thigh 
 and lateral inclination of the trunk. 
 
 Splenic and Jiepatic tumours, if we except abscesses, form 
 without causing fever, and often painlessly. They have a more 
 anterior situation and are more defined in outline, and move 
 freely up and down in respiration. The pain, numbness, and 
 flexion of the lower limb are wanting. 
 
 Empyema and abscess of lung will be recognisable by their 
 usual symptoms ; but when secondary to perinephritis or peri- 
 iiephric abscess, as they sometimes are, the flexion of the thigh 
 and other local symptoms of inflammation of the tissue about 
 the kidney would probably be noticeable. Dr. Bowditch gives a 
 forcible illustration of this fact. This aid to diagnosis should 
 always be in the mind of the surgeon, because cure may follow 
 prompt and judicious treatment. 
 
 Typhoid fever. The insidious onset of typhoid as of peri- 
 nephritis, and the fact that occasionally both are masked by 
 pneumonia, will show the wisdom of withholding an opinion, 
 in certain cases, for a fe\v days ; but in typhoid there are no 
 evidences of local inflammation, and there will soon come the
 
 IS ABSCESS PRIMARY OR SECONDARY ? 297 
 
 characteristic temperature and tongue, the rose spots, the tumid 
 abdomen, the enlarged spleen, and the Widal blood reaction ; 
 whereas in perinephritis there will be evidence of local inflam- 
 mation with the absence of the above-named symptoms. 
 
 2. Having arrived at the diagnosis that the case is one of 
 perinephric abscess, the next question which the surgeon will 
 want to satisfy himself upon is as to whether it is primary 
 or secondary ; and if secondary, whether the primary affection 
 is renal, or concerns some other organ or structure than the kidney. 
 In deciding this question the clinical history of the case will 
 be all important. The history of a blow or a strain, exposure 
 to damp or cold or to some special source of blood-poisoning, 
 over-fatigue, the depressing influence of a continued fever such 
 as typhoid or typhus ; together with the absence of any pre- 
 ceding symptoms such as would have been caused by renal calculus, 
 renal tubercle, etc. ; and the absence of any sign of disease 
 of the liver, spleen, colon, or caecum, or of disease of the spine, 
 would point to the primary nature of the abscess, and would 
 encourage a favourable prognosis. 
 
 On the other hand, when attacks of nephritic colic, the passage 
 of pus or blood in the urine, the development of a tumour in 
 the flank, or the symptoms of spinal caries, of appendicitis, of caries 
 of the ilium or sacrum, or of empyema or of any other affection 
 which may have given rise to retro-peritoneal suppuration, have 
 preceded the symptoms of perinephritis, then we may be fairly 
 sure that the abscess is secondary, and the prognosis will depend 
 upon the cause of the abscess. 
 
 The primary abscesses often commence without any definite 
 cause, and in persons apparently in good health. 
 
 If the pus of a perinephric abscess has an odour of urine, 
 it will not only suggest the secondary character of the abscess 
 but it will indicate that a renal fistula communicates with the 
 abscess. If the pus has even a strongly faecal odour it does 
 not necessarily indicate an intestinal origin of the abscess : 
 some quite simple perinephric abscesses have contained pus the 
 stench of which is only equalled by that of ischio-rectal and 
 various faecal abscesses. 
 
 The escape of intestinal gas or of liquid faeces would of course point 
 to a communication with the bowel. Such a communication is
 
 298 SURGERY OF THE KIDNEY AND URETER. 
 
 nearly always with the colon, but occasionally with the caecum 
 or duodenum. Renal calculus is such a common cause of 
 consecutive perinephritis that the kidney should always when 
 possible be examined, and a calculus searched for when an abscess 
 in the circumrenal cellular tissue has to be opened. 
 
 3. How can the precise seat of a small abscess be localised ? 
 As a small abscess in the perinephric tissue sometimes causes 
 severe symptoms, and if left unopened is prone to spread, it 
 would be well if w r e could with precision exactly localise it. The 
 following points having reference to both anterior and posterior 
 regions, though more especially to the latter, may probably assist 
 us in localising a small abscess w r ith tolerable precision. 
 
 Perinephritis occurring in the upper tracts is likely to be com- 
 plicated by pleuritic friction, pleural effusion, empyema, expectora- 
 tion of pus, and dyspnoea. In the middle tracts the indications are 
 suprapubic, scrotal, or vulvar pain or anaesthesia, through the 
 ilio-hypogastric and ilio-inguinal nerve ; redema of the scrotum, 
 or varicocele of the left side through obstruction in the renal 
 and thereby in the left spermatic veins ; and albuminuria and 
 partial uraemia and suppression of urine due to renal congestion 
 from pressure on the renal vein. Pain in the groin and scrotum 
 with albuminuria coming on in the course of the inflammation 
 would strongly suggest the posterior middle tract. In the lower 
 tract flexion of the hip, pain, or anaesthesia of the front, inside, 
 or outside of the thigh through the influence of the external 
 cutaneous, anterior crural, or obturator nerves, retraction of 
 testicle, pain at the knee, scrotal or vulvar pain without albumin- 
 uria, oedema of leg of the affected side, and pointing of an abscess 
 in the groin, would be the signs. 
 
 In deciding upon the line of incision after making a diagnosis 
 as to the locality of the abscess, the anatomical relations of the 
 kidney to the surface of the trunk, as set out in Chapter I., should 
 be borne in mind by the surgeon. 
 
 Treatment. Primary perinephritis may be sometimes checked 
 in its early stages by local blood-letting by means of leeches or 
 the cupping glass, and by hot baths, and hot emollient poultices 
 or stupes. When the acuteness of the symptoms has passed, 
 or the inflammation is of the subacute or chronic character, 
 absorption of the inflammatory products may follow blistering.
 
 INCISION REQUIRED TO DETECT FLUCTUATION. 299 
 
 or hot fomentations applied over some absorbent ointment such 
 as iodide of potassium or iodide of lead. The bowels should be 
 well opened at the onset by a brisk purgative, and kept acting 
 moderately by enemata or mild laxatives. Pain must be relieved 
 by morphia in form of suppository or given by the mouth. The 
 diet should be milk, beef-tea, or something equally simple and as 
 readily digested. As soon as the presence of pus is suspected 
 an exploratory incision in the loin should be made. When matter 
 is detected it should be let out through a free opening in the 
 loin. There should be no waiting for fluctuation ; the increasing 
 fulness, hardness, and tenderness, and perhaps the commencing 
 redness and oedema of the skin, are ample signs to warrant, and 
 indeed to demand, an incision. The ancients recognised the 
 necessity of this practice. Fabricius Hildanus knew its value, 
 and Kayer has again and again insisted upon it. Trousseau 
 pointed out the difficulty of detecting fluctuation, which he remarked 
 is almost always deep, requiring great experience to detect. But 
 the doughy feel of the lumbar region, the increase of the fever 
 and other general symptoms, and perhaps the oedema of the 
 skin in the lorn, are indications for a free incision which the 
 surgeon must not hesitate to act upon, and with promptitude. 
 
 The incision may be either vertical, transverse, or oblique, 
 but preferably oblique, and after dividing the integument and 
 muscles with the knife, the suppurating tissue should be at first 
 entered by a puncture incision, to be afterwards enlarged. The 
 abscess cavity should be examined with the finger and the kidney 
 carefully palpated in search for a stone. Any loose sloughs of 
 cellular tissue should be removed with the finger or dressing 
 forceps. The abscess should be irrigated with a solution of 
 iodine or carbolic solution, and a drainage tube should be inserted. 
 The loin should then be enveloped in a large hot fomentation 
 of cotton-wool soaked in equal parts of water and carbolic acid 
 solution (1 in 40) ; or better still, if there is redness or oedema 
 of the skin, equal parts of lead lotion and carbolic acid solution 
 (1 in 40). Absolute rest in bed should be enforced throughout 
 the convalescence. 
 
 Even when no pus exists, if the signs of acute or subacute 
 perinephritis are accompanied by much pain, tenderness, and 
 swelling, great benefit will accrue from the relief of tension which
 
 300 SURGERY OF THE KIDNEY AND URETER. 
 
 the loin incision affords ; and the wound should be prevented from 
 superficially closing by the retention for some days of a drainage 
 tube. In certain cases of early incision no pus has been observed 
 to escape at the time, and the surgeons have been disposed to 
 regard the operation as a failure ; but it has not been so, for 
 in these cases immediate relief from suffering has been secured, 
 pus has escaped within a short time after the incision was made, 
 and the swelling in the loin has soon disappeared. All surgeons must 
 agree (1) with Raver, who said that when pus is accumulating 
 around the kidney, one must hasten to let it out ; " the abscess 
 ought to be opened with the bistoury " ; (2) with Trousseau, 
 who strongly urged free incision; and (3) with Bowditch, who, 
 in urging the advisability of an early incision, remarks, " if ever 
 there be occasions for a cautious boldness on the part of the 
 surgeon, these abscesses present them." 
 
 The published records of cases show that this teaching still 
 needs to be enforced : and they afford an ample illustration of 
 the fatality which attends a procrastinating or timid handling 
 of deep-seated suppuration. 
 
 Another precaution is needed, and is suggested by some of 
 the recorded cases. Consecutive abscesses, and also some of the 
 less acute forms of primary abscesses which do not soften down 
 very quickly, must not be allowed to close too early. On the 
 contrary, the drainage tubes should be retained until, by the 
 granulating process in the wound, they are forced out by degrees. 
 If the wound is allowed to close early in these cases, fresh in- 
 flammation occurs and fresh pus is formed, which will need a 
 second incision or run 011 to some fatal termination by burrow- 
 ing far and wide. Dickinson has recorded a case in which the 
 abscess was both opened too late and allowed to close externally 
 too soon, so that the patient died by the bursting of the pus 
 into the lungs. 
 
 Haemorrhage rarely occurs when a free incision is made ; 
 and if it does the bleeding will be easily restrained by pressure 
 or ligature. When a tistulous opening persists after the trial 
 of suitable treatment, it should be laid freely open, the callous 
 walls of the fistulous track should be excised and the freshened 
 surfaces brought together by deep sutures. Should a fistula 
 again follow this operation, then will arise the question as to
 
 EARLY INCISION AND PROLONGED DRAINAGE. 301 
 
 nephrectomy or ureterectomy, a point which will be fully con- 
 sidered in the chapters on renal and ureteral fistula, and need 
 not be discussed here. 
 
 A lumbar hernia may follow the incision for the evacuation 
 of an abscess, as it may one for the examination of the kidney, 
 but this is quite exceptional. I have only once seen it result from 
 an exploratory incision, and that was in a case of suspected 
 renal calculus in the person of a thick-set indolent man who 
 grew very stout. 
 
 After the incision is made, and whilst suppuration continues, 
 nutritious food, tonics, and possibly a regulated allowance of 
 stimulants, should be given. 
 
 Kayer"* quotes a case which shows the length of time that 
 an abscess in the circumrenal tissue, but communicating with 
 the cavity of the kidney, may continue ; and how, when it 
 ceases to discharge through an external opening, it may do so 
 through the ureter and lower urinary passages. 
 
 Such a case ought to be treated by free incision in its earlier 
 stage, and well-maintained drainage for a considerable time ; this 
 failing, lumbar nephrectomy would, in all probability, be required 
 to relieve the patient from periodical and dangerous feverish 
 attacks. 
 
 The success of early incision and continued drainage has been 
 thoroughly proved. Dufnn says that in twenty out of twenty- 
 six cases collected by him, early puncture had been made ; and 
 of these twenty, twelve quite recovered ; in six others there was 
 " a fair modicum of success," which means that in many cases 
 complete success could not be expected, owing to the character of 
 the exciting cause of the abscess, foland f tabulated twenty- eight 
 
 * Vol. i., p. 269. 
 
 t British and Foreign Medico-Chirurgical Review, vol. ii., p. 235(1871). 
 To avoid the counting of the same cases twice over or oftener, it may be well 
 to point out that Duffin's cases consist of Trousseau's, three of Bowditch's, and 
 Gull's, Reed's, Quain's, Dickinson's, Hullet Browne's, Chuckerbutty's, and 
 his own. 
 
 Poland's sources are Trousseau 16, Bowditch 10, Bryant's case, and 
 Duffin's, and those in Duffin's collection, except Trousseau's and the cases 
 included in Bowditch's first paper (May 4, 1868). 
 
 Nieden's list included the cases of Trousseau, Bowditch, Duffin, and 
 numerous others. 
 
 COLLIE I- If < ! :> 'I- AT 
 
 l-H\ S 1C l^Kt: L' ivC LO
 
 302 SURGERY OF THE KIDNEY AND URETER. 
 
 cases of primary perinephric abscess, i.e. not due to pyelitis, or 
 calculous nephritis, or to other renal causes. In fifteen of these, 
 free incision was adopted, and recovery occurred in all but one, 
 which succumbed to hectic fever and diarrhoea. Of eight cases not 
 operated upon at all, six died ; in one, the abscess burst into the 
 bladder and vagina and the patient recovered ; in the other it 
 burst into the lung with relief. Of five cases in which the 
 abscesses were evacuated by trocar and canmila, or by caustic 
 potash, one died, two recovered after the evacuation of pus, and 
 in two no pus was detected by the trocar at the time, but pus 
 was discharged subsequently. Of ten cases of secondary abscess 
 tabulated by Poland, the only ones which recovered were three 
 which were operated upon ; all those not operated upon died.
 
 303 
 
 CHAPTER XI. 
 
 ACUTE AND SUBACUTE PYELO-NEPHRITIS 
 WITHOUT SUPPURATION. 
 
 ACUTE and subacute interstitial inflammation, without suppuration, 
 may affect the whole or a part of a kidney. As a rule, both 
 kidneys are involved, though frequently to an unequal extent. 
 
 The changes produced consist of a gradual sclerosis of the 
 renal parenchyma, together with a thickening and desquamation 
 of the epithelium of the renal pelvis ; these changes greatly 
 impair the resistance of the organ against the action of patho- 
 genic microbes, so that it is very prone to suppuration should 
 any infection reach the kidney, either through the circulation, 
 the lymphatics, or by ascending along the ureter from the lower 
 portions of the urinary tract. On account of this proneness to sup- 
 purate, perhaps, it is that sight is apt to be lost of the fact that 
 pyelo-nephritis occurs without running on to the development of pus. 
 
 Etiology. The causes of interstitial nephritis met with in 
 surgical practice' are (1) all those conditions which give rise to 
 obstruction to the outflow of urine, whether of an acute or chronic 
 kind, and which will be found enumerated in the chapter on Neph- 
 rectasis (p. 395), and (2) injury caused by external violence. 
 
 When interstitial nephritis and pyelo-nephritis occur as a 
 consequence of external violence the inflammation may be either 
 primary or secondary, that is, it may occur primarily in the 
 kidney itself, or extend to it from the surrounding cellular tissue. 
 When blood has been extravasated into the cavity of the kidney, 
 and the urine is retained there because of the impaction of a 
 blood-clot in the ureter, pyelitis and pyelo-nephritis may arise 
 as in any other case of obstruction to the outflow of urine. 
 
 It is seldom, if ever, that the pelvis of the kidney alone is 
 inflamed as a result of injury. Almost invariably when pyelitis 
 occurs there is also interstitial inflammation of the kidney sub- 
 stance. On the other hand, interstitial nephritis, either of an 
 acute or chronic character, may occur without any of those
 
 304 SURGERY OF THE KIDNEY AND URETER. 
 
 indications in the urine which point to inflammation of the pelvis 
 of the kidney. 
 
 The onset may be very insidious, and the condition may remain 
 imdiagnosed until attention is drawn to it by an acute exacerba- 
 tion of pain or some other prominent symptom. Thus, not unfre- 
 quently the onset is dated from the passage of a catheter, but whether 
 this ever actually gives rise to the condition is difficult to say. 
 In most cases the probability is that the passage of an instrument 
 intensifies a previously existing nephritis, either reflexly or by 
 causing an acute congestion, as sometimes occurs after rapidly 
 relieving a long-standing retention in cases of enlarged prostate. 
 Or the instrument may serve as a carrier of micro-organisms; 
 and the absorption of some septic material through an abrasion 
 may rapidly make itself felt on the already diseased kidneys. 
 
 Drugs. Inflammation of the renal substance and the pelvis 
 is excited by large doses of certain drugs, such as cantharides? 
 turpentine, and other diuretic irritants. 
 
 The action of these drugs is chiefly upon the tubules of the 
 kidney, and therefore, strictly speaking, their effects do not come 
 under the headings of this chapter which treats of interstitial 
 not tubular nephritis. 
 
 It has, however, been thought advisable to- refer to them here 
 at some length, not only on account of the pyelitis they produce, 
 which comes under this section, but also by reason of the fact 
 that the acute changes in the tubules of the kidney may be 
 followed later by more chronic interstitial changes, and because 
 the injury to the kidneys produced by these drugs lowers their 
 resisting power very greatly and predisposes them to ascending 
 or descending infections. It will therefore be seen that these 
 drugs must be given with the greatest care to persons who are 
 buffering from any disea.se of the genito-urinary track. 
 
 Robin has studied these inflammatory changes and has 
 described a catarrhal and a fibrinous variety. The catarrhal 
 inflammation follows the elimination of turpentine, copaiba and 
 other drugs, and is characterised by renal pain, highly coloured 
 urine which may contain albumen, and a frequent desire to 
 micturate ; all these symptoms usually rapidly disappear when the 
 drug is withdrawn. The fibrinous variety follows large doses 
 of cantliarides and has been experimentally studied in animals.
 
 SYMPTOMS OF INTERSTITIAL NEPHRITIS. 305 
 
 The lesions in the kidneys are diffuse and are characterised by 
 swelling and desquamation of the epithelium of the convoluted 
 tubules, followed later by exudation of leucocytes into the inter- 
 stitial tissue. There is congestion of the mucous membrane 
 of the pelvis, accompanied sometimes by the formation of a 
 membranous exudation. 
 
 I have the notes of one case in which the renal pelves of 
 a man, aged twenty-nine years, who died from oxalic-acid poison- 
 ing, were most acutely inflamed and the seat of numerous 
 ecchymoses. 
 
 It is not, however, probable that these drugs are ever the 
 direct cause of suppuration, for in most of them the chief seat 
 of disturbance is the bladder or prostate; still the conditions they 
 give rise to in the kidney are those which favour an infection, 
 if such be in any way introduced into the system, either locally 
 through the bladder or generally through the circulation. 
 
 Irritant drugs, such as cantharides and turpentine, have been sup- 
 posed however to cause renal abscess. In the College of Surgeons 
 museum is a kidney in which pus was extensively diffused througr 
 the cortical substance, and between it and the capsule. This 
 kidney was removed from the body of a man aged sixty, to 
 whom tincture of cantharides had been administered for in- 
 continence of urine following retention. 
 
 Symptoms. (1) The mode of onset of the first form of interstitial 
 nephritis varies with the cause. The more chronic forms, which 
 arise during long-continued obstruction to the flow of urine, are 
 usually very insidious in their onset. There is often no rigor, 
 and frequently not even a chill to mark the time of their com- 
 mencement, and they run a very irregular course, extending 
 sometimes over many weeks or months, during which there may 
 be intervals of considerable improvement which give rise to the 
 idea that recovery has taken place. The more acute cases, which 
 frequently follow upon a chronic condition, are accompanied by 
 a rigor or a succession of severe chills, which may be continued 
 at intervals until the attack has subsided. 
 
 As soon as the inflammation has thoroughly set in the general 
 
 health of the patient is much impaired. This is shown by 
 
 weakness, languor, drowsiness, loss of appetite, flatulence, and 
 
 often by a feeling of extreme flatulent distension of the abdomen, 
 
 VOL. i. u
 
 306 SURGERY OF THE KIDNEY AND URETER. 
 
 rapid emaciation, pinched features, and a dull, leaden, or sallow 
 complexion. 
 
 The temperature in the morning is normal or sub-normal, 
 but rises at night to 100, 101, or 102 Fahr. ; and thus it 
 may continue for days or weeks together ; or there may be in- 
 tervals during which the morning temperature is one or two 
 degrees above normal, and the evening temperature one or two 
 degrees above the morning ; or, again, periods may occur during 
 which the evening temperature does not reach above normal, 
 and the morning temperature remains normal or slightly sub- 
 normal. As a consequence of the difference in the constitu- 
 tional states suggested by the temperature, the patient feels better 
 in the morning and also during the periods of normal night 
 temperature ; his skin is cool and he is free from thirst. As the 
 day wears on, and when the intervals of normal evening tem- 
 perature have passed, languor and drowsiness overtake him, his 
 skin is hot and pungent, and there is great thirst, with marked 
 disinclination for, and even loathing of, food. Sometimes profuse 
 sweats break out all over the body, and occasionally are frequent 
 and severe enough to require a change of linen three or four 
 times in the twenty -four hours. The tongue is sometimes but 
 little altered, being moist and only slightly furred ; but in most 
 cases it is dry or coated with a dirty white fur. JSTausea is 
 often complained of ; sometimes actual vomiting is present, but 
 this is not the rule. The bowels may act regularly, or may 
 be constipated or relaxed ; usually there is but little deviation 
 from the habitual state. 
 
 llarely, if ever, is there any tenderness on deep pressure 
 about the kidney, and pain is seldom felt ; though in some cases 
 there is muscular aching, described variously as lumbago, rheu- 
 matic pains in the limbs, or a feeling of soreness, as of having 
 been " beaten all over with a stick." Generally, however, there 
 is freedom from pain, unless it be caused by the primary disease ; 
 and the patient is either in a state of drowsy languor, or when 
 for the time free from fever he expresses himself as comfortable 
 and doing well. 
 
 But little information is to be gleaned from the urine, though 
 it should always be most carefully and repeatedly examined. Too 
 often, especially when the renal inflammation is the result of
 
 SYMPTOMS OF INTERSTITIAL NEPHRITIS. 307 
 
 obstruction, pus, mucus, and even blood derived from the in- 
 flamed mucous membrane of the pelvis mask the characters 
 possessed by the urine as secreted. In other cases of obstruction, 
 where no cystitis is present, the urine is of lower specific gravity, 
 and more abundant in quantity than normal, but this is owing 
 probably more to the chronic pressure changes in the kidney 
 than to the nephritis. In. other cases, again, and more especially 
 where the nephritis has not been preceded by chronic renal changes, 
 there is nothing abnormal either in the character or quantity 
 of the urine. 
 
 There is never more than a trace of albumen in the urine 
 as it is secreted, but when cystitis, prostatitis, or urethritis exists, 
 there may be a considerable admixture of pus or blood. Under 
 such circumstances, in order to ascertain the real nature of the 
 urine, the bladder and urethra should be well washed out, and 
 the urine which is secreted immediately afterwards should be 
 drawn off through a clean catheter, tied in the bladder for a 
 quarter or half an. hour. In all probability this urine will be 
 acid and free from pus and blood. 
 
 When the disease is going to terminate favourably, the symp- 
 toms just described gradually disappear ; the patient feels less 
 drowsy and stronger, his appetite returns, flatulence ceases, the 
 temperature becomes and continues normal, and thus by degrees, 
 and sometimes very quickly, he returns to thorough health. In 
 some cases, however, this apparent recovery is delusive, and after 
 a longer or shorter time all the same symptoms recur ; the 
 improvement and subsequent relapse being generally caused by 
 a corresponding improvement in, and aggravation of, the original 
 disease ; or, in other cases, the relapse is excited by a fresh 
 instrumental disturbance of the urinary passages. When the 
 nephritis does not terminate favourably, the above symptoms 
 either exist for a long time, while the patient grows weaker 
 and weaker, until at length he dies of sheer exhaustion ; or, 
 what is more frequent, suppuration of the kidney, to be described 
 in the next chapter, supervenes, and rapidly carries off the patient, 
 who becomes first more or less delirious and then comatose. 
 Patients occasionally die who have had all the symptoms of sup- 
 purative pyelo-iiephritis ; and yet on post-mortem examination 
 the kidnevs to the naked eve are merely small, tough, and
 
 308 SURGERY OF THE KIDNEY AND URETER. 
 
 granular, but on microscopic examination marked interstitial 
 inflammation and, perhaps, foci of commencing suppuration, are 
 found. 
 
 Symptoms. (2) The onset of traumatic nephritis is nearly always 
 announced by a rigor ; then follow thirst, dry tongue, heat of sur- 
 face, restlessness, and all the other symptoms which characterise the 
 febrile state. The initial rigor may be severe or slight, but it is 
 rarely wanting altogether. Pain in the renal region is not con- 
 stant in character, and is very variable in degree. That which 
 was due to the original violence may have entirely ceased under 
 rest and treatment ; and then, after some days of ease, fresh 
 suffering, often more intense than the first, is felt in the neigh- 
 bourhood of the kidney. This pain is commonly felt over the 
 affected side only, but it may involve both, though the injured 
 side more severely. 
 
 It is deep-seated, referred to the loin rather than to the front 
 of the kidney ; is sometimes circumscribed and limited to a point 
 in the flank, at others diffused over the whole flank, or even 
 extending along the course of the ureter, to the groin or testicle. 
 Sometimes the pain is widely diffused over the lumbar, hypo- 
 chondriac, and central areas of the abdomen, even in cases in 
 which no perinephritis exists. It may be acute, and increased 
 on the slightest pressure ; or of a dull aching character, scarcely, 
 if at all, aggravated by pressure ; or so slight and obscure that 
 only firm pressure, first over one loin and then over the other, 
 brings out the fact that one side is tender and the other not. 
 The pain is seldom of the same intensity throughout, exacerbations 
 and remissions being the rule. It is rarely of a throbbing or 
 plunging character, except when the perinephric tissue is also 
 inflamed. Sneezing, coughing, lying on the affected side, bending 
 the trunk forwards, and nearly all movements of the body, 
 aggravate the pain, and this is more especially the case when 
 perinephritis or peritonitis complicates the nephritis. 
 
 Though traumatic nephritis usually involves one kidney only, 
 yet either as the effect of the inflammation of the injured organ, 
 or in consequence of the fever which the nephritis causes, it is 
 not very unusual to find, after an injury to one kidney, that 
 the amount of urine is greatly diminished or altogether suppressed 
 for a time.
 
 SYMPTOMS OF TRAUMATIC NEPHRITIS. 309 
 
 If the disease sets in shortly after the receipt of the injury, 
 the urine always contains a trace of blood, sufficient sometimes 
 to give it a brownish or red tint. When the blood ceases, 
 the urine, though it looks natural, still continues to be albu- 
 minous for a time. Later on, pus in small quantity may be 
 found in the urine, but this is not usually the case ; and 
 when it is found its presence indicates that the suppurating area 
 of the renal substance communicates with the cavity of the kidney, 
 or, what is comparatively more probable and frequent, that the 
 mucous membrane of the pelvis and calyces of the kidney is 
 involved in the inflammatory process. In many cases in which, 
 at the inspection after death, suppurating foci are found in the 
 cortical and medullary parts of the kidney, the urine during 
 life was free from pus. The presence of pus, therefore, means 
 pyelitis as well as nephritis, or else that an abscess formed in 
 the renal substance has broken into the pelvis or into a calyx of 
 the kidney. 
 
 The reaction of the urine in nephritis, uncomplicated with 
 disease of the lower urinary track, is acid ; or it may be neutral 
 from excess of blood or pus. 
 
 The cessation of the pain in the loins, and of the feverish 
 symptoms, and the return of the urine to its natural quality 
 and quantity, indicate the termination of the inflammation by 
 resolution. The persistence of pain and fever, the irregular 
 occurrence of rigors and elevations of temperature, the frequency 
 and smallness of the pulse, the sallow skin, emaciation, vomiting, 
 the development of cerebral or typhoid symptoms, point to the 
 termination by suppuration in the kidney substance. The 
 presence of pus in the urine does not necessarily mean that the 
 inflammation of the kidney substance has gone on to suppuration ; 
 in the large majority of cases it signifies only that pyelitis has 
 been engrafted upon a non-suppurative interstitial inflammation. 
 
 When perinephritis follows an injury to the loin and is itself 
 followed by nephritis, it is generally very difficult, if not quite 
 impossible, to be sure as to the time at which the inflammation 
 reached the kidney. Sometimes, but by no means always, the 
 commencement of the nephritis is marked by a decided diminu- 
 tion in the amount of urine excreted. 
 
 When perinephritis terminates in perinephric abscess, it is
 
 310 SURGERY OF THE KIDNEY AND URETER. 
 
 often not clear whether the kidney is or is not involved, though 
 it is easy to diagnose the extrarenal abscess by the swelling, 
 and oedema, and throbbing pain in the loin. 
 
 An occasional result of injury to the loin or kidney is the 
 discharge of a quantity of red sandy deposit in the urine. This 
 has long been known and described as one of the consequences 
 of an accident involving the renal region. M. Yerneuil in 1885 
 drew attention to the fact that the urine of patients who have 
 sustained injuries to or undergone surgical operations upon other 
 parts of the body, sometimes exhibits a rose-coloured deposit 
 of a peculiar material easily recognisable with the naked eye 
 as it adheres to the urine glass. It is a transient condition, 
 lasting only two or three days, and comes on soon after the 
 injury. These deposits indicate, so M. Yerneuil considers, a 
 tendency to secondary haemorrhage and gangrene after injuries. 
 The nature of the pigment has not been ascertained, but its 
 origin has been supposed to be in some way related to hepatic disease. 
 It does not seem to be a consequence of traumatic nephritis. 
 
 Caesar Hawkins f reported a case of a man, aged forty-six, 
 who on January 26th, 1829, fell from a height and severely 
 injured both loins. Three days afterwards he had pain in the 
 right renal region extending to the groin, and pain on micturition ; 
 in his urine, which was excreted in ordinary quantities, there 
 was a red sand which made the urine turbid, and became de- 
 posited on the sides of the urine bottle. 
 
 Diagnosis. When a patient is suffering from cystitis, whether 
 due to stricture, stone, prostatic enlargement, cancer, or other 
 cause ; or when a surgical operation has been performed for 
 stone, bladder tumour, stricture, urinary fistula, urinary abscess, 
 or extravasation, it is often impossible to decide as to how far 
 the symptoms are caused by the primary disease or to superinduced 
 interstitial nephritis. Under any of these conditions, chronic 
 blood poisoning, due to the absorption of decomposing urine or 
 pus, may arise, and excite much the same symptoms as subacute 
 interstitial nephritis ; whilst the acute form of the disease, even 
 when no suppuration exists, may possibly be mistaken for pyaemia, 
 septicaemia, typhoid fever, or septic peritonitis. 
 
 * La France Mi'dicale, Mai 2, 1885. 
 
 t Lon. Med. Gazette, vol. iii., p. 399, 1S29.
 
 PROGNOSIS OF INTERSTITIAL NEPHROS1S. 311 
 
 When the symptoms above described come on shortly after 
 passing an instrument along the urethra, or after the performance 
 of some surgical operation, there ought to be little doubt as to 
 their cause, and active renal inflammation should be diagnosed. 
 In cases of urinary obstruction, interstitial nephritis ought to be 
 suspected when loss of appetite, elevation of evening temperature, 
 lassitude, thirst, dry tongue, flatulence, and nausea, are accompanied 
 and followed by progressive emaciation. If, in addition, there be 
 occasional chills and profuse perspirations, the diagnosis is made 
 fairly clear ; and if with these other symptoms the urine is over- 
 abundant in quantity, of low specific gravity, and with very little 
 or no albumen, it may be looked upon as certain. 
 
 A due appreciation of the above symptoms, with a close inquiry 
 into the clinical history of the case, and the antecedent condition 
 of the patient, ought to point to the exclusion of pyaemia, septi- 
 caemia, typhoid fever, and septic peritonitis. 
 
 Prognosis. If the primary cause of disease is removable, 
 recovery may be hoped for, and in a large proportion of cases 
 will IDC realised. If the cause of obstruction cannot be removed, 
 or, after being removed, leaves behind so severe a condition 
 of bladder or prostate that the urine continues to decompose 
 as soon as it reaches the bladder, suppuration in the kidney 
 will in all probability supervene, and a fatal termination will 
 certainly occur. Death may ensue before the disease has 
 passed into the suppurative stage. 
 
 In cases in w r hich the onset of the nephritis is associated with 
 prolonged suppression of urine, great danger exists, and a fatal 
 termination should be apprehended. It was said by Beck that 
 suppression, if lasting over one day, is almost always fatal. I have, 
 however, seen recovery in one case after suppression for fifty-two 
 hours, and in others, after suppression for thirty-six and forty- 
 two hours. 
 
 As a rule, traumatic nephritis is not fatal, and often 
 not even serious hi its course or consequences, provided that the 
 damage inflicted on the kidneys by the injury is not great, 
 and that the large vessels are not ruptured. The inflammation, 
 under these circumstances, yields readily to treatment, and the 
 duration of the attack is completed in from ten days to a 
 fortnight, The prognosis in nephritis which is the result of
 
 312 SURGERY OF THE KIDXEY AND URETER. 
 
 obstruction depends largely upon the cause of the obstruction, and 
 as to whether it is removable or not, and upon the stage which 
 the inflammation has reached. When the cause is removable and 
 the nephritis not greatly advanced, complete recovery may be 
 expected. 
 
 Pathology. Both kidneys are almost invariably affected in the 
 non-traumatic form. Their appearance varies considerably with the 
 stage of the disease; in recent cases they will be found somewhat 
 increased in size, while in the later stages they will be found di- 
 minished and misshapen owing to the contraction of the recently 
 formed connective tissue. 
 
 The capsule is thickened, and vascular, and is as a rule some- 
 what adherent to the renal tissue, leaving a roughened granular 
 surface when stripped off. There is often also an excess of 
 perinephric fat, which is closely adherent to the renal capsule and 
 grows into the kidney itself at the hilum. 
 
 On section the kidney surface bulges, owing to the amount 
 of intertubular exudation, and it often presents a pale or mottled 
 aspect, like the uncut surface of the organ. The aspect of the 
 pyramids varies : sometimes they are of a deep red colour, con- 
 trasting markedly with the pale cortex, while at other times 
 they are pale ; but they usually preserve their conical form in 
 spite of dilatation of the pelvis, which often exists when there is 
 obstruction to the urine below. Sometimes again, yellowish streaks 
 pass through them parallel with the tubules. 
 
 The pelvis of the kidney sometimes appears quite normal, 
 though there is usually some degree of dilatation present ; at other 
 times it is deeply congested and ecchymosed, or coated with a 
 layer of false membrane ; at others again it is acutely inflamed. 
 
 The condition of the urine also is naturally very various ; 
 it may be quite normal and acid, or alkaline, purulent, and 
 decomposing. 
 
 The ureter, like the renal pelvis, presents different appearances 
 according to the duration of the disease. In long-standing cases 
 it is dilated and its walls are thickened and sometimes thrown 
 into folds which, acting as valves, tend further to obstruct the 
 outflow of urine. 
 
 Microscopically the principal alteration seen is an increase of 
 connective tissue: this affects almost simultaneously the medulla
 
 PATHOLOGICAL CHANGES IN INTERSTITIAL NEPHRITIS. 313 
 
 and the cortex. The distribution of the connective tissue is 
 irregular, and different areas of the kidney may l)e very unequally 
 affected, so that a true hypertrophy of some parts and consider- 
 able disease of the remainder are very possibly present in the same 
 organ. 
 
 The tubules and vessels are pressed upon, and the former 
 are distorted, being constricted in some parts and dilated in 
 others. The tubular epithelium may be granular and swollen, 
 and is often easily detached from its membraiia propria. 
 
 The microscopic characters were closely studied by Beck, 
 who pointed out that the anaemic condition of the cortex, 
 as often seen after death, is no evidence that during life it was 
 in the same condition ; but that as the kidney, owing to the 
 amount of exudation, is tightly compressed within its capsule, 
 the vessels are emptied as soon as the heart ceases to beat. 
 
 In cases arising from acute retention of urine the changes 
 are characterised by marked congestion, sometimes accompanied 
 by actual haemorrhages into the kidney substance. There is also 
 some desquamation of the epithelium of the tubules, and an 
 increase in the entire volume of the kidney, varying, of course, 
 with the intensity and duration of the attack. The secretion 
 of urine under these circumstances is much diminished and poorer 
 in salts than usual, while it often contains albumen, blood, and 
 epithelial casts. After the retention has been relieved there is 
 often polyuria, and the kidney gradually returns to its normal 
 condition. 
 
 An important fact connected with traumatic nephritis is the 
 disposition to the formation of renal calculus and gravel ; this 
 explains the occasional occurrence of renal colic after wounds, 
 concussion, or severe shakings of the kidney. A clot of blood, 
 derived from traumatic haemorrhage into the renal pelvis, has 
 not uiifrequently formed the nucleus of a renal calculus ; but 
 there is no doubt at all that acute and chronic inflammation of 
 one of the kidneys, quite apart from the presence of blood-clots in 
 its pelvis, has been an occasional cause of urinary concretions. 
 
 Cicatricial kidney. When recovery occurs after acute in- 
 terstitial nephritis, the kidney is granular and contracted, and 
 often deeply and broadly scarred and puckered. This is the 
 condition which has been called the '" cicatricial kidnev "
 
 314 SURGERY OF THE KIDNEY AND URETER. 
 
 (Marcus Beck), and is the result of an intertubular exudation of 
 inflammatory material, followed by its contraction. Sometimes 
 this state is associated with the wasting and distension of 
 the kidney, which are brought about by urinary obstruction. 
 There is good ground for believing that under favourable con- 
 ditions, and especially after the amelioration or removal of the excit- 
 ing cause, even small abscesses may be recovered from, the abscesses 
 disappearing and leaving small scars or cicatrices in the renal tissue. 
 
 Moxon's researches'* point to this as a termination of dis- 
 seminated abscesses of the kidney without very marked destruc- 
 tion of the renal tissue. 
 
 Treatment. In no disease is the old adage, " Prevention 
 is better than cure,'' more true than in these secondary affections 
 of the kidney. Prevention, too, is all the more desirable because 
 our means of cure are uncertain, and for the most part quite 
 inefficient. 
 
 As steps towards the prevention of nephritis, it cannot be too 
 forcibly stated : 
 
 (1) That the causes of obstruction to the passage of urine 
 should as soon as possible be overcome, and retention, or partial 
 retention, obviated by the catheter. Stricture must be dilated 
 or divided ; perinseal abscesses opened ; the condition of the 
 prostate should be ascertained, and when found to be enlarged, 
 the patient should at once be taught the use of the catheter ; 
 vesical calculi should be crushed or removed by lithotomy, though 
 it must be understood that the rapid method of lithotrity has 
 now done away with the need of replacing lithotrity by the 
 more dangerous operation of lithotomy in cases in which renal 
 disease complicates vesical calculus. 
 
 (2) That all instrumentation should be as gentle and as limited 
 as the requirements of the particular case will allow, so as to 
 avoid the risk of reflex irritation of the kidney. 
 
 (3) That decomposition of the urine within the bladder should 
 be prevented or checked by the evening and morning irrigation 
 of the bladder with some antiseptic wash. A solution of sali- 
 cylate of soda (five grains to the 3J)> of quinine (one grain to 
 the 3j), of acetate of lead (one grain to ^iv), of borax (five grains 
 
 " On Recovery from Surgical Suppuration of the Kidney," Path. Soc. 
 Trans., vol. xxiii.
 
 AXIOMS ON TREATMENT OF NEPHRITIS. 315 
 
 to 3J)> of warm water coloured pink with Condy's fluid, or con- 
 taining a trace of carbolic acid, or of thymol and glycerine (in 
 the proportion of one part of thymol in seven of glycerine), 
 may be used for this purpose. The fluid should be introduced 
 through as large a catheter as can be comfortably passed, and 
 the catheter should have two large well-formed eyes. Not more 
 than 3\\j to .^iv of the solution should be thrown in at a time ; 
 then this should be allowed to run out, and the same process 
 should be repeated four or five times, or more, at a sitting. 
 
 In any case in which subacute or acute renal mischief is 
 anticipated, and certainly from the outset of its existence, the 
 patient must be confined to his room, and, as a rule, absolutely 
 to his bed ; his skin should be kept thoroughly warm, and free 
 from the risk of chills or the effects of changes of temperature ; 
 all exertion should be avoided from the first ; the bowels should 
 be acted upon daily by enemata ; hot baths or wet packing 
 or vapour baths should be employed if they can be borne ; hot 
 dry bran or flannels should be applied to the loins, and dry or 
 moist cupping in the same region should be resorted to, especially 
 if there is pain or tenderness about the kidneys. The food should 
 be of a bland, nutritious, and easily digested character ; stimulants, 
 as a rule, should not be allowed, or, if allowed at all, only in 
 small quantity, and in as pure a form as possible ; but if patients, 
 who have always drunk freely, are in a very weak condition, 
 and cannot take sufficient food, then a moderate measured quan- 
 tity of some pure wine or spirit will be needful. 
 
 No medicines are of any special use ; still, I have seen marked 
 benefit in cases uncomplicated by pre-existing chronic renal dis- 
 ease, but attended with suppression o urine, from the hypodermic 
 injection of one-eighth to one-fourth of a grain of morphia with one 
 hundred and twentieth to one-eightieth grain of atropine. Tannic 
 acid in two-grain doses, given every three or four hours, has 
 been recommended especially in cases of abundant mucus secretion 
 in the urinary passages (Ebstein). Quinine in grain and a half 
 or two-grain doses, with citrate of potash (twenty grains) and 
 mucilage 3J> together with a little opium (five to ten min.) is 
 often beneficial. If the temperature is rising, a dose of five to 
 ten grains of quinine with lemon-juice 3J> and vin. opii 5ss, is 
 sometimes of much value.
 
 316 SURGERY OF THE KIDNEY AND URETER. 
 
 Opium by some surgeons is considered the most useful of 
 drugs, because by increasing the action of the skin it tends to 
 relieve the congestion of the kidneys ; but it is a remedy which 
 ought to be given with great caution, for it must be remembered 
 that symptoms much resembling, sometimes actually expressive 
 of, uraemia occur in acute interstitial nephritis. 
 
 When acute or subacute interstitial nephritis has been pre- 
 ceded by intrarenal tension and chronic interstitial inflammation, 
 the amount of urine secreted is very large indeed ; and under 
 these circumstances I have seen .good results follow the adminis- 
 tration of the liquid extract of ergot given in 5ss doses every 
 three or four hours for thirty -six or forty-eight hours. 
 
 Surgical operations, and more especially operations upon the 
 urinary organs, if it be possible to postpone them, should never 
 be undertaken during the existence of acute or subacute inter- 
 stitial nephritis, or of any of the forms of " congestive " urinary 
 fever.
 
 317 
 
 CHAPTER XII. 
 SUPPURATION OF THE KIDNEY. 
 
 THE kidney, or its pelvis, may become infected by septic 
 organisms in various ways : 
 
 1. The micro-organisms may reach the kidneys through the 
 circulation and, lodging in the capillaries, give rise to numerous 
 small suppurating foci ; or one or more larger infective emboli 
 may occur, as in cases where a particle of an infected cardiac 
 valve becomes detached, and, lodging in the kidney, gives rise 
 to a septic infarction followed by an abscess. 
 
 In both these conditions the infective process usually com- 
 mences in the kidney substance, to which it may be entirely 
 confined ; but in many cases it spreads into the pelvis, and 
 thence into the ureter, and gives rise to a descending pyelo- 
 nephritis. 
 
 2. The kidney may become infected from some septic con- 
 dition situated in the lower parts of the genito-urinary tract, 
 such as, for instance, cystitis, which is one of the most frequent 
 causes. In these cases the micro-organisms either ascend to the 
 kidney by a process of continuity along the mucous membrane 
 of the ureter, or they are conveyed by the lymphatics in the 
 ureteral wall. The renal pelvis will thus, in most cases, become 
 infected before the kidney substance, and the condition is then 
 spoken of as an ascending pyelo-nephritis, . in contradistinction to 
 the condition already described, in which the pelvis is affected 
 secondarily to the kidney. 
 
 3. Occasionally the kidney becomes invaded through the 
 direct spread of suppuration from neighbouring organs, but, 
 owing to the anatomical position of the kidneys and their protec- 
 tion by thick capsules, this mode of infection is not common. 
 
 4. Lastly, it must be remembered that two or more of 
 the above conditions can co-exist. For instance, an ascending 
 pyelo-nephritis may be progressing at the same time that infective 
 micro-organisms are reaching the kidney through the circulation.
 
 318 SURGERY OF THE KIDNEY AND URETER. 
 
 The varieties of suppurative affections of the kidney may be 
 classified as 
 
 A. Diffuse Suppuration. 
 
 B. Circumscribed Suppuration, i.e. Abscess. 
 
 The former class Diffuse Suppuration may be sub-divided 
 thus : 
 
 1. Suppurative nephritis, due to infection through the circu- 
 lation. 
 
 2. Suppurative nephritis ascending in origin. 
 
 3. Suppurative pyelitis, either primary, or "ascending in origin. 
 
 4. Suppurative pyelo-nephritis, either primarily renal, or of 
 ascending origin. 
 
 5. Pyo-nephrosis, i.e. suppuration of a dilated kidney. This 
 form of suppuration is dealt with in the chapter on Nephrectasis 
 (see p. 444). 
 
 Suppurative nephritis, or, in other words, " acute interstitial 
 nephritis, with scattered points of suppuration " (Beck), occasion- 
 ally occurs alone, without any affection of the ureter and pelvis 
 of the kidney ; this, however, is not the common case. Usually 
 acute pyelitis and suppurative nephritis exist simultaneously. 
 If suppurative nephritis happens to be uncomplicated by pyelitis, 
 the nephritis is prone to be clinically overlooked, because the 
 urine contained in the pelvis of the kidney, and passed off 
 through a catheter immediately after washing out the bladder, 
 is acid and without the odour of decomposition. Nevertheless 
 the temperature and other constitutional symptoms ought to pre- 
 vent this mistake. An. important distinction consists in the pre- 
 sence or absence of distension of the renal pelvis. 
 
 Pyelo-nephritis without distension shows itself by high tempera- 
 ture and other symptoms, and admits of medicinal treatment; 
 pyelo-nephritis with distension usually manifests itself by the pre- 
 sence of an abdominal tumour and other definite signs, and 
 generally speaking needs surgical methods. 
 
 Bacteriology. The variety of micro-organisms in any given 
 case of suppuration of the kidney or its pelvis naturally 
 depends upon the source of the infection. But while it is possible 
 that any pyogenic organisms may be present, it is found, as a 
 matter of fact, that the bacillus coli is by far the most common, 
 the infection by this organism in most of the cases probably
 
 MICRO-ORGANISMS IN RENAL SUPPURATION. 319 
 
 arising from the intestine. The bacillus coli communis can escape 
 from the intestine under a variety of circumstances, and may 
 reach the kidney in its wanderings ; whether it infects the organ 
 or not depends upon the virulence of the bacillus and the local 
 resisting power of the kidney. A kidney, weakened by injury 
 or previous disease, is always more liable to infection than one 
 which is healthy ; and the virulence of the bacillus coli, as in 
 the case of many other organisms, is known to l)e capable of 
 undergoing considerable variations. 
 
 Under these circumstances, it is not difficult to understand that 
 in many cases the kidneys may be able to excrete the bacteria 
 without injury, while in others the organisms find a suitable soil 
 upon which to grow. 
 
 Streptococci and staphylococci are not unfrequently present, 
 especially in the ascending varieties of pyelo-nephritis ; and in 
 many instances there is a mixed infection. 
 
 The exact relative importance of these different organisms in 
 suppurative diseases of the kidney is not at present fully known. 
 Guyon, Albarran, Halle, and others consider that in the 
 majority of cases the bacillus coli plays the principal part. Rov- 
 sing, on the other hand, believes the bacillus coli to be less in- 
 jurious than the staphylococci and streptococci, on account of its 
 feebler power to decompose urine. Rovsing also considers that 
 the ability of the coli bacillus to attack normal mucous mem- 
 brane of any part of the genito-urinary tract to be very slight ; and 
 in proof of this he cites twenty -nine cases of coli pyelitis, which 
 he had observed, in which the bladder remained normal though 
 it had in some cases been for years the reservoir of very puru- 
 lent urine swarming with coli bacilli. In all such cases Rovsing 
 considers that the coli infection was secondary to some slight 
 injury to the renal pelvis, such as might be produced by a cal- 
 culus, or in a floating kidney which had undergone a sudden swell- 
 ing or become incarcerated. 
 
 Whatever be the relative importance of these several or- 
 ganisms, there seems but little doubt that the bacillus coli 
 is the one most frequently present, and most observers in this 
 country are inclined to ascribe the chief importance to it. It 
 must, however, be remembered that its frequent predominance 
 does not necessarilv bear anv direct relation to its virulence,
 
 320 SURGERY OF THE KIDNEY AND URETER. 
 
 and it is probable that some of the most severe cases of 
 suppuration of the genito-urinary tract are the result of a 
 mixed infection. The diplococcus pneumonise, the bacillus lactis 
 serogenes, the bacillus pyocyaneus are all recorded as having 
 been found on various occasions, and in one case Bockhart claims 
 to have found the gonocoecus,* and Gerster and Bransford Lewis 
 have found it in others (see post, p. 450). 
 
 A large number of the suppurative cases are due to secondary 
 infections, and the organism of the primary infection may exist 
 alongside that of the secondary, as so often is the case in the 
 tuberculous kidney. 
 
 A. DIFFUSE SUPPURATION. 
 
 VARIETIES: (1 AND 2) SUPPURATIVE NEPHRITIS, (3) SUPPURATIVE PYELJTIS, 
 (4) SUPPURATIVE PYELONEPHRITIS. 
 
 Either suppurative nephritis or suppurative pyelitis may occur 
 separately, but much more frequently they occur together. 
 
 Suppurative nephritis is the most common, but not the only, 
 fatal form of kidney affection consecutive to disease lower down 
 in the urinary passages. Acute interstitial nephritis without 
 suppuration sometimes ends fatally. Nor is suppurative nephritis 
 invariably associated with suppuration in the pelvis of the kidney, 
 i.e. \vith pyelitis ; but so generally do the two conditions co-exist 
 that the terms suppurative nephritis and suppurative pyelo-nephritis, 
 as ordinarily used, are well-nigh synonymous. It occurs in the 
 dilated and sacculated as well as in the undilated kidney ; and 
 in a number of cases pyelo-nephritis and pyo-nephrosis co-exist. 
 
 Suppuration of the ureter, of the renal pelvis, and of the kidney 
 substance are some of the commonest sequelae of obstruction of 
 the urinary passages associated with decomposition of the urine; 
 and it is to these cases that the term " surgical kidney " has 
 been so inaptly applied. 
 
 In the large majority of the cases suppurative pyelo-nephritis 
 is ascending in character, but in others the infection reaches the 
 kidney through the circulation, and in these the suppuration 
 begins in the kidney and then later on descends to the pelvis 
 and ureter. 
 
 * It may be mentioned in this connection that in the pus from an 
 abscess of the testicle of a patient not long since under my care, Mr. Fouler- 
 ton found the gonococciiK. The man most positively denied ever having had 
 gonorrhoea, and had certainly no signs of it at the time.
 
 PATHOLOGICAL EFFECTS OF BACK PRESSURE. 
 
 321 
 
 Occasionally several areas of suppuration coalesce and form 
 an abscess of large size, which may burst into the surrounding 
 tissue or into the pelvis of the 
 kidney, but these cases have been 
 fully considered in dealing with 
 renal abscesses (Chapter X.). 
 
 An ascending suppurative pyelo- 
 nephritis is in most cases preceded 
 by dilatation of the pelvis and 
 calyces, and this is also of clinical 
 importance, since any considerable 
 dilatation of the pelvis will often 
 give rise to a definite tumour, 
 which can easily be recognised on 
 careful palpation. 
 
 Causes. Obstruction to the flow 
 of urine. The principal causes 
 which give rise to suppurative 
 pyelo-nephritis are those which 
 
 Dilatation and ulceration 
 of urethra behind . 
 second stricture. 
 
 Tight stricture 3 inche 
 from external ineatus. 
 
 A second stricture near the bulb. 
 
 Fig. 36. Dilatation Effects of Stricture on Ureter and Kidney, with absorption of 
 kidney substance. From a young man who died from extravasation of urine 
 and gangrene of the scrotum. (Middlesex Hospital Museum.) 
 
 retard or prevent the outflow of urine, such as enlargement 
 of the prostate, stricture of the urethra (Fig. 3C), vesical calculus, 
 especially when of large size, atony or paralysis of the bladder 
 VOL. i. v
 
 322 SURGERY OF THE KIDNEY AND URETER. 
 
 such as occurs in many diseases and injuries of the spinal cord ; 
 congenital phimosis, foreign bodies or new growths such as calculi, 
 blood-clots, parasites, and cancer in the ureter, renal pelvis or 
 calyces. In. the female, pregnancy, affections of the sexual organs, 
 such as perimetritis, ovarian disease, malignant disease, and pelvic 
 inflammations, may each cause secondary nephritis by encroaching 
 upon the bladder or lower end of the ureters and causing ob- 
 struction to the outflow of urine. 
 
 According to Navas, a slight amount of pyelo-nephritis during 
 the course of pregnancy is not an uncommon occurrence, and is 
 due to the pressure of the gravid uterus upon the ureters causing 
 retention and congestion of the kidneys, which may easily be 
 followed by infection ; the usual microbe being the bacillus coli, 
 which is especially predisposed to activity by the constipation 
 which usually accompanies pregnancy. There is nothing special 
 regarding the symptoms of these cases as compared with those 
 arising from other causes, but Navas considers they are often 
 thought to be due to cystitis. The prognosis would seem to 
 l)e sufficiently grave : out of eleven cases quoted by Navas, two- 
 died after delivery, and in two others abortion occurred ; a good 
 recovery is usually made after delivery has been effected. 
 
 Chamberlain also has at some length discussed the close re- 
 lationship between pregnancy and pyelo-nephritis, and he points 
 out that while the kidney becomes congested by pressure upon 
 the renal veins, the bladder is also liable to cystitis owing to 
 the pressure exerted upon it, and to the hindrance which is 
 often caused to the free outflow of urine ; and thus the kidney 
 is rendered more liable to any infection through both these con- 
 ditions. 
 
 Suppurative pyelo-nephritis may also occur from the decom- 
 position of the urine arising out of any case of neglected cystitis, 
 whether due to obstruction or not. 
 
 (riiyoii has shown that general arterio-sclerosis also is an 
 important predisposing cause, for it not only gives rise to- altera- 
 tions in the prostate which eventually lead to urinary obstruction, 
 but it also produces chronic interstitial changes in the kidneys 
 which considerably lower their powers of resisting infection ; long- 
 coiitinuect hypenemia or congestion also acts as a predisposing 
 cause in the same wav.
 
 MECHANICAL AND PATHOLOGICAL EFFECTS OF OBSTRUCTION. 323 
 
 The mechanism of obstruction in cases arising from this class 
 of causes is as follows : 
 
 The outflow of urine from the bladder becomes obstructed 
 either through enlargement of the prostate, stricture of the 
 urethra, or some other cause, and retention is the result. If 
 the retention is acute it will shortly be followed by a congestion 
 of the kidneys and their pelves, varying in intensity according 
 to the duration and intensity of the retention. If, on the other- 
 hand, the condition is a chronic one, the changes are much 
 more slowly produced. The bladder gradually undergoes alterations 
 in its size and in the structure of its walls ; the ureter dilates,, 
 its mucous membrane is congested and its walls are thickened, and 
 later on the pelvis and calyces undergo analogous changes : finally 
 the kidney itself is affected, its canaliculi are dilated, and a gradual 
 slight sclerosis takes place throughout the organ. During these 
 stages, called by Albarran the " aseptic period," the kidney and 
 its pelvis are still free from infection, but their resisting power- 
 is greatly lowered, and they easily succumb to any organisms 
 which may reach them. 
 
 The next stage is the period of infection, and is characterised 
 by a septic condition of the urine in the bladder, either through 
 the frequent passage of instruments or some other cause. 
 
 The inflammation which results gradually spreads from the 
 bladder to the ureters and pelves, and finally gives rise to typical 
 suppurative pyelonephritis. If the stagnant urine in the bladder 
 is albuminous, the condition becomes still more favourable for the 
 growth of bacteria, and the disease then spreads more rapidly. 
 
 In Fig. 37 is shown a well-marked suppuration of the kidney 
 with a dilated pelvis which had occurred as the result of cystitis, 
 in a man, aged fifty-three. The surface of the kidney was. 
 irregular and numerous small suppurating foci projected from 
 it. In addition to these foci, there was on the anterior surface 
 a dark globular mass (shown in section in the figure) in which 
 there were 110 signs of suppuration, but which was filled with 
 blood- clot, and was evidently a hsematoma, a condition of things 
 which is very rarely found in cases of this description. 
 
 General infections. Suppurative pyelo-nephritis may occur 
 during the course of diphtheria, typhoid, typhus, and other 
 exanthemata, and the general constitutional disturbance accom-
 
 324 
 
 SURGERY OF THE KIDNEY AND URETER. 
 
 panying these conditions renders the kidneys very prone to infec- 
 tion through catheterisation. I have known acute suppurative 
 nephritis to occur in a young woman suffering from typhoid 
 fever who had been daily catheterised for twenty-five days 
 before death. It also occurs as a result of general pysemic con- 
 ditions, and it is by no means an uncommon complication in 
 
 Dilated pelvis. 
 
 Fig. 37. Suppurative Pyelonephritis of right Kidney and a Haematoma in the 
 Parenchyma consecutive to Cystitis. (Middlesex Hospital.) 
 
 cases of general infection arising from erysipelas, carbuncles, and 
 osteomyelitis ; in the last named disease it is especially common, and 
 Laimelongue found abscesses in the kidneys in seven out of ten 
 fatal cases. It is likewise very freq.uent in infective endocarditis, 
 the infection reaching the kidneys through the emboli arising 
 from the diseased cardiac valves. It may also occur as a com- 
 plication of other general diseases, such as acute and chronic 
 Bright's disease, scurvy, cholera, and diabetes ; being induced by 
 the alteration in the characters of the urine secreted under the 
 influence of severe constitutional disorder. Or it mav be due to
 
 CAUSES OF PYELONEPHRITIS. 325 
 
 changes in the urine under the continued effects of atony of 
 the bladder and catheterism. When complicating general diseases, 
 the affection often runs a very insidious course. 
 
 Drugs. Irritant drugs such as cantharides have been supposed 
 to give rise to diffuse suppuration and multiple abscesses of the 
 kidney ; but in the cases which have been reported there has 
 generally been enlarged prostate, stricture, or some other affection 
 of the lower urinary passages, which of itself may have caused 
 the renal changes, and in the treatment of which the drugs 
 have very probably been employed (see p. 305). 
 
 Traumatism. Injury to the kidney, ureter, or bladder 
 is sometimes followed by suppurative pyelo-nephritis. Under 
 this heading calculi may be classed, for when situated in the 
 renal pelvis or calyces they produce a mechanical irritation 
 which leads to desquamation of the epithelium and to chronic 
 changes in the walls that predispose them to receive any 
 infection. 
 
 From the records of the Middlesex Hospital, I found thirty- 
 nine cases of pyelo-nephritis amongst the records of 2,610 post- 
 mortem inspections in the ten years ending 1883. In twenty- 
 six of them there was suppurative nephritis with more or less, 
 severe pyelitis, but without dilatation of the cavity of the kidney, 
 and without perinephric abscess. In twelve cases pyo-nephrosis 
 was associated with the suppuration in the renal substance. In 
 one case perinephric suppuration resulted from the bursting of 
 a small abscess through the capsule of the kidney. This occurred 
 in a man, aged fifty, who had locomotor ataxy, prostatic abscess 
 and cystitis. Both kidneys had small points of suppuration 
 scattered in them, and the pelvis of each kidney was inflamed. 
 Around the left kidney in the perinephric fat there was a large 
 abscess. 
 
 Of the twenty-six cases of pyelo-nephritis seven were unas- 
 sociated with disease of or involving the lower urinary organs 
 or ureters. Four out of the seven were unquestionably pysemic, 
 and the other three were almost certainly metastatic abscesses. 
 Septicaemia, chronic phthisis, enteric fever, ulcerative endo- 
 carditis, periostitis, pericarditis, and mammary cancer with recur- 
 rence in the intestines, were the causes of death in these seven 
 cases.
 
 326 SURGERY OF THE KIDNEY AND URETER. 
 
 In the other nineteen cases there was disease involving the 
 lower urinary organs, the nature of which was as follows : 
 
 Cancer of rectum . . . . . . . . . . . . . . 2 
 
 Cancer of uterus . . . . . . . . . . . . 1 
 
 Enlarged prostate and cystitis .... . . . . 3 
 
 Abscess in prostate and chronic Bright' s disease . . . . 1 
 
 Rupture of urethra with extravasation of urine 3 
 
 Stricture of urethra and cystitis . . . . . . . . . . 1 
 
 Cystitis from various causes, including three of spinal cord) 
 
 affections . . . . . . . . . . . . . . J 
 
 In two of this last group of eight cases it is possible that 
 the nature of the disease was pysemic, for the cause of the cystitis 
 is not mentioned, and one of the patients died with epithelioma 
 of the lower jaw, and the other with carbuncle in the neck. 
 
 From a further analysis of the post-mortem records of the 
 Middlesex Hospital, there were seventy-five cases of suppurative 
 nephritis, excluding cases of pyo-nephrosis, occurring in 3,926 
 post-mortems. Of these, fifty-one were consecutive to diseases 
 of the bladder or pelvic organs, and in the large majority sup- 
 puration was present in both kidneys ; thirteen were due to 
 the presence of calculi ; and the remainder occurred during the 
 course of general diseases. Of these, two occurred during enteric 
 fever, two in acute pulmonary tuberculosis, one in. albuminoid 
 disease, one in the course of diabetes complicated by gangrene, 
 one from ulcerative colitis, and four in the course of other general 
 pyoemic affections. 
 
 The symptoms may be acute or chronic. The acute form 
 is characterised by high fever which is usually ushered in by 
 rigors of varying intensity, from the most severe shivering fits 
 to a slight sensation of cold ; the skin becomes dry and hot, 
 the tongue brown and dry with reddened edges, the appetite is 
 lost, there is great thirst, and constipation is generally very trouble- 
 some. If the case runs an unfavourable course all these symptoms 
 rapidly become intensified, and the patient sinks into a semi- 
 comatose condition with muttering delirium, and dies. 
 
 If the case runs a more chronic course the symptoms are 
 practically those of uraemia accompanied by the additional effects 
 of the continual absorption of septic material which is taking 
 place. The temperature is not so high, and the symptoms are
 
 SYMPTOMS OF SUPPURATIVE PYELO-NEPHRITIS. 
 
 327 
 
 often particularly referred to the alimentary tract, which may 
 lead to the digestive disturbances being regarded as the principal 
 complaint ; thus the saliva is deficient and the mouth dry, the 
 pharynx is red, there is but little desire for food, and its ingestion 
 gives rise to vomiting and 
 flatulence ; obstinate con- 
 stipation is the general rule, 
 but it is occasionally re- 
 placed by diarrhoea. Sleep 
 is disturbed, and there may 
 be some slight delirium at 
 night. The circulatory sys- 
 tem is not much disturbed, 
 the pulse may be a little 
 quickened, but no grave 
 alterations usually occur un- 
 til the end is approaching. 
 
 Between the most acute 
 and chronic forms there is 
 every degree of variation; 
 and in some cases of chronic 
 obstruction the symptoms 
 almost imperceptibly pro- 
 gress over a period of many 
 months, and their ultimate 
 gravity may for some time 
 remain unrecognised. 
 
 The temperature also 
 varies very greatly; (1) it 
 is in many cases raised 
 throughout the disease, 
 and in some cases runs a 
 very high course, the even- 
 ing temperature being 105 
 or 106; (2) in other cases 
 periods of fever alternate with periods when the temperature is 
 normal and the general symptoms in abeyance. 
 
 As an example of the first, or continued high fever, I give 
 the accompanying temperature chart (Fig. 38), of a man, aged sixty
 
 328 SURGERY OF THE KIDNEY AND URETER. 
 
 three, who had dilated and sacculated kidneys caused by very 
 extensive papillomata of the bladder. At the post-mortem examina- 
 tion both kidneys were found to be in a state of suppurative 
 pyelo-nephritis, the right kidney being the most advanced in 
 disease. The ureters and kidneys were much dilated. A glance 
 at the chart shows that though the morning temperature fell 
 occasionally to normal, or even to a little below, it was frequently 
 above and sometimes more than two degrees above the normal ; 
 the evening temperature was always high, reaching on one or two 
 occasions nearly 104 Fahr. 
 
 As an example of the intermittent form I may refer to 
 the case of George C., aged sixty-seven, who succumbed after an 
 illness of six weeks to suppurating interstitial nephritis engrafted 
 upon dilated kidneys, and chronic interstitial nephritis. For four 
 or five years this gentleman had entirely neglected the warning- 
 symptoms of retention of urine from enlargement of the pros- 
 tate, notwithstanding that his condition had necessitated the use 
 of a urinal when travelling or in society. 
 
 At length an attack of severe flatulent dyspepsia, combined 
 with obstinate constipation, great thirst, and the secretion of 
 very large quantities of thin limpid urine (eighty to ninety- 
 three ounces a day being excreted), led to the discovery of a 
 tumour to the left of the hypogastrium. The tumour proved 
 to lie the bladder filled with over two pints and a quarter of 
 urine, of a thin light colour and low specific gravity. Then 
 the regular use of the catheter commenced, and soon afterwards 
 there came periods, of days together, when the morning tem- 
 perature rose to 100 or more and the evening temperature to 
 103. The periods were followed by five or seven consecutive 
 days when the temperature both morning and evening Avas. 
 normal, as seen in the following records of the case. From 
 September 27th to October 3rd it was as follows : 
 
 Morning. Evening. 
 
 Sept. 27 99'4 102 
 
 28 100*2 103'4 
 
 29 101-4 103'4 
 
 3D 101-4 103 
 
 Oct. 1 101 102 
 
 ., -1 99'2 100'2 
 
 3 98'2
 
 TEMPERATURE IN THE INTERMITTENT FORM. 329 
 
 From October 3rd to October 10th the temperature remained 
 normal, but from the 10th to the 16th inclusive it ran : 
 
 Morning. Evening. 
 
 Oct. 10 100 103 
 
 ,,11 102 104 
 
 ,,12 102 104 
 
 ,,13 102 104 
 
 ,,14 101 103 
 
 ,,15 100 102 
 
 ,,16 98'4 
 
 It was a notable feature in this case, that with the subsidence 
 of the feverish attacks not only did the general condition 
 improve, but the quantity of urine diminished, so that it fell, for 
 example, from the 3rd to the 10th of October, to between forty- 
 two and sixty ounces per diem. During as well as before the 
 first attack of fever, from eighty to ninety, and even ninety- 
 three ounces of urine were voided in twenty-four hours ; but 
 later in the course of the case, though the quantity was larger 
 during the febrile than during the non-febrile periods, it never 
 exceeded seventy-four ounces in twenty-four hours, and sixty 
 to sixty-five was about the average quantity. After the third 
 febrile attack it varied from forty -four to fifty ounces, but never 
 exceeded fifty-five ounces. The amount of urea, though from 
 the first somewhat deficient, diminished still more as the case 
 progressed, being sometimes from seven to ten grammes less than 
 the normal. The urine, for a time limpid, pale, acid and of sp. 
 gr. 1015, became, during the last three weeks, offensive and 
 largely charged with pus and bacteria. 
 
 In some cases profuse sweating occurs at intervals ; as a 
 rule, the skin keeps moist, and is very often bathed in a clammy 
 perspiration, which towards the end of the disease becomes 
 cold. The tongue is dry, cracked, parched, and brown. Aphthae 
 often affect the mouth ; the appetite and power of digestion are 
 lost during the fever; the bowels are frequently costive and dis- 
 tended with flatus, or diarrhoaa from time to time may occur ; 
 sometimes there is nausea, and much less frequently vomiting ; 
 and emaciation is very pronounced and rapid. There is little 
 or no pain about the loins, but I have frequently observed that 
 severe spasms, referred to the neck of the bladder, are complained 
 of as soon as any moderate quantity of urine accumulates in its
 
 330 SURGERY OF THE KIDNEY AND URETER. 
 
 cavity. After the discomfort clue to the parched condition 
 of the mouth and the disturbed state of the digestive organs, 
 these spasms are the chief cause of distress. The mental aspect 
 of the patient is for the most part unaffected ; he is perhaps 
 silently anxious and apprehensive about himself, but there is 
 no excitement or active delirium. On the contrary, he may 
 at first read a great deal, but he is apt to doze much over 
 his book or paper ; or he lies dreamily, as if under the effect 
 of morphia ; but as the disease advances there is more actual 
 somnolence and torpor, he rouses himself with effort, starts during 
 his sleep, and perhaps even mutters incoherently. Though 
 generally conscious or semi-conscious nearly up to the last, coma, 
 which may be profound, often anticipates death by a few hours. 
 The pupils are but little interfered with during the course of the 
 case, unless they are contracted from the effect of opium or 
 morphia. 
 
 The character of the urine varies in different cases : if the state 
 of the bladder is unhealthy the urine is of course largely mixed 
 with mucus, pus, phosphates, and perhaps blood ; but in other 
 cases, in which the pelvis of the kidney suppurates quickly, the 
 urine is purulent and acid at first, afterwards becoming puru- 
 lent, phosphatic, and alkaline, whilst the bladder remains in .a 
 fairly healthy condition. This is a proof, if any were needed, 
 that pyelo-nephritis does not require for its production an un- 
 healthy state of the bladder, nor the ammoniacal decomposition of 
 urine within the bladder. It is even the fact that these conditions 
 of the bladder may themselves result secondarily from the entrance 
 into the bladder of septic urine from the kidneys. In many 
 cases the amount of urine is increased and the quantity of urea 
 excreted is diminished, owing to the chronic changes which have 
 previously taken place in the kidneys. These characters may be the 
 result of chronic Blight's disease, but are more often indicative of 
 tubular and interstitial changes due to increased urinary pressure 
 from long-standing obstruction to the outflow of urine. If the fever 
 is of the intermittent character the urine is generally more abundant 
 during the periods of fever than between them. Usually it 
 continues to be excreted in considerable quantity up to the end, 
 but the amount is often comparatively decreased towards the 
 close of the disease. This is explained, I think, thus : Each
 
 GREAT IMPORTANCE OF FEVER IN DIAGNOSIS. 331 
 
 accession of fever represents the outbreak of the acute inflamma- 
 tory process in a fresh area of the kidney. An increased quantity 
 of blood is thus brought to the kidneys, from which the portions 
 of the organs not yet affected extract an increased quantity of 
 water ; after the destruction of this newly attacked area the 
 increased activity of the circulation in the kidneys subsides for a 
 time. Afterwards, there is so much less excretory substance left 
 for future use ; hence the diminution of urine during the intervals 
 of immunity from the fever, and also towards the end of the 
 patient's life. The presence of albumen varies with the pus 
 and blood ; generally there is no free albumen. Hyaline, 
 granular, and even pus casts may be found, though but rarely; 
 for this, if for no other reason, that long before they are shed 
 the urine has generally become too foul to permit of their dis- 
 covery. When the bladder is unaffected, epithelial cells from the 
 renal pelvis may be discovered in the purulent urine, more 
 especially if it maintains an acid reaction. 
 
 Diagnosis. When purulent urine of acid reaction, and 
 containing renal epithelium, is voided by one who is suffering 
 from pains in the region of the kidney extending along the ureters 
 to the bladder, we may safely diagnose the existence of pyelitis. 
 If, on the other hand, there is some disease of the bladder, so 
 that the renal epithelium, if any be voided, is masked by the 
 changes which take place in the urine after it reaches the bladder ; 
 and if, also, as is frequently the case, there are no pains in the 
 lumbar regions, then pyelitis is likely to be overlooked. 
 
 Pyelo-nephritis, when secondary to disease of the bladder, is 
 too often unrecognised until discovered at the post-mortem ex- 
 amination. But this should not be so ; because in cases of 
 disease of the lower urinary organs, especially when associated 
 with partial or complete retention of 'urine, there are two 
 sets of symptoms which ought at once to lead the surgeon to 
 a correct diagnosis. These are fever and the typhoid state 
 into which the patient quickly passes. If, therefore, a person 
 suffering from stricture of the urethra, prostatic enlargement, 
 tumour of the bladder, cancel 1 of the uterus, or other disease 
 involving the lower urinary tract, develops a high temperature 
 at night (i.e. from something over 100 to 105 or even 106), 
 and becomes drowsy, prostrated, and rapidly loses flesh, has a
 
 332 SURGERY OF THE KIDNEY AND URETER. 
 
 dry coated tongue, a quick, weak pulse, a tendency to nausea, 
 and from time to time profuse perspirations, and, it may be, 
 an occasional chill, the diagnosis of pyelo-nephritis admits of 
 no doubt. 
 
 From whatever cause arising, suppurative nephritis and pyelo- 
 nephritis are to be distinguished from acute Bright's disease by 
 the absence of convulsions, of oedema, and of the harsh and 
 dry skin of Bright's disease. In pyelo-nephritis, if coma occurs 
 at all, it is only for a few hours at most before death ; and 
 the urine, instead of being scanty and of a reddish-brown colour, 
 as in Bright's disease, is abundant in quantity, purulent in 
 character, and but slightly, if at all, tinged with blood. 
 
 Pycemia may generally be distinguished from pyelo-nephritis by 
 the secondary abscesses, and the tender purulent swelling of the 
 joints, as well as by the extreme variations in the high temperature 
 which mark the rigors and the succeeding sweats so characteristic 
 of pyaemia. In pyelo-nephritis there may be no rigor throughout ; 
 in pyaemia some days may pass without any rigor at all, and then 
 two or three may occur in the same day. In pyelo-nephritis, 
 when occasional profuse sweating occurs, it is not as a sequence 
 to a rigor. In pyaemia the sweating follows the rigors. The 
 rigors of pyaemia are accompanied by a rise of temperature, 
 reaching often as high as 105 to 107 ; the succeeding sweats 
 by a sudden fall to normal or subnormal ; but very shortly 
 after this fall the temperature rises again to, and continues at, 
 the high febrile level of the disease. Both in subacute and acute 
 interstitial nephritis I have known muscular pains about the 
 thighs hips, and wrists complained of, and pyaemia has in con- 
 sequence been suspected ; but in renal disease there is no tender- 
 ness, redness, or swelling of the painful parts, and the pain is 
 relieved by gentle friction and soon passes off altogether. In 
 pyelo-nephritis there is not the sweet mawkish odour of the 
 breath, the offensive diarrhoea, or the jaundiced tint of the 
 skin, which often attracts attention in pyaemia. 
 
 From acute septicaemia pyelo-nephritis is to be distinguished 
 by its less rapid course and by the absence of that restless anxiety, 
 delirium, and tossing of the extremities which accompany the 
 prostration and rapid sinking in septicaemia. There are never 
 in suppurative pyelo-nephritis the purpuric stains in the skin,
 
 DIAGNOSIS OF SUPPURATIVE PYELO-NEPHRITIS. 333 
 
 nor are there found after death the ecchymoses of internal organs 
 which result from the blood changes of acute septicaemia. 
 
 From the less acute forms of septiccemia, those, namely, 
 which last from two to three weeks, and in which no secondary 
 abscesses or purulent deposits are formed, it is difficult to diagnose 
 suppurative inflammation of the kidney. Some of the fatal cases 
 of so-called urinary fever of a typhoid form, in which the autopsy 
 reveals no renal changes sufficient to explain death, are really 
 cases of septicaemia. Others are doubtless due to chronic cystitis, 
 or a combination of chronic cystitis and septicaemia. In chronic 
 cystitis, as Brodie pointed out, a low febrile disturbance -of 
 the system, attended with great debility, occurs. This low 
 form of continued fever may terminate fatally, especially when 
 the mucous membrane of the bladder is eroded, ulcerated, or 
 sloughing. In pyelo-nephritis also, death is perhaps less due 
 to the distinctive changes in the kidney than to the inoculation 
 of the whole system by septic matter absorbed from the damaged 
 organ or the offensive urine (Beck). 
 
 From typhoid fever the history and course of the disease, 
 and the absence of Widal's serum reaction and Ehrlich's test, 
 will usually sufficiently serve to distinguish pyelo-nephritis. The 
 temperature chart, and the typhoid character of the general 
 symptoms in the latter disease, are, however, like to those of the 
 later period of typhoid, the temperature rising at night to a point 
 varying from 101 to 104, and falling in the morning to 99 or 
 lower. Moreover, be it remembered, pyelitis and pyelo-nephritis 
 are occasional complications of typhoid fever. 
 
 No difficulty in diagnosis ought to arise between ague and 
 secondary suppuration of the kidney. It is asserted, and it is 
 probably true, that rigors after catheterism and operations on 
 the urinary organs are of frequent occurrence in persons who 
 have had ague or lived in malarial districts. But the general and 
 progressive symptoms above described ought to distinguish pyelo- 
 nephritis or suppurative interstitial nephritis from ague. 
 
 From urcemia the diagnosis is much more difficult. It must 
 be remembered that in some of the fatal cases of urinary fever 
 there is complete suppression of urine for some hours or some 
 few days before death, so that death is more or less immediately 
 due to uraemic poisoning. Uraemia is but a name for a group
 
 334 SURGERY OF THE KIDNEY AND URETER. 
 
 of symptoms, and these symptoms may sometimes occur, though 
 they by no means always do so, during the fever which follows 
 catheterisation and operations on the urinary organs. 
 
 Septicaemia plays a by no means insignificant part in causing 
 death in certain cases of urinary trouble. In old men with 
 enlarged prostates, in long-standing stricture cases, in typhoid 
 and other continued febrile states, in disease and injury of 
 the spine, and even in simple atony of the bladder, decom- 
 position of the urine occurs, and the mucous membrane of 
 the bladder becomes inflamed and eroded. So, also, in cases 
 of pyelitis from calculus or tubercle of the kidney, the mucous 
 membrane becomes diseased, and fermentative changes occur in 
 the urine. Thus septic material may be absorbed from the 
 bladder or renal pelvis, and give rise to constitutional infection 
 quite independently of instrumental irritation. Again, in sup- 
 purative nephritis and pyelo-nephritis, septic material may be 
 absorbed from the purulent tracts of the kidney or from the 
 putrid urine within the renal pelvis, and death may be caused 
 partly by the damage to the kidney and partly by septicaemia. 
 The symptoms of all these cases are of a low typhoid character,, 
 very like those which have been detailed above. 
 
 In some cases in which the symptoms during life point most 
 strongly to suppurative pyelo-nephritis, the kidneys are found 
 free of suppuration, sacculation, or dilatation ; and nothing presents. 
 itself to the naked eye, either within or without these organs, 
 sufficient to account for the symptoms and death yet the kidneys 
 are really the cause of death. 
 
 Cases occur in which it is expected that well-marked scattered 
 foci or even much larger suppurating areas will be found in 
 one or both kidneys, but at the post-mortem examination these 
 organs are apparently only small and toughened. There is 
 not the slightest trace of suppuration evident to the naked eye ; 
 yet under the microscope there are seen collections of nuclei 
 around some capillary vessels as in the early stage of " miliary 
 abscesses." 
 
 Prognosis. The prognosis of suppurative pyelo-nephritis is 
 very unfavourable, and most patients thus afflicted die within 
 three or four weeks. 
 
 In some verv acute cases death occurs in three or four
 
 PROGNOSIS OF SUPPURATIVE PYELO-NEPHRITIS. 335 
 
 days ; the average duration is, however, from two to three 
 weeks. 
 
 Occasionally, when the cause of the disease can be removed, 
 and the state of the bladder improved by irrigation, the patient 
 recovers. It is not unfrequent to find in the bodies of persons 
 with other evidences of former obstruction in the urinary pas- 
 sages, shrunken irregular kidneys with cicatrices on their surfaces 
 and in their capsules. Probably in some instances, though not 
 necessarily in all, these cicatrices indicate the healing long ago 
 of small abscesses ; but the same appearances are more probably 
 left by severe inflammatory changes in the kidney short of actual 
 suppuration. 
 
 C. Feiiger states that a pyelo-iiephritis in its early stage is 
 amenable to cure, as has been shown experimentally by Eovsing ; 
 and Geyl may be right in calling attention to the possibility 
 that pyelo-iiephritis, if not far advanced, may disappear when 
 the distal end of the ureter is implanted into the bladder in 
 certain cases of injury to the lower end of the duct. 
 
 If the fever be high and of the intermittent character, and 
 is accompanied by marked depression, loss of appetite, flatulence, 
 and constipation ; and if each attack of fever leaves the patient 
 permanently weaker bodily and mentally, the prognosis is bad, 
 and the patient will die within a few weeks. 
 
 If the fever be high and continuous, the downward course is 
 more uninterrupted and the fatal end will ensue even more quickly. 
 
 If the feve"r, whether intermittent or continued, be but mode- 
 rate ; and if the strength of the patient is ftot rapidly worn away, 
 a favourable termination may follow on the removal of the cause 
 of obstruction. 
 
 Pathology. In all cases of ascending suppurative pyelo- 
 nephritis due to urinary obstruction, there are pathological changes 
 preceding the actual suppuration which are due to the pressure 
 exerted by the retained urine. These changes resemble those 
 described in the preceding chapter on interstitial nephritis, and 
 Consist of dilatation and thickening of the walls of the ureter 
 and pelvis, accompanied by some sclerosis of the kidney substance 
 itself which in old-standing cases causes the organ to become 
 considerably diminished in size and irregular in shape. Micro- 
 scopically a general increase of connective tissue is observed.
 
 336 SURGERY OF THE KIDNEY AND URETER. 
 
 Sometimes the sclerosis is distributed throughout the kidney in 
 patches of unequal extent, and Albarran has described cases in 
 which the remaining healthy portions appeared to have under- 
 gone a true compensatory hypertrophy, the tubes and glomeruli 
 retaining their normal structures although much increased in 
 volume. 
 
 When the kidney is in a state of suppuration it is usually some- 
 what increased in volume, but this, of course, must depend largely 
 on the amount of sclerosis that has previously taken place, as 
 well as on the degree of dilatation of the kidney; for the same 
 reason the surface of the organ varies, in some being smooth 
 and in other's very granular : there are often also very firm 
 adhesions between the renal capsule and the perinephric fat, and 
 the perinephric fat is often much increased in thickness and 
 toughness. On section numerous foci of suppuration are seen 
 varying in size from a pin's head upwards, and occasionally form- 
 ing large abscesses involving extensive areas of both the cortical 
 and pyramidal portions of the kidney. Pale yellow streaks are 
 often seen radiating through the pyramids into the cortex, each 
 surrounded by a deep red zone, while the intervening parts of 
 the organ appear healthy to the naked eye. These yellow 
 radiating streaks are often very striking in appearance, and are 
 sometimes the prominent pathological condition present ; they 
 constitute the "nephrite rayonnant" of Albarran. 
 
 When suppurative nephritis affects granular cystic kidneys, 
 the cysts often contain pus and look like small 1 circumscribed 
 abscesses. 
 
 Occasionally, when the abscesses are very extensive, they may 
 give rise to perinephric suppuration by penetration of the in- 
 fection through the capsule, by the lymphatics, or by actual 
 rupture of the capsule itself. The renal pelvis is usually dilated, 
 its walls are thickened, its mucous membrane injected and often 
 ecchymosed, or it may be ulcerated in patches. Sometimes a 
 gritty deposit, of amorphous phosphates coats the surface of the 
 pelvis and calyces as well as the apices of the pyramids. 
 
 Microscopically there is seen to be a variable increase in the 
 connective tissue, together with an exudation of leucocytes ; the 
 leucocytes being chiefly collected in the canaliculi and round the 
 glomeruli, and, though much more rarely, in the blood vessels.
 
 MICROSCOPICAL CHANGES IN SUPPURATIVE NEPHRITIS. 
 
 337 
 
 Subsequently the tissue between the tubules becomes affected, 
 and a general purulent infiltration is the final result, epithelium, 
 tubules and connective tissue alike disappearing and becoming 
 replaced by collections of pus. 
 
 When the seat of the primary disease is in or in front of the 
 bladder, both kidneys are, as a rule, affected, though one is often 
 more extensively involved than the other. If the primary disease be 
 in the ureter or pelvis of one kidney, that organ alone will be 
 affected. Beck states that he has seen a case in which both 
 kidneys were equally dotted with minute points of suppuration 
 but in one the pelvis was free from inflammation and the urine 
 therein was acid, whereas in the other the pelvis was suppurating 
 and contained decomposing urine. I have also observed the same 
 disposition of the pathological changes. 
 
 Fig. 39. Swelling of Renal Epithelium; 
 Nuclei obscured and Protoplasm opaque 
 (probably necrotic). Intertubular tissue 
 in excess. (Cortex x 250.) 
 
 ^ 
 
 Fig. 40. Degenerated Malpighian 
 Body (hyaline fibroid change). 
 (Cortex x 250.) 
 
 The accompanying figures (39-43 inclusive), from drawings by 
 Dr. Coupland, show the changes found in a case of suppurative 
 nephritis following obstruction to the outflow of urine from the 
 bladder, and supervening upon chronic interstitial nephritis. 
 
 The changes shown are : (1) marked increase of intertubular stroma, 
 with abundant infiltration of leucocytes in the connective tissue, 
 both of the medulla and cortex ; (2) a swollen, opaque condition of 
 the epithelium, especially in the cortical portion, where the cells 
 were apparently necrotic ; (3) and atrophy of some of the Malpighian 
 tufts with sclerosis and thickening of their capsules. These 
 figures show well the several changes of acute inflammation as 
 VOL. i. w
 
 338 
 
 SURGERY OF THE KIDNEY AND URETER. 
 
 well as the changes in the Malpighian tufts which had been 
 wrought by the antecedent chronic interstitial nephritis. 
 
 Albarran made experimental investigations on animals by 
 introducing the organisms into the ureters, and then examining 
 the kidneys at variable times afterwards. The earliest signs were 
 those of congestion ; the surface of the kidney became dark red, 
 and subcapsular haemorrhages were often seen ; the size and weight 
 of the organ increased, and about the third day suppuration 
 commenced, which finally ended in dilatation of the renal 
 pelvis and complete destruction of the kidney substance. With 
 regard to the kidney on the opposite side to that upon which 
 the experiment was performed, nothing of note was observed for 
 
 Fig. 41. Nuclear Proliferation of 
 Epithelia. Excess of interstitial 
 tissue, imperfectly fibrous. (Me- 
 dulla x 250.) 
 
 Fig. 42. Cell Infiltration (in- 
 flammatory) of Intertubular 
 Tissue. (Medulla x 250.) 
 
 some days beyond a little augmentation of volume and cortical 
 congestion, with occasionally some small ecchymoses ; but about 
 the sixth or seventh day some miliary abscesses appeared immedi- 
 ately beneath the capsule, which gradually extended further into 
 the medulla, following the line of the arterioles. The pelvis of 
 the kidney in these cases generally preserved its normal appear- 
 ance, but in one case it was found to contain a turbid fluid, 
 which was very rich in bacteria. 
 
 There has always been some difference of opinion concerning 
 the precise origin of the changes ; for while Ivlebs, Ebstein, and 
 others have held that the uriniferous tubules are primarily affected, 
 others consider that the tissue between the tubules is the first 
 to be attacked, and that the changes in the tubules themselves 
 are only seen later. Dickinson, whilst of opinion that the virus 
 entered the kidneys by the uriniferous tubules, held that it 
 passed thence into the veins, and was thus carried far and wide 
 through the organ. Marcus Beck, on the other hand, considered
 
 MICROSCOPICAL CHANGES IN SUPPURATIVE NEPHRITIS. 339 
 
 that the septic matter passed from the uriniferous tubules into 
 the lymphatic spaces. 
 
 It is probable that each of these views is correct, and that 
 the differences depend upon the method by which the infection 
 enters the kidney, for, as we have already seen, the micro-organ- 
 isms may reach the kidney in three ways, viz. by the urinary 
 tubules, the blood vessels, or the lymphatics ; and it is only reason- 
 able to assume that the mode of onset would vary under these 
 different conditions. Moreover, the question is still further com- 
 plicated by the fact that two or even three of these conditions 
 may be present at the same time ; for 
 in a case of ascending nephritis the in- 
 fection mav not onlv reach the kidnev t&^^tt^&t 
 J " in lt>d* u9\ >\^ 
 
 9x.iv5c& ufcjj ^^~&^ *^f* 
 
 by way of the ureter, but it may also ^-^^sd^^^f 
 
 be carried to the organ by means of the 
 circulation after having been taken up 
 from some point in the lower part of 
 
 ,1 rpi - i Fig. 43. Cell Infiltration of 
 
 the urmarv tract. Ihus it must be , , , m- 
 
 Intel-tubular Tissue, and 
 
 borne in mind that although it is for Destruction of Tubules. 
 
 purposes of description convenient to (Cortex x 250.) 
 
 draw a sharp division between the ascend- The purulent tcu in the meduii. 
 
 have on each side of them 
 
 ing and descending forms, in practice no deep red, highly congested 
 
 II- 11^ -i i f j_i streaks, running parallel with 
 
 such line can be definitely made, for the thc tubules. 
 
 two imperceptibly merge into one another. 
 
 With regard to the lymphatics, it was long ago shown 03- 
 Dr. Steven, by means of injections, that the lymphatics of the 
 ureter communicate with those of the kidney. In this way, 
 therefore, the process of infection may take place freely at the 
 same time that it is passing upwards along the uriniferous tubules. 
 When the infection enters by the tubules the changes would 
 commence in the tubules themselves ; when it enters by the 
 lymphatics the tissues outside the tubules would be the first to 
 te affected. 
 
 When the virus obtains entrance by the lymphatics the small 
 abscesses are most numerous, being in some cases almost entirely con- 
 fined to the cortex. The shape of the cortical abscesses when they 
 spread inwards along the pyramids is elongated or wedge-shaped ; 
 but when, as is often the case, they are situated between the 
 capsule of the kidney and the renal substance, and involve the
 
 340 SURGERY OF THE KIDNEY AND URETER. 
 
 capsule quite as much as the cortex, the abscesses are oval or 
 round. The position of the microbes in the kidney also varies 
 with the mode of infection. Albarran has shown that in cases 
 of infection by the bacillus coli the organisms ascend the medul- 
 lary canals until they reach nearly to the cortical tubules, where 
 they form large masses. They can also be seen traversing the 
 walls of the tubules and passing into the lymphatic spaces. The 
 bacilli are also found around the glomeruli. In cases of strep- 
 tococcus infection the method of simple ascension is said to be 
 less marked, as this microbe tends much more to propagate itself 
 by the blood vessels and the lymphatics. 
 
 In the early stages of the acute form of descending suppurative 
 pyelo-nephritis the characteristic changes are swelling and desqua- 
 mation of the tubular epithelium, with exudation of leucocytes and 
 haemorrhages, these severally predominating according to the 
 intensity and nature of the infection. Small points of suppuration 
 then appear, and the whole organ soon becomes studded with 
 small abscesses. 
 
 Treatment of suppurative nephritis and pyelo-nephritis. 
 This is essentially the same as that recommended for acute 
 and subacute interstitial nephritis without suppuration. Every 
 precaution should be taken to prevent their occurrence. If 
 there is any obstruction to the outflow of urine, or any in- 
 capacity to completely empty the bladder, it should be remedied 
 or counteracted : thus, stricture of the urethra should be dilated 
 or divided, vesical calculus should be removed, and the effects of 
 enlarged prostate counteracted by the early and regular use of 
 the catheter. 
 
 If chronic cystitis exists, daily irrigation of the bladder will 
 be necessary, both to obviate decomposition of urine and to restore 
 the mucous membrane to a healthy state. If a stone is impacted 
 in the lower end of the ureter, it should be removed through 
 the bladder when possible ; if impacted higher up in the ureter, 
 or in the pelvis of the kidney, the question of ureterotomy, 
 nephrotomy, or nephrectomy, must be considered. 
 
 Confinement to bed is necessary as soon as inflammation has 
 once set in. With the view of obviating the tendency to inflam- 
 mation which is prone to be excited by the use of instruments 
 on persons with diseased kidneys, and more especially when
 
 TREATMENT OF SUPPURATIVE PYELO-NEPHRITIS. 341 
 
 men with enlarged prostates are commencing what is called 
 " catheter life," absolute quietude and confinement to the 
 house, and to an equable temperament, should be enjoined 
 before the introduction for the first time of any instrument at 
 all. Whether with the object of avoiding the slighter forms 
 of urinary fever, or the much more severe and dangerous changes 
 of pyelo-nephritis, the above precautions should be strictly observed. 
 
 The bowels should be kept well opened, and for this purpose 
 warm abundant enema ta are of great and special service. 
 
 The diet should be light and* moderate, and should consist 
 chiefly of fish, milk, or chicken, light farinaceous and milk 
 puddings, and well-cooked vegetables ; uncooked vegetables or 
 fruits and butcher's meats should be avoided. Stimulants 
 should be taken, if at all, in very small quantities ; and during 
 their administration, if the -pulse is quickened, the temperature 
 raised, or the urine becomes more purulent, they should at once 
 be discontinued. 
 
 Fluids should be taken in only moderate quantity if there 
 is an abnormally large quantity of urine secreted ; but where 
 cystitis exists, and much mucus is passed in the urine, Contrexeville 
 and Kronenquelle, Vittel, and similar waters are useful adjuncts 
 in slaking thirst and relieving the irritation of ammoniacal urine. 
 As for medicines, but little can be said in their favour. From 
 quinine and opium combined, most good seems to result. A 
 mixture of quinine and citrate of potash has proved of benefit 
 in some cases. 
 
 When constipation exists, and a large quantity of urine is 
 secreted, I have seen great benefit accrue from a few doses of 
 ergot of rye. This drug, by acting upon the involuntary mus- 
 cular fibres of the gut, overcomes the constipation, and by its 
 influence on the coats of the blood-vessels restricts and regulates 
 the renal circulation. The constipation, flatulence, atony of 
 bladder, and general arterial and muscular feebleness, suggest 
 remedies which will give tone and contractile force to the muscular 
 fibres of the viscera. 
 
 When the febrile attacks take the remittent form, five grains 
 of quinine in an ounce of lemon juice is sometimes very efficacious 
 in checking the rise of temperature. 
 
 Traube obtained good results from injections into the bladder
 
 342 SURGERY OF THE KIDNEY AND URETER. 
 
 of acetate of lead in a solution of from half a grain to one 
 and a half grains in four ounces of distilled water ; and the 
 internal administration of pills of tarniic acid (from one to one 
 and a half grains) every two hours. He recommends Ijoth 
 these remedies because of their antiseptic and antiphlogistic 
 action. Drugs, like tannin, alum, acetate of lead, and chloride 
 of iron, which act as astringents upon the blood-vessels of the 
 mucous membrane and so lessen the excessive secretion of 
 
 mucus, have l)een recommended, and certainly deserve fair trial. 
 
 
 
 B. CIRCUMSCRIBED SUPPURATION (ABSCESS OF KIDNEY). 
 
 By abscess of the kidney I do not here refer (1) to any 
 of those forms of suppurative nephritis characterised by the 
 development of minute and scattered points of pus the origin 
 of which, as described in the preceding section, may be due to 
 (a) some septic material carried into the kidney by the blood ; 
 or (6) to some infective matter derived from disease or injury 
 of the lower urinary organs, and passing upwards either by 
 the ureter and uriniferous tubules of the kidney, or by the 
 lymphatics of the ureter and kidney. Nor (2) do I mean to 
 include cases of miliary abscesses due to the irritation of calculous 
 matter in the kidney ; to the decomposition of urine in the 
 pelvis of the kidney from the impaction of a stone in the renal 
 pelvis or ureter ; or to any other of the numerous causes of 
 obstruction to the outflow of urine. In short, the varieties of 
 surgical kidney or suppurative nephritis, no matter what their 
 cause, are not here classed under renal abscess. Nor (3) is tuber- 
 culous abscess of the kidney included, for renal tuberculosis 
 requires to be separately and specially considered. So, likewise, 
 does (4) pyo-nephrosis, i.e. suppuration with dilatation of the 
 kidney. 
 
 What we have now to describe is circumscribed suppuration, 
 which results in the formation of one or more abscesses of fair 
 or considerable size in the substance of the kidney. 
 
 Etiology. It must be stated at once that renal abscess of 
 large size, involving the greater part or even the whole of the 
 kidney, occurs as the result of the fusing together of a large 
 number of miliary abscesses. When the renal tissue intervening
 
 EMBOLISM OF RENAL ARTERY CAUSING ABSCESS. 348 
 
 between the small miliary abscesses rapidly yields to the sup- 
 purative process, these minute abscesses (whether metastatic 
 and due to blood poisoning, or secondary and clue to infec- 
 tiye material derived from the lower urinary organs) enlarge 
 and coalesce, until at length the whole kidney may be converted 
 into one large abscess, or into two or three separate abscesses 
 of considerable if not large size. Suppuration of this kind may 
 be limited to one kidney, the other being quite unaffected. 
 
 Metastatic and secondary abscesses of large size may be 
 also formed in another manner, besides that of coalescence 
 just described. Thus, in pyaemia, or in cases of embolism 
 derived from ulcerative endocarditis, instead of a number of 
 minute and scattered emboli followed by minute and scattered 
 points of inflammation < and suppuration, one large vessel 
 may be obstructed by an embolus and a large abscess may follow 
 . as the consequence. 
 
 Mayer reports, in Virchow's Archives, a case of this sort due 
 to ulcerative endocarditis ; a large embolus had plugged the 
 right renal artery and led to the formation of a large abscess. 
 So in cases of abscess secondary to disease of the lower uriiiary 
 organs, suppuration may extend by continuity from the bladder 
 along the ureter to the pelvis of the kidney and thence involve 
 the w r hole of the secreting and tubular parts of the kidney, instead 
 of localised and scattered areas of it. In these last-mentioned 
 cases, however, the pelvis of the kidney and the ureter are 
 ulcerated or sloughy in patches, and pyo-nephrosis as a rule forms 
 an important feature in the character of the renal suppuration. 
 Sometimes, however, a circumscribed abscess may form in the 
 tubular substance of the kidney as a result of stricture or some 
 other disease of the lower urinary organs ; a specimen of this 
 kind may be seen in the Hunterian Museum, in which an abscess 
 cavity with irregular walls followed an operation for stone. 
 
 Wounds, contusions, and lacerations of the kidney, and 
 kicks, blows, or falls involving the loin or the renal region of 
 the front of the abdomen, are occasional causes of abscess of 
 the kidney. Injuries, by causing obstruction by blood -clot 
 impacted in or by cicatricial contraction or sclerosis of the 
 ureter, may be followed by suppuration of the renal tissue. 
 From the appearances in cases upon which I have operated
 
 344 SURGERY OF THE KIDNEY AND URETER. 
 
 I have no doubt that small hsematomata hi the renal substance,' 
 caused by injury, sometimes become abscesses in which phosphatic 
 concretions are apt to form. Moreover, injury to the kidney may 
 lead to the formation of renal calculus in the injured organ, 
 and hi this way may be an indirect cause of renal abscesses of 
 large size. The relationship of injuries to the formation of 
 renal calculi will be further referred to in the chapters on calculus 
 in Vol. II. (p. 43 eb seq.). 
 
 A preparation placed by Dr. Bright hi the museum of Guy's 
 Hospital shows an abscess of the kidney the result of contusion 
 or laceration of the renal substance. A quantity of pus mixed 
 with coagulum and blood occupied a space between the fibrous 
 capsule and the surface of the organ. The capsule was greatly 
 thickened, in places to the extent of nearly half an inch. The 
 kidney had been injured nine months before death by a blow 
 on the loin. 
 
 Rayer reported a case in which the left kidney of a sailor 
 aged thirty was considerably contused by his falling from a height 
 and striking his left loin against a yard. Death occurred a 
 fortnight after the fall ; and in the kidney was found an 
 abscess containing about an ounce of thin offensive pus. 
 
 I have previously referred to a case of renal abscess followed 
 by perinephric suppuration and caused by a kick on the lorn 
 over a calculous kidney. More usually, when renal abscess occurs 
 as the result of injury to the loin, whether attended with imme- 
 diate injury to the kidney or not, the suppuration of the kidney 
 has been preceded by suppuration in the circumrenal cellular 
 tissue, so that the abscess involves the kidney by spreading to it 
 from without, and is not primarily a renal abscess. 
 
 llenal calculus is one of the most common causes of large 
 renal abscess. A calculus which originates in a renal tubule, 
 or one which becomes more or less shut off by inflammatory 
 adhesions from the general cavity of the pelvis of the kidney, 
 not unfrequently gives rise to an abscess in the substance of the 
 kidney ; two, three, or more calculi may be contained in as many 
 separate abscess cavities in the same kidney : in extreme cases 
 the whole organ may be converted into a number of separate 
 and non-communicating abscesses, in each of which there may be 
 a calculus. Pyelitis leading to pyo-iiephrosis is, however, a more
 
 BRISTLE IN RENAL PELVIS CAUSING ABSCESS. 345 
 
 frequent consequence of the impaction of a stone in the renal 
 pelvis or ureter than is a renal abscess. 
 
 Foreign bodies other than calculi, such as a piece of bone, 
 or a fragment of clothing, or a bullet, may gain entrance into 
 the kidney, and lead to a renal abscess of large size. 
 
 Dr. Steven* has described an interesting case in which a 
 bristle, partially encased in a branched phosphatic calculus, was 
 the cause of a renal abscess. The specimen was obtained from 
 the body of a man who died soon after sustaining a fracture 
 of the skull. Most of the organs were healthy, but on laying 
 open the right kidney a large quantity of pure yellow pus was 
 found in a series of large cavities chiefly in. the upper part of 
 the organ ; and lying in the long diameter of the renal pelvis 
 was a long black bristle one inch and a half in length and of 
 the thickness of a soda-water bottle wire. The lower end of this 
 bristle passed right through and was immovably fixed in a 
 branched phosphatic calculus which had been deposited round 
 about it, and the branches of the calculus projected into the 
 calyces adjacent to it. The bristle lay exactly in the direction 
 assumed by a probe when passed up the ureter into the pelvis. 
 Dr. Steven considered that it must have obtained entrance into 
 the bladder, and then made its way up the ureter to the pelvis 
 of the kidney. 
 
 Pathology. Abscess usually affects only one kidney. There 
 may be one or several abscesses in the same organ. They 
 vary in size from that of a hazel nut, or smaller, to that of an 
 orange or larger. These abscesses may or may not communicate 
 with the pelvis of the kidney, or through the capsule with the 
 circumrenal cellular tissue. When they open through the 
 capsule they lead to a circumscribed perinephric abscess, or to 
 diffused retro-peritoneal suppuration. When they open into 
 the renal pelvis they may partially or entirely empty them 
 selves through the ureter and bladder. When two or more 
 abscesses affect the same organ they may or may not com 
 municate with one another. Often they do not. Sometimes one 
 of the abscesses opens into the renal pelvis and the other does not 
 (Fig. 44). In other cases, two, three, or more abscesses completely 
 separate from one another will each open by a small aperture 
 
 * Glasgow Medical Journal, September, 1884, p. 187.
 
 346 
 
 SURGERY OF THE KIDNEY AND URETER. 
 
 into the pelvis of the kidney. This isolation of several abscesses 
 should be borne in mind in performing nephrotomy for abscess. 
 It is not only possible, but very probable, that one abscess only 
 may be opened by the first incision into the kidney ; and this 
 should always be suspected when, on introducing the finger 
 within the abscess, its wall, on one side or the other, is convex 
 and bulging towards the evacuated cavity, or the cavity feels to be 
 shut off from the rest of the calyces and the pelvis of the kidney. 
 In a very considerable number of specimens of renal abscess 
 
 the whole organ, including 
 the pelvis, is involved. The 
 pelvis may be little or much 
 dilated ; and the rest of the 
 organ, perhaps greatly en- 
 larged, may be converted into 
 a mere fibrous cyst with large, 
 strongly developed fibrous 
 septa or partitions, and with 
 little, if any, renal substance 
 remaining ; that little may 
 be represented by flocculent 
 shaggy shreds. It is not easy 
 in some of these cases, espe- 
 cially when the ureter of the 
 affected organ is pervious, and 
 
 Fiar. 44. Abscess of Kidney, not communi- , i , , , j i 
 
 ... ,, ,-, IT,,. the opposite kidney and lower 
 
 eating with the Renal Perns. 
 
 urinary organs are not diseased, 
 
 to say whether the morbid process commenced as a pyo-nephrosis, 
 or as an abscess in the renal substance. It is undeniable that 
 many of the cases reported in the journals and elsewhere as renal 
 abscess are really far advanced cases of pvo-nephrosis. 
 
 Symptoms. These may be either acute or chronic. In 
 the acute cases there is pain, often severe, in the loin and in 
 the front of the region of the diseased organ. Fever and rigors 
 are common, the febrile disturbance tending to assume a typhoid 
 character. The rigors are sometimes marked and frequent ; in 
 other cases only one or two occur throughout the course of the 
 disease, and those at uncertain and irregular periods. 
 
 Hsematuria often precedes the formation of abscess when the
 
 RENAL ABSCESS SIMULATING CALCULUS. 347 
 
 cause is traumatic. When haematuria occurs partial suppression 
 of urine for a time may be expected. 
 
 The absence of pus in the urine is no contra-indicatioii of 
 abscess ; in many cases there has been none throughout. In 
 other instances, if the abscess breaks into the ureter or pelvis 
 of the kidney, pus, and it may be in large quantity, will be seen 
 in the urine. If a tumour has been formed in the loin the 
 discharge of pus by the bladder will probably be followed by 
 diminution or subsidence of the tumour. 
 
 It is not often, however, that any tumour perceptible during 
 life is formed by a circumscribed abscess of the renal substance. 
 If a tumour, with the history or the symptoms suggestive of sup- 
 puration, is present, dilatation of the cavity of the kidney may be 
 with fair certainty predicted. 
 
 When the abscess is chronic in character, it forms without 
 causing any definite symptoms ; indeed, it may be found at 
 the post-mortem examination without having caused a sus- 
 picion of its existence during life. Abscesses which follow 
 injuries are likely to give rise to the symptoms of renal cal- 
 culus. I have operated on cases in which symptoms attri- 
 buted to calculus had existed for several years, and have found 
 in the kidney one or two small abscess cavities containing 
 small phosphatic concretions. 
 
 In some cases, general impairment of health, occasional chilli- 
 ness or rigors, obscure aching in the loin, gradual emaciation^ 
 and an increasing sallowness or duskiness of skin, indicate 
 some grave disorder, but do not point with any distinctness 
 to its nature. 
 
 Prognosis. In the acute cases a fatal termination may 
 occur in from a fortnight to three weeks, the cause of death 
 being most probably typhoid prostration. If the abscess bui-sts. 
 into the cellular tissue, the intestine, the renal pelvis, or the 
 ureter, life may be prolonged for an indefinite time, and death is. 
 tardily brought about by exhaustion or prolonged suppuration. 
 
 Possibly recover}- may ensue. In some cases it is pretty 
 certain that the contents of the abscess, instead of escaping in 
 any of the directions mentioned, become inspissated and remain 
 quiescent for the rest of life. What I believe to be a good illus- 
 tration of this is described bv Dr. Bristowe in the fifth volume
 
 348 SURGERY OF THE KIDNEY AND URETER. 
 
 (p. 178) of the Pathological Society's Transactions. A man, thirty- 
 one, whose urine, whilst he was under treatment, contained 
 albumen and phosphates, died from congestion and oedema of the 
 lung and pulmonary apoplexy. In his right kidney, which 
 was small and lobulated and gave a vague impression of fluctua- 
 tion, there were found after death several cavities varying in 
 size from a walnut to a Spanish nut, filled with a uniform soft 
 but not fluid material, resembling very fine moistened plaster 
 of Paris. These cavities were limited by a thin fibrous mem- 
 brane. The putty-like contents presented under the microscope 
 a large number of imperfect broken-down cells, like pus cells, 
 a quantity of free granular matter, small oil globules, and a few 
 plates of cholesterine. From the absence of tubercle elsewhere 
 in the body, and from the uniform character and microscopical 
 appearances of the material, Dr. Bristowe regarded it as concrete 
 pus, the result of bygone suppuration. 
 
 Treatment. The treatment of renal abscess may be summed 
 up briefly by saying that it should be opened and drained at 
 as early a period as possible. The treatment of the inflammation 
 in the stage antecedent to the formation of pus has been described 
 in the chapters preceding ; it will depend largely on the cause. 
 If it be due to external violence, restricted diet and fluids, rest, 
 anodynes, leeches, or cupping over the loin, and the constant appli- 
 cation of hot fomentations, is the treatment that must be followed. 
 If caused by renal calculus the treatment suitable for the varying 
 phases of this disease will be required. In any case in which 
 there is clear indication of a renal abscess the pus ought to be 
 evacuated through an incision in the loin. It would be quite 
 right in the absence of a tumour, but with the history and 
 symptoms suggestive of suppuration, to make an exploratory 
 incision down to the kidney. If, when the kidney is exposed, 
 pus is found, it is not sufficient to evacuate it with a trocar 
 and cammla. A free incision should be made into .the abscess, 
 and the wall of the cavity, if a large one, should be stitched 
 to the edge of the wound to prevent infiltration of the 
 perinephric tissue with pus. For want of such an incision, an 
 untoward result, which otherwise might have been prevented, 
 is but too likely to occur. Several cases might be quoted to 
 prove this, but the following will suffice. Mr. Stanley is reported
 
 MORE THAN ONE ABSCESS TO OPEN T . 349 
 
 in the Medical Times and Gazette for 185-4 * to have punctured 
 an abscess in a kidney after making an incision over it in the 
 loin. The patient shortly died, and in the large renal abscess 
 were found oxalate of lime calculi, which, as the reporter remarks, 
 could only have been reached and removed through a free inci- 
 sion, but which were not even detected by the puncture. 
 
 It will occasionally happen that two or three separate ab- 
 scesses exist, and an incision into one will not suffice to evacuate 
 the others. When, therefore, the finger enters a space hi the 
 kidney which does not communicate with the general pelvic 
 cavity of the organ, or does so only by a small orifice, the rest 
 of the surface of the kidney should be carefully manipulated ; 
 and if fresh pus is found, a second or even a third incision of 
 the renal substance should be made so as to open the other 
 abscesses. Small circumscribed collections of pus may be evacu- 
 ated, and the abscess walls scraped or well rubbed by swabs 
 of antiseptic wool or gauze. I have in several cases removed 
 wedges of the renal substance, and thus taken the abscess away 
 en masse. If the kidney is very much disintegrated it would be 
 best at once to remove it through the lumbar incision. 
 
 Vol. ii., p. 342
 
 350 
 
 CHAPTEE XIII. 
 URINARY FEVER. 
 
 THE term " urinary fever " is used here to indicate the febrile 
 disturbances which frequently follow the passage of a catheter 
 or bougie, or the performance of some other operation on the 
 genito-urinary organs which entails a distinct impression being 
 made upon the urethra or bladder ; it does not include the 
 febrile conditions arising from suppuration of the kidney, which 
 will be found described in the preceding chapters dealing with 
 these diseases, or from uraemia, septicaemia and pyaemia. As 
 will be seen further on, it is probable that cases of urinary 
 fever vary considerably as regards their pathology, and on this 
 score the inclusion of different types under the one heading, 
 which after all is but the chief symptom common to all of them, 
 might at first sight seem unnecessary and somewhat unscientific. 
 But while the pathology of these cases is not at present com- 
 pletely worked out, their clinical importance is enormous, and 
 for practical purposes it seems best to continue to treat them 
 from this standpoint and to group them together as cases of 
 fever which depend on impressions produced upon the urethra, 
 either by the passage of an instrument or some other cause. 
 
 It is a well-known fact that the mere passing of a catheter 
 along a healthy urethra into a healthy bladder often causes a 
 very definite shock, as shown by a feeling of faintness, nausea 
 and a sense of chilliness ; and occasionally these symptoms are 
 great!}' intensified and are accompanied by scanty or complete 
 suppression of urine, and a fatal termination may ensue, although 
 the kidneys, as well as the rest of the urinary tract, have not been 
 aft'ected by any previous disease. Again, it is equally well known 
 that the commencement of catheter life by an elderly man with 
 enlarged prostate, or the performance of some simple operation 
 for stricture of the urethra, has been followed within a few days 
 or weeks by the death of the patient. It is a striking fact 
 that urinary fever is scarcely ever caused by a severe injury
 
 URETHRAL DISTURBANCE CAUSING URINARY FEVER. 351 
 
 to the urethra or bladder, or by the introduction of a catheter 
 in isolated fits of painful retention, of urine. False passages, 
 ruptured urethra, ruptured bladder, extravasation of urine, 
 scarcely ever provoke it. It is generally brought about by some 
 very slight interference with the urethra, often but by no means 
 exclusively in cases of long-standing disease of the urinary organs, 
 e.g. the passage of a bougie in stricture, of a catheter in pros- 
 tatic disease, or of a sound in vesical calculous affection. But 
 although the passage of an instrument along the urethra is the 
 commonest cause, the condition also occurs after other forms 
 of irritation ; for example, after internal and external urethrotomy, 
 lithotrity, the use of Holt's dilator, the passage along the urethra 
 of bubbles of air, of blood-clots, of a renal calculus or a 
 quantity of oxalate of lime or uric acid gravel, as well as when 
 urine first flows again through the urethra after lithotomy. 
 <ruvon found that out of 250 cases of simple dilatation of the 
 urethra by a bougie, urinary fever occurred in forty, i.e. in about 
 a sixth of the total number of cases ; in all these the onset 
 took place on the same day as the operation and usually about 
 six or seven hours after the bougie had been passed. 
 
 Moreover, it is not as has sometimes been stated in any par- 
 ticular part of the urethra that the irritation must be excited ; 
 the fever arises from causes which act in front of as well as 
 behind the bulb of the urethra, and one of the most severe cases 
 of transient paroxysmal fever which I ever witnessed occurred in 
 a gentleman aged seventy-two with cancer of the penis. Whilst 
 micturating, the disease suddenly opened into the urethra just 
 behind the glans, and some of the urine dribbled through the 
 fistula thus formed. He was at once seized with a rigor so 
 severe that it caused him to fall, and it was described to me 
 by his nephew, who witnessed it, as appalling. It lasted about 
 half an hour. On my arrival, an hour or more afterwards, 
 the temperature was 103. For several hours he remained in 
 an alarming condition, faint, sick, aching all over, and with a 
 tendency to delirium. By the next day he had quite rallied, 
 and continued free from any similar attack until his death, from 
 the cancer, nearly three weeks afterwards. 
 
 I shall, under intermittent urinary fever with swelling of 
 the joints, refer to a case in which the fever was excited by
 
 352 SURGERY OF THE KIDNEY AXD URETER. 
 
 irritation about an old fistula of the urethra, situated within one 
 and a half inches of the meatus ; and I shall also describe a 
 case of the recurring acute paroxysmal form of fever due to 
 the passage of a bougie through a stricture situated three inches 
 from the meatus. I have known one instance of an acute 
 transient attack in a female after an operation for vesico- 
 vaginal fistula. 
 
 The presence of renal disease, stricture, enlarged prostate, 
 and any chronic affection of the bladder, all predispose to the 
 fever which in these diseases is more easily produced and is of 
 greater severity than when occurring in a healthy subject. 
 
 It seems, therefore, that only certain impressions on the mucous 
 membrane of the urethra and bladder tend to produce fever, and 
 that the fever is not produced with any certainty, for. when two 
 patients are catheterised under exactly the same conditions one 
 may suffer and the other escape. It seems also that these im- 
 pressions may take effect on perfectly healthy organs, but are 
 more likely to do so on. organs which are already the subject 
 of disease. 
 
 The exact method by which the simple passage of a bougie 
 or catheter gives rise to such a general reaction, accompanied 
 by fever and perhaps retention of urine, is not at present pre- 
 cisely known. There are two principal views held : one is 
 that the condition is a nervous one, produced by the irritation 
 of the urethral nerves, causing a far-spreading effect which is 
 primarily felt by the kidneys, and secondarily by the entire system. 
 The second view regards all these cases as being due to an 
 infection of the genito-urinary tract, followed by the absorption 
 of toxines ; and this view is the natural outcome of the bacterio- 
 logical work which has been done during the last few years. 
 
 As to the first view, there is a very close anatomical connection 
 between the nerves of the different parts of the genito-urinary 
 system, and it is not difficult to believe that an irritation of the 
 nerves of one part might produce reflex effects in other parts. 
 It is on this ground that the supporters of this theory explain 
 the acute effects which are produced on the kidneys, namely, 
 suppression of urine, accompanied by marked congestion of the 
 organs. Moreover, the cases are often very transient, and in 
 this way suggest a passing functional condition which might
 
 "NERVOUS" AND "SEPTIC" THEORIES OF CAUSATION. 353 
 
 be produced by a moderate vasomotor disturbance. Again, in 
 nearly all cases in which a catheter is used for the first time 
 there is a certain amount of " shock " produced, quite apart from 
 any general febrile disturbance which may follow ; this initial 
 shock is undoubtedly nervous in origin and has its counter- 
 part in the intense nervous disturbances which often accompany 
 operations on certain other parts of the body, as for instance 
 when the spermatic cord or the optic nerves are severed. 
 
 Another point which has been urged in favour of the ner- 
 vous origin is the fact that febrile disturbances often manifest 
 themselves at an exceedingly short interval after the operation ; 
 this, however, is not of much value, since under certain conditions 
 septicsemic symptoms are very rapidly developed, and the possible 
 fallacy of this argument has been shown in a case recorded by 
 Albarran, in which a patient died very soon after an internal 
 urethrotomy. The man was seized with a rigor about an hour and 
 a half after the operation, the temperature rose to 104, and 
 death took place in twelve hours. At first sight this case 
 would appear to support the nervous theory, especially as 
 regards the interval between the operation and death; but 
 at the autopsy there was, in addition to great congestion and 
 ecchymoses of the kidneys, a small collection of pus situated 
 behind the urethral stricture which contained the bacillus 
 coli and other organisms, and it is highly probable that death 
 was due to the absorption of these organisms through the 
 wound. It must also be acknowledged that since the impor- 
 tance of absolute cleanliness in the use of instruments has been 
 more full}' recognised, cases of urinary fever directly traceable 
 to the passage of an instrument are fewer and of less severity 
 than they were formerly, and Guyon now teaches that by careful 
 choice of instruments and by equally careful handling, so that 
 the urethra be not unduly dilated or exposed to severe friction, 
 all unpleasant symptoms may usually be avoided. 
 
 Another important point to be remembered in the discussion 
 of these cases is the variation in the virulence of bacteria, and 
 this ma}- possibly be, at any rate in part, an explanation of the 
 reason why the attacks are so uncertain in their occurrence. 
 
 In one case a slight injury to the mucous membrane of the 
 urethral canal is followed by the absorption of virulent organisms, 
 
 VOL. i. x
 
 354 SURGERY OF THE KIDNEY AND URETER. 
 
 in another by the absorption of organisms comparatively harm- 
 less ; and further there is the question of the varying susceptibility 
 of each individual patient to be taken into account. 
 
 In conclusion, it is probable on the whole that a large number 
 of these cases do depend upon infection ; others, however, cannot 
 at present be clearly attributed to this cause, and it is most 
 likely that in many of them the nervous element, which un- 
 doubtedly is a factor to be taken into account in the perform- 
 ance of urethral operations, plays the chief part. 
 
 Practically, this much may be stated, that however careful 
 an operator may be in the choice and the cleanliness of liis cathe- 
 ters, bougies, and other instruments, cases of urinary fever, for- 
 tunately for the most part mild ones, will occur from time to 
 time, and these often after the most simple and apparently trivial 
 operations ; and, moreover, the same person may suffer after the 
 passage of a catheter at' one time and not at another, although 
 the same instrument be used and as far as can be judged the same 
 gentleness and strict precautions are observed on both occasions. 
 I have often known one solitary transient paroxysm to occur 
 during a course of catheterism extending over some weeks. 
 
 The clinical varieties of urinary fever may be classified as 
 follow : 
 
 1. Acute transient paroxysmal fever. 
 
 2. Acute or subacute recurring paroxysmal fever. 
 
 3. Acute or subacute intermittent paroxysmal fever. 
 
 1. THE ACUTE TRANSIENT PAROXYSMAL FEVER is the commonest 
 effect of the simple passage of a catheter or bougie, and it varies 
 greatly in intensity and duration. 
 
 It is always ushered in by a rigor, which may however, in 
 mild cases, amount to nothing more than a sense of chilliness, and 
 this, together with a rise of temperature of one or two degrees and 
 perhaps some nausea, sense of faintness and headache, may constitute 
 the whole attack and entirely pass off in from three to six hours. 
 
 On the other hand, the rigor may persist from half an hour 
 to an hour or even more, and is sometimes of a very violent 
 description, so that the chattering of the teeth and severe tremors 
 of the whole body are distressing to witness. The temperature 
 during this stage rises rapidly and often reaches 105 or 106.
 
 SYMFfOMS OF THE "SINGLE PAROXYSM" FORM. 355 
 
 As a rule the intensity and duration of the whole attack 
 vary with the degree of the rigor, which, if severe, usually indi- 
 cates that the attack will be prolonged. 
 
 The shivering stage gradually passes into one of heat, char- 
 acterised by a dry burning skin, flushed face, and accelerated 
 respiration, and this stage again is finally replaced by profuse 
 perspiration. 
 
 The temperature, which rises so rapidly during the rigor, 
 remains high for a short time after its cessation, and then falls 
 by degrees until during the sweating stage it often subsides to a 
 point below normal. 
 
 Vomiting, headache, pain in the back and limbs, and injection 
 of the conjunctivas are the other prominent symptoms of a severe 
 case. 
 
 The urine may be completely suppressed, or secreted in much 
 smaller quantities than normal, in which case it is often turbid 
 and contains albumen and blood. 
 
 Disturbances of the digestive system are generally a prominent 
 feature, and are characterised by nausea and vomiting some- 
 times quite uncontrollable, and often accompanied by diarrho3a. 
 The tongue is dry and furred, and the saliva often gives an 
 acid reaction. The respirations vary from a slight increase to 
 positive dyspnoea, and the pulse becomes increased hi frequency. 
 Delirium is another frequent complication and varies from vague 
 wandering to actual violence : according to Guyon this symptom, 
 when present, nearly always commences during the cold stage, 
 occasionally in the hot stage, but scarcely ever in the sweating stage. 
 
 Such an attack, even when most severe, if it occurs in 
 a young and healthy adult, or even in an aged person with 
 healthy organs, will in all probability be recovered from, and 
 the patient will feel in his usual health again in from twenty- 
 four to thirty-six or forty-eight hours. If, however, the patient 
 be infirm, weakly, or unhealthy ; if he has a feeble, irregular 
 circulation, a fatty heart, or some other serious organic lesion, 
 he may succumb within as short a time to the shock of the 
 fever. 
 
 The condition of the kidneys in fatal cases of this variety 
 is almost invariably one of intense congestion, which accounts for 
 the scanty, albuminous urine passed during life, and its occasional
 
 356 SURGERY OF THE KIDNEY AND URETER. 
 
 complete suppression. In. some cases blood has been extravasated 
 into the tubules of the kidney, and in others ecchymoses have 
 been observed beneath the capsule. 
 
 Lord Lister, Sir Joseph Fayrer, Sir Henry Thompson, Sir 
 William Mitchell Banks, and others have all recorded cases of death 
 from urinary fever, within a few hours or days, in which the 
 kidneys were more or less actively and intensely congested. Marcus 
 Beck recorded a case of suppression of urine and death on the 
 third day, in which the microscopical examination of the kidneys 
 led him to the conclusion that during the first few hours the 
 renal vessels became dilated, and that then a considerable exuda- 
 tion of small round cells took place into the intertubular tissue 
 throughout the kidney ; this exudation at the same time com- 
 pressed both the blood-vessels and the renal tubules, and thus 
 lowered the blood pressure in the Malpighian tufts, and obstructed 
 the flow of urine in the tubules. In this manner equilibrium 
 was produced between the blood pressure and the pressure of the 
 urine in the tubules, all exudation from the Malpighian tufts ceased, 
 and complete suppression was the result. In this case the kid- 
 neys were large, tough, and pale in colour (anaemic in fact), 
 and quite free from vascular engorgement. Yet this was no 
 proof that during life there had not been a period of acute con- 
 gestion. It is only after a very careful microscopic examination 
 that the kidneys can be pronounced free from the effects of 
 such a degree of hyperaemia as may end fatally ; and it is impos- 
 sible to say in any individual case what amount of congestion 
 is required to cause death. If the kidneys are granular or 
 fatty, or have undergone chronic interstitial changes, it is easy 
 to see how serious this fresh disturbance may be, even though 
 it be simply clue to vaso-motor action, excited in a reflex manner 
 by the urethral nerves; while, on the other hand, if it is due to a 
 septic infection (as it certainly often is), the previously diseased 
 kidneys can offer but little resistance, and an acute or suppurative 
 inflammation may result. 
 
 Another way in which, after long-standing obstruction to the 
 outflow of urine, the kidneys may be brought into a condition pre- 
 disposing to serious pathological changes, is by the vascular tension 
 induce:! by catheterisation. In kidneys long subjected to intrarenal 
 urinary pressure, a state of active congestion is brought alxmt by the
 
 SYMPTOMS OF RECURRING PAROXYSMAL FEVER. 357 
 
 release of the distension on withdi*awing the urine. This congestion 
 tends to stimulate a degenerated structure into extra functional 
 activity by bringing to the secreting apparatus, within a given time^ 
 an extra amount of blood for it to work upon. The increased 
 now of blood to the kidneys cannot be even in part controlled 
 or checked by the natural elasticity of the solid organs and their 
 capsules, because the pre-existing chronic changes have led to the 
 adhesion of the over-stretched capsule, not only to the degenerate 
 renal substance, but also to the surrounding fatty tissue ; and 
 further, the elasticity of the renal substance itself has been de- 
 stroyed by the iiitrarenal pressure of long pent-up urine. The 
 resisting power of such a kidney is very weak, and inflammation 
 and suppuration are easily superadded if any infection reaches 
 the organ, either through the circulatory system or by any other 
 channel. The same mechanical effect is produced upon the 
 mucous membrane of the bladder, but, in all probability, to a 
 much less extent, because the bladder can collapse, and receives 
 pressure and support from the circumjacent intestines and other 
 viscera. There can be little doubt, therefore, that* in these cases 
 the morbid changes commence at once in the kidney, from 
 which they perhaps spread downwards to the bladder ; and 
 not in the bladder to pass upwards to the kidneys. That this 
 is so is clearly proved, in some cases by the chronological order 
 of the symptoms, as well as by the post-mortem appearances 
 of the urinary organs. 
 
 2. THE ACUTE OR SUBACLTE RECURRING PAROXYSMAL FEVER 
 is very similar to the acute transient form just described, 
 and varies in degree to the same extent. It differs from the 
 transient form in being more prolonged, and in the repeti- 
 tion of rigors, and of the elevations of temperature. It rarely 
 lasts for less than, three days, and often continues four or rive 
 days, or a week. It has the same tendency towards recovery ; 
 but may terminate fatally when it occurs in the very aged, in 
 persons of highly nervous organisation, or of delicate or un- 
 healthy constitution. It commences in the same manner, with 
 a slight or severe rigor, lasting from a few minutes to twenty 
 minutes or half an hour; it comes on usually after the first 
 act of micturition, though it may not be until after the second
 
 358 SURGERY OF THE KIDNEY AND URETER. 
 
 or third act, and is sometimes independent of micturition alto- 
 gether. The temperature rapidly rises, until by the end of the 
 rigor, or shortly after it, the thermometer reaches some point 
 between 102 Fahr. and 107 Fahr. ; it then declines by stages, 
 and within six to eighteen hours will fall considerably, probably 
 nearly to or below the normal. A second or third rigor will 
 follow, and again the temperature will rise three, four, or five 
 degrees or more, and again it will subside steadily through a 
 few hours. The variations in temperature may recur without 
 a repetition of the initial rigor. These recurring rigors and 
 alternations of temperature will take place once, twice, thrice, 
 or oftener, and will happen within two successive days, or be 
 spread over three or four or more days, according to the mild- 
 ness or severity of the attack. Ultimately, when the fever has 
 passed, the temperature falls to or below normal ; if below normal, 
 it will so remain for twenty-four hours or longer, before it as- 
 cends to the healthy standard. 
 
 During the whole course of such an attack the patient looks 
 and feels excessively ill. When first seized, he has a sense of 
 the utmost exhaustion, may be too helpless to walk to his bed, 
 or unable to undress himself. His face is dusky, his eyes suf- 
 fused, tongue dry and coated, appetite quite lost ; nausea or 
 actual vomiting of a dirty greenish fluid distresses him, and he 
 complains much of frontal headache, pain in the loins or hypo- 
 gastrium or back of his neck, or in his limbs. Perhaps he will 
 express himself as being " sore all over," or say he feels as if 
 he had been " beaten all over with a stick." 
 
 The urine will contain albumen or perhaps blood, or there 
 may be partial or complete suppression. The bowels may be 
 either relaxed or constipated, more often the latter. The con- 
 dition of the skin is not the same in all cases ; in some, profuse 
 sweating follows each rigor ; in others, there is no marked sweating 
 stage, but after the rigors the skin is hot and moist, and later on 
 is hot, dry, and pungent. With the permanent reduction in the 
 temperature the other symptoms pass off, the appetite returns, the 
 bowels act naturally, the urine is secreted in normal quantity, ceases 
 to be tinged with albumen or blood, and resumes the normal specific 
 gravity and other characters ; in fact, the patient is well again. 
 
 Bo tli the transient paroxysmal and the recurring paroxysmal
 
 INTERMITTENT PAROXYSMAL FEVER. 359 
 
 forms may occur again and again in the same person after fresh 
 irritation ; or, what is perhaps less frequent, the transient form 
 may be excited at one time and by one kind of irritation, and 
 the recurring form at another time or by a different kind of 
 irritation. A remarkable case of this kind was recorded by me 
 in my work on the "Surgical Diseases of the Kidney" (1885). 
 It occurred in a Dutchman, aged sixty-four, suffering from re- 
 tention of urine and severe haemorrhage into the bladder, due to 
 an enormous number of small prostatic calculi. It afforded an 
 excellent illustration of a striking fact, and one which has great 
 importance in treatment, namely, that the division of a stricture 
 of the urethra takes away the disposition to urinary fever. 
 
 3. THE ACUTE OR SUBACUTE INTERMITTENT PAROXYSMAL FEVER. 
 This form of urinary fever, except when associated with chronic 
 interstitial nephritis, is rare, and although it appears in many cases 
 to be directly excited by the simple passage of a bougie or catheter, 
 it usually depends in reality upon septic absorption from some 
 part of the urinary tract, and its septic nature is sometimes in- 
 dicated by effusions into joints and other septicaemic symptoms 
 which complicate it. When due to congestion, not to inflammation 
 of the kidney, it may, like the other two forms, be either slight 
 or severe. It may be either acute or subacute, that is, each 
 febrile period may be high and the general symptoms severe, 
 or the rise in temperature may be only moderate, and the 
 general symptoms mild. In either case, the state of the 
 patient between the febrile attacks is one of considerable im- 
 provement, though he will not describe himself as feeling well, 
 and will, indeed, often say he is far from being so. 
 
 If any complication, such as swollen joints or effusion into 
 the sheaths of tendons or other local trouble complicates the fever, 
 the patient will have to keep his bed, and will be more or less 
 severely ill throughout. 
 
 As a rule, the termination of these cases is favourable ; the 
 intervals between the accessions of febrile temperature lengthen ; 
 and after three, four, or more elevations, which occur chiefly to- 
 wards evening, the temperature keeps low, and the patient 
 gradually recovers health and strength. 
 
 When the symptoms have been severe, and the patient is much
 
 360 SURGERY OF THE KIDNEY AND URETER. 
 
 shaken by the fever, a herpetic eruption on the face has some- 
 times been the harbinger of recovery (P. Heron Watson). When 
 the fever is going to take an unfavourable course, it assumes 
 a continued form before death. This stage is marked by the same 
 typhoid symptoms as are characteristic of interstitial nephritis. 
 At the post-mortem examination the kidneys will be found in- 
 flamed or suppurating. 
 
 This intermittent form resembles, in some respects, the re- 
 curring paroxysmal fever ; but with this difference, that in the 
 latter the variations of temperature occur in quick succession, 
 and within a very limited space of time, whereas the intermittent 
 fever lasts over some few w T eeks, or even months. But there 
 are these further distinctions : the recurring paroxysmal fever 
 comes on suddenly with a rigor within a few hours after the 
 provocation, 'and the patient is very ill throughout the attack, 
 from which, however, he, as a rule, recovers ; and he does not 
 suffer a relapse, except as the result of a fresh provocation. The 
 intermittent fever often comes on insidiously some days after 
 the use of an instrument, or after exposure to some other cause 
 of irritation ; its onset is not alw r ays marked by a rigor ; relapses 
 take place without any fresh provocation from without ; and 
 the patient, as previously stated, has intervals of comparatively 
 fair health between one febrile period and another. It is this 
 form of fever which is so often described as " aguish " ; and 
 surgeons ought to be mindful of the fact that some patients 
 with stricture of the urethra are liable to these intermittent 
 feverish attacks, and are frequently treated for ague. Enquiry 
 in all doubtful cases of " aguish attacks " in adult males should 
 always be made for, and will sometimes lead the surgeon to the 
 discovery of, a long-standing stricture of the urethra. 
 
 Besides the rheumatic pains so much complained of in certain 
 cases, another symptom occasionally prominent in intermittent 
 urinary fever is swelling of the joints. Perhaps the joints most 
 commonly affected are the knees and ankles, but I have seen 
 the elbows, wrists, and shoulders also involved. There is con- 
 siderable swelling f rO m effusion into the synovial cavity of the 
 joint, but no redness, heat, or tenderness, although some amount 
 of pain is complained of when the joint is moved. Sometimes 
 the sheaths of tendons are similarly swollen, and there mav be
 
 EFFUSION INTO TENDON SHEATHS AND JOINTS. 361 
 
 also oedema of the cellular tissues of the lower limbs. I have 
 seen the feet and legs pit on pressure. These cases are generally 
 very chronic, three, four, and five months being required for 
 their cure. During this period the patient feels exceedingly weak 
 and depressed ; and from time to time, at variable intervals 
 (sometimes only of a few days), there is an exacerbation of tem- 
 perature in the evening ; 101 or 102 being often reached. On 
 these days the patient feels worse, looks ill, has, perhaps, a dusky 
 complexion, and loses his appetite entirely. The effusion into 
 the joints and tendon sheaths is not in the first place purulent, 
 and as a rule does not become so in aged or weakly subjects, 
 though it may do so, just as the synovia! fluid poured out after a 
 slight injury occasionally does. 
 
 A man with stricture who is prone to " aguish attacks " may 
 in one of them find himself affected by these arthropathies. Such 
 a case came under my notice some time ago in the person of 
 a physician, since dead, who had often suffered from attacks 
 of intermittent fever coming on without any known cause. He 
 had " had such attacks, lasting from a few days to a week 
 or longer, all his adult life, and did not know to what they 
 were due ; the}' had sometimes been considered gouty." On 
 my first seeing him during one of these attacks, his joints 
 were for the first time affected in the way just described ; but 
 I learnt moreover that he had had a stricture of the urethra 
 just behind the meatus, and a fistulous opening close to the 
 stricture and under cover of the prepuce for over thirty-six years. 
 There was a slight purulent discharge from the fistula, and some 
 excoriation of the surface of the glans around it ; a No. 7 catheter had 
 been passed at frequent intervals during all these years. I now 
 had no difficulty in understanding not only the existing attack 
 which I followed throughout, but the previous attacks of which 
 I had heard the description. The illness was protracted, many 
 joints were involved, and for a while it was feared one knee- 
 joint would suppurate ; but under the influence of tincture of 
 iron internally, soothing and disinfectant washes to the fistula, 
 and warmth and compression to the affected joints, a complete 
 recovery with proper use of the joints was obtained in from 
 four to five months, between two and three of which had been 
 passed in bed.
 
 362 SURGERY OF THE KIDNEY AND URETER. 
 
 Prognosis. It is exceptionally rare for any serious termina- 
 tion to follow any of the above types of urinary fever, even 
 though the attack be violent. When the kidneys are healthy 
 the febrile storm, however appalling for the time, generally passes 
 over, and the victim of it soon recovers. Even though the 
 urine be completely suppressed for many hours, recovery under 
 appropriate treatment is the rule. I have never had a fatal 
 case in my own practice, nor have I known of one in the practice 
 of my colleagues. It is, however, undeniable that death is caused 
 by each form of the fever ; and, as stated above, fatal cases, in 
 which no organic disease of the kidney was found, have occurred 
 to Mitchell Banks, H. Smith, Fayrer, Lister, Henry Thompson, 
 Velpeau, Heyfelder, and others. When antecedent renal disease 
 exists rapid death is by no means unfrequent as the result of 
 the acute paroxysmal or recurring paroxysmal seizures (Beck, 
 Erichsen, and others) ; and a fatal termination is only too fre- 
 quent after two or three weeks' duration of the disease as the 
 result of acute or suppurative nephritis. 
 
 Evil consequences short of death may ensue. Sir 'B. Brodie 
 has recorded a case in which the introduction of a small gum 
 catheter through a stricture was followed by a severe rigor and 
 an attack of fever attended with inflammation of the muscles 
 of the neck, from the effects of which the man never entirely 
 recovered. He also alludes to another case in which a rigor 
 followed the application of caustic to a stricture, and an attack 
 of mania lasting nearly one month was the sequel. 
 
 Diagnosis. The transient or " congestive " forms of urinary 
 fever are to be distinguished from acute interstitial nephritis 
 and suppurative nephritis by the suddenness and rapidity of 
 the symptoms, and the short duration of the fever ; by the 
 clinical history of the case, and often by the presumably healthy 
 state of the kidneys ; and especially by the state of the lower 
 urinary passages at the time of the fever. The intermittent 
 fever is the form most likely to be confused with interstitial 
 nephritis, and indeed, as we have seen, the two may co-exist. 
 A careful consideration of all the clinical symptoms taken in 
 conjunction with the previous history of the case will, however, 
 often make it clear that the intermittent urinary fever has become 
 engrafted on to the already diseased kidneys ; a conclusion which
 
 DIAGNOSIS FROM SEPTICAEMIA AND PYAEMIA. 363 
 
 is of considerable practical importance since the existence of the 
 two conditions together naturally makes the prognosis far graver 
 than when either is present alone. 
 
 From septicaemia. To those who consider all these cases 
 to arise from septic absorption, this differentiation may seem 
 unnecessary, but clinically it must be recognised that whatever 
 the origin of these cases they usually run a course which is 
 different from septicaemia arising from most other causes. 
 
 In the acute transient and the acute remittent fever, their 
 sudden onset, and short and usually favourable course, are sufficient 
 to distinguish them ; and taken with the fact that they have 
 commonly been preceded by an operation on the urethra their 
 nature becomes still more plain. The fever arising from a con- 
 tinued absorption of pus from the urinary passages, as hi ascend- 
 ing pyelo-nephritis, will be distinguished by its duration and by 
 the insidious and progressive nature of the illness, while an examina- 
 tion of the urine will generally at once reveal the nature and 
 source of the infection. 
 
 In the intermittent form of urinary fever the patient's compara- 
 tively good health between the attacks serves to distinguish it from 
 an infection due to constant absorption of septic matter ; and where 
 as in many of such cases the nature of the disease is undoubtedly 
 due to infection, the symptoms point to an intermittent absorption 
 of some toxic substance into the circulatory system, and this is 
 often in some way excited by the passage of an instrument. 
 It may be that in some cases there is a small collection of pus 
 in the urethra which every now and then, owing to some impedi- 
 ment in its drainage, is absorbed into the circulation and gives 
 rise to an intermittent attack of fever ; or it may be due to 
 variations in the virulence of organisms under conditions which 
 at present are not fully known. In any case it is essential both 
 for accuracy in the prognosis, and for the treatment of the patient, 
 that this intermittent form of fever be carefully distinguished from 
 that due to the constant absorption of pus from a widespread 
 suppuration along the urinary tract 
 
 The same considerations will usually enable the condition to be 
 distinguished from the ordinary forms of pyccmia, which are ac- 
 companied by delirium and the formation of metastatic abscesses. 
 The third form of urinary fever, especially when accompanied by
 
 364 SURGERY OF THE KIDNEY AND URETER. 
 
 swelling of the joints, is the most liable to be confounded with 
 this condition, but the absence of redness and tenderness of the 
 swollen parts, as well as of frequent rigors and subsequent profuse 
 sweats, the delirium, high pyrexia with irregularly recurring ex- 
 acerbations, the metastatic abscesses, foul breath, icteric coloration 
 of the skin, which are all prominent features of pj'semia, will 
 enable the true nature of the case to be recognised. 
 
 From uraemia the diagnosis is much more difficult. It 
 must be remembered that in some of the fatal cases of urinary 
 fever there is complete suppression of urine for several days, 
 so that the mode of death is partly by way of uraemia. But 
 in the more rapidly fatal cases death occurs before uraemia can 
 take effect ; moreover, in cases of suppression a large quantity 
 of urea is got rid of by vomiting ; and, finally, in some few 
 fatal cases there is 110 suppression. The absence of coma, drowsi- 
 ness, and convulsions, and (after the rigor has passed off) of 
 blueiiess or lividity of the skin, and the retention of consciousness, 
 will serve to exclude uraemia. 
 
 Ague ought not to be mistaken for urinary fever, nor the 
 fever for ague. The sudden onset ; the presence of stricture 
 or a known cause of irritation in the urethra or bladder prior 
 to the rigors and feverishness ; as well as the absence, in many 
 cases of urinary fever, of all malarial influences ; and, finally, 
 the complete cure of the " aguish " symptoms, by the cure of 
 the stricture of the urethra or the removal of some other source 
 of urethral or vesical irritation, will serve to distinguish urinary 
 fever from ague. 
 
 GonorrhcBal rheumatism. - - Urethral arthropathies are ex- 
 cited by other causes than gonorrhoeal urethritis. Any purulent 
 discharge from the urethra, balanitis, and, in the female, vaginal 
 and cervical leucorrhcea, as well as gonorrhoea, have been known 
 to cause them. Hence, when fever, complicated with swelling 
 of the joints, and a urethral purulent discharge, affects an 
 adult who has stricture of the urethra, the diagnosis between 
 urinary or urethral fever, and gonorrhoeal synovitis or urethral 
 rheumatism, is clinically impossible, and only to be determined 
 by the discovery of the gonococcus in the discharge. 
 
 From another form of gonorrhea! rheumatism, that, namely, 
 in which the fibrous tissues of the joint are chiefly, and the
 
 URINARY FEVER AND GONORRHXEAL RHEUMATISM. 365 
 
 synovia! membrane only secondarily affected, urinary fever is to 
 be distinguished : (1) by the presence of diffuse, sometimes 
 widely diffuse, redness and pain in the tissues over the inflamed 
 fibrous structures, and of the softening, and consequent abnormal 
 movements which may be communicated to the joints in gonor- 
 rhoeal rheumatism ; (2) by the more severe constitutional dis- 
 turbance and more marked synovial effusion in urinary fever ; 
 (3) urinary fever occurs generally in males, and is commonly 
 associated with stricture of the urethra ; (4) in urinary fever, 
 complicated with joint affection, there will sometimes be a past 
 history of previous and repeated " aguish attacks " in which the 
 joints were quite unaffected ; (5) gonorrhoaal rheumatism occurs 
 in young persons, in females as often as, or even more often 
 than, in males ; it comes on during the acute stage of gonorrhoea, 
 or of some other purulent discharge from the genital organs ; 
 and is apt to be confounded with phlegmonous erysipelas, lym- 
 phangitis, or phlebitis. It seems to be very prone to affect 
 recently-seduced girls and young married women who, having 
 a purulent discharge, are also pregnant ; * (6) gonorrhoea! rheu- 
 matism is often complicated by inflammation of the sclerotic or 
 iris ; it rarely or never causes suppuration of the joints, but 
 is prone to terminate in fibrous ankylosis. 
 
 In gonorrhoeal rheumatism and in urinary fever several joints 
 may at first be affected, as in acute rheumatism ; but at a later stage 
 one joint becomes chiefly implicated ; in both diseases the evening 
 temperature will often rise to 101 or 102 ; and in both, the 
 general and arthritic symptoms will improve with the cure of 
 the urethral or other purulent discharge on which it depends. 
 
 Pathology. The pathological changes in urinary fever have 
 been indicated under the etiology of the disease. In urinary fever, 
 as distinct from the fever of acute and suppurative nephritis, 
 the only pathological change discoverable outside the urethra 
 and bladder is more or less congestion of the kidney. The 
 degree of congestion varies from a slight mottled redness to the 
 most intense engorgement of the renal vessels, extravasation of 
 blood into the renal tubules, and greatly increased softness and 
 
 * For an excellent account of acute gonorrhosal rheumatism the reader is 
 referred to an article by the late Mr. Davies Colley in the Guy's Hospital 
 Reports for 1882.
 
 366 SURGERY OF THE KIDNEY AND URETER. 
 
 friability of the renal substance. The almost complete absence 
 of congestion found after death in some fatal cases is no criterion 
 of the state during life. After death the renal vessels, which 
 during life were over-distended, rapidly empty themselves, and the 
 blood flows back into the large abdominal vessels. How little 
 evidence may remain of the severe shock which during life had 
 caused a sharp and fatal paroxysm of fever is seen in Mitchell 
 Banks' case. Half an hour after a No. 4 metallic bougie had 
 been passed through a tight penile stricture the patient vomited, 
 had a rigor, followed by a second rigor in two and a half hours, 
 and death in six and a half hours. At the post-mortem there 
 was no injury of the urethra or laceration of the stricture, and 
 only slight congestion of the kidneys ; a tablespoonful of thick 
 muddy urine was in the bladder, and a little thick turbid urine 
 escaped from the calyces of the kidney on pressure. 
 
 In other cases, as in Lister's and Henry Thompson's, for 
 example, the kidneys were found in a state of the most in- 
 tense congestion ; in Lister's case of rapid death preceded by 
 complete suppression of urine, the kidneys, which had been pre- 
 viously perfectly healthy, were " affected throughout with most 
 intense inflammatory congestion." 
 
 In Thompson's case death occurred within fifty-four hours 
 of passing an instrument through a narrow stricture ; the kid- 
 neys were found " congested to an extraordinary degree, and 
 their substance was so soft and friable as to give way under 
 gentle pressure. Very rapid changes had evidently taken place 
 in these organs, but 110 sign whatever of inflammation existed 
 in any other part of the urinary apparatus." 
 
 The appearances vary according to the length of time between 
 the initial rigor and death : when several hours have elapsed 
 the renal changes may be expected to be most marked ; when 
 only a few, as in Banks' case, the post-mortem signs of con- 
 gestion are slighter. 
 
 In cases of intermittent urinary fever which have passed into 
 a continued fever and then ended fatally, the kidneys have 
 usually become the seat of acute inflammation or suppuration ; 
 this, however, may only be discoverable by the microscope. 
 
 The kidneys have been found healthy in other cases in which 
 death has been caused by chronic 'cystitis, or by .septicaemia the
 
 TKEATMENT OF URINARY FEVER. 367 
 
 result of absorption of septic material from the putrid urine. A few 
 years back it was contended in a discussion on "catheter fever" 
 that fatal cases of a low continued fever arise from the use of 
 the catheter, and that an autopsy reveals no definite visible struc- 
 tural lesion adequate to account for death. When this is true 
 as regards the kidney, and it very rarely is so, cystitis is found, 
 and the bladder is the reservoir of decomposing mucus and urine ; 
 its "mucous lining, congested and in part eroded, and everywhere 
 coated with a gre}~ish-white stinking mucus " (Sir A. Clark), has 
 doubtless teen the starting point of blood poisoning. In such 
 cases it matters little whether the ureters, pelves, and substance 
 of the kidneys are inflamed or not ; septicaemia can arise from 
 the absorption of putrid urine from the bladder or urethra. 
 Such cases may perhaps more correctly than by any other 
 name be called urinary septicaemia ; but they are improperly 
 called catheter fever, because they are not set up entirely through 
 the irritation of catheterisation, and may occur quite independently 
 of the use of instruments. 
 
 The pathological cause of the joint troubles in urinary fever 
 is, as has been previously pointed out, probably of a septic nature. 
 
 Treatment. The surgeon's efforts should be directed to 
 the prevention as much as to the cure of urinary fever. To 
 avoid shock, convulsions, or any of the paroxysmal forms of 
 urinary fever, it has long been the practice to prescribe a dose 
 of hot spirit and water immediately before, or after, the first 
 introduction of an instrument ; to which, for nervous or excitable 
 persons, or those whose urethra is very sensitive or irritable, a few 
 minims of tincture of opium may with advantage be added. If there 
 is any known tendency to urinary fever, or if the patient has 
 lived in the tropics or been the subject of malarial fever, two 
 minims of Fleming's tincture of aconite, or 5 to 20 grains of quinine 
 in lemon juice, with or without a drachm or half a drachm of 
 liquor morphise, should be given at once after the use of the 
 instrument ; or a short course of these drugs should be tried for a 
 few days beforehand ; or a dose of opium or a subcutaneous injection 
 of morphia should be given immediately before the operation. In 
 highly nervous persons, and in those who are mentally or physically 
 much depressed, or excessively sensitive to pain, it is well to give 
 an anaesthetic before introducing an instrument at all. It is by no
 
 368 SURGERY OF THE KIDNEY AND URETER. 
 
 means those who suffer most from catheterisation who are most 
 prone to urinary fever ; but manipulations under chloroform are 
 verv much less likelv to be followed bv urinary fever than when 
 
 / w 9 
 
 made without the aid of anaesthesia. I have known men suffer urinary 
 fever from the simple passage of a bougie who have borne prolonged 
 manipulations when under chloroform without having any ill effect. 
 
 In cases hi which the urethra alone requires to be examined, 
 it is not necessary to take further precautions than those just 
 named. But in a person whose bladder is to be explored, or 
 the regular use of the catheter for retention commenced, previous 
 rest upon the sofa or bed for two or three days is desirable. 
 The instrument should be first used, not in the consulting 
 room of the surgeon, but in the bedroom of the patient. To 
 explore a bladder for stone without previous preparation of 
 the patient, or to empty the bladder of a man with enlarged 
 prostate who up to the time of his seeking advice has been 
 going about his business as usual, are things to avoid when 
 possible. Many a patient under these circumstances has experi- 
 enced a sharp chill or an attack of urinary fever, who subsequently 
 to resting might have borne the use of instruments with impunity. 
 
 It is true that in the out-patient department of a hospital 
 it is not practicable to insist absolutely on every patient who 
 requires the catheter or a vesical exploration resting for a day 
 or two beforehand ; and it is fortunate that in the very urgent 
 cases, such as those of painful retention of urine, catheterisation 
 does not appear to excite urinary fever. But it is often possible to 
 make some amount of preparation, by getting the bowels well 
 open by gentle saline purgatives, by regulating the diet, and 
 avoiding excessive exercise or fatigue, and perhaps by prescribing 
 a course of quinine, aconite, or arsenic for a few days or a 
 week. 
 
 The desire of house surgeons and young practitioners to 
 make a good diagnosis and discover an " interesting case " should 
 not lead them to explore the bladder of any patient hastily or 
 recklessly ; it is a light matter to them to introduce a sound, 
 but it may turn out to be a most serious one to the patient. 
 Ilather let it be a rule of practice to prepare a patient just as 
 if he were alxmt to undergo any other ordinary surgical operation. 
 Having decided that " catheter life " must Ije commenced, or a
 
 PREPARATION FOR URETHROTOMY OR LITHOTRITY. 369 
 
 sound introduced into the bladder for the purpose of diagnosis, 
 the surgeon should insist on some such preparation as I have 
 indicated, and if it can be continued for four or five days so 
 much the better for the patient. 
 
 When any operation such as urethrotomy or lithotrity is to 
 be undergone, still more necessary is previous preparation. In 
 lithotrity the urethra might be educated for a day or two 
 for the reception of the lithotrite by the daily introduction of 
 soft and flexible instruments of increasing size, as was recommended 
 by Civiale. This preliminary use of instruments is, however 
 unnecessary now that an anaesthetic is invariably employed for 
 litholapaxy as well as for other urethral operations. In all cases, 
 no matter what the nature of the disease, the utmost gentleness 
 in handling an instrument within the urinary passages is essential ; 
 force is never justifiable in introducing an instrument, and rough- 
 ness when once it is within the bladder cannot be too strongly 
 condemned. 
 
 That a certain amount of force is necessary, for example, in the 
 use of the internal urethrotome and Holt's dilator, is quite certain ; 
 but this force is exercised under the controlling action of a guide 
 or director, and is regulated to the requirements of the indi- 
 vidual case. And although it is true that by the division of 
 the stricture, and thereby the removal of the obstacle to the 
 outflow of urine, the patient is freed from one of the causes 
 of urinary fever, yet it must be confessed that, in spite of the 
 advantages gamed by them, these very operations are amongst 
 the most frequent excitants of the fever in its most severe forms. 
 
 Force, when used upon the bladder, whether by sounding 
 it roughly, or by distending it abruptly, is never free from danger, 
 and it has been said by M. Guyon, though I cannot confirm 
 the statement from my own experience, that the fever which 
 results therefrom is proportionate to the violence inflicted. 
 
 An instrument which is to be tied in the urethra should 
 not be sufficiently large to quite fill the canal or stretch the 
 stricture. If the urine is in a very bad state it should be im- 
 proved prior to an operation, when time permits ; this is done 
 by irrigating the bladder daily with Condy's fluid in warm water, 
 boracic acid, salicylate of soda (grams 4 ad 3j), acetate of lead 
 (grain 1 ad siv), or by one of the many other medicated solutions 
 
 VOL. I. Y
 
 370 SURGERY OF THE KIDNEY AND URETER. 
 
 usually recommended for the purpose. Cystamine and other anti- 
 septic drugs are sometimes beneficial. It is scarcely necessary to say 
 that every instrument the surgeon uses should be scrupulously 
 clean; in urinary operations this is a point of great importance. 
 
 In old men with prolonged partial retention, the urine should 
 be drawn off slowly, and always while the patient is in the re- 
 cumbent position and under circumstances which will ensure 
 rest, quietude, and an equable temperature for two or three 
 days after the first catheterisation. The object in these cases is to 
 favour the gradual and safe, and to avoid the sudden and dan- 
 gerous, change in the intrarenal pressure by the withdrawal of 
 long pent-up urine ; and unless the patient will consent to the 
 above precautions it is the surgeon's duty to decline to interfere. 
 In all cases it is desirable to protect the patient from exposure 
 to cold or fatigue after the use of either catheter, bougie, or 
 sound, as well as after any operation on the urinary organs. 
 The slightest chilliness afterwards, especially if followed by head- 
 ache, sickness, or scanty secretion of urine, should be at once 
 treated by confinement to bed, a dose of brandy or other diffusible 
 stimulant, restricted simple diet, warm drinks, and hot fomen- 
 tations to the loins and hypogastrium ; the vapour bath as a 
 means of inducing perspiration may be employed with benefit 
 in this stage as well as during the course of more pronounced 
 fever. 
 
 As soon as the initial rigor has occurred, and the fever sets 
 in, it becomes, if possible, even more necessary to keep the patient's 
 skin warm, and, indeed, to promote free perspiration. With 
 this object he should be covered with blankets, and the steam 
 or hot - air bath should be used. Hot tea, in large and 
 frequent draughts, is a favourite and useful beverage, and great 
 benefit is very often derived from the rapid and diffusible stimu- 
 lant effects of one good dose (say of an ounce or an ounce 
 and a half) of brandy or rum added to the tea, or taken in 
 hot water. 
 
 If there be diarrhoea, as there sometimes is, nothing need 
 be done to check it, especially if partial or complete suppression 
 of urine complicates the fever. Sweating and diarrhoea are the 
 two great means of eliminating that which the kidneys are failing 
 to remove from the blood. On more than one occasion I have
 
 MEDICINAL AND DIETETIC TREATMENT. 371 
 
 had reason to be satisfied with the result, when I have 
 allowed diarrhoea to go on unchecked. The one precaution 
 which is requisite, when diarrhoea occurs, is to take care that 
 the patient incurs no chill while passing his stools, and to this 
 end the bed-pan must be used and the body kept well covered 
 during the proceeding. 
 
 Diet is a matter of the first importance, and those patients 
 are fortunate who like and can digest milk. Milk is the appro- 
 priate and indeed the only fitting diet in urinary fever. Solid 
 food of any kind is out of the question as long as fever deprives 
 the mouth of saliva. Beef tea and the extracts of meat are 
 unsuitable during the functional imperfection or inactivity of 
 the kidneys. If there is a tendency to acid fermentation in 
 the stomach or to sickness, lime-water should be added 
 to the milk ; or Vichy water may be taken between the 
 draughts of milk, or just after them. Milk and barley water 
 in equal parts form a very useful drink. If sickness without 
 diarrhoea exhausts the patient, enemata of milk and eggs with 
 a little brandy should be given. Stimulants are sometimes needed 
 throughout the attack, but except in a single dose at the onset, 
 or after recurring rigors, they should be given with caution. 
 When the bowels are costive, as they very often are, some saline 
 aperient should be given as soon as the high temperature declines ; 
 warm laxative enemata are also of the greatest service in urinary 
 fever, as well as in all prostatic and vesical troubles. The 
 medicines which enjoy most repute are quinine and tincture of 
 aconite. I am in the habit of ordering five to ten grains of 
 quinine in lemon juice, combined with half an ounce or an ounce 
 of brandy, and half a drachm of liq. morphinae hydrochl., every 
 four or six hours, as long as the temperature keeps above 100. 
 Sometimes the second dose is given within two hours of the 
 first if the rigor has been very severe and the temperature 
 keeps very high. This treatment has been very satisfactory in 
 my hands for the transient and recurrent paroxysmal forms of 
 urinary fever, but it is useless and may be dangerous in cases in 
 which thare is suppression of urine. 
 
 Morphia, by increasing the action of the skin, relieves the 
 congested blood-vessels of the kidneys. When there is suppression 
 of urine in persons without organic renal disease, I have seen
 
 372 SURGERY OF THE KIDNEY AND URETER. 
 
 most marked improvement follow the subcutaneous injection of 
 rko gr- to -gV gr- of atropine, with i to ^ gr. of morphia. One 
 such injection of T^ gr. of atropine with ^ gr. of morphia has 
 checked vomiting and induced sleep immediately ; and four ounces 
 of urine were excreted at the end of six hours after their use, 
 though suppression had lasted for forty-three hours before the 
 injection was given. The vomited matter in the case to which 
 I refer contained (by Russell and West's test) 2'7 per cent, of 
 urea, and as a large quantity of fluid was ejected, and the 
 kidneys were perfectly healthy, the patient did not become coma- 
 tose, and made a rapid recovery. If organic disease of the 
 kidneys is present there is a fear of morphia inducing coma. 
 
 P. H. Watson's experience is in favour of quinine and digitalis 
 given for some days before the first introduction of the catheter ; 
 and bromide of potassium or an opiate for twenty-four hours 
 afterwards. He also strongly recommends the internal use of 
 perchloride of iron throughout the whole period of the fever. 
 
 I have tried one-eighth of a grain of pilocarpin subcutaneously 
 injected ; it created a marked effect upon the skin by increasing 
 perspiration, but its effect on the kidney is uncertain. 
 
 Gouley, of New York, and Harrison recommend for its diuretic 
 action a teaspoonful of infusion of digitalis every hour or two ; 
 the action of this drug upon the circulation requires, however, 
 to be closely watched. 
 
 In the intermittent form of urinary fever, close attention to 
 the digestive and excretory organs should be paid during the 
 intervals between the paroxysms of fever. Regularity of the 
 bowels ; a bland diet, consisting of milk, milk pudding, fish, 
 fowl, and cooked vegetables ; warm clothing ; and a mix- 
 ture composed of mineral acids, and bark or quinine, are the 
 lines of treatment to employ. With some persons a moderate 
 allowance of claret or some light wine is beneficial. Tincture 
 of iron through this form of fever is one of the most valu- 
 able remedies. When the joints are affected an application 
 composed of iodide of potassium 5ij> glycerine 5ij, spts. vin. 
 rect. sij, aqiuv svj, as recommended by Lund, should be painted 
 over the affected joint, which should then be covered with a 
 thick casing of cotton-wool, retained by an elastic bandage. If 
 there be much effusion, and rest and remedies do not remove
 
 WHEN SURGICAL TREATMENT IS INDICATED. 373 
 
 the fluid, the aspirator should be used ; its employment should 
 not be long delayed, as its timely and judicious use saves many 
 joints from suppurating. Rest in bed, with the application of 
 splints to the affected limb, is absolutely requisite. Recovery 
 in these cases must not be looked for in less than ten to twelve 
 or fifteen weeks. 
 
 In certain cases surgical treatment is indicated as a curative 
 means. Whenever there is any urethral discharge it must be 
 checked by appropriate injections. Urethral fistulse should be 
 healed, and if this is difficult or impossible, they must at least 
 be kept as clean and free as possible from purulent or urinous 
 secretions. In my earlier work I recorded a case of stricture 
 of urethra in which a disposition to urinary fever was cured by 
 the use of Holt's dilator; and in another case therein mentioned, 
 repeated attacks of fever occurred until internal urethrotomy was 
 performed, and completely destroyed the febrile susceptibility. 
 The effect of the operation in this respect was very striking. 
 M. Guyon has observed similar results, and, with full know- 
 ledge of this fact, has even operated during the height of an 
 acute paroxysm, with excellent result.* He regards the tendency 
 to urinary fever possessed by some patients with urethral stricture 
 as one of the indications for urethrotomy. Sir Henry Thompson, 
 in his lectures at the Royal College of Surgeons, drew attention 
 to the same thing. 
 
 In cases of imperfect, frequent, and painful micturition, whether 
 due to stricture or to enlarged or inflamed prostate, in which 
 there is a repetition of, or a tendency to, attacks of urinary 
 fever, a cure may be effected by internal or external urethrotomy 
 or the regulated evacuation of the bladder, according to the 
 special requirements of the case. It is not, however, often de- 
 sirable to operate during a paroxysm of fever ; as a rule, the 
 surgeon ought to wait for the complete subsidence of the attack 
 before again interfering with the urinary passages. 
 
 * Guyon, " Les Maladies des Voies Urinairee," p. 569.
 
 374 
 
 CHAPTER XIV. 
 RENAL AND CIRCUMRENAL FISTULA. 
 
 IN this chapter will be described the fistulse communicating 
 with the kidney and renal pelvis. Those implicating the ureter 
 are dealt with in the chapter on Ureteral Fistula (Vol. II.. p. 494). 
 Reference will also be made to those cases of purulent fistula 
 which occur in the perinephric tissue without communicating 
 with the renal substance or cavity, and which occur after renal 
 operations, and after perinephric suppuration, either from injury 
 or disease. 
 
 Fistulae communicating with the kidney or renal pelvis may 
 be the direct result of disease, originating either in the kidney 
 itself or in its perinephric tissue ; or they may be the sequelae 
 of injuries or surgical operations. 
 
 These fistulae may be classified (1) on an anatomical basis, 
 according to whether the fistula arises from the renal or circum- 
 renal tissue ; (2) according to the nature of the fluid excreted, 
 whether urine or pus, or a mixture of both ; (3) according to 
 the parts at which they establish an opening ; (4) according to 
 their causes ; (5) according to their characters, as to whether 
 they are simple or callous, or attended with loss of tissue.* 
 
 The method adopted in this chapter will be to describe the 
 general characters, etiology, and treatment of all fistulas which 
 communicate with the kidney and pelvis of the kidney, or the 
 peri renal tissue, and then to give an account of the various ways 
 by which they open, either on to the external surface or into 
 some of the internal viscera. 
 
 Etiology. In a few cases of nephrotomy the operation 
 has been performed with the intention of establishing a lumbar 
 renal fistula (see chapter on Nephrotomy, Vol. II., p. 199). 
 
 The various forms of suppurative nephritis are among [the most 
 common antecedents of renal fistulap. Tuberculous disease of the 
 
 * See J. A. Jagielski, " De Fistulis Trinariis Adjecta hujus Morbi Historia."
 
 A KENAL FISTULA NOT ALWAYS URINOUS. 375 
 
 kidney is also a very pregnant cause of this troublesome condition ; 
 a fistula sometimes persisting even after the kidney has been 
 removed. 
 
 Direct injuries to the kidneys which are not accompanied 
 by suppuration are not generally followed by fistulae, but excep- 
 tions frequently occur ; and stabs, incised and lacerated wounds 
 in the back and loins, are sometimes followed immediately, or 
 after an interval, by discharge of urine. The records of military 
 surgery contain many examples of fistulae caused directly by gun- 
 shot wounds of the kidney, or indirectly by the kidney becoming 
 involved in the suppuration which follows gun-shot wounds of the 
 loins. Nephrotomy for hydro-nephrosis and pyo-nephrosis is 
 liable to be followed by a permanent fistula if the cause of obstruc- 
 tion is permanent, and the remnant of the kidney is not removed 
 by nephrectomy. All traumatic renal fistulae may be expected 
 to close sooner or later. 
 
 Abscess of the kidney, whether due to the irritation of a 
 renal calculus or to tuberculous or other form of renal disease, 
 is not an unfrequent cause of urinary fistula in the loin, either 
 by the abscess spontaneously bursting, or owing to the non- 
 healing of the wound if the abscess has been opened by the 
 surgeon. The discharge of pus and urine in such cases is often 
 very obstinate, the wound contracting to a certain extent, and then 
 remaining as a chronic, and sometimes even as a permanent, fistula. 
 
 The various causes of perinephric suppuration may indi- 
 rectly lead to renal fistula if a communication is formed with 
 the kidney, either before or after an opening has been established 
 externally. After an operation in which the kidney has been 
 incised, a fistula may end in a smooth-lined space, containing 
 more or less pus, and surrounding one or other pole of the kid- 
 ney, but without any communication whatever with the kidney 
 or ureter. A fistula may have a communication with the renal 
 cavity or ureter without there being any escape of urine through 
 it ; this can in some cases be demonstrated by the injection into 
 the fistula of an aqueous solution of fuchsin. In not a few cases 
 in which the ureter has been blocked, the kidney or its pelvis, 
 as well as the circumrenal tissue, has suppurated, an abscess 
 has opened on the surface, and a fistula has thus been formed 
 
 McClelland, of Pittsburgh, records a case in which two fistulae
 
 376 SURGERY OF THE KIDNEY AND URETER. 
 
 formed as the result of obstruction of the ureter by calculi : the 
 first opened in the loin, and gave exit to a calculus, and a 
 sinus continued ; four years afterwards a second abscess formed, 
 and was opened in the groin, giving exit to pus and urine. As 
 the excretory function of the kidney remained, the woman's state 
 became very offensive, and she was successfully cured by lum- 
 bar nephrectomy. 
 
 In a case reported by Mr. Wright, a fistula in the groin fol- 
 lowed nephrotomy for obstruction of the kidney by a calculus 
 in the ureter. An abscess formed in the groin and was opened; 
 three weeks later a calculus escaped through this opening, and 
 a urinary fistula persisted. 
 
 Dr. Stephen H. Weekes and Dr. James McFaddon Gaston 
 have published cases of fistula with discharge of calculi in the 
 groin. 
 
 A primary cause of renal fistula, in a great number of cases, 
 is a calculus in the pelvis of the kidney or in the ureter. A 
 fistula of calculous origin may be either in communication with 
 the kidney or ureter, or limited to the perinephric tissue. 
 
 Position of fistulous openings. A fistula may open in one 
 of several directions, namely, at the loin or groin, into the colon, 
 duodenum, or stomach, into the pleural cavity or lung, or into the 
 peritoneum. 
 
 Generally there is but a single opening into the cavity of 
 the kidney or ureter, and that is upon the posterior aspect ; 
 but occasionally there are two or three, or even several openings 
 on this surface of the organ. 
 
 It is much rarer for a fistula to open into the peritoneum 
 than in any other direction ; but in cases of ureteral obstruction, 
 in which pyelitis has gone on to ulceration, this direction is some- 
 times taken, and death from acute peritonitis rapidly follows. 
 Exceptionally, the escape of urine into the peritoneum is slow, 
 and then a circumscribed collection, limited by adhesions, may 
 be formed. 
 
 The right kidney, when the seat of abscess or pyo-nephrosis, 
 may open either into the ascending colon or the duodenum, 
 and when into the duodenum pus and urine may be detected 
 in the vomited matter. Fistula of the left kidney more frequently 
 open into the descending colon than do those of the right into either
 
 URINE OR PI'S, OR BOTH, MAY ESCAPE. 377 
 
 ascending colon or duodenum. The kidney is often dilated before 
 the fistula forms, and in some cases a pyo-nephrosis has attained 
 a very large size before it gives way. In other cases a small 
 renal abscess, or some minute suppurating point in a kidnev 
 the subject of pyelo-nephritis gives way, and is followed by sup- 
 puration in the circumrenal cellular tissue which in turn opens 
 on the cutaneous surface, or into the bowel, lung, or pleura, 
 and gives rise to a urinary fistula. 
 
 In a collection which I have made of unselected cases of fistula 
 due to renal calculi, some of the fistulfe followed the bursting 
 of pyo-nephrotic kidneys ; and others were the result of peri- 
 nephritic suppuration and the bursting of the extra-renal abscess. 
 Some opened spontaneously into, the lung ; others into the 
 stomach, duodenum, or colon ; one into the colon and lung, 
 and as both of these organs communicated with the renal pelvis 
 it thus happened that the lung communicated with the colon .* 
 Of those which opened on the external surface one did so below 
 the trochanter, one between the eighth and ninth ribs, one or 
 two in the groin, but the majority in the loin. 
 
 When a perinephric abscess burrows beneath the ribs and 
 points posteriorly in an intercostal space, the course taken by the 
 pus is through the costo-diaphragmatic hiatus (Fig. 6, p. 11). 
 This hiatus, formed by the absence of the muscular fibres of the 
 diaphragm, exists 011 both sides of the trunk, and gives facility for 
 the ascent of pus between the liver and peritoneum, or spleen and 
 peritoneum in front, and the ribs and intercostal muscles behind. 
 
 Xature of the fluid which escapes. The fluid which escapes 
 from a renal fistula is sometimes pus, sometimes pus and 
 urine, sometimes urine alone. It depends upon the condition 
 of the kidney which is involved in the fistula ; if the organ has 
 been converted into a tuberculous abscess cavity, then pus escapes ; 
 if a pyo-nephrosis from obstruction in the ureter has been the 
 cause, then pus and urine ; if a wound of the kidney, either 
 surgical or accidental, or a ruptured or nephrotomised hydro- 
 nephrotic cyst has given rise to the fistula, then urine, sometimes 
 many ounces in the day, will be discharged. 
 
 The urinous character of the fluid is recognised in some cases 
 by its odour, in others by the deposit of phosphates about the 
 
 * See Specimen No. 2351A, in St. Bartholomew's Hospital Museum.
 
 378 SURGERY OF THE KIDNEY AND URETER. 
 
 orifice of the fistula, or by detecting the presence of urea, uric 
 acid, or the urates in the fluid either by chemical reaction 
 or microscopical examination. Sometimes there is much excoria- 
 tion about the external orifice of the fistula ; or a number of 
 unhealthy granulations surround it. 
 
 Relative frequency of fistula, after operations on the kidney. 
 A good idea of the proportion of cases of fistulas which 
 follow operations on the kidney and their relative importance in 
 connection with the surgery of this region may be gathered from 
 the following statistics, which are taken from the 276 operations 
 of all kinds on the kidney which I had performed up to the 
 first week in March, 1898.* 
 
 Of these -276 operations three were nephrectomies performed 
 on account of fistulse the direct results of previous operations on 
 the kidney the fistula having followed a nephrotomy, a nephro- 
 pexy, and the opening of an abscess of the kidney respectively. 
 In a fourth case nephrectomy was performed on the eleventh 
 day after an exploratory incision on account of recurrent sec- 
 ondary haemorrhage from the kidney. Deducting these four cases 
 and eight others in which an operation was performed for calculous 
 anuria, we find that of the remaining 264 cases operated upon for 
 various causes, thirty-five did not live long enough to enable any 
 conclusions to be drawn from them, while of the rest (229) there was 
 a fistula during recovery in thirty-two. The numbers are as below. 
 
 Nephrolithotomy 33 operations. Fistula in 5 cases. 
 
 Nephrotomy for Calculus .... 32 ,, ,, 10 
 
 Nephrectomy for Calculus .... 12 ,, 2 
 
 Nephrectomy for Acute Suppuration . 1 ,, 
 
 Exploration of Kidney .... 42 ,, 1 
 
 Operations for Nephropexy ... 57 ,, 7 
 Operations for Hydro-nephrosis and 
 
 Pyo-nephrosis 16 ,, 2 ,, 
 
 Operations upon Tuberculous Kidneys . 21 ,, 3 
 
 Operations upon Tumours of Kidney .11 ,, ., 
 
 Operations for Injury of Kidney 4 ,, 2 
 
 229 32 
 
 The proportion of renal fistuloe in the cases of nephrolithotomy 
 
 * These cases are fully tabulated in "The Origin and Progress of Renal 
 Surgery" (Hunterian Lectures, 1898).
 
 FISTULA PREVENTED BY EARLY OPERATIONS. 379 
 
 was not nearly so high as it appears, for in one of the cases a 
 fistula was purposely kept open on account of acute symptoms 
 which arose whenever the wound commenced to close ; and of 
 the other four, two only were of urinary character, the others 
 being merely superficial. The fistulae which followed nephro 
 pexy were not urinous, and did not communicate with the kidney 
 cavity. Of the total of thirty-two cases, which includes all varie- 
 ties, whether superficial or deep, of long or short duration, fifteen 
 are known to have closed, and most of them within a short time ; 
 three more are noted as closing when last seen, and one other 
 closed, but broke down again on the formation of a fresh abscess. 
 Three only are recorded as permanent, and these include the one 
 purposely kept open which is mentioned above. There is no 
 history of the ultimate result of the remaining ten cases, but 
 there is no reason to suppose that the majority of them did not close. 
 
 In 128 cases which during the years 1884-1894 were collected 
 by me from British and American literature of operations for 
 renal calculi followed by recovery, there were nine cases of fistula. 
 
 Though the possibility of a fistula forming need not be con- 
 sidered a serious argument against renal operations, yet it must 
 be borne in mind that in any individual case the chances of a 
 troublesome or permanent fistula are much greater if there is 
 suppuration or much disorganisation of kidney substance present, 
 and this is one important reason, among many others which 
 are pointed out elsewhere, for recommending early operations for 
 renal calculus, instead of delaying till the case has become compli- 
 cated by a pyo-nephrosis, as is too often the case. 
 
 The part which foreign bodies may play in preventing the 
 closure of wounds is well exemplified by the temporary fistulae 
 which follow nephropexy ; the final closure of these wounds 
 is sometimes delayed, or after healing by primary intention 
 the wound at some point may break open, owing to the irrita- 
 tion kept up by a suture, and when this has been discharged 
 the sinus usually rapidly heals. 
 
 Fistulse which follow operations are much less serious than 
 those which occur spontaneously after perinephric suppuration. 
 It is after nephrotomy for calculous and tuberculous pyo-nephrosis 
 that fistula is especially apt to follow operation ; and these fistula? are 
 specially intractable if there has been much perinephritis present.
 
 380 SURGERY OF THE KIDNEY AND URETER. 
 
 To avoid infection of the perinephric tissue after nephrotomy for 
 pyo-nephrosis, it is often advisable to suture the cut edges of 
 the kidney to the margins of the external wound. 
 
 RENAL FISTULA WHICH OPEN ON THE CUTANEOUS SURFACE. 
 
 Renal fistulas which open in the loin may follow operations 
 upon the kidney, and may be due to any of the causes named 
 above : calculus, wounds, various forms of external violence, 
 parasites, foreign bodies, tuberculosis, or sloughing of the kidney 
 or its pelvis after distension of the cavity of the organ. La 
 Peyre* related a case in which a fistulous opening communicated 
 with the right kidney. The kidney was transformed almost 
 into a fatty mass, and contained three worms three and a half 
 inches long ; three other worms were embedded in the neigh- 
 bouring muscles, and there was caries of the spine near the 
 pillars of the diaphragm. 
 
 Traumatic fistulae are more easily cured than those which 
 follow disease, or result from the incision and drainage of a renal 
 abscess. There are very few traumatic renal fistulse which are 
 not closed sooner or later, and generally within a short time. 
 The history of the American War of the Rebellion has proved 
 this. So also has the operation of nephrolithotomy. When a 
 foreign body is impacted in the fistulous track, or within the 
 pelvis of the kidney or the ureter, the fistula may remain open 
 for a very long time, but will usually close immediately or shortly 
 after the escape or removal of the foreign body. 
 
 Diagnosis. There is but little difficulty in diagnosing a 
 lumbar renal fistula from the clinical history and the course of the 
 disease, and from the urinous or uri no-purulent characters of the 
 fluid which escapes from the opening ; but in any case of un- 
 certainty as to whether the discharge contains urine or not, the 
 diagnosis may be further strengthened by giving the patient 
 methylene blue or iodide of potassium internally, and then finding 
 the drug in the fluid ; or fuchsin may be injected into the fistula, 
 and if the latter communicates with the kidney the colouring 
 will rapidly make its appearance in. the urine. 
 
 When a fluid having a urinous odour, or containing urea, 
 uric acid, or urates, issues from a fistula which followed upon 
 
 * Journ. dc M<'dec ine, tome Ixv., p. 375 (1785).
 
 DIAGNOSING LUMBAR RENAL FISTULA. 381 
 
 an attack of nephritis, pyo-iiephrosis, hydro-nephrosis, or injury 
 to the kidney, there is no room for doubt. It must be borne 
 in mind, however, that urinary fistulse in the loin are some- 
 times the consequences of disease in the lower urinary passages, 
 and communicate with the ureter, bladder, or even the urethra, 
 but not at all with the kidney. A remarkable case of this sort 
 was published by Desault.* There were several fistulae, some in 
 each loin, following a blow from the fist on the scrotum ; and 
 though the patient recovered after a long illness, Desault appears 
 to have had no doubt that these fistulae opened internally, either 
 into the bladder or the urethra. 
 
 A remarkable case of renal lumbar fistula is related in the 
 chapter on perinephric abscess, (see p. 288 and Fig. 35). 
 
 There are many cases on record of urinary fistulas communi- 
 cating with the kidney and opening externally in the loin or 
 the groin, through which calculi have been discharged spon- 
 taneously or removed by the surgeon. 
 
 The appearance of the cutaneous orifice of a fistula varies con- 
 siderably according to the cause and length of time the condition 
 has existed. In cases which depend upon tuberculous infection 
 the opening is often patulous and its edges are covered with 
 coarse granulations ; while in other septic conditions the opening 
 may be actually retracted and inclined to be funnel-shaped. 
 
 The walls of the fistula in long-standing cases are much 
 thickened, and contain an excess of fibrous tissue which prevents 
 healing. The fistulous track frequently communicates directly with 
 the kidney, but it may also burrow in the circumrenal tissue 
 as well, and if it has arisen primarily from a circumrenal abscess 
 its communication with the kidney may be very indirect. 
 
 The opening into the kidney varies with the cause of the 
 fistula from a small shallow depression to an aperture of large 
 size. In cases of advanced pyo-nephrosis the whole of the interior 
 of the kidney may communicate with the fistula. 
 
 The condition of the ureter is of course important ; it is 
 usually affected, to some degree, in cases which arise from sup- 
 puration within the kidney; thickening of its walls with partial 
 obliteration of its lumen being one of the most constant lesions 
 found . 
 
 * " (Euvres Chirurg.," tome iii., p. 301 (3rd ed., 1813).
 
 382 SURGERY OF THE KIDNEY AND URETER. 
 
 EENAL FISTUL.E OPENING INTO THE STOMACH. 
 
 A very rare form of fistula between the left kidney and the 
 stomach has been described. Pus, urine, and urinary calculi 
 are said to have been vomited. Such a case is recorded in 
 the Philosophical Transactions (1678, No. 3), wherein a w r oman, 
 aged twenty-one, after violent nephritic pains and retention 
 of urine, vomited a quantity of coffee-coloured gravel weighing 
 half an ounce, and subsequently passed gravel and small stones 
 by the mouth, rectum, and urethra. Another and very similar 
 case, also in a young woman, is recorded in the Journal de 
 Medecine* After an attack of nephritic colic and retention of 
 urine, a calculus was detected by the catheter in the neck of 
 the bladder and was extracted by forceps ; on several occasions 
 subsequently, after similar attacks of renal colic, large numbers of 
 small and medium-sized stones were cast up, and others were 
 voided at the anus. Lazarus Kiveriusf and FerneliusJ have re- 
 corded cases of the sort. Fernelius's observations also include cases 
 of rupture of the kidney, and of sacculated and suppurating kidneys 
 opening into the duodenum, the stomach, and large intestine. 
 
 There is a considerable degree of uncertainty as to the genuine- 
 ness of the symptoms and accuracy of diagnosis in these cases of 
 gastro-renal fistula. Rayer said he knew of no well-authenticated 
 case of such a fistula. In an instance related by him the patient 
 was at length proved beyond doubt to have been an impostor, 
 though Haver admits that for the time he was completely duped 
 by her. A single woman, aged thirty-six years, was admitted 
 into La Charite Hospital in July, 1836. Nine months previously 
 iShe had fallen from a height of six feet, and five days after the 
 fall she passed blood in her urine and from the anus, and vomited 
 blood. The haemorrhages continued for four or five months, 
 retention of urine followed, a tumour formed in the light kidney, 
 the urine became purulent, and on the 4th of October, after 
 seven days of suppression of urine, diarrhoea, bloody stools, 
 and fever, it was stated that the matter vomited tasted, smelt, 
 and gave the reaction of urine. The tumour in the Hank con- 
 
 * Tome xvii., p. 173. 
 
 t " Observations Medicje et Curationee Insignes" (1646). 
 
 I " Universa Medicina Pathologia," lib. vi.
 
 GASTRO-RENAL FISTULA : AN UNMISTAKABLE CASE. 383 
 
 siderably diminished in size, and it really seemed that there had 
 been a veritable discharge of urine by the mouth. It was 
 discovered, however, that the matter said to have been vomited 
 was a composition of urine and particles of food, ingeniously 
 blended by the patient whilst she reclined over the edge of the 
 bed pretending to be vomiting.* Nysten has recorded two 
 cases, both in women, in which urine was proved to exist in 
 the matter said to have been vomited. One of the two women 
 was clearly an impostor. The other w T as, so Nysten. supposed, 
 genuine and above suspicion. 
 
 In the following case of gastro-renal fistula the nature of the 
 fistula was verified by post-mortem examination. 
 
 A coachman, aged twenty-six, was admitted, under my care, 
 into the Middlesex Hospital, on November 1st, 1884, with the 
 following history. Eleven months before he had an attack of 
 " inflammation of the bladder," and passed pus both with his 
 urine and motions. Five months afterwards he first felt tender- 
 ness, and noticed a swelling in the left loin. Six weeks later 
 this swelling was " larger than his fist," and burst, discharging 
 more than a pint of pus. Four small fistulous openings, one 
 over the last rib in the vertebral groove, and three over the 
 left sacro-iliac region, had since been discharging pus freely. 
 He had been progressively declining in health. On admission 
 he was fairly nourished, but pale and looking ill. All the four 
 sinuses in the back were discharging pus. On exploring the 
 upper opening with a probe, it was found to extend vertically 
 upwards parallel with the spinous processes, further than the 
 length of the probe ; outwards, the probe could be passed for 
 half its length ; and downwards it could be made to emerge 
 at each of the openings. It was thus evident that there was 
 a wide separation between the integuments and the superficial 
 surface of the sheath of the erector spinse muscle. Careful per- 
 cussion and palpation of the abdomen, and an examination of 
 the chest, disclosed nothing. No diseased bone had been known 
 to exist, and no caries could be felt. The sacro-iliac joint was 
 not diseased. Pelvic cellulitis and circumrenal abscess were 
 considered, but the physical signs of neither could be made 
 out. There was, however, the history of " inflammation of the 
 
 * Nysten, " Rech. de Physiol. et de Chimie Pathol.," p. 280.
 
 384 SURGERY OF THE KIDNEY AND URETER. 
 
 bladder," and of " pus in the motions," as well as in the 
 urine. The urine, on examination after his admission to the 
 hospital, was found to be of an amber colour, flocculent, 
 faintly acid, of specific gravity 1025, containing phosphates, 
 but no free albumen, and pus cells were seen under the 
 microscope. On November 5th an anaesthetic was given, and 
 two incisions were made, one over the twelfth rib and the 
 other nearly vertically through the upper fistulous opening. A 
 sinus, large enough to admit a probe, led from the sub- 
 cutaneous space thus laid open down to the twelfth rib. The 
 rib was not diseased ; the probe was prevented from passing 
 farther inwards by it. The surfaces of the old abscess walls were 
 scraped, and a drainage tube was inserted. The anaesthesia 
 lasted about fifteen minutes. The patient had a good night, 
 and was as well as usual the next morning ; but at midday, 
 November 6th, he could not take his food, and was sick, 
 and at 1.20 p.m. he was seized with a rigor which lasted 
 twenty minutes. All the afternoon and evening the tempera- 
 ture continued high, varying from 102' 6 to 103' 8. During 
 the evening his bowels were moved six times, the motions being 
 very offensive, and of pea-soup consistence and colour. At 
 10 p.m., November 6th, complete anuria was established. The 
 pulse was small, rapid, and felt with difficulty ; hands and 
 feet cold ; fingers and lips of a bluish hue. He was very restless, 
 and apprehensive of death ; not quite coherent in speech, but 
 asserting positively, in answer to questions put to him, that he 
 had 110 pain. The abdomen and chest were again examined, 
 but 110 disease detected. A catheter was introduced into the 
 bladder, but no urine was withdrawn. On removing the 
 catheter, about a tea-spoonful of thick and offensive pus ran 
 from it. I next examined the rectum and found it distended 
 with air and a quantity of liquid, and 011 stretching open the 
 anus there was a free flow, continuing for several seconds, of 
 most offensive pus. It was now 110 longer doubtful that there 
 was an abscess, involving the kidney, communicating with the 
 sinuses in the back, and opening into the intestinal tract. The 
 man died at 1 a.m. the same night. At the post-mortem exam- 
 ination the left kidney was found embedded in a thick layer 
 of circumrenal cellulo-fatty tissue, from one and a half to two
 
 FOOD PARTICLES IN URINE A DOUBTFUL SIGN. 385 
 
 inches thick. This was firmly adherent to the fibrous capsule 
 of the kidney. On subsequently laying open the kidney, it was 
 seen to be considerably enlarged and riddled by abscesses, which 
 had dilated the calyces and hollowed out the pyramids. Opening 
 into one of the caseous and suppurating cavities of the kidney 
 at the upper and back part of the organ was a fistulous track, 
 which, by its other extremity, opened into the old superficial 
 abscess space in the loin. By another fistulous track, filled with 
 yellow pus and of the diameter of a crowquill, the left kidney 
 communicated with the left margin of the greater curvature 
 of the stomach. The spleen, as well as the stomach, was closely 
 adherent to the renal mass. The small intestines were not 
 adherent at any point ; the descending colon passed over the 
 anterior surface of the kidney mass, but it, together with its 
 mesentery, was freely movable upon the kidney. The colon 
 and rectum contained milky-looking pus, but no communication 
 existed between the bowel and the kidney. A most careful 
 examination of the whole length of the gastro-intestinal tract 
 proved that the only communication which existed between it 
 and the kidney was that at the left end of the great curvature 
 of the stomach. Through this, therefore, the pus which was 
 found in as well as that which had been passed off by the bowel 
 must have entered. The right kidney was large, its capsule 
 non-adherent, and its surface smooth and pale. On section the 
 cortex was swollen and very pale, and the pyramids were partly 
 obliterated by the swelling of the inter-pyramidal portions. The 
 whole of the medullary portions were very pale. There was 
 a recent thrombus in one of the large branches of the renal 
 vein (see Fig. 34, p. 272). 
 
 Dr. J. E-. Chadwick* brought a case of gastro-nephric fistula 
 before the notice of the Obstetrical Society of Boston. In this 
 case solid particles of food were withdrawn from the bladder 
 through a catheter. The most careful investigation, however, 
 is requisite before accepting this as a symptom of a gastro-renal 
 or intestino-renal fistula. In a lady whom I saw several times 
 in consultation such a fistula was supposed to exist : but the 
 explanation of the presence of food particles in the urine was 
 subsequently proved to be a communication between the bowel 
 
 * Obstetric Gazette, Cincinnati. 
 VOL. I. z
 
 386 SURGERY OF THE KIDNEY AND URETER. 
 
 and the bladder above a carcinomatous stricture of the bowel, 
 for which colotomy had ultimately to be performed. 
 
 RENAL FISTULA OPENING INTO THE DUODENUM. 
 
 Fistulous communications between the right kidney and the 
 duodenum, though very rare indeed, have been proved to exist. 
 Campaignac supplied Raver with full notes of such a case, which 
 Rayer has illustrated in his atlas .* The patient was a tailoress, aged 
 forty-five, who had a tumour in the right flank and lumbar region, 
 formed by the distension of the right kidney. At the post- 
 mortem examination it was proved that this tumour, then much 
 collapsed, communicated with the second part of the duodenum 
 by means of a small brownish opening. Two other small fistulous 
 openings, an inch higher than the first, communicated with a 
 pouch scooped out as it were at the expense of the right kidney 
 and liver. Some days before death vomiting set in at -the 
 time that the tense tumour began to subside. The vomited 
 matter was bitter and of an acrid odour resembling stale urine. 
 
 Diagnosis. It is possible that some of the cases which have 
 been supposed to be gastro-renal fistula have really been duodeno- 
 renal ; and this may have been the case even where renal calculi, 
 as well as urine, have been vomited. 
 
 If a tumour of the right flank associated with renal colic 
 and the presence of pus or blood in the urine, or other symptoms 
 suggestive of renal disease, diminishes or completely subsides after 
 the patient has vomited, and especially if the vomited matter 
 has the taste, odour and reaction of urine, a gastro- or duodeno- 
 renal fistula would naturally be suspected. If the tumour was 
 of the right side, the duodenum in all probability would be the 
 point of communication, with the right kidney ; if of the left 
 flank, the stomach would probably be in communication with the 
 left kidney. Raver's and Nysteirs cases, referred to above, ought, 
 however, to place us on our guard against too readily accepting the 
 diagnosis of gastro-renal fistula, even in cases in. which the existence 
 of a renal tumour renders such a fistula not improbable. 
 
 RENAL FISTULA OPENING INTO OTHER PARTS OF THE INTESTINES. 
 
 A renal fistula may communicate with almost any portion of 
 the intestine, large or small ; but those which open into the 
 
 * Plate XX., Fig. 1.
 
 DIAGNOSIS OF RENO-COLIC FISTULA. 387 
 
 colon are by far the least uncommon. Instances of renal abscess 
 opening into the large intestine have been recorded from very ancient 
 times. Bayer, with the remarkable industry with which he 
 worked up the history of the literature of almost all the diseases 
 of the kidney, gives extracts from several ancient as well as 
 modern authors who have described such cases. He also 
 himself reports a case of tuberculous abscess of the left kidney 
 which communicated with the colon. 
 
 In a case recorded by Annandale* a communication with the 
 colon on the right side formed on the fifteenth day after a lumbar 
 abscess arising from renal calculus had been opened and the stone 
 removed ; faecal matter escaped by the sinus till the twenty-fourth 
 day after the operation, the patient finally making a good recover v. 
 
 Dr. John Ogle has also related the case of a patient, aged 
 thirty-one,f in whom a perinephritic abscess on the right side burst 
 into the colon and discharged calculi through the intestinal tract. 
 
 Diagnosis. When a communication exists between the 
 large intestine and an abscess of the kidney, a pyo-nephrotic 
 cyst, or a perinephric abscess connected or not with the cavity 
 of the kidney, the subsidence or complete disappearance of the 
 tumour in the flank will be followed by the discharge of pus, 
 or urine and pus with the stools. The presence of urine or 
 pus in the stools will be very soon disclosed w r hen the abscess 
 communicates with the descending colon. In the case of a gastro- 
 renal fistula related above I found pus in the rectum some hours 
 before death, but I cannot say how long after the establish- 
 ment of the opening into the stomach. The fistula had certainly 
 existed a long time ; and the man had passed pus by the rectum 
 eleven months before I saw him. Sometimes the fasces have been 
 noticed to have a urinous odour ; but when the whole of the 
 renal substance has been destroyed, and the kidney has been 
 converted into a mere pus cavity, there will be no trace of urine 
 mixed with the pus discharged through the fistula. 
 
 Between an abscess of the kidney or a pyo-nephrosis which 
 has discharged into the descending colon on the one hand, and 
 the escape of purulent urine into the rectum through a recto- 
 vesical fistula on the other hand, it might be difficult to diagnose, 
 
 * Edin. Med. Journ., April, 1893. 
 
 t St. Georges Hospital Reports, 1867, p. 373.
 
 388 SURGERY OF THE KIDNEY AND URETER. 
 
 if the rectal orifice of the fistula was high up out of reach of 
 the finger. The clinical history of the case would, however, help 
 materially towards a correct opinion, and if gas or fecal matter 
 was passed by the urethra, as well as purulent urine by the 
 anus, the probability would be greatly in favour of a recto-vesical 
 fistula. Faeces and intestinal gas might, though less probably, be 
 discharged through the urethra after gaining entrance to the urin- 
 ary passages through an intestine-renal or ureteral fistula. 
 
 The prognosis of the gastro- and intestino-renal fistulae is 
 very unfavourable ; death generally ensues at an earlier or later 
 period from acute inflammation of the bowel, colliquative diarrhrea, 
 or prolonged suppuration. Cruveilhier * has put on record the case 
 of a woman who died of hectic fever, the cause of which he was 
 unable to discover during life ; but on opening the body he found 
 the two kidneys united and situated in the true pelvis behind 
 the rectum. This double kidney contained a large quantity of 
 pus and had burst into the rectum. In other cases recto-renal 
 fistulae arise through the formation of a secondary perinephric 
 abscess, the pus from which burrows and bursts into the rectum 
 
 KENAL FISTULAE OPENING INTO THE LUNG. 
 
 These are very rare. Raver could only find four cases. Three 
 were of the left kidney, and one of the right. An interesting 
 case was that of a locksmith, aged thirty-nine, who was admitted 
 into La Charite in May, 1839. Eighteen years before he had 
 been operated upon for vesical calculus. Eleven years after his 
 recovery from this operation he suffered pains in the region of 
 the left kidney, and passed purulent urine. These symptoms, 
 however, disappeared, and seven months before his admission 
 into hospital very acute pains again affected the left renal 
 region, and extended along the course of the left ureter. The 
 urine was loaded with pus. Abundant purulent expectoration 
 occurred suddenly on two occasions, and was each time followed 
 by a marked diminution of pus in the urine. Death took place 
 on the 18th of June, and at the post-mortem a communication 
 was found between the bronchi of the left lung and the left 
 kidney, at the upper part of which a small perforation existed 
 which o ened through a dilated calyx into the renal pelvis. The 
 
 * " Anatomic Descriptive," tome ii., p. G94.
 
 CAUSES OF DEATH IN RENO-PULMONARY FISTULA. 389 
 
 fistulous track penetrated the diaphragm at the edge of the left 
 branch of the central apoiieurosis, and was surrounded by dense 
 fibrous adhesions, connecting together the posterior surface of 
 the stomach, the spleen, and the upper part of the kidney. The 
 kidney substance was atrophied, and the calyces and pelvis were 
 dilated, and filled with a large branched calculus. A calculus 
 and some pus occupied the fistulous passage between the ' lung and 
 renal pelvis. 
 
 In a case recorded by Marcet* of a man, aged twenty-seven, 
 an abscess following a traumatic pyelitis opened into the colon 
 and also communicated with the right lung. There was also in 
 this case a large stone in the pelvis of the kidney. A specimen 
 of a very similar condition is that already referred to, which is 
 in the museum of St. Bartholomew's Hospital (see p. 377). 
 
 In another instance! a female of twenty-four suffered from 
 pyuria with septic fever, followed later by symptoms of pulmonary 
 abscess. A fatal termination ensued, and the post-mortem exami- 
 nation revealed a large calculus in the substance of the right kid- 
 ney and another in its pelvis. Both the kidney and its pelvis were 
 distended with pus, which formed a layer under the renal capsule 
 separating it from the parenchyma. From this region the pus 
 had burrowed upwards behind the liver and had formed an 
 abscess beneath the under surface of the diaphragm. There was 
 a corresponding collection of pus 011 the upper surface of the 
 diaphragm, but no actual perforation of the muscle had taken 
 place, and there was another large abscess in the adjacent part 
 of the right lung. 
 
 Prognosis. The termination of reno-pulmonary fistulas is 
 death from septicaemia, or from dyspnoea and exhaustion due to 
 incessant cough and the expectoration of large quantities of pus. 
 The renal abscess may open (1) at once into the lung, the renal 
 tumour having enlarged until it is hi contact with the under 
 surface of the diaphragm, and the lung itself having become 
 adherent to the upper surface of this muscle ; (2) a long sinu- 
 ous track, surrounded by adhesions, may extend between the 
 kidney and lung ; or (3) a sub-diaphragmatic abscess may have 
 formed, and ultimately have broken into the lung. Sometimes 
 
 * Bull, de la Soc. Anat., tome xxviii. 
 
 t Dublin Med. Press, 1865, 2nd series, xi., p. 562.
 
 390 SURGERY OF THE KIDNEY AND URETER. 
 
 the lower lobe only of the lung is involved, and this only to the 
 extent of some inflammatory thickening around the sinus ; or a 
 small abscess may have formed in the base of the lung ; in other 
 instances the whole lung is more or less involved, and one or 
 more entire lobes may be transformed into a large abscess. 
 
 BENAL FISTULA WHICH OPEN INTO THE PERITONEUM. 
 
 In cases where septic urine, or urine and pus, have been ex- 
 travasated into the peritoneum, death is, as a rule, so rapid that 
 nothing can be done in the way of treatment. Sometimes the 
 patient dies within twenty-four or thirty-six hours after the 
 extravasation commences ; rarely is life prolonged beyond a few 
 days. When, however, as in rare cases of calculous pyelitis, 
 the peritonitis is localised and inflammatory adhesions have formed 
 around the kidney, the urine is effused very slowly into the 
 circumscribed space, the symptoms are chronic, a localised abscess 
 is formed, and a favourable termination may occasionally be 
 obtained by incision and drainage. 
 
 Treatment of Renal and Circumrenal Fistulae. In consider- 
 ing the treatment of every case of renal or circumrenal fistula, 
 the first question which has to be decided is whether the kidney 
 itself is involved or not. If the kidney is involved, it becomes 
 necessary to decide whether the ureter is pervious, or partially 
 or entirely obstructed, or in a diseased condition without being 
 obstructed. Finally, if after the failure of other treatment 
 nepbrectomy is contemplated, it becomes a matter of the first 
 importance to ascertain the condition of the opposite kidney. 
 
 When urine, or urine and pus, escape from the fistula, there 
 is no doubt as to there being a connection with the kidney or 
 its duct. The rare cases in which a lumbar fistula with the 
 escape of a urinous fluid has followed extravasation of urine 
 from the urethra or bladder are diagnosable by their history. 
 
 When the discharge consists only of pus it is very difficult 
 in many cases, even when the fistula is a sequel of nephrotomy, 
 to determine whether it is renal or perirenal ; and still more so 
 is it when the fistula has followed the bursting or opening of 
 a perinephric abscess. In some instances of spontaneous fistula, 
 the history will help to decide whether the original mischief
 
 TREATMENT OF RENAL FISTULA. 391 
 
 was renal, ureteral, spinal, or osseous, or was due to some 
 other extra-renal cause. But occasionally the diagnosis will not 
 be cleared up in spite of careful analysis of the urine, and the 
 injection of coloured fluids into the fistula, until the fistulous 
 track or tracks are freely laid open, and followed to their source 
 in the kidney or otherwise. 
 
 In all cases the parts around the fistulous orifice must be kept 
 clean and free from irritation and from the contact of discharges. 
 Time should be allowed for the spontaneous closure of the fistula, 
 and in many instances the surgeon will not be disappointed. 
 
 If, however, the fistula persists, caustics, the cautery, or a 
 free incision must be- tried, so as to lay open any sinuous track, 
 vivify or excise callous surfaces, and remove spongy granula- 
 tions or calculous deposits. 
 
 The injection of iodine or mercuric solution, besides acting as 
 a disinfectant, will sometimes stimulate the sinus to healthy 
 action. If a foreign body, such as a bullet, a piece of bone or 
 clothing, or a calculus, is keeping up irritation and preventing 
 healing, it should be removed. 
 
 When pus has burrowed far in the surrounding tissue, the 
 extremity of the fistula may be a long wa} r from the kidney 
 as well as from the external orifice ; and it may be necessary 
 to make very extensive incisions through the lumbo-ilio-inguinal 
 regions, or to remove portions of one or several ribs. I have 
 thus had to track circumrenal fistulas below the brim of the bony 
 pelvis, and to remove portions of several of the ribs. I have 
 ("Hunterian Lectures," p. 84) reported a most successful case in 
 which I removed from a gentleman, after a long and severe illness 
 from calculous pyo-nephrosis which had been allowed to burst into 
 the perinephric tissues, portions of the last four ribs, scraped out 
 sinuses, and extracted several fragments of calculus from the 
 cellular tissue high up above the kidney. The patient made an 
 excellent recovery, and remains well at the present time without 
 having had his kidney excised. 
 
 In uro-purulent, as well as in purulent fistulae, an effort should 
 be made to stop infection by antiseptic injections and suitable 
 drugs. If the suppurative process can be cured the fistula, 
 if it has been kept up by pyelitis and obstruction due to ureteritis, 
 mav in time close without any surgical intervention. In. renal
 
 392 SURGERY OF THE KIDNEY AND URETER. 
 
 fistula the treatment will, in the first place, often largely depend 
 upon the state of the ureter. In two or three cases of partial 
 obstruction of the ureter catheterisation of the ureter, or the 
 retention of a ureteral catheter for many days, is said to have 
 been followed by some success ; but later information would prob- 
 ably show that the stricture or stenosis of the ureter had relapsed ; 
 and in one case the fistula is stated not to have closed. There is 
 little hope of permanently re-establishing the patency of the ureter 
 by the catheter en demeure, and the catheter is apt to excite a 
 great deal of irritation, and is not free from risks both of a local 
 and constitutional character. 
 
 The most satisfactory and most permanently successful pro- 
 ceeding is to cut down upon the kidney and remove the obstruc- 
 tion, whether by ureterotomy for valve stricture' or calculus, or 
 by a plastic operation on the renal pelvis in the manner described 
 in the chapters on these subjects. 
 
 In two or three cases of urinary or uro-purulent fistula in 
 my practice, success has followed the operation of excising the 
 fistulous track in the kidney, and suturing the cut surfaces of 
 the parenchyma just as after an ordinary nephrotomy. In these 
 cases the callous tissues between the kidney and the cutaneous 
 surface have also been cut out. If the ureter is completely 
 impermeable, it may be possible to re-establish the channel by 
 cutting out the affected piece of ureter and uniting the ends by 
 a uretero-ureteral graft ; or, if the obstruction is near enough to 
 the bladder, by a uretero-vesical graft. An impacted calculus can 
 be removed from any portion of the ureter in either sex. If it 
 is quite impossible to re-establish the patency of the urine channel 
 and the other kidney be sound, the best treatment for a perma- 
 nent fistula communicating with a diseased organ is iiephrectomy. 
 This operation should be practised in any case in which, all other 
 treatment having failed, the life of the patient is threatened or 
 his comfort sacrificed, provided the opposite kidney is in good 
 functional order. It should, however, be borne in mind that 
 persons may live in excellent health and for many years with 
 a lumbar fistula which discharges urine freely : and also that 
 although for a long time urine may have been escaping from a 
 fistula, the quantity of urine discharged may become less and 
 less, or the flow may even cease altogether.
 
 URETERECTOMY SOMETIMES REQUIRED FOR FISTULA. 393 
 
 A patient upon whom I operated in December, 1883, for jhydro- 
 nephrosis attended with agonising pain, and due to impacted calculus, 
 or stenosis of the ureter after calculus, is alive, very active and very 
 well to this day seventeen years after the operation. His affected 
 kidney discharges daily through the loin fistula many ounces of 
 practically normal urine, and this is collected in a convenient 
 apparatus adjusted over the opening and retained by a belt round 
 the waist. This gentleman has repeatedly refused offers of surgical 
 treatment to close the fistula, and continues to discharge his 
 duties as a clerk in a Government office. The case was fully 
 reported in my earlier work on " Surgical Diseases of the Kidney " 
 (1885), p. 312 et.seq. 
 
 If a purulent fistula persists after iiephrectomy has been per- 
 formed, and resists all simpler treatment, it will probably be 
 due to a continuance of ureteritis or peri-ureteritis or both; and 
 if so it will be requisite to excise the whole of the ureter (see 
 the chapter on Ureteral Fistula, Vol. II., p. 494). 
 
 In most cases a renal or ureteral fistula, of calculous origin, 
 will I believe close permanently after nephrectomy, even if a 
 stone be left impacted in the ureter at the time of the operation. 
 But should it not do so, it may be necessary, as in the case 
 of fistulas kept up by tuberculous ureteritis, to perform partial 
 or complete ureterectomy. If the lower end of the ureter be 
 blocked and the tube above the obstruction is suppurating, the 
 cellular tissue of the loin is very likely to become septic after 
 the excision of the kidney even if the upper end of the ureter 
 is ligatured at the time of the operation, and it is almost sure 
 to do so if the end is not ligatured. In a lady whose right 
 kidney I removed for calculous pyo-nephrosis (the calculus weigh- 
 ing G^- ounces), the wound, after completely healing, subsequently 
 suppurated profusely, and continued to do so until after I had 
 removed the ureter quite down to the bladder, together with nine 
 fair-sized calculi which were impacted in the ureter. This ureter- 
 ectomy was performed by the sacral route. 
 
 A urinary fistula, due to obstruction in the ureter, may 
 in time cease to discharge urine owing to complete atrophy 
 of the kidney. The length of time required for this to be ac- 
 complished depends on the degree of obstruction which the fistula 
 on the one hand, and the ureteral block on the other, ofi'er
 
 394 SURGERY OF THIJ KIDNEY AND URETER. 
 
 to the escape of urine. The more complete the obstruction, the 
 more rapid the atrophy, and vice versa. In a case of my own 
 the process took seven years (see Vol. II., pp. 348, 349, of this 
 work). Even after a fistula ceases to be urinous, it may persist 
 as a suppurating sinus. 
 
 The closure of the fistula by surgical treatment is often tedious, 
 and sometimes impossible ; and hi some cases in which it has been 
 successfully accomplished, the fistula, after remaining closed for 
 many months, or a year or two, will reopen. 
 
 The treatment of renal and circumrenal fistulae which open 
 into a viscus or visceral cavity 'must depend upon the conditions 
 and connections of the particular case. The fistulous opening may 
 be left to close naturally if it communicates with a bronchus, the 
 stomach, or the bowel, if the patient's strength is not becoming 
 exhausted by the irritation and discharge, and if neither the lung 
 in one case nor the renal or circumrenal abscess in the other 
 is threatening to become actively infective. Lumbar nephrotomy 
 and drainage may succeed in curing the visceral fistula, and 
 afterwards the lumbar opening may be allowed to close. 
 
 If after a trial of this treatment a cure is not in prospect 
 and the patient's general condition and the state of the opposite 
 kidney render it advisable, nephrectomy ought to be performed. 
 Any obstruction to the course of the natural flow of urine ought 
 in these cases as well as in the external fistulae to be removed. 
 
 There is no doubt that many cases of spontaneous fistula (as 
 distinct from fistula following surgical operations) might have been 
 entirely prevented had proper surgical treatment been resorted to 
 in good time.
 
 395 
 
 CHAPTER XV. 
 NEPHRECTASIS, OR RENAL DISTENSION. 
 
 IN considering the causes and mode of development of renal 
 distension it will be convenient for the moment to disregard 
 the distinction between hydro- and pyo-nephrosis ; the septic 
 infection, whether primary or secondary, having no particular 
 influence on the process, which is mainly one of hydrostatic 
 pressure and unequal extensibility of the limiting structure of the 
 kidney. The distending force is supplied by the continuous secretion 
 of urine behind an obstruction in the urinary passages, which 
 obstruction is either incomplete, intermittent, or of gradual develop- 
 ment, for it has been demonstrated both by observation and experi- 
 ment that a sudden complete stoppage of the outflow of urine leads 
 to rapid atrophy and ultimate disappearance of the affected kidney. 
 
 Guyon showed (Ann. des Mai. des Organ. Genito-urinaires, 
 1892) by experiments upon dogs the different effects which partial 
 and complete obstruction of the ureter produced upon the corre- 
 sponding kidneys, effects which in the human subject clinical and 
 post-mortem observation had already taught us. Partial obstruc- 
 tion gave rise to hydro-nephrosis, while a complete obstruction 
 was followed by renal atrophy after a slight temporary distension. 
 
 Eobiiison of Chicago (Ann. of Surg., vol. xvii., 1893) per- 
 formed similar experiments, and his results show that a ureter 
 may sometimes be occluded for several weeks without producing 
 any special harm, and that the kidney may resume its natural 
 functions after the obstruction has been removed. In support 
 of this view, Robinson quotes the case of a lady in whom the 
 ureter of one side was ligatured for six weeks, and when at the 
 end of that time the ligature was removed the kidney resumed 
 its functions as before. 
 
 Experiments upon this important question have more recently 
 been made in this country by J. Rose Bradford (Trans. Path. 
 Soc., 1897) upon dogs. The ureter was ligatured in two places 
 near the bladder and divided between. After an interval of
 
 396 
 
 SURGERY OF THE KIDNEY AND URETER. 
 
 from ten to forty days, the distended ureter was exposed, sutured 
 to the skin of the abdominal wall and drained, 50 to 70 cc. of 
 
 urine being evacuated. The fluid was clear 
 in nine cases and purulent in three. The 
 animals were killed at periods varying from 
 seven to fifty days later, and on examining 
 the kidneys they were found to have re- 
 sumed their normal shape, but were only 
 one-third or one-fourth their normal size. 
 There was very little change to be seen 
 by the naked eye, and microscopically there 
 was no cirrhosis found. Some of the 
 tubules had disappeared, and in others the 
 epithelium had in part been shed ; but the 
 main cause of the atrophy was the crowd- 
 ing together of the tubules, and more 
 especially the small size of the cells lining 
 them. These cells had lost all their gran- 
 ules, their protoplasm being clear and 
 glass-like ; the nuclei stained well. The 
 appearances were those of "resting cells." 
 Etiology. The causes of renal disten- 
 sion may be enumerated as follows : 
 
 Congenital. Those occurring during 
 gestation which lead to the presence of this 
 condition at birth ; usually not within the 
 range of surgical interference. They include 
 (a) abnormalities of the ureter and of the 
 lower urinary passages ; and (6) abnormal- 
 ities of vessels, or in the attachment of 
 the ureter to the renal pelvis, which lead at 
 a later period of development to obstruction. 
 Acquired. (a) "Crethral stricture, pro- 
 static enlargement, frequent and sustained 
 vesical systole ; (6) simple or malignant 
 pelvic tumours or displacements ; (c) other 
 growths in the pelvis or lower abdomen, 
 such as enlarged glands or exostoses ; (d) bands and adhesions 
 resulting from peritonitis ; (e) stenosis from ureteritis, simple or 
 
 
 Fig. 4 5 . Unilateral Hydro- 
 ncphrosis associated with 
 great but irregular dila- 
 tation of the Ureter, and 
 not causing Tumour. 
 He-moved after death ; 
 no cause detected on 
 post-mortem examination. 
 (Middlesex Hospital Mu- 
 seum.)
 
 THE MECHANISM OF HYDHO-NEPHROSIS. 
 
 397 
 
 tuberculous ; (/) impacted calculi and pockets and valves in the 
 ureter ; (</) bends and twists of the ureter from undue mobility of 
 the kidney ; (Ji) valvular obstruction at the junction of the regnal 
 pelvis and ureter or in the renal pelvis itself ; (i) obstruction result- 
 ing from traumatism. 
 
 Some years ago I pointed out in the Medical Society's Trans- 
 actions (1894, p. 80) that it was hardly reasonable to expect 
 always to find the cause of an advanced hydro-nephrosis. 
 Former mobility of the kidney which 
 had from time to time kinked or 
 otherwise obstructed the ureter 
 might lead to obstruction and dila- 
 tation, but the organ might be- 
 come fixed in the process of its 
 enlarging, so that on subsequent 
 examination, the cause as a patho- 
 logical entity no longer exists. I 
 further suggested that often there 
 is a variation in the resisting power 
 of different parts of the kidney 
 and ureter (Fig. 45) ; the weak 
 parts yielding first and most ; that 
 
 it 18 quite Conceivable indeed Cases Fig. 46. Hydro-nephrosis with great 
 ill process of development tend to dilatation of the Pelvis and very 
 
 show that a slight temporary ob- 
 struction might bulge the pelvis at 
 one part and that this pouch may by degrees completely obliterate 
 the ureter by its weight, very much as an aneurysm some- 
 times obliterates the artery above or below it ; or a valve may 
 come to be formed at the uretero-renal orifice. Maintenance 
 of the recumbent position might have much to do with the 
 production of hydro-nephrosis, particularly in invalids suffering 
 from pelvic disease. In the horizontal posture some comparatively 
 slight obstruction low down in the ureter would be sufficient 
 to keep that tube full without dilating the whole of it, and yet 
 some weak part of the wall or renal pelvis might yield. It 
 does not follow that the obstruction had not been low down 
 in its course simply because the ureter was not dilated in its 
 whole length, nor that a cause of obstruction had not existed 
 
 little Renal Substance remaining. 
 (Middlesex Hospital Museum.)
 
 398 SURGERY OF THE KIDNEY AND URETER. 
 
 because none is found at the post-mortem examination. A cal- 
 culus for example, after causing partial obstruction for months 
 or gyears, might pass and leave no trace of its existence. 
 
 Two forms of renal distension, in particular, come before the 
 notice of operating surgeons, either or neither of which may 
 cause a tumour clinically detectable the one a large thin- 
 walled cyst in which scarcely any renal tissue remains (Figs. 46 
 and 48), which completely empties on tapping; the other pre- 
 senting dilated calyces separated from one another by dense fibrous 
 septa and having in addition a large amount of thickened and 
 hypertrophied parenchyma (Figs. 47 and 49). This condition is 
 especially apt to be met with when in consequence of the functional 
 disuse of one kidney, the other has undergone compensatory hy- 
 pertrophy before it, in its turn, becomes dilated ; and also in 
 cases w r here great irritation as well as intermittent obstruction 
 has existed for a long period, as in some instances of calculous 
 pyo-nephrosis in which interstitial nephritis has been going on 
 simultaneously with dilatation. 
 
 I. HYDRONEPHROSIS. 
 
 Hydro-nephrosis is the term applied to over-distension of 
 the kidney with urine. It is a mechanical result of obstruction 
 to the outflow of urine from the kidney, no matter whether the 
 cause of the obstruction be situated in the urethra, bladder, or 
 ureter ; nor whether a renal tumour appreciable during life be 
 formed by the dilated kidney or not. It is necessary, however, 
 for the production of a hydro-nephrosis that the obstruction 
 be incomplete, or if complete only temporary, for a complete 
 and permanent obstruction is followed by atrophy of the kidney. 
 
 In the most extreme cases the seat of obstruction is generally 
 the ureter or the vesical orifice of the ureter. In. double hydro- 
 nephrosis, in which the degree of distension is often less excessive, 
 the seat of the obstruction is in, or in front of, the bladder. 
 
 It is long since a special name was first given to this con- 
 dition. Martineau, in 1785, called it " hydrops reiiis " ; Frederick 
 A. Walter, in 1880, called it " hydrops renalis '' ; and James 
 Johnson, in 1816, suggested "hydro-renal distension"; but since 
 the publication of Haver's " Traite des Maladies des Reins " in 1841, 
 the term " hydro-nephrosis " has been in common use.
 
 ETIOLOGY OF HYDRO-NEPHROS1S. 
 
 399 
 
 Hydro-nephrosis is not to be confounded with renal cysts, 
 and therefore the term " cystic tumour of the kidney," which 
 has also been employed, is too vague ; for whilst it includes and 
 implies many different cystic conditions, it by no means indicates 
 " distension by backward fluid pressure." 
 
 It is more especially since the days of ovariotomy and the 
 
 \ 
 
 ^ 
 
 Fig. 47. Hydro-nephrotic Kidney, with large amount of Secreting Tissue remaining. 
 From a case of cancer of the uterus involving the base of the bl dder, and causing 
 obstruction of the ureters. (Middlesex. Hospital iluseum.) 
 
 removal of other abdominal tumours that cases of hydro-nephrosis 
 have been carefully studied and better understood. 
 
 Etiology. The causes of hydro-nephrosis are (1) congenital 
 and (2) acquired. Probably in one-third of the cases in which a 
 palpable tumour is formed the obstruction is of a congenital nature. 
 Roberts found a congenital malformation (affecting kidney, ureter, 
 or renal artery) in twenty out of fifty-two cases. In four v - cases 
 the ureter was congenitally imperforate ; hi three it entered 
 too obliquely into the pelvis of the kidney ; in two a super- 
 numerary renal artery crossed and compressed the ureter near
 
 400 SURGERY OF THE KIDNEY AND URETER. 
 
 its origin. In thirteen out of the twenty cases the hydro-nephrosis 
 was double ; and of these, two were still-born, five died within 
 five months, and the others lived for periods varying from five 
 and a half to thirty-eight years. 
 
 The congenital causes do not always give rise to hydro-nephrosis 
 in infancy or very young life. There are several cases on record 
 which show that a congenital cause has acted very slowly and 
 incompletely, if at all, for a long time ; but that after some, 
 even many years, a hydro-nephrotic tumour has been formed 
 
 Fig. 48. Hydro-nephrotic Kidney which has become a mere Cyst. 
 (Middlesex Hospital Museum.) 
 
 and terminated fatally. Hydro-nephrosis due to a congenital 
 cause is not therefore the same thing as " congenital hydro- 
 nephrosis," a subject upon which something will be said later on. 
 Amongst the congenital causes are to be found a very tightly 
 contracted preputial orifice (see Fig, 50) twists of the ureter 
 upon its own axis (Hare), undue obliquity of its insertion 
 into the renal pelvis so that a valve-like condition is formed 
 which prevents a free outflow (Roberts, Thompson, Dumreicher), 
 reduplications, folds, contractions (Raver), and other anomalies 
 of the ureter. Sometimes the ureter has been replaced in part, or 
 throughout, by a fibrous cord (Thurnam) ; but absence of the ureter 
 is generally accompanied by atrophy of the kidney. Occasionally 
 hydro-nephrosis and pyo-nephrosis arise from congenital diver- 
 ticula connected with the kidnevs. In a case recorded bv Braun,
 
 HYDRO-XEPHROSIS OF PART OF KIDNEY. 401 
 
 a tumour of this kind was found in a child, four months 
 old, and formed a pyo-nephrosis at least as large as a child's 
 head. 
 
 In other cases the vesical orifice of the ureter is thick, rigid, 
 and of merely pin-hole size (Reynaud and Sterner) ; in others, 
 again, minute cysts are developed upon its mucous membrane; hi 
 others, the ureter joins the kidney at such an acute angle that urine 
 can only flow downwards with difficulty, if at all, though a probe 
 
 Fig. 49. Hydro-nephrotic Kidney, with thick partitions between the Sacculi and 
 considerable dilatation of the Pelvis. (Hunterian Museum.) 
 
 can be readily passed along the ureter from below. In other cases, 
 again, an anomalous opening of the lower end of the ureter 
 into the urethra or elsewhere may prevent a free outflow of 
 urine. 
 
 Walter described the case of a man, aged thirty years, who 
 had two ureters and two pelves to each kidney ; the upper part 
 of his right kidney was converted into a cyst, the right upper 
 ureter was dilated and opened into the bladder close to the pros- 
 tate, and passed down in front of the right lower ureter, which 
 opened almost in the median line of the bladder. The right lower 
 ureter and lower half of the right kidney were not distended. 
 VOL i. 2 A
 
 402 
 
 SURGERY OF THE KIDNEY AND URETER. 
 
 A specimen in the Middlesex Hospital Museum well shows a 
 kidney with two ureters, the lower of which is opening into the 
 bladder near the vesical orifice. This ureter is sacculated, and 
 
 Fig. .50. Double Hydro-nephrosis and dilatation and torsion of Ureters in a child 
 with a very small preputial aperture. (St. Bartholomew's Hospital Museum.) 
 
 the lower part of the kidney which it drains is converted into 
 a pyo-nephrosis. The upper part of this kidney, drained by a 
 ureter opening normally into the bladder but in which a small 
 calculus is fixed at its upper extremity, is becoming hydro-nephrotic 
 (Fig. 51). At the Congress of Surgery in 1801 a case was reported
 
 RENAL ARTERY CAUSES ABNORMAL HYDRO-NEPHROSIS. 
 
 403 
 
 in which the superior half of the kidney was healthy. This 
 is contrary to the statement made by Brinon (These de Paris, 
 1896), who says that it is almost always the ureter corresponding 
 
 Calculus impacted in 
 the upper end of the 
 ureter. 
 
 Fig. 51. Hydro-nephrosis of the Right Kidney with Double Ureters 
 (see text, p. 402). (Middlesex Hospital Museum.) 
 
 to the upper half of the kidney which opens abnormally, and 
 therefore the upper half of the kidney which becomes dilated. 
 
 In a c'ase related by Boogard of a young man, aged twenty, 
 
 who died five days only after the hydro-nephrosis was first 
 
 observed, the right renal artery divided into two branches the 
 
 lower of which compressed the ureter. Roberts* records a case 
 
 * " Urinary and Renal Diseases," p. 545 (4th ed.).
 
 404 SURGERY OF THE KIDNEY AND URETER. 
 
 in a young man of twenty years, who had double hydro-neph- 
 rosis, that on the left side having been caused by a contracted 
 and too oblique ureter, and that on the right side by the pres- 
 sure of a branch of a renal artery on the ureter. Krause described 
 the case of a woman in whom a valvular flap of membrane at the 
 renal orifice of the ureter was the cause of obstruction. Lagrave 
 found a kidney hydro-nephrotic from compression of the ureter 
 by menses retained in one-half of a bifid uterus. 
 
 Torsion of the penis is another congenital cause of double 
 hydro-ureter and hydro-nephrosis. A case of this kind I recorded 
 and illustrated in the Lancet for June 8th, 1895 (see section 
 on Congenital Hydro-nephrosis, p. 440). 
 
 Dr. Strange * records the case of a farm labourer, aged eighteen, 
 in whom diabetes insipidus had existed from infancy. The kid- 
 neys at the time of death were mere sacs two or three times 
 larger than normal kidneys, and there was a complete absence of 
 all pareiichymatous substance, both cortical and tubular ; the sacs 
 were divided into a number of cells by the intertubular septa 
 which occur in the foetal state. The ureters were also greatly 
 dilated, being from three to four and a half inches in circum- 
 ference. The urine contained in the sacs and ureters had no 
 urea, no albumen, and no sugar. 
 
 Another very similar case is recorded by Faber,f in which the 
 belly was enlarged from birth, and there were recurring paroxysms 
 of symptoms like those of stone in the bladder ; the boy died at 
 the age of five and a half years, when both kidneys were found con- 
 verted into large sacculated pouches without a trace of renal sub- 
 stance in them ; and the ureters were like the small intestine in size. 
 
 In these two cases the atrophy of the renal substance had 
 doubtless commenced at or before birth, and had gone on pro- 
 gressively afterwards. 
 
 The acquired causes of hydro-nephrosis are numerous, and, like 
 the congenital, may be situated in, behind, or in front of the bladder. 
 
 From the records of the post-mortem examinations of 2,610 
 Ixxlies, made during the ten years ending 1883 at the Middlesex 
 Hospital, I found 142 cases of marked hydro-nephrosis. Slight 
 and only moderate dilatations of the kidney are not included 
 
 * Beule's " Archives," p. 276 ; 1862. 
 
 t Wurtz, Correspondenz-Blatt, Bd. xii., p. 266.
 
 an 
 
 " pelvis distended and renal sub- 
 
 UTERINE CANCER A FREQUENT CAUSE OF HYDRO-NEPHROSIS. 405 
 
 in this number, but only those cases in which there was very 
 advanced change in the kidney. Many of these kidneys are 
 described by the words " enormously dilated " ; as large as 
 orange " or as "a cocoanut 
 stance atrophied, so as to 
 leave a thin-walled cham- 
 bered cyst " ; " pelvis di- 
 lated into a large pouch " 
 (Fig. 52) ; " renal substance 
 wasted so that the solid 
 part of the kidney formed 
 a mass not larger than a 
 large walnut " ; " kidney 
 small, but converted into 
 a mere chambered cyst, the 
 ureter greatly dilated " ; 
 "pelvis and calyces widely 
 distended, ureter the size 
 of the small intestine of a 
 child." These and similar 
 expressions are used to de- 
 scribe the cases included 
 in the list. In some in- 
 stances of double hydro- 
 nephrosis it is quite clear 
 that one kidney was affected 
 long before the other ; and 
 that in the meanwhile the 
 second kidney had under- 
 gone considerable hyper- 
 
 Fig. 52. Hydro-nephrosis with great dilatation 
 of the Renal Pelvis, from a lady whose other 
 Kidney became movable and then hydro-neph- 
 rotic, and was subsequently submitted to 
 nephrotresis (see p. 437). (Midd. Hos. Mus.) 
 
 trophy. Hence the apparently incompatible conditions of great 
 distension of ureter, of the pelvis and calyces of the kidney, and 
 great bulk of renal substance, were sometimes co-existing in the 
 same organ. 
 
 An analysis of the 142 cases shows the causes to have been : 
 
 1. Cancer of the pelvic organs, uterus, vagina, bladder, 
 or rectum, in 116 cases. 
 
 2. Cancer of one or both ovaries in two cases. 
 
 Of the 116 cases (most of which were primarily uterine cancers,
 
 406 SURGERY OF THE KIDNEY AND URETER. 
 
 though in many of these the vagina, bladder, or rectum became 
 subsequently involved) 
 
 93 were double hydro-nephrosis. 
 16 affected the right kidney only. 
 7 affected the left kidney only. 
 
 Of the two cases of ovarian cancer 
 
 1 affected the right kidney only, the right ovary only being diseased. 
 1 affected both kidneys, both ovaries being diseased. 
 
 Of the t went v-f our remaining cases the cause was 
 
 Unknown in 4. 
 
 Cystitis in 3. 
 
 Vesical calculus, 3. 
 
 Villous growth of bladder, 1. 
 
 Enlarged prostate, 3. 
 
 Ovarian cysts, 4. 
 
 Constriction of ureter, 3. 
 
 Cancer of abdominal organs pressing 
 
 on ureter, 3. 
 Of these twenty-four cases due to causes other than pelvic cancer 
 
 12 were double. 
 
 9 affected the right kidney only. 
 3 affected the left kidney only. 
 
 Of the twelve cases in which the hydro-nephrosis was single, 
 the dilatation was due 
 
 To causes " unknown " ....... 4 
 
 To constriction of one ureter ...... 3 
 
 To S-shaped twist in ureter ...... 1 
 
 To cancerous tumours in abdomen ..... 3 
 
 To ovarian cyst ......... 1 
 
 In the twelve cases in which the hydro-nephrosis was double, the 
 causes were 
 
 Cystitis 
 Vesical calculus 
 
 Enlarged prostate . 3 
 
 Ovarian cysts . . 3 
 
 In a further analysis of 3,920 cases from the post-mortem 
 records of the Middlesex Hospital between 1884 and 1897, there 
 were 239 cases of hydro-nephrosis due to pressure on the ureters, 
 in most cases from malignant disease in the pelvis ; of these, 
 170 were bilateral and sixty -nine unilateral. 
 
 In addition to these, there were five cases of unilateral hydro- 
 nephrosis due to renal or ureteral calculus. 
 
 Thus, out of a total of 381 cases of hydro-nephrosis, taken 
 from the post-mortem records of the Middlesex Hospital, 274 
 were bilateral and 107 unilateral.
 
 HYDRO-NEPHROSIS SOMETIMES CAUSED BY INJURY. 407 
 
 In thirty-two cases recorded by the late Sir William Koberts, 
 the cause was found to be impaction of calculus in the ureter in 
 eleven, and in three others it was presumably due to this same 
 cause, though the calculus was not actually discovered ; in five there 
 was a narrowing or obliteration of the ureter near its origin or 
 termination, produced presumably by some preceding inflammation 
 or ulceration ; in six cases the ureter had been compressed by 
 pelvic tumours ; and in three by peritoneal inflammatory bands. 
 Simon found calculus to be the cause of hydro-nephrosis 
 seven times in eighteen cases (Legueu). 
 
 It will be thus seen that a not uncommon, and to the prac- 
 tical surgeon a very important cause, is a calculus impacted in 
 the renal pelvis or in the ureter ; and besides the cases in which 
 there is a calculus discovered, there are also those in which the 
 passage of a calculus from the kidney to the bladder has left its 
 effects in the form of ulceration and subsequent contraction of the 
 ureter at some spot or other. 
 
 Traumatism is occasionally, though not very commonly, fol- 
 lowed by hydro-nephrosis, and many cases supposed to be of 
 this nature are in reality due to urinary effusions into the retro- 
 peritoneal tissue after an injury to the kidney or ureter, an in- 
 stance of which was well described by Stanley.* This condition 
 has been termed " pseudo-hydro-nephrosis," and is generally to be 
 distinguished from the true variety by the earlier onset after the 
 accident ; and in the cases where a post-mortem examination has 
 bsen made, there has been no dilatation of the renal pelvis found. 
 When a true hydro-nephrosis results from traumatism it generally 
 depends upon a stricture of the ureter, and is not developed until 
 a long time after the injury. 
 
 A case of this kind is recorded by Dr. Pye Smith in a farrier, 
 aged twenty-four, who was kicked " under the short ribs," and 
 passed blood with his water ; two years later a hydro-nephrotic 
 tumour on the same side of the abdomen (the left) was discovered 
 and twice tapped ; at the post-mortem examination the ureter 
 was dilated for an inch and a half and then suddenly became 
 contracted so as not to admit the smallest probe. The cyst 
 communicated with the adherent intestine. The contraction of 
 the ureter was supposed to have been caused by the kick. 
 
 * Trans. Roy. Med.-Chir. Soc., xxvii., p. 1.
 
 408 SURGERY OF THE KIDNEY AND URETER. 
 
 Other cases in which hydro-nephrosis has followed an injury to 
 the ureter are recorded in the chapters on Injuries of the Ureter 
 in the second volume of this work. A more doubtful case is 
 referred to later in the present chapter (p. 425). 
 
 In other cases, again, the ureter has been found degenerated 
 into a hard, slender, impervious cord, but the cause of the obliter- 
 ation was not so clear as in the above-quoted cases. Thus, Cooper 
 Rose records the case of a young lady who suffered from a tumour 
 of the abdomen for fifteen years, which was throughout supposed 
 to be ovarian, and was tapped ; nothing but a thin layer of cortical 
 substance was left of the kidney ; the ureter was quite impervious. 
 
 Other causes of obstruction to the outflow of urine are con- 
 traction of the vesical orifice of the ureter from inflammation, 
 ulceration, and tumours or abscess of the bladder ; abscess of 
 the pelvic cellular tissue when affecting the lower part of the 
 ureter ; enlarged lymphatic glands which press upon the ureter 
 in any part of its course ; adhesions, or bands of fibrous tissue ; 
 cancer of the pelvic organs ; stone in the bladder ; enlarged 
 prostate, stricture of urethra ; and in the female various morbid 
 conditions of the uterus and its appendages. A case of obstruc- 
 tion of the ureter by a gumma has been recorded by Hadden in the 
 Transactions of the Pathological Society (xxxvii., p. 301). The 
 patient, a man fifty-five, died of strangulated inguinal hernia. The 
 right ureter was dilated to more than twice its normal size down to 
 a point 4 inches from its entrance into the bladder ; below this 
 the duct became very small, and its lower end just admitted 
 the passage of an ordinary probe. The obstructing mass involved 
 the bifurcation of the common iliac artery. The right kidney 
 was entirely cystic. There were gummata in the liver and spleen. 
 
 Ebstein* gives an instance of double hydro-nephrosis due to 
 an abscess at the fimdus of the bladder following lateral lithotomy : 
 the orifices of the ureter lay within the area of the abscess ; 
 each ureter was dilated to the size of the small intestine ; 
 lx>th kidneys were exceedingly enlarged, the left being com- 
 pletely transformed into a hydro-iiephrotic sac with scarcely 
 a trace of renal substance remaining. I have seen a sacculus 
 in a thin dilated bladder (associated with, if not caused by, en- 
 larged prostate) which had produced great dilatation of one ureter 
 
 * Ziemssen's " Encyclopaedia," vol. xv., p. 647.
 
 RELATION OF MOVABLE KIDNEY TO HYDRO-NEPHROSIS. 40JJ 
 
 from dragging upon and partly occluding the ureteral orifice. 
 Prolapse of the vesical orifice of the ureter, and a calculus lodged 
 in a pouch of the ureter at or just above the vesical orifice, have 
 also given rise to unilateral hydro-nephrosis. 
 
 In two cases which have been under my care villous papillomata 
 of the bladder have been the cause of hydro-nephrosis. One case 
 will be again referred to further on ; in the other, extensive double 
 hydro-iiephrosis (not, however, amounting to an abdominal 
 tumour) was due to widespread villous disease of the bladder. 
 
 Movable kidney is said to be a frequent cause of hydro-nephrosis, 
 especially of the intermittent variety. The change in the position 
 of the kidney causes a kink to form in the ureter, which may 
 vary from the slightest torsion to an extreme degree of spiral 
 twisting. A very slight amount of flexion of the ureter is suffi- 
 cient to check the flow of urine, with the result that the ureter 
 and renal pelvis undergo dilatation above the point of obstruction. 
 This dilatation increases and persists until the pressure of the 
 urine becomes great enough to overcome the resistance, or else, 
 as frequently happens, the mobile kidney assumes a new position, 
 which is more favourable to the outflow of the urine, and the 
 sac then empties itself. The rapidity with which the urine 
 escapes varies in each case according to the nature of the 
 obstruction, and external manipulation or alterations in the 
 position of the patient not unfrequently facilitates the flow. The 
 relation between movable kidney and hydro-nephrosis has been 
 studied experimentally on animals by Tuffier; and although he 
 found a definite causal relationship between the two conditions 
 to exist, a movable kidney was by no means invariably followed by 
 hydro-nephrosis. This fact is in keeping with clinical observations, 
 for only a very small proportion of the movable kidneys in men and 
 women are complicated by hydro-nephrosis ; and lam much disposed 
 to think that in several cases in which hydro-nephrosis and movable 
 kidney co-exist, the mobility was acquired after, not before, the hydro- 
 nephrosis, and is a result of the dragging weight of the distended organ. 
 
 Silbermann mentions a case seen by him in a child ten 
 years old, in whom hydro-nephrosis of the right kidney was 
 caused by a fibroma of the bladder about the size of a walnut 
 which blocked the vesical orifice of the right ureter.* The case 
 
 * Berliner kliniscfie \\'ochenschrift, xx., p. 518 ; 1883.
 
 410 SURGERY OF THE KIDNEY AND URETER. 
 
 is of interest because the condition suggested to Silbermann 
 the instrument he has devised for temporarily closing one 
 ureter. 
 
 Dr. Simpson* saw a right kidney which had been converted 
 into a cyst the size of a fostal head by a thickened band of 
 fibrous tissue passing along the brim of the pelvis from the pro- 
 montory of the sacrum, and compressing the right ureter. 
 
 Eayer mentions the case of a woman, aged forty, who had a 
 fluctuating tumour in the right side caused by compression of 
 the ureter by enlarged and indurated lymphatic glands, between 
 the uterus and iliacus muscle, secondary to cancer of the uterus : 
 the left kidney and ureter were unaffected. 
 
 Pelvic tumours, cancer of the pelvic organs, versions and 
 flexions of the uterus, enlargement of the prostate, stricture of 
 the urethra, and phimosis, though frequent causes of hydro-neph- 
 rosis, only occasionally lead to such an amount of distension as 
 to produce an abdominal tumour. 
 
 Amongst the numerous cases of cancer of the pelvic organs 
 annually examined at the Middlesex Hospital, there had not 
 been, up to 1885, in the memory of any of the surgeons then 
 attached to the hospital, a single clinical instance of an abdominal 
 tumour from hydro-nephrosis due to pelvic cancer ; nor am I aware 
 that any such case has occurred since. Raver had only seen one 
 case, that just referred to, in which hydro-nephrosis from cancer 
 of the uterus gave rise to an abdominal swelling, and in that case 
 the immediate cause of the renal distension was pressure by 
 enlarged pelvic lymphatic glands. 
 
 Hildebrandt considers retroflexion of the uterus an occasional 
 cause of hydro-nephrosis, and he records such a case in his writing 
 on retroflexion ; he explains it by the bending of the ureters, 
 as they pass along by the side of the neck of the uterus, owing 
 to the version of the womb, and this in turn causing obstruction 
 to the outflow of urine from the kidneys. He found a large 
 soft tumour above Poupart's ligament on the left side, which 
 was removed by pressure on the abdominal walls when a catheter 
 was introduced into the bladder and the uterus was straightened 
 by a sound. The swelling in another and similar case was best felt 
 when the patient was upright, because in the recumbent position 
 
 * Glasgow Medical Journal, vol. ii., 1867.
 
 SPASMODIC CONTRACTIONS OF THE BLADDER. 411 
 
 the urine was dispersed along the whole length of the ureter, 
 and thus did not form a circumscribed swelling. 
 
 There is one cause of obstruction to the outflow of urine from 
 the kidneys which, though it may not be sufficient of itself to 
 give rise to a hydro-nephrotic tumour, doubtless aids materially 
 any partial obstruction of one or both ureters from any other 
 cause, such as renal calculus or morbid growth of the bladder. 
 I allude to frequency of micturition, which means frequent con- 
 traction of the muscular walls of the bladder ; frequent closure 
 of the vesical orifices of the ureters owing to the anatomical 
 arrangement whereby these ducts traverse the parietes of the 
 bladder ; and thus frequent resistance to the outflow of the urine 
 from the ureters. 
 
 Dr. Alexander James has reported a case in the Edinburgh 
 Medical Journal (p. 135, 1877), in which frequent micturition due 
 to phimosis was, he believes, the proximate cause of the hydro- 
 nephrosis, the contractions of the bladder preventing the flow of 
 urine through the ureters. I refer with special satisfaction to Dr. 
 James's paper on hydro-nephrosis because I did not know of its 
 existence when writing the above many years ago. Dr. James * ob- 
 served many times, in washing out the bladder of a paraplegic 
 patient, that its walls would remain so firmry contracted round the 
 catheter for thirty seconds or longer at a time, as not to allow a 
 single drop of water, even with a head of three feet, to enter the 
 viscus. This, as he remarks, is specially interesting, as helping to 
 show that the increased frequency of micturition which occurs in 
 irritable bladders will cause dilatation of the ureters and renal pelvis 
 by damming back the urine in those tubes. It seems to me very 
 probable that it is in this manner that phimosis, stricture of 
 the urethra, prostatic enlargement, vesical calculus, and other such 
 causes of frequent and straining micturition, lead to hydro- 
 nephrosis ; for these conditions do not directly obstruct the urctrr* 
 as do an impacted renal calculus, a papilloma growing over the 
 ureteral orifice, a pelvic tumour, and the various other obstacles 
 situated above the bladder. Hydro-nephrosis has occasionally arisen 
 in the course of diabetes, probably through the secretion of urine 
 being so much in excess of the outflow that dilatation finally takes 
 place (Saundby. See also Dr. Strange's case, quoted on p. 404). 
 
 * Edinburgh Medical Journal, Nov., 1878.
 
 412 SURGERY OF THE KIDNEY AND URETER. 
 
 Hydro-nephrosis may affect both kidneys, or only one, or may 
 even be limited to only part of one kidney. According to Roberts, 
 out of thirty-two cases in which the cause of obstruction was not 
 congenital, the hydro-nephrosis was double in seven ; as against 
 thirteen cases out of twenty in which the cause of the obstruction 
 (and in several the tumour also) was congenital. As stated on 
 p. 406, the hydro-nephrosis was double in 276 out of 386 cases of 
 hydro-nephrosis collected from the records of the Middlesex Hospital. 
 
 In rare cases the hydro-nephrosis has been partial as well 
 as unilateral ; i.e. it has involved some only of the calyces of 
 the kidney. This has been the condition in some few instances 
 in which there have been two ureters to a kidney, one of which 
 only has been occluded or obstructed (see Fig. 51) but it has 
 also been seen when the cause of the obstruction has occupied the 
 renal pelvis and upper end of the ureter (Figs. 53 and 54). Cases 
 of partial nephrectasis (hydro-nephrosis and pyo-iiephrosis) were 
 referred to by Raver, and by myself in my earlier work on the 
 " Surgical Diseases of the Kidney" (1885). The subject has been 
 more recently illustrated by Fenger of Chicago,* Israel, and others. 
 
 Unsymmetrical as well as horse-shoe kidneys may of course 
 become hydro-nephrotic, and children have been born with a 
 single kidney and ureter greatly dilated. There are several 
 cases of hydro-nephrosis of single kidneys on record. 
 
 John Woodf recorded the case of a girl, aged ten years, with 
 a double pelvis and ureter to her left kidney, and a single 
 undersized ureter issuing from the lower end of the right kidney. 
 At the upper end of the right kidney was a cyst the size of a 
 walnut, with tough fibrous walls, and with a thin layer of cortical 
 substance spread some way over its walls. The interior was 
 lined by a smooth membrane, had 110 communication with the 
 true pelvis of the kidney, and here and there was marked by 
 saccular depressions like the remains of calyces. Emerging from the 
 cyst was a fibrous tube of the average diameter of a goosequill, 
 but sacculated in places. Its lumen communicated with the 
 cavity of the cyst ; its lower end opened into the bladder by 
 a narrow aperture guarded by a valve near the urethral orifice. 
 Towards its lower end were two or three distinct valvular folds 
 
 * Annals of Surgery, 1890, and Amer. Med. Assoc. Journal, 1894. 
 t Path. Soc. 'Trans., vol. vii., p. 261.
 
 "PARTIAL" HYDRO-NEPHEOSIS AND ABDOMINAL TUMOUR. 413 
 
 of the lining membrane, strengthened by fibrous tissue, and 
 disposed so as to resist upward flow. The cyst seems to have 
 been a hydro-nephrotic distension of certain calyces communi- 
 cating with the aberrant ureter. 
 
 Dr. Ewart* has recorded a case in which the lower part 
 of each kidney was a sacculated cyst, the cause being tuberculous 
 disease of the corresponding ureter. Each kidney had two ureters. 
 
 Fig. 53. Section of Hydro-nephrotic Kidney with a Uric Acid Calculus impacted in 
 the Pelvis, and extending into the upper part of the Ureter, which it blocks. 
 The pelvis is dilated, and the medullary and cortical substances of the kidney 
 have undergone absorption in very different degrees in different parts of the 
 organ. (Westminster Hospital Museum.) 
 
 The distension of only one calyx has even given rise to an 
 al)dominal tumour, as in Fugel's case.f In a case of horse-shoe 
 kidney J the left part of the organ was atrophied, and its pelvis 
 was dilated owing to pressure on the ureter of this part. The 
 right part of the horse-shoe mass weighed fifteen to sixteen ounces, 
 its pelvis also was somewhat dilated and inflamed, and its sub- 
 stance was suppurating. There was inflammation of the whole 
 
 * Path. Soc. Trans., vol. xxxi., p. 188. 
 
 t Referred to by Staples in Journ. of Amer. Med. Assoc., April 19, 1884. 
 
 J Guys Post-mortem Records, 1877, No. 372.
 
 SURGERY OF THE KIDNEY AND URETER. 
 
 of the retro-peritoneal tissue surrounding the kidney. The cause 
 was pelvic cellulitis after delivery. Two or three cases of ab- 
 dominal tumour, caused by one half of a horse-shoe kidney, 
 are on record. I have given an illustration in the section on pyo- 
 nephrosis of a horse-shoe kidney one-half of which is distended into 
 a large pus sac. Sutherland and Edington have also figured a 
 horse-shoe kidney from a child aged three years, the left half 
 of which is greatly enlarged, and has the characters of an ordinary 
 
 non-tuberculous pyo-nephrosis.* 
 
 The proportion of cases in which 
 hydro-nephrosis produces a palpable 
 abdominal tumour is very small, 
 compared with the great frequency 
 of hydro-nephrosis as it is seen 
 in the post-mortem room. When 
 an abdominal swelling exists there 
 has been more or less complete 
 obstruction affecting a kidney in 
 its full functions ; the kidney may 
 even be greatly hypertrophied. 
 Moreover, in all probability the ob- 
 struction will have been of long 
 standing, and either intermittent, or 
 continuous and partial in its action. 
 Up to the time of obstruction 
 the kidney will have been actively 
 secreting ; it still goes on secreting, 
 and the urine, finding difficulty in 
 its exit, dilated the renal pelvis, and 
 
 as much of the ureter as is above the obstruction. In proportion as 
 the renal tissue becomes destroyed by the compression, the amount of 
 urine secreted is lessened ; but still the distension will increase, and 
 the sacculated kidney will enlarge as long as there is any secreting 
 structure left to add more urine to that already accumulated. If 
 the kidney thus obstructed has previously undergone hypertrophy, 
 the distension will increase with even greater force than in a kidney 
 of usual size, and the hypertrophied organ will, from its own size, 
 assist in making the hydro-nephrotic swelling more prominent. 
 
 Fig. 54. Kidney shown in section 
 in Fig. 53. The upper end of the 
 ureter is blocked by the calculus. 
 
 Glasgow Medical Journil, Feb., 1898.
 
 NO TUMOUR IF HYDRO-NEPHROSIS IS BILATERAL. 
 
 415 
 
 When, on the other hand, the obstacle is slight at first, and 
 only very gradually increases (as in organic stricture and cancer 
 of the uterus), there is a continual mild resistance, rather than 
 an actual obstruction, to the flow of urine, so that the secreting 
 substance of the kidney wastes more quickly than the renal pelvis 
 distends, and death occurs generally before a tumour is formed. In 
 
 Fig. 55. Hydro-nephrosis, showing dilatation of the Renal Pelvis and lobulation 
 of the Hydro-nephrotic Sac. (St. Thomas's Hospital Museum.) 
 
 urethral stricture, and in most cases of uterine disease, resistance is 
 offered to both kidneys, and they each suffer, but cannot share the 
 results of the obstruction. Thus there is little chance of detecting 
 hydro-nephrosis from such causes during life, unless the obstruc- 
 tion has been confined to one side for a time, and affects the 
 other kidney after it has become hypertrophied. 
 
 When sudden and complete, or nearly complete obstruction 
 affects the kidney, atrophy, and not hydro-nephrotic distension 
 of that organ, will result, as has already been explained. 
 
 It is seldom that the clinical history and course of a case
 
 416 
 
 S r JRGERY OF THE KIDNEY AND URETER. 
 
 of hydro-iiephrosis afford accurate data for forming an opinion 
 as to the rate of " growth," or development of an abdominal 
 tumour of this nature ; but a case of hsemato-nephrosis, communi- 
 cated by M. Danyau and quoted in one of the chapters on Injuries 
 of the Kidney, is of much value as proving that the pyramidal 
 and cortical substance of the kidney may be quite destroyed, 
 
 Fig. 5G. Hydro-nephrosis ; the kidney distended into a thin-walled sac, which is 
 lobulated externally. The upper end of the ureter is dilated. (St. Thomas's 
 Hospital Museum.) 
 
 and a large tumour formed, by intrarenal pressure in a period 
 of less than two calendar months. As there was no reason to 
 suppose that the injured kidney had been at all dilated prior to 
 the accident, we have in this instance almost certain knowledge 
 of the maximum time within which these extreme results of 
 intrarenal pressure were produced. The condition was not, how- 
 ever, the same as it is in hydro-nephrosis, because the dilating 
 force in that case was the projection of arterial blood into the ob- 
 structed kidney ; and the result was the formation of a false 
 aiieurvsm within the renal cavitv.
 
 HYDRO-NEPHROSIS EITHER UNI- OR MULTI-LOCULAR. 417 
 
 Pathology. The characteristic changes in hydro-nephrosis con- 
 sist of a dilatation of the pelvis followed by gradual absorption of the 
 kidney substance, until in the late stages there is nothing but a mere 
 cyst or a combination of pouches. It is, however, rare to find all the 
 renal tissue entirely destroyed, and Ayrer* found this condition 
 only eleven times in 473 cases. The anatomical appearances may also 
 vary with the nature of the hydro-nephrosis, as to whether it is of 
 
 Fig. 57. Kidne}- removed for extreme Hydro-nephrosis. The kidney had been 
 
 movable for several years. The renal pelvis is greatly dilated. (Author's case.*! 
 
 u, Ureter as it leaves the hilum of the kidney. 
 
 the open or closed variet}*, or whether the distension affects only 
 part of the organ, as it does in some cases where there are 
 two ureters. In a typical case the pelvis, of the kidney 
 first becomes converted into a spheroidal sac, then the calyces are 
 widened and stretched in every direction, and at length the cap- 
 sule of the kidney is expanded, and what remains of the 
 cortical and medullary substance of the organ becomes still 
 further compressed and absorbed, until at length there is nothing 
 left but a multi-locu lated bladder or cyst (Figs. 55 and 
 56). Thus the tension exerted by the urine, which accumulates 
 
 " On Complete Atrophy of the Kidney Substance in Hydro-nephrosis," 
 Deut. Med. Wochschr., Leipz. u. Berl, 1893, xix., pp. 1108 and 1159. 
 VOL. I. 2 B
 
 418 
 
 SURGERY OF THE KIDNEY AND URETER. 
 
 behind the obstruction, stretches the calyces and flattens and 
 wastes the pyramids to such an extent that the calyces are con- 
 verted into huge spaces or pouches jutting off from the dilated 
 pelvis and separated from one another by slender septa formed 
 by the wasted "columns of Bertini" (Fig. 57). On laying open 
 the cavity of such a hydro-nephrotic cyst, nothing but a complete 
 fibrous skeleton of the kidney will be seen. Sometimes nothing 
 
 but a pellucid sac, with at most 
 one or two, if any, septa is present 
 (Fig. 48, p. 400) ; at others, again, 
 and this is more generally the 
 case, traces of the renal tissue re- 
 main as in Fig. 49 (p. 401), where 
 the pelvis of the kidney is seen 
 greatly enlarged, and areas of 
 secreting substance have been 
 exposed in the section. 
 
 As a rule, the pouches formed 
 by the dilated calyces communi- 
 cate indirectly with one another 
 through their openings into the 
 pelvis (Fig. 58) ; but in rare cases 
 one or other or all of them may be 
 shut off from the pelvis, and there- 
 fore from one another, either by 
 Fig. 58. Hydro-nephrosis which sub- the presence of a large branched 
 
 sequently suppurated. Great dilata- 
 tion of the Renal Pelvis (A) and 
 upper end of Ureter, with Atrophy 
 of Renal Vessels (B). Calyces open- 
 ing by three apertures into the pel- the proportions in which the 
 
 pelvis and the body of the kid- 
 ney enter into the formation of 
 the cyst ; in one case it is formed in greater proportion by the 
 pelvis, which is converted into a rounded tumour as in Fig. 52 
 (p. 405) and Fig. 59 ; in another, the absorption of the renal sub- 
 stance, far from being complete, may not amount to more than 
 an effacement of the papillae and a flattening of the pyramids (Fig. 47, 
 p. 399). Again, in another case the whole of the pyramids may 
 have disappeared, but the cortical portion remains scarcely, if at all, 
 encroached upon ; in a third stage, the cortical as well as the pyra- 
 midal substance has vanished, and nothing but mere reddish areas 
 
 calculus or by fibrous septa. 
 
 There are great varieties in 
 
 vis. Removed by author, 
 dlesex Hospital Museum.) 
 
 (Mid-
 
 CALCAREOUS DEGENERATION OF THE CYST WALL. 419 
 
 on the fibrous parietes (if anything) remain of the secreting tissue 
 (Fig. 4<>, p. 397). 
 
 The wall* vary in thickness very much ; in one case they 
 are composed of a thin translucent delicate membrane ; in another, 
 of condensed white connective tissue tough and strong, and some- 
 times even of the consistence of cartilage ; in a third, fibro- 
 cartilaginous nodules may be found embedded in them. G. "VV. 
 Perkins records a case of traumatic hydro-nephrosis, with cal- 
 cification of the cyst wall, in a man aged thirty-nine. When 
 eight years old he had been run over by a waggon, which tra- 
 versed his abdomen and rendered him for a time unconscious, 
 but otherwise he suffered no immediate serious symptoms. After 
 the lapse of a year, a lump the size of a hen's egg appeared 
 in the right iliac region, which enlarged only slowly till he was 
 fifteen. At twenty-three 1 , after a fall, some pain ensued, and the 
 swelling was tapped ; a quantity of clear yellow fluid, weighing thirty 
 pounds, with a glistening oily scum on the surface, was removed. 
 
 Three years later the swelling returned, and ultimately the 
 whole of the right side of the abdomen was filled with an elastic 
 swelling. Nearly nine pounds of semi-solid and fluid contents 
 were removed, leaving an enormous cavity, with dense strong 
 walls which did not collapse, but maintained nearly the original 
 shape and size of the tumour, and gave out a ringing sound 
 when tapped with an instrument. There was no kidney tissue 
 present. The urine at the time was normal. Eight weeks later 
 death occurred, within ten minutes, from sudden haemorrhage 
 into the cavity. Post-mortem a cyst was found, kidney shaped, 
 measuring eleven inches by six, and with walls half an inch thick, 
 composed of fibrous tissue, with a lining of calcareous matter, 
 sV to T V inch thick. The left kidney was greatly enlarged, 
 weighing twelve ounces.* 
 
 In all cases the sac wall consists of the tunica propria of 
 the kidney, into which the fibrous tissue of the ureter and renal 
 pelvis is continued. Blood-vessels are not often very easily distin- 
 guished in the walls, but the renal vessels, though they atrophy, do not 
 do so pari passu with the glandular substance of the kidney (Fig. 58). 
 
 The size of the hydro-nephrotic sac may not exceed the size 
 of a normal kidney ; it may be even smaller ; or, on the other 
 hand, it may be sufficiently large to form a tense irregularly 
 * Ann. Surg. Phila., 1895, xxi. p. 695.
 
 420 
 
 SURGERY OF THE KIDNEY AND URETER. 
 
 rounded swelling in the renal region, and may even occupy a 
 great part of the abdominal cavity (Fig. 59). 
 
 In some instances the tumour extends as high as the costal 
 margins, as low as the iliac crest, as far inwards as the median line 
 or beyond it, and sufficiently far backwards to cause bulging of the 
 loin. In exceptional cases the tumour attains such a size as to 
 distend the whole abdomen, bulge out the lower ribs, and assume the 
 appearance and physical characters of an immense ovarian cyst. 
 
 Dilated pelvis. 
 
 Lower pole of kidney. 
 
 Fig. 59. Hydro-nephrosis forming a very large rounded tumour, consisting almost 
 entirely of the renal pelvis. There is also a good deal of sacculation of the paren- 
 chyma. Nephrectomy. Recovery. Author's case. (Middlesex Hospital Museum.) 
 
 Sometimes adhesions form between the tumour and the parts 
 around ; thus the peritoneum may be firmly united with the 
 greater part of the wall of the cyst ; or the omentum, mesentery, 
 pancreas, large intestine, liver, or spleen, may be firmly united 
 to it ; and in long-standing cases a large quantity of fat may 
 grow into the hilum (Fig. GO). 
 
 Histologically the first changes in the kidney are characterised 
 by dilatation of the canaliculi and alterations in the shape of the 
 epithelium owing to the pressure exerted upon it. There is also 
 often considerable hypeniemia, and there may lie some haemorrhages 
 into the interstitial tissue. The next change is the increase of con-
 
 FLUID IN HYDRO-NEPHROSIS NOT LIKE URINE. 421 
 
 nective tissue, which renders the kidney very tough, and further dam- 
 ages its secreting substance. The walls of the arterioles also become 
 thickened and the circulation is impaired. Lastly, atrophy of all 
 the elements occurs and the kidney may be reduced to a mere shell. 
 The fluid of a hydro-nephrotic cyst is rarely like urine pure 
 and simple. Often it is odourless, gives no reaction with heat 
 or nitric acid or with cupric tests, has a low specific gravity ; 
 
 r 
 
 "j 
 
 Fig. 60. Sacculated Hydro-nephrosis, showing a considerable increase of fat in 
 the hilum. (Westminster Hospital Museum.) 
 
 leaves scarcely any residue on evaporation, and affords no evidence 
 of urea or uric acid ; in fact, it is only water holding a large 
 quantity of chloride of sodium in solution, and containing a 
 few epithelial cells. This has been the character of the fluid 
 in several cases of congenital hydro-nephrosis, and hi some acquired 
 cases in which atrophy has advanced until the glandular substance 
 has become entirely obliterated. Experiments have shown that 
 even a healthy kidney, if there be obstruction to the outflow of 
 the urine, secretes a fluid which is deficient in urea, and, there- 
 fore, of very low specific gravity. After ligature of the ureter, 
 Ludwig has shown that the sodium chloride is the first salt to 
 disappear from the fluid, by being absorbed into the blood ; this 
 is followed by the sulphates and phosphates, and later on by the
 
 422 SURGERY OF THE KIDNEY AND URETER. 
 
 uric acid and urea, but kreatinin may remain. Dr. Dickinson 
 remarks that if the dilatation, as often happens in double hydro- 
 nephrosis, is common to all the urinary cavities, " their contents 
 will be urine little changed, save that the specific gravity may be 
 low, as with urine secreted against pressure, and it may have 
 become ammoniacal." * Uric acid, urates, and oxalate of lime may 
 be found in the fluid ; at other times the contents of the cyst 
 are turbid and mixed with muco-pus, or with blood-clot of old 
 or recent date which gives a brawn or red colour to the fluid. 
 At others, again, urea and chlorides may be found in it in similar 
 quantities as in natural urine ; and this, too, according to Prout, 
 even in congenital h-ydro-nephrosis. Epithelial and granular cells 
 phosphates, and albumen, are frequent constituents. 
 
 Sometimes the contents are colloidal in character, as in Dum- 
 reicher's case ; and in a case described by Dickinson the same 
 " nasty stuff " had occasionally been passed per urethram. In a 
 case of hydro-nephrosis recorded by Dr. Coghill,t cholesterine was 
 found in the fluid, so was it also, and in conjunction with a large 
 quantity of albumen and 9 per cent, of urea, in a case recorded 
 in the January, 1898, number of the St. Mary's Hospital Gazette. 
 Mr. Hurry Fenwick exhibited to the Pathological Society of London 
 (January 2, 1894) a hydro-pyo-nephrotic kidney in the fluid of which 
 were crystals of cholesterine ; and in March of the same year Dr. 
 Cecil F. Beadles showed a left kidney, embedded in the substance 
 of which was a small cyst containing cheesy material and numerous 
 cholesterine crystals. Probably the presence of cholesterine in the 
 kidney is less rare than is supposed, and is to be found in small 
 renal cysts with clear fluid and in those which contain pus, and also 
 in caseous foci within the organ. 
 
 The quantity of fluid contained in a hydro-nephrotic cyst is 
 often enormous ; nine gallons, twenty -five gallons, and even 
 thirty gallons (Glass) have been removed ; and in several cases 
 sero-mucous, albuminous, or even well-nigh normal urine had 
 drained away through a fistulous opening in the loin in quantities 
 varying from four to ten ounces per diem. 
 
 Symptoms. Hydro-nephrotic distension affects each kidney 
 about equally. It occurs at any period, from birth to extreme 
 old age, and is met with also in the foetus. It is nearly twice 
 
 * See also case by Mr. Barker, in the Lancet, January 17, 1885. 
 t Edin. Med. Journ., February, 1875, p. 747.
 
 NO TUMOUR IF KIDNEY IS ATROPHIED. 423 
 
 as frequent in females as in males. The duration of symptoms 
 is very variable and in many cases extends over a number of 
 years ; thus in one case of a female, aged twenty-four, there hail 
 been pain and milky urine at intervals since childhood. 
 
 In cases in which the dilatation is insufficient to give rise to a 
 tumour, there are generally no symptoms characteristic of hydro- 
 nephrosis ; it is simply a silent complication, or consequence, of 
 some condition to which, and not to the insidious changes going on 
 in the kidney, the attention of the surgeon or physician is called. 
 
 It must be borne in mind that the whole series of morbid 
 changes described above may have occurred in the kidneys 
 without there being any sign of an abdominal swelling. Out 
 of forty-two cases of non-congenital hydro-nephrosis in which 
 the renal changes were well pronounced, there was a palpable 
 tumour in twenty-five ; and in nineteen of these the tumour 
 was unilateral, whereas in six it was double (Roberts). Out 
 of the 381 Middlesex Hospital cases an abdominal tumour was 
 clinically observed in but very few, though the atrophy of the 
 renal tissue was very advanced in all. 
 
 In some advanced cases in which there is no tumour, symp- 
 toms * are excited simply by the renal distension : these are 
 pain in the back and along the course of the ureter, frequent 
 micturition, and total or partial or intermittent anuria. 
 
 When the disease is bilateral, as in cancer of the uterus, 
 uraemia may be looked for ; and though in many of these cases 
 nothing can be made out from an examination of the urine, yet 
 evidences of renal degeneration are seen in the dry and sallow skin, 
 the aching loins, the nausea and sickness. When the pressure effects 
 of cancer of the pelvic organs are associated with ulceration of the 
 bladder, pyelo-nephritis and the symptoms to which it gives rise are 
 found ; when simple obstruction by pressure is caused, and there is 
 no ulceration of the bladder, hydro-nephrosis alone exists, and the 
 symptoms referrible to the kidney are less marked. 
 
 Vomiting, convulsions, febrile symptoms, and coma are occa- 
 sional phenomena. 
 
 Tumour. When a tumour is formed, hydro-nephrosis has 
 to be dealt w r ith as a distinct disease, and on itejown account; 
 and more especially so when it threatens to damage neigh- 
 bouring organs by its pressure, or to destroy life by bursting into 
 the peritoneum, or in some other direction.
 
 424 SURGERY OF THE KIDNEY AND URETER. 
 
 The tumour is dull on percussion, and is sometimes irregular 
 or lobulated in outline, and frequently fluctuates. By its size 
 it may cause much, pain, displacement of viscera, disturbance of 
 the action of the diaphragm, and thus of the lungs and heart ; 
 and it is especially prone to interfere considerably with the action 
 of the colon, thus inducing constipation. 
 
 If it arises from some innocent and painless cause, such as 
 pregnancy or flexion of the uterus, its development is unattended 
 by any constitutional or local disturbance ; but if from some 
 condition such as impacted calculus or movable kidney, the 
 symptoms incidental to the particular cause will occur before 
 the tumour makes its appearance, and will probably mask the 
 development of the swelling. 
 
 The enlargement has all the characters of a renal tumour, 
 being situated in the flank, pressing fonvards and outwards 
 the parietes, causing fulness in the ilio-costal area, having the 
 colon in front of it, and the small intestine either in front or 
 thrust over to the opposite side of the abdomen, according 
 to the bulk of the swelling. 
 
 Dr. Dickinson estimates that in about one-fourth of the cases 
 of single hydro-iiephrosis in which a swelling is observed during 
 life, the tumour extends beyond the median line of the body, 
 and that in one-third of these it has at length occupied the 
 greater part of the belly. 
 
 In Mr. Glass's case, by far the largast yet recorded, the belly 
 of the patient (a tall, well-proportioned woman of twenty-two) 
 measured six feet four inches in circumference, and the cyst 
 held thirty gallons of fluid ; the heart was pushed up to the 
 clavicle, and the lungs by compression were reduced to the size 
 of those of a new-born child. 
 
 Pain. It is often stated that a hydro-nephrotic tumour is 
 quite painless, and so it may be when not of any great size. 
 But 011 the other hand, when the tumour is large, the pain 
 may be of the most agonising character, as agonising as the 
 pain of unrelieved retention of urine in the bladder, or even 
 more so. 
 
 In some cases the sufferings amount to the most severe torture, 
 and the writhings of the patient are terrible to witness.* 
 
 * See case related in my " Surgical Diseases of the Kidney," 1885, 
 p. 311 et seq.
 
 "INTERMITTENT" HYDRO-NEPHROSIS. 425 
 
 A hydro-nephrotic sac may rupture into the peritoneal cavity 
 and give rise to severe pain for several days before death ensues. 
 Such a case has been recorded by Hebb in the Transactions 
 of the Pathological Society (vol. xlviii.). The patient, a man aged 
 fifty-three, was admitted into hospital for pain in and enlargement 
 of the abdomen. Some fifteen to twenty years before he had 
 had a severe blow on the left flank, since which occasional attacks 
 of pain had occurred, but he was able to work up to within 
 fourteen days of admission, when he was seized with severe pain in 
 the abdomen and felt something give way in the left side. He 
 vomited, and from this time the abdomen began to swell. After 
 death many pints of reddish-brown fluid were found in the 
 peritoneal sac, escaped from the left kidney, which was con- 
 verted into a cyst with secondary cysts representing the pelvis 
 and calyces. There was a rupture of the wall communicating 
 with the peritoneal sac at the junction of the ureter and pelvis. 
 The ureter was dilated and sacculated and was occluded by 
 adhesive fibrosis of its wall about one inch from the bladder. 
 It contained a small oval calculus, quite free, weighing 67 grs., 
 and composed of oxalate of lime. 
 
 Intermittence.-The symptom of intermittence is one which 
 gives a very important character to certain hydro-nephrotic 
 tumours (and pyo-nephrotic and haemato-nephrotic tumours also). 
 
 In March, 1876 (Trans. Roy. Med.-Chir. Soc.), I recorded a 
 case of intermittent hydro-nephrotic tumour due to a papilloma 
 of the bladder ; there were portions of the growth in con- 
 nection with both ureteral orifices, but the hydro-nephrotic 
 kidney was hypertrophied, the other was atrophied. At the same 
 time I published a table of six other cases of intermittent 
 hydro-nephrotic tumours due to different causes. I have since 
 seen other cases in which the tumour has been intermittent and 
 in which the hydro-nephrosis has occurred in non-movable kidneys. 
 I believe Dr. Cole of Bath, in 1874 (Brit. Med. Journ.), to have 
 been the first to give the distinguishing name " intermittent " to 
 certain cases of hydro-nephrosis ; Dr. Cole considered the cause in 
 his case to be an oxalate of lime calculus in the renal pelvis. 
 Certainly it was from Dr. Cole's paper that I adopted the 
 term. It is interesting to me, and only just to Dr. Cole, that I 
 should refer to this, because Albarran in his recent admirable 
 treatise (" Maladies du Eein ") states (and so far as English
 
 426 SURGERY OF THE KIDNEY AND URETER. 
 
 writers go erroneously states) that Landau " created the type 
 of intermittent hydro-iiephrosis which he attributed to movable 
 kidney." He then refers to me and others as following Landau, 
 and controverts the theory of Landau on the double ground 
 (1) that the variations in size of movable kidneys are often due 
 to states of congestion of the organ and not to the accumulation 
 of urine within the renal calyces and pelvis ; and (2) that inter- 
 mittent hydro-nephrosis is not always due to mobility of the 
 organ but to other causes, such as renal calculus and tubercle, 
 and stricture and stenosis of the ureter. Had Albarran read 
 my paper in the Medical Chirurgical Transactions, he would 
 have found cases due to these various causes there quoted in detail. 
 Moreover, the date of Landau's work is July, 1881, more than 
 five years later than my paper and seven years after Dr. Cole's 
 article in the British Medical Journal. Terrier and Baudouin 
 collected eighty-three cases of intermitting hydro-nephrosis and 
 found that the most usual cause of this special form of the 
 affection was a floating kidney causing a kink in the ureter."* 
 
 There is good reason to think that the varying degrees of 
 tension with which this feature intermittence of distension 
 is associated explains the alternation of local ease and suffering 
 which many patients experience even when there is no appreciable 
 renal tumour. When the renal distension amounts to a clinical 
 tumour, then the patient and the medical attendant find that 
 there are days and times when no tumour can be found, and others 
 when the tumour is quite prominent. With the occurrence of 
 the swelling there are pain and scanty urine ; as the tumour 
 subsides, the pain ceases, and an increased discharge of urine 
 from the bladder will soon follow. 
 
 Intermitting hydro-nephroses in which a tumour is prominent 
 at one time and not distinguishable at another are not very 
 uncommon ; in many others the tumour diminishes from time 
 to time without actually vanishing. Dr. Eoberts says that this 
 happened in nine out of the twenty-five cases collected by him, 
 in which the existence of a tumour was clinically ascertained. 
 In most of such cases the subsidence of the swelling is followed 
 by the discharge per urethram of an increased quantity of urine, 
 and when this can be proved to occur we obtain a most 
 important diagnostic sign of hydro-nephrosis. There is usually 
 * Annual of the Universal Medical Sciences, E. 28.
 
 HAEMORRHAGE IN HYDRO-XEPHROSIS. 427 
 
 considerable pain before the onset of the swelling and relief 
 usually precedes its complete disappearance. 
 
 The urine during the increased flow is usually of a lower 
 specific gravity than normal and occasionally there may be an 
 admixture of blood, pus or mucus, but these complications are 
 very rare in those cases which do not depend upon the presence 
 of papillomata or calculi. At other times, and in cases which do 
 not subside or intermit, the urine gives no information whatever. 
 
 The characters of the urine secreted by a hydro-nephrotic kidney 
 have already been described. When only one kidney is involved, the 
 urine passed by the patient may have nothing abnormal about it, 
 and beyond a somewhat low specific gravity it may be quite natural. 
 
 Hcematuria. It must be remembered that hsematuria, some- 
 times, though very rarely, copious, may be a symptom in 
 hydro-nephrosis. It was so in the case of a boy, aged seven, 
 who was under my care in 1893, and from whom I removed 
 a hydro-nephrotic kidney, as related in the Lancet (January, 
 1894, p. 205). Allingham* has reported a case, and others have 
 been published by Israel, Reclus, and Albarran. 
 
 Diagnosis. Hydro-nephrotic distension has to be diagnosed, 
 whea of moderate size, from renal abscess, perinephric abscess, 
 and perinephric extravasation. When it forms a palpable tumour 
 it may be mistaken for pyo-nephrosis, or for a hydatid or serous 
 cyst of the kidney, liver, or spleen ; and when of very great 
 size so as almost to fill the abdomen, it is most likely to 
 IDC mistaken for an ovarian cyst or for ascites. If there is 
 haematuria with hydro-nephrosis, the question of malignant renal 
 new growth may arise. 
 
 There is one sign which when it occurs is almost conclusive 
 of hydro-nephrosis, and that is the subsidence of the tumour, fol- 
 lowed by an increase in the outflow of urine ; but this very often does 
 not occur ; and we have, therefore, to rely on other symptoms. 
 
 Renal abscess and perinephric abscess are more acute in their 
 course, and excite much more pain and constitutional disturb- 
 ance in their onset and early part of their progress, certainly 
 l>efore any lumbar or abdominal swelling exists. 
 
 Perinephric abscess causes fulness in the loin, tending to 
 spread upwards and downwards, but does not present a circum- 
 scribed more or less movable tumour coming forwards in the 
 * Med. Press and Circular, 1892, vol. ii.
 
 428 SURGERY OF THE KIDNEY AND URETER. 
 
 abdomen, and felt, as the patient lies on his back, to be passing 
 beyond the umbilicus. There are often oedema and redness of 
 the skin of the loin in perinephric abscess, but not so in hydro- 
 nephrosis, at any rate not until after the tumour has reached too 
 large a size to be mistaken for perinephric abscess. In perinephric 
 abscess the matter may burst in the loin or at or below Poupart's 
 ligament, but is not likely to point higher up in front ; in hydro- 
 nephrosis redness and superficial fluctuation are sometimes felt at 
 a spot on the side, or towards the front of the belly. 
 
 Perinephric extravasation. After an injury to the loin or renal 
 region, it may be a question whether a tumour in this situation is 
 a collection of urine within the calyces and pelvis of the kidney due 
 to occlusion of the ureter by blood-clot or partial laceration of 
 its coats ; or is a circumscribed collection of urine and blood 
 in the perinephric tissue due to a more or less complete rupture 
 of the kidney or its pelvis. In the latter case the swelling will 
 attain a considerable size in a short time, because the kidney, 
 being displaced and not compressed from within, will offer less 
 obstruction to the secretion and outpouring of urine than when 
 the dilatation is of the kidney itself. The swelling, though to 
 an extent circumscribed, is likely to be much less defined* and 
 limited in front, and more diffused behind, above, and below, 
 than a hydro-nephrotic swelling. 
 
 Pyo-nephrosis. Between hydro-nephrotic and pyo-nephrotic 
 tumours the diagnosis is often impossible. If the urine is or has 
 been distinctly purulent, and if rigors, feverishness, and other indi- 
 cations of suppuration have preceded and accompany the swelling, 
 then pyo-nephrosis may be diagnosed. But in many cases of 
 pyo-nephrosifl these symptoms are wanting ; moreover, a hydro- 
 nephrotic sac may suppurate quietly, and thus pass by degrees 
 into a pyo-nephrotic tumour. Either may be completely closed 
 against the bladder. 
 
 Hydatid and serous cysts of the kidney will best be diagnosed 
 by their history. Is there or has there been any cause of obstruc- 
 tion ? If so, the swelling is in all probability hydro-nephrotic. 
 Hydatid of the kidney is often secondary to, or associated with, 
 hydatid of liver. If a hydatid vesicle has escaped with the urine, 
 the diagnosis is clear ; but this aid is not always forthcoming. 
 
 In hydatid of liver or spleen the tumour bulges less into the 
 loin, and more towards the front of the abdomen, or upwards
 
 HYDRO-NEPHROSLS AND OVARIAN TUMOUR. 429 
 
 against the diaphragm, than a renal tumour ; it is continuous 
 with the liver or spleen ; moves more decidedly and freely in a 
 vertical direction during respiration, and is moved less freely by 
 palpation from side to side. Even if, as may be the case, 
 there is resonance over a great part of the front surface of a 
 hydatid cyst of the liver, the extent of the anterior limits of 
 the tumour, together with the absence of fulness in the loin 
 and of the other symptoms mentioned above, will generally suffice 
 to exclude hydro-nephrosis. A hydro-nephrotic cyst may contain 
 large quantities of crystals of cholesterine, and if it forms a 
 large tense tumour passing up under the ribs and occupying the 
 epigastric and umbilical, as well as the right hypochondriac and 
 lumbar regions, it may very possibly, even after tapping, be mis- 
 taken for a hepatic hydatid cyst, unless the fluid is tested for 
 urea, which possibly may be found present in fair quantity, although 
 its absence or presence in minute amount would go for nothing. 
 
 Where the tumour is of great size, hydro-nephrosis is most 
 likely to be mistaken for ovarian tumour. This error has been 
 many times committed. Out of twelve cases of hydro-nephrotic 
 cysts in women which I collected in 1876, no less than seven 
 had been diagnosed as ovarian, and no less than five of the seven 
 were submitted to abdominal section on the strength of this 
 wrong opinion. I think it highly probable that a great many 
 of the tumours which have been diagnosed as ovarian, but which, 
 nevertheless, have spontaneously vanished, were hydro-nephrotic 
 in their nature, and disappeared by the discharge of the urine 
 through the natural channel; though it must be borne in mind, 
 as has been pointed out by Wilson,* that ovarian cysts may also 
 occasionally intermit, and the process be accompanied by profuse 
 .diuresis. 
 
 With care, however, an ovarian tumour will be excluded if 
 attention be paid to the direction of the growth of the enlarge- 
 ment, to its relation to the colon, and to the evidence afforded 
 by a vaginal and rectal examination. I have seen an ovarian 
 cyst even after removal very closely simulate a hydro-nephrosis. 
 The diagnosis had been very difficult, and when the cyst had 
 been excised the Fallopian tube was found adherent to its wall, 
 and communicating with its cavity. It resembled a hydro- 
 nephrotic kidney with a dilated ureter. 
 
 * Thomas Wilson, Annals of Surgery, May, 1897.
 
 430 SURGERY OF THE KIDNEY AND URETER. 
 
 When the tumour is renal the uterus is neither displaced 
 nor fixed, and there are generally some symptoms referrible to 
 the urinary organs. A renal cyst is rarely so mobile as many 
 ovarian tumours are. The large intestine can generally be de- 
 tected in front of a hydro-nephrotic cyst ; sometimes it may be 
 even rolled between the cyst and the fingers on the front of 
 the abdomen ; or gurgling and the sensation of flatus may be 
 detected. A caution is needed respecting the relation of the 
 colon ; occasionally, and especially when the tumour has attained 
 a great size, the colon gets behind the bulk of the tumour, 
 whereas on the other hand a portion of the intestine is in some 
 cases found in front of an ovarian tumour. 
 
 If with the fingers in the vagina or rectum a calculus or some 
 other cause of ureteral obstruction can be made out in the lower 
 end of the ureter, the diagnosis would be assisted and the cause 
 of the hydro-nephrosis explained. The relation of the tumour 
 to the uterus and ovaries should be ascertained by vaginal or 
 rectal examination, and the examination is assisted by pressure 
 with the other hand upon the front of the abdomen at the same 
 time. 
 
 When the renal dilatation is very considerable, and the attenuation 
 of the cyst very extreme, fluctuation may be so general and so 
 superficial that ascites may be thought to exist, as in Dr. Hillier's 
 case.* The character of the fluid, if withdrawn by aspiration or 
 tapping, will correct such an error, as it will probably have a 
 urinous odour, and may contain urea and uric acid. Ascites 
 may, however, co-exist with hydro-nephrosis as with any other 
 solid or fluid growth within the abdominal cavity. 
 
 The prognosis depends much upon the cause of the distension, 
 but chiefly upon whether one or both organs are involved. If 
 only one kidney is a ffected the other can do duty for both, and 
 life may be indefinitely prolonged, provided the size of the tumour 
 is not great, or relief from distension is afforded in good time. 
 If the distension increases, and is unrelieved, death will result 
 from the effects of pressure on neighbouring organs, from rupture 
 into the peritoneum, or from suppression of urine or uraemia. 
 Traumatic rupture of the cyst has been the termination of several 
 reported cases. Simon mentions four cases of this kind. Spon- 
 taneous rupture into the peritoneum is not, however, a frequent 
 * Med.-Chir. Trans, vols. xlviii. and lii.
 
 HYDRO-NEPHROSIS INCREASES RISKS OF OPERATIONS. 431 
 
 occurrence ; Roberts found it only once in nineteen fatal cases. Tay- 
 lor* records a case in a girl, aged fifteen, of acute hydro-nephrosis 
 which ruptured into the peritoneal cavity, but which w r as suc- 
 cessfully treated by laparotomy in the median line, and stitching 
 the cyst walls to the abdominal opening. All the urine from the 
 kidney (left) in this case came by way of the fistula. In most 
 cases where the distension affects both kidneys, the fatal result 
 is brought about by the destruction of their glandular substance, 
 and the gradual cessation of the renal function. 
 
 In some cases the tumour has spontaneously subsided and 
 never returned ; this was the termination in six cases out of 
 a total of forty-seven of hydro-nephrotic tumours which I 
 collected many years ago ; in a seventh case where the tumour 
 intermitted many times, it at length subsided, and had not re- 
 appeared when the patient was heard of a long time afterwards. 
 If the tumour is small and does not increase, there is no tendency 
 for it to be directly causative of death ; but there is always the 
 fear lest a calculus or some affection of the opposite kidney may 
 supervene and lead to a fatal issue by suppression of urine or by 
 uraemia. When the ureters and calyces of both kidneys are 
 dilated as a result of stricture, enlarged prostate, vesical growths, 
 etc., operations upon the lower urinary organs are full of risk to 
 the patient, owing to the great liability of inflammation spreading . 
 up the ureters, and ending in diffuse suppurative pyelo-nephritis. 
 
 Treatment. In considering the treatment of hydro-nephrosis, 
 it is as well to bear in mind that these swellings may (1) in- 
 termit ; (2) subside entirely and never recur ; (3) subside partially 
 but not quite disappear, or (4) suppurate and after suppur- 
 ating may undergo either of the changes just mentioned. Several 
 instances of each of these conditions are tabulated in my paper in 
 the Med.-Chir. Trans, (vol. lix., 1876). The great majority, how- 
 ever, never either intermit or subside. An intermittent hydro- 
 iiephrosis after refilling and subsiding many times may at length 
 subside and never recur : this was the termination of the tumour 
 which had existed off and on for four years in Dr. Cole's case. It 
 should also be remembered that many hydro-nephrotic kidneys do 
 not give rise to a tumour, yet cause pain, possibly haematuria, 
 and in some cases occasionally large discharges of urine ; and 
 if these kidneys were surgically treated in good time, the organs 
 * Lancet, October, 1884.
 
 432 SURGERY OF THE KIDNEY AND URETER. 
 
 would be prevented from becoming entirely destroyed, and many 
 of them would be capable of regeneration to a great degree. The 
 treatment of hydro-nephrotic tumours is purely surgical; nothing 
 can be done for them by medicinal remedies. When they cause 
 trouble either by their weight, pressure, or size, the aspirating 
 needle may be employed, if there is any reasonable ground for 
 believing that the obstruction is temporary, and that a reaccu- 
 mulation is not likely to recur ; but this is rare. 
 
 Massage. Attempts have been made to overcome the obstacle to 
 the passage of urine by friction. Two cases at least are on record 
 in which the tumour subsided after manipulation (Roberts' and 
 Broadbent's). In Roberts' case the tumour was rubbed in every 
 direction with a lubricating ointment ever}* other morning, and 
 after the third application the patient, a girl, aged eight, suddenly 
 passed a large quantity of urine, and the swelling forthwith 
 subsided and did not return. In Broadbent's case a child three 
 months old, whose abdomen had been large from birth, though 
 urine had been passed in usual quantity, had an enormous 
 tumour which disappeared after friction with iodine ointment. 
 The child, however, subsequently died. Probably this treatment, 
 which was thought to answer well in these two cases, was suggested 
 by a third case reported by Mr. Thurnam in 1837. A little boy, 
 four months old, had a lobulated tumour from alternate dilatations 
 and contractions of the whole length of the ureter ; the mother 
 of the patient was in the habit of rubbing it with her hand 
 to relieve pain, and when she did so she noticed the child's bladder 
 swelled up as large as an egg. 
 
 I have on several occasions known a hydro-nephrotic cyst to 
 disappear, or diminish markedly in dimensions, after palpation 
 in the course of a bedside examination ; but there is no curative 
 tendency in thus fortuitously emptying the cyst. Moreover, the 
 treatment by manipulation is not free from risks, and cannot 
 always even be tried, either because the tumour is far too pain- 
 ful to allow of it, or because the degree of distension would 
 make the risk of rupturing the cyst wall too great. 
 
 Tapping. Aspirating the tumour may eft'ect a complete cure 
 
 either by relieving pressure or by releasing torsion of the ureter. 
 
 Sometimes recovery occurs after a single tapping, as in Dr. CoghilFs 
 
 case,* in which an exploring needle let out four pints six ounces 
 
 * Brit. Med. Journ., February G, 1875.
 
 PUNCTURE OF HYDRO-NEPHROSIS VERY UNSATISFACTORY. 433 
 
 and a half of straw-coloured fluid, and the patient, a lady, aged 
 thirty, recovered. 
 
 In Croft's* case of hyclro-nephrosis, in a boy, aged twelve, 
 occurring forty-nine days after an injury, the tumour was tapped 
 eight times within three months ; between three and four pints 
 were withdrawn on each of seven occasions, thirty-eight ounces 
 of urinous fluid were removed on the eighth occasion, and after 
 this there was no subsequent reaccumulation, and the cure was 
 complete. The obstruction was probably due to a clot. 
 
 Recovery after a single tapping is rare ; as a rule, repeated tap- 
 pings are requisite. Of eighteen cases treated by simple puncture, 
 ten were cured, five died, and three were relieved ; but in more 
 than one of the fatal cases further treatment ought to have been 
 adopted, and if it had been, there is little doubt that these cases 
 might have been removed from the list of deaths into a list 
 headed " unrelieved by puncture, but cured by incision." 
 
 It must be expected, if aspiration, or the trocar and cannula 
 are employed, that the cyst will repeatedly refill, or that sup- 
 puration may possibly occur ; in either event, nephrotomy and 
 drainage, or nephrectomy will be required. Uraemia, erysipelas, 
 perinephritis resulting in inguinal abscess, and oedema of the 
 lungs, have caused death after puncturing. When the puncture has 
 been made far forwards, death has been hastened by peritonitis 
 due to the escape of fluid from the cyst into the peritoneum. 
 In one or two instances in which the puncture treatment has 
 been employed death occurred, long subsequent to the last punc- 
 ture, from spontaneous rupture of the cyst, a termination which 
 would have been prevented by lumbar nephrotomy or nephrec- 
 tomy. Puncture, followed by the injection of iodine, tincture of 
 iron, or other fluid intended to excite adhesion or contraction of 
 the cyst walls, is dangerous, and hitherto has been utterly futile. 
 I know of no case in which the practice has been successful, 
 though it has been several times tried. 
 
 Puncture with a large trocar and cannula, followed by the 
 retention of the cannula, is the oldest method of drainage ; but it 
 is imperfect, and not comparable with nephrotomy followed by 
 the stitching of the cyst wall to the parietes of the loin. 
 
 In the absence of any very distinctly fluctuating area where 
 the skin is discoloured or the sac thin, no better spot can be 
 
 * Clin. Soc. Trans., vol. xiv. p. 107. 
 VOL. I. 2 C
 
 434 SURGERY OF THE KIDNEY AND URETER. 
 
 selected, if the tumour be of the left kidney, than one just an- 
 terior to the last intercostal space ; but if the tumour be of 
 the right kidney this is too high, as the liver in all probability 
 would be traversed. I have on several occasions tested the truth 
 of this statement in the post-mortem room, and in only one 
 experiment did the liver escape ; in this single instance it was 
 very small and markedly distorted from cirrhosis. In one case, 
 that of a young person with healthy viscera, whose death had 
 been caused by a fall, the liver was considerably displaced up- 
 wards by effused blood ; but in spite of its upward displacement 
 it was transfixed by the needle three-quarters of an inch above 
 its right free edge. 
 
 In no instance was the spleen punctured by inserting the 
 needle in front of the eleventh intercostal space on the left side. 
 
 If there be no indication for operating elsewhere, the best 
 spot to select, when the tumour is of the right kidney, is one 
 half way between the last rib and the crest of the ilium, between 
 two inches and two inches and a half behind the anterior superior 
 spine of the ilium. This spot is on a level with the front of 
 the bodies of the lumbar vertebrae, and a needle here passed 
 horizontally inwards will be altogether in front of the normal 
 kidney, and will either transfix or pass in front of the ascending 
 colon when in its usual place. It may, however, with safety 
 lie conjectured that in any case of hydro-nephrosis of the right 
 side requiring to be tapped, if the trocar be inserted at the spot 
 I propose, and directed somewhat forwards, the peritoneum and 
 colon will be sufficiently in front to escape injury, and the liver 
 will be safely out of reach above, while the dilated kidney will 
 l)e tapped at its anterior and lower part. 
 
 Cauterisation of the abdominal walls to excite adhesions be- 
 tween the parietes and the cyst prior to iiephrotomy or to draining 
 with a cannula, is unnecessary, tedious, and fraught with danger. 
 Peritonitis and septicaemia have followed, and caused death. 
 
 Nephropexy. If the hydro-nephrosis is the result and not 
 the cause of movable kidney, iiephropexy may suffice. But no 
 case should be treated in this way without first making a careful 
 examination of the superior ureteral orifice, and testing the patency 
 of the ureter by means of the ureteral bougie passed from the 
 renal pelvis into the bladder. Even iu cases in which the mobility 
 of the kidney and the consequent kinking of the ureter have
 
 FAILURE AND RISKS OF CATHETERISATION OF URETER. 435 
 
 been the cause of the hydro-nephrosis, the normal relation of the 
 ureter to the renal pelvis may have become permanently altered, 
 or the kinking may have been made permanent by perinephric 
 adhesions, so that the mere anchorage of the kidney will not 
 give relief to the obstruction. 
 
 Catheterisation of the ureter from the bladder upwards has 
 been recommended and practised by a few surgeons in cases of 
 stenosis, valves, curves and strictures of the ureter when the channel 
 for the urine is only partially occluded ; but it is not a plan of treat- 
 ment which ought to be, or which can be frequently employed ; it 
 should not be attempted in the great majority of cases, and never, even 
 in the exceptional ones, save by an expert with the ureteral catheter. 
 
 It is admitted that the only cases of hydro-nephrosis which 
 are suitable for ureteral catheterisatioii are just those which are 
 most suitable for lumbar puncture, or for treatment by the aspi- 
 rator or trocar and cannula. The puncture has the advantage 
 over the ureteral catheter that asepticity can be more certainly 
 secured and thus the danger of infecting a hydro-iiephrotic sac 
 can be more completely avoided ; it is much easier of perform- 
 ance and more certain to empty the cyst ; it is not so painful 
 and unpleasant to the patient, who, if a woman, is caused a good 
 deal of distress by the manipulations and inspection of the bladder 
 in an objectionably exposed posture.* Further, it must be re- 
 membered that abrasions followed by contraction of the vesical 
 orifice of the ureter have been caused by the catheter in some 
 cases in which this treatment has been tried for hydro-nephrosis 
 from valves or curves in the ureter; also that, though a bougie 
 most readily passed upwards from the bladder to the kidney, 
 the urine was prevented from passing down to the bladder ; and 
 lastly that in cases in which a hydro-iiephrotic cyst has been 
 emptied and for the time apparently cured by the ureteral catheter, 
 relapses recur and the tumours have again refilled owing to the 
 subsequent contraction of the ureteral stricture or re-formation of 
 the ureteral curve. 
 
 Nephrotomy, Putting aside, therefore, massage, ureteral catheter- 
 isation and puncture as either unsafe or too uncertain, I would 
 summarise the treatment of every case of hydro-nephrotic tumour, 
 and of every case in which though there is no tumour the other 
 symptoms point to hydro-nephrosis, as consisting first in making 
 * See the illustrations in some recent works on gynaecology.
 
 436 SURGERY OF THE KIDNEY AND URETER. 
 
 an exploratory lumbar incision on the affected side and examining 
 the kidney and ureter in the manner detailed in the chapters on 
 operations ; and secondly in removing the cause of the obstruction. 
 
 The exact procedure must then depend upon the condition 
 found : (1) The obstacle if possible should be removed. If a calculus 
 in the renal pelvis or ureter, or a valve, stricture, or stenosis of 
 the ureter is present, this can be done by pyelotomy, ureterotomy, or 
 a plastic operation. If the obstruction is near the bladder uretero- 
 vesical grafting may possibly be indicated. (2) If the obstacle can- 
 not be removed and the opposite kidney is absent or diseased, lumbar 
 nephrotomy must be performed and a permanent fistula established. 
 (3) If the obstruction is one which is likely to be of only tem- 
 porary duration, or which cannot be removed at the time of 
 the lumbar exploration because of the state of health of the 
 patient, or if the condition of the opposite kidney is unknown, then 
 nephrotomy with drainage is the proper operation. Secondary 
 nephrectomy can be performed at any subsequent period if 
 necessary. (4) If the renal parenchyma has been destroyed past 
 secreting to any useful degree, and if the general state of health 
 of the patient and the known condition of the opposite kidney 
 warrant it, then primary nephrectomy is the only proper thing 
 to be done. This operation has been in my own hands and 
 those of others most successful for hydro-nephrosis when per- 
 formed in the manner I have recommended and practised for 
 many years past (see Vol. II., p. 260). 
 
 If nephrotomy with the view of establishing a permanent 
 fistula, or nephrotomy as a temporary expedient, is performed, 
 the edges of the cyst should be stitched to the edges of the wound 
 in the lumbar parietes. If the lumbar incision is made high 
 and carried far enough forwards, plenty of room is obtained, so 
 that the cyst wall can be readily drawn up into the loin wound. 
 
 Drainage and antiseptic irrigation are effected by means of 
 a large rubber tube, which should be fixed in the cyst, and weak 
 Condy's fluid, thymol, or weak carbolic acid in solution should 
 be passed through it daily, if requisite, to keep it aseptic. 
 
 This practice has been very successful, and ought certainly to 
 be adopted unless the surgeon is quite sure about the soundness 
 of the opposite kidney, before nephrectomy is entertained, provided 
 of course that there remains any secreting renal parenchyma and 
 that the cyst wall is not simply a fibrous or calcified membrane.
 
 NEPHROTOMY AND PLASTIC SURGERY ADVISED. 437 
 
 Xephrotomy has given me a most excellent result in a case 
 in which I operated upon the right kidney, which was movable 
 and hydro-nephrotic, for Dr. Knight of Brixton in 1893. Four 
 years before this date I had removed the left kidney of the same 
 lady for hydro-nephrosis (see Fig. 52, p. 405). The case is reported 
 in full in Dr. Knight's able thesis on " Movable Kidney and 
 Intermitting Hydro-nephrosis" (1893). This lady was alive in 
 July, 1899, and Dr. Knight, then kindly replying to my inquiries, 
 wrote: "After all these years Miss S. continues in good health. 
 The menopause has passed tw r o years. The fistula still remains 
 open, but the quantity of urine passed by it has diminished 
 during the last few years, until now it rarely exceeds two ounces 
 per diem; and a good quantity of healthy urine passes naturally 
 from the bladder. I saw her so that I might give you the latest 
 report, and I think she looks well and healthy, and has every 
 probability of reaching a good old age." The later history of 
 this case tends to show that such a change may take place 
 gradually, after fixing the kidney to the loin, that, though at 
 first all the urine escapes by the fistula, it may by degrees come 
 to find again its natural exit through the bladder. 
 
 In Taylor's* case, in which, after rupture of a hydro-nephrotic 
 cyst into the peritoneum, the abdomen was opened, the peri- 
 toneum cleared of the urine, and the cyst wall stitched to the 
 opening in the parietes, the patient made a good recovery with 
 a permanent fistula, which, however, did not drain nearly so 
 perfectly as it would have done through a lumbar opening. 
 
 A ephrectomy '. When a fistula remains in the loin after ne- 
 phrotomy and the fluid is very purulent or offensive, or what 
 remains of the renal tissue is incapable of performing the proper 
 function of the kidney, the patient runs risks from the con- 
 tinuance of such a sinus, and cannot derive any benefit from 
 retaining such a useless remnant of the kidney. Lumbar 
 nephrectomy should in such a case be performed. 
 
 The method of nephrectomy for hydro-nephrosis is by the lum- 
 bar incision. The cyst wall, having been reached, is punctured and 
 the contents are drawn off. As the fluid flows away, the sac is 
 gradually withdrawn through the wound and the cellular tissue 
 peeled off from it as it is withdrawn. The detachment of these 
 adhesions is easy and simple if care is taken not to begin the 
 * Lancet, October, 1884, p. 589.
 
 438 SURGERY OF THE KIDNEY AND URETER. 
 
 enucleation till the sac is actually reached. The cyst comes 
 away just as in ovariotomy. The pedicle is then ligatured in 
 the usual manner, and the wound closed. Xo fistula results, 
 and recovery is uninterrupted. 
 
 II. CONGENITAL HYDRO-NEPHROSIS. 
 
 By congenital hydro-nephrosis is meant hydro-nephrosis in the 
 foetus and new-born ; not hydro-nephrosis which occurs some 
 time after birth and is due to a congenital cause. 
 
 In by far the larger number of cases of congenital hydro- 
 nephrosis both kidneys are involved ; but this is not always 
 so. When one kidney only is affected, the obstruction will have 
 been caused by some abnormality of the corresponding renal 
 artery ; or some obliquity, contraction, or actual occlusion of the 
 ureter. Adler* describes the case of a child, aged three and a half, 
 who had suffered pain in the left side for a year and a half, 
 and whose abdomen was entirely occupied by a large tumour- 
 This was opened and the edges sutured to the skin, 650 cm. 
 of fluid being removed. Subsequent complications necessitated 
 nephrectomy, when the congenital origin of the condition was 
 shown by the abnormal arrangement of the colon, the nearly 
 horizontal direction of the ureter, and a fan-shaped distribution 
 of the renal vessels. 
 
 Congenital strictures of the ureter are sometimes a cause of 
 hydro-nephrosis, as in a case recorded by W. W. Ord in the Trans- 
 actions of the Pathological Society (vol. xlvi.), in which a hydro- 
 nephrosis was due to an apparently congenital stricture at the upper 
 part of the ureter, at the point of its exit from the pelvis of 
 the kidney. The case occurred in a boy, aged one year. In 
 the famous case cited by Bonetus in the " Sepulchretum " f an 
 evident tumour of the right kidney was produced by complete 
 occlusion of the ureter. Billard * has recorded the case of a 
 male child who had a large rounded hydro-nephrotic tumour 
 in the left lumbar region due to malformation of the ureter. 
 Towards the bladder the ureter terminated as usual, but above 
 it formed two small thin impervious cords, which joined the renal 
 pelvis by a number of filaments resembling a goose's foot. The 
 
 * Deutsch. Mcd. Wclnisdir., 1S94, xx., p. 151. 
 
 t Tome ii., p. 290. 
 
 I " Traite des Maladies des Xoiiveau-nes," p. 434.
 
 CAUSES OF CONGENITAL HYDRO-NEPHROSIS. 439 
 
 right kidney was somewhat larger than normal, and contained 
 turbid urine and a large quantity of sand-like calculous matter. 
 The infant lived one month. Cruveilhier mentions a case due 
 to congenital absence of the ureter. Cockburn has recorded in 
 the Pathological Society's Transactions, vol. xlviii., a case of hydro- 
 nephrosis in a child of five weeks, due to pressure on the ureter 
 by a congenital cystic tumour of the pelvis, of uncertain origin. 
 Reliquet has published a case* in which the cause was a cyst 
 compressing the ureter, and developed near the bladder in a 
 vestige of the canal of Mtiller. 
 
 When both kidneys have been involved, the most common cause 
 has been imperforate urethra ; this malformation may be a mere 
 membranous septum at some point, or a more or less complete ab- 
 sence of the urethra without any communication with the bladder. 
 Lamotte recorded a case in which a thin membrane situated 
 at the vesical orifice of the urethra and producing hydro-nephrosis, 
 was readily broken down on passing a sound. Billard f has 
 described the case of a still-born male in whom there was only 
 about an inch of urethra extending from the end of the penis 
 to the front of the perineum ; an internal orifice of the urethra 
 did not exist. The rectum ended in a cul-de-sac adhering to the 
 bladder ; there was no anus, and only a very doubtful representa- 
 tive of a prostate gland. Howship | gives the description of 
 three cases in which the cause was imperforate urethra. Dr. 
 Kennedy exhibited to the Dublin Pathological Society the body 
 of a new-born infant with enormous distension of the urinary 
 organs due to obstruction of the urethra. 
 
 In an instance of a still-born child (male) brought under my 
 notice by Dr. George Roper, and which I dissected, the kidneys, 
 ureters, and bladder were all greatly distended, and the only 
 ascertainable cause was a small cyst in the mucous lining of the 
 membranous urethra. This cyst did not quite fill the lumen 
 of the urethra, but being situated on the floor of the passage, 
 it formed an effective barrier to the outflow of urine. It was 
 one of the mucous follicles of the urethra much enlarged. 
 
 Torsion of the penis is a congenital cause. The accompany- 
 
 * Progres Mecl, 1877. Xo. 11. 
 
 t "Traite des Maladies des Xouveau-nes." 
 
 t " Treatise on Diseases of the Urinary Organs." 
 
 Dublin Journ. Med. Sciences, 1840.
 
 440 SURGERY OF THE KIDNEY AND URETER. 
 
 ing figures illustrate a case of this sort, which I had under 
 my care in 1893, and published in the Lancet, June 8, 1895 
 (p. 1435). The case is of interest because the infant (a male) 
 was operated upon within twenty-four hours of its birth, a 
 urinary fistula being established in each loin, and the child's 
 life thus prolonged for ninety-four days. 
 
 In another case, the details of which I published in 1876,* 
 the cause of the obstruction could not be ascertained, but there 
 was no reasonable ground for doubting that it was either such 
 
 Fig. 61. Torsion of the Penis, which caused double Hydro-ureterosis and Hydro- 
 nephrosis. (Reproduced from the author's work on " Injuries and Diseases of 
 the Genital and Urinary Organs." 1895.) 
 
 a cyst as in the case just mentioned, or else a thin, easily 
 broken-down membranous septum in the urethra. 
 
 Cases in which no stricture or other cause of obstruction 
 has been found are recorded by Braxton Hicks,| Gervis,^ 
 Smellie, Honerkopff, and Dr. A. K. Simpson. 
 
 In each of these cases the seat of the obstruction, whatever 
 its cause, must have been at the vesical orifice of the urethra 
 or altogether in front of the bladder. It was most likely some 
 slight obstacle which was overcome on the introduction of a 
 bougie, without being noticed, or by the pressure to which the 
 foetus was subjected during parturition. 
 
 Any cause, such as mtra-uterine pressure in the urethra or 
 bladder, preventing the discharge of urine, which goes on naturally 
 during the later months of intra-uterine life into the sac of the 
 amnion, may give rise to congenital hydro-nephrosis. 
 
 * Lancet, vol. i. The case was read before the Royal Med.-Chir. Society. 
 t Trans. Obstetrical Soc.. vol. v. * Ibid., vol. vi. 
 
 Glasgow Med. Journ. (now series), vol. ii. ]>. 330.
 
 CONGENITAL HYDRO-NEPHROSIS FROM TORSION OF PENIS. 441 
 
 It is quite possible that tonic spasm of the urethra or sphinc- 
 ter of the bladder may be the cause of double congenital 
 hydro-nephrosis in some cases. In support of this view there 
 is the undoubted fact that spasmodic muscular action occurs 
 in the foetus in utero to such a degree as to cause many 
 
 Fig. 62. Dissection showing condition and position of the Ureters and Kidney. From 
 a child (the same as in Fig. 61) upon whom a double lumbar operation was 
 performed within 24 hours after birth. 
 
 congenital deformities, such as club-foot, congenital dislocation, wry- 
 neck, etc. 
 
 It is certain that in some cases of congenital double hydro- 
 nephrosis the cause has resided in both the ureters. Braxton 
 Hicks recorded a case of enormous distension of the abdomen of 
 a foetus, which impeded labour and necessitated the use of the 
 crotchet. The abdominal distension was due to double hvdro-
 
 442 SURGERY OF THE KIDNEY AND URETER. 
 
 nephrosis from obstruction of each ureter. Broadbent* has 
 published a case, in which the obstruction affected both kidneys 
 of a female infant, and was due to valves of the mucous membrane 
 near the pelvis of each kidney. Lee reported a case in a female 
 in which the cause was impervious ureters. 
 
 The period over which congenital hydro-nephrosis extends 
 varies. In many cases the fostuses are born dead, sometimes 
 before the completion of the full period of gestation. In other 
 instances the children are born alive, but die within a short 
 period after birth, viz. from a few hours to three or four 
 months. In Broadbent's case the tumour subsided after friction, 
 but the infant died when between three and four months old. 
 Faber's case (a male) died from a fall when five and a half years 
 old ; he had been ventricose from birth. Lamotte's case seems 
 to have survived ; for though no urine was passed and a large 
 abdominal tumour existed, yet urine escaped, and the swelling 
 entirely vanished after a membranous obstruction in the urethra 
 had been broken down. 
 
 The character of the fluid in congenital hydro -nephrotic 
 cysts. The urine removed from cases of congenital hydro- 
 nephrosis varies considerably in its composition, and in some 
 cases contains little or no urea. In the specimen supplied from 
 Hay's case Prout found at first only faint and somewhat 
 doubtful traces, but after the fluid had stood several days 
 these became distinct. An acid principle was also detected, which 
 Prout thought somewhat resembled the allantoic in some 
 of its properties, though it differed from it in others. In 
 Kennedy's case, no trace whatever of urea could be found hi 
 the fluid removed either from the bladder or kidney, notwith- 
 standing a most careful analysis. In a case of foetal hydro- 
 nephrosis reported by Madge | the fluid contained in the 
 renal sacs had no urinous odour on boiling, and unsuccessful 
 attempts were made to find urea and uric acid in it. The fact that 
 such a condition as congenital hydro-nephrosis is possible, proves 
 that the secretion of urine goes on to a very considerable extent 
 during the latter half of intra-uterine gestation, and that when 
 any obstacle to the outflow of urine exists, the same pernicious 
 effects of distension of the bladder, ureters, and kidneys occur 
 
 * Path. Soc. Trans., vol. xvi., p. 16-4. 
 t Obstet. Soc. Trans., vol. xi.
 
 OTHER CONGENITAL DEFECTS. 443 
 
 before birth as are commonly known to arise from urethral 
 stricture, calculus, and other causes of obstruction after birth.* 
 
 A special point of interest connected with these cases is the 
 frequency with which they are associated with other congenital 
 deformities and malformations. Hare-lip, club-foot, some abnor- 
 mality of the anus or intestine, or some malformation of the 
 external genital organs, has often been found in the subjects 
 of congenital hydro-nephrosis. In Simpson's case the feet 
 were clubbed ; in Hay's case (reported by Lee), a still-born 
 hydro-nephrotic female infant had impervious ureters, double 
 hare-lip, and two clubbed feet. In Billard's case, a still-born male 
 had many defects of development in rectum, urethra, and prostate. 
 In one of Howship's cases, a male infant born alive at the eighth 
 month, the feet were distorted, the anus imperforate, and the 
 lower part of the belly was occupied by a large circumscribed 
 tumour. The child died the same evening ; the kidneys and 
 ureters, as well as the bladder, were found excessively distended 
 by urine ; the bladder, though it had attained an extraordinary 
 degree of thickness and strength, had given way posteriorly, 
 where a large cyst or pouch was formed ; and the natural struc- 
 ture of the kidneys had entirely disappeared. 
 
 In my own case, referred to above, there was an absence 
 of part of the rectum, and a cul-de-sac in place of an anus. 
 
 It has been chiefly, though not exclusively, with double con- 
 genital hydro-nephrosis that these various malformations have 
 been associated. The frequency of this association is of importance 
 to the practical surgeon, as well as of interest to the patholo- 
 gist ; for when considered side by side with the fact that mal- 
 formed and misplaced kidneys are also often associated with such 
 malformations, it teaches us to suspect renal imperfections, and 
 to be careful before undertaking nephrectomy, in one who has 
 any visible or ascertainable defect or error of development. 
 
 Lastly, an important practical point which must not be for- 
 gotten is that the size of the abdomen of a foetus affected with 
 hydro-nephrosis is often a serious impediment to labour, and 
 may under some circumstances render parturition impossible until 
 some means have been taken to reduce the volume of the child. 
 
 * See abstract of paper by the author, Lancet and British Medical 
 Journal, 1876; and also "Surgical Diseases of the Kidney," 1885, p. 330 
 et seq.
 
 444 SURGERY OF THE KIDNEY AND URETER. 
 
 III. PYO-NEPHROSIS. 
 
 By pyo-nephrosis is understood dilatation of the pelvis and calyces 
 of the kidney with pus, or pus and urine. It is a result of mechan- 
 ical obstruction with suppuration superadded. (1) The dilatation 
 may have preceded the suppuration for a longer or shorter period, 
 in which case pyelitis will have been superadded to hydro-nephrosis ; 
 or (2) the dilatation and suppuration of the renal calyces and pelvis 
 may have commenced and proceeded together. When the two 
 processes begin and advance simultaneously, the pyo-nephrosis is 
 always the result of some lesion, attended with suppuration in 
 the lower urinary organs. When the pyo-nephrosis is due to 
 suppuration supervening upon a previously existing hydro-nephrosis, 
 the septic infection may have ascended from the lower urinary 
 organs to the kidney ; or may have been conveyed to the kidney 
 through the blood or the lymphatics. In the latter event the 
 suppurative changes which have commenced in the hydro-nephrotic 
 organ may or may not descend to the lower urinary organs. 
 (3) In a third group the suppuration may have preceded the 
 dilatation, the distension of the renal pelvis and calyces following 
 from the obstruction caused either by masses of pus or muco-pus, 
 or blood - clot or calculus. Sometimes the amount of pus is so 
 small, the pyelitis so slight, and the amount of pent-up urine 
 so large, that the tumour is more a hydro-nephrosis than a pyo- 
 nephrosis, and the condition is then by the French writers named 
 uro-pyo-nephrosis. But in all cases where there is suppuration 
 as well as dilatation of the pelvis and calyces of the kidney, the 
 condition is, strictly speaking, pyo-nephrosis. 
 
 In advanced cases, the dilatation and suppuration go on to the 
 compression, atrophy, and breaking down of the medullary and 
 cortical substances of the kidney, until at length the whole organ 
 is converted into a large and loculated sac. This sac contains pus, 
 or purulent urine, or urine mixed with muco-pus in larger or smaller 
 quantity ; or pus and urine mixed with blood ; or a white phosphatic 
 deposit may line the renal pelvis and the loculi into which the 
 calyces are distended ; or these spaces may be filled with com- 
 pact inspissated putty -like pus, and with debris of renal calculi- 
 according to the cause of the obstruction. 
 
 Etiology. The conditions necessary for the production of 
 pyo-nephrosis being an obstruction to the outflow of urine
 
 DESTKUCTIVENESS OF PYO-NEPHROSIS. 445 
 
 and the penetration of pyogenic micro-organisms to the affected 
 part, these two conditions may, as has been just stated, take 
 place together or either of them may precede the other. Suppuration 
 may be induced through the elimination of micro-organisms by 
 the kidney from the blood, and herein may be the starting of 
 the subsequent cause of obstruction ; but in the majority of cases, 
 whether the septic infection is derived from the lower genito- 
 urinary tract or not, there exists, prior to the commencement 
 of suppuration, a state of dilatation of the kidney and often of 
 the ureter also. When the septic infection is ascending and is 
 secondary to dilatation, cystitis and ureteritis precede the pyelitis. 
 When the septic infection and dilatation affect the kidney 
 simultaneously, the kidney having previously been almost, if not 
 quite healthy, it is to the ascending ureteritis (with perhaps peri- 
 ureteritis) and the consequent changes in the ureter that the 
 obstruction to the outflow of urine is due. 
 
 As hydro-nephrosis becomes pyo-nephrosis as soon as sup- 
 puration ' occurs, the causes which produce hydro-nephrosis are 
 the primary causes of pyo-nephrosis also. But when an ob- 
 struction causes pyo-nephrosis at once, it is more complete in its 
 character, and more rapid in its irritative effects upon the kidney, 
 than when it causes hydro-nephrosis first. When pyo-nephrosis 
 is the primary effect, both kidneys are very frequently affected 
 at the same time ; but if only one kidney is involved, it in all prob- 
 ability has not had time, as in hydro-nephrosis, to go on gradually 
 dilating and gradually atrophying whilst the other kidney pari 
 passu is undergoing compensatory hypertrophy. 
 
 When pyelitis or pyelo-ureteritis has preceded the obstruction, the 
 cause of the obstruction is either a product of the inflammation 
 of the kidney, or is the same as that which excited the pyelitis. 
 As a result of pyelitis, the ureter may be blocked by a clot of blood, 
 or a little mass of inspissated pus or muco-pus, or a fragment of 
 cancerous or tuberculous material or of some semi-organised false 
 membrane, or by some white pultaceous matter containing more or 
 less gravel, from the pyo-nephrotic cavity. A vesical calculus or 
 growth, or a cancer of one of the pelvic organs, may be the cause 
 lx)th of the suppuration and the obstruction ; exciting, first of all 
 cystitis, and then pyelitis, by extension upwards along the ureter of 
 the inflammatory process ; and afterwards giving rise to obstruc - 
 tion by involving and occluding the lower ends of the ureters.
 
 446 
 
 SURGERY OF THE KIDNEY AND URETER. 
 
 To enumerate all the various causes of pyo-nephrosis would be 
 to give a complete list not only of the causes of hydro-nephrosis, 
 but of those of acute and chronic pyel it-is also. The most fre- 
 quent is calculous pyelitis ; indeed, renal calculus is so largely 
 in excess of the other causes of pyo-nephrosis that it has been 
 implied, if not explicitly stated, by some writers, that pyo-neph- 
 rosis and calculous pyelitis, when they assume the dimensions of 
 
 Fig. 63. Pyo-nephrosis (forming a Tumour) due to an oxalate of lime Calculus. 
 (Guy's Hospital Museum.) 
 
 a renal tumour (Fig. 63) are one and the same thing. This, 
 however, is not the case, and moreover the relation between 
 renal calculi and pyo-nephrosis is a double one ; 011 the one 
 hand the calculus may be and frequently is the cause of the 
 pyo-nephrosis, but, on the other hand, it may be secondary 
 and arise from the phosphatic deposits of the alkaline urine in 
 the renal cavity. It must also be borne in mind that very marked, 
 and indeed fatal, pyo-nephrosis may exist, whether the result 
 of renal calculus or of other causes, without giving rise to any
 
 PYO-NEPHROSIS MAY NOT CAUSE PALPABLE TUMOUK. 
 
 447 
 
 palpable tumour during life, as the subjoined particulars prove 
 (see Fig. G4). 
 
 During the ten years ending 1883 the post-mortem records 
 of the Middlesex Hospital contain thirty-six cases of pyo-nephrosis, 
 
 Fig. 64. Calculous Pyo-nephrosis; great destruction of Kidney substance. The 
 kidney is below the normal size. (Guy's Hospital Museum.) 
 
 unaccompanied by suppurative nephritis, from causes other than 
 stones in the kidnev. 
 
 Cancer of uterus and vagina . 
 
 Stricture of urethra 
 
 Cyst of ovary . 
 
 Uterine fibroid . 
 
 Epithelioma of penis 
 
 Abscess in bladder walls and cystitis 
 
 Stone in bladder .... 
 
 Villous disease of bladder 
 
 Sarcoma of bladder 
 
 Cause of obstruction not stated 
 
 13 
 
 4 
 2 
 1 
 1 
 1 
 1 
 2 
 1 
 10 
 
 Of the ten cases hi which the cause of the dilatation is not 
 stated there was injury or disease of brain, or spinal cord in seven, 
 heart disease in one, Bright's disease in one, and cancer of the 
 breast in one. 
 
 In the majority of these cases the pelvis of the kidney is 
 stated to have been " much distended," or " distended and full 
 of purulent urine," or the kidney was found " reduced to a mem- 
 branous sac, dilated and divided into compartments/' etc. In only 
 one of them, however, was there a renal tumour of any great size.
 
 448 SURGERY OF THE KIDNEY AND URETER. 
 
 This was in a man, aged thirty-nine, and its cause was stricture 
 of the urethra. The right kidney was enormously dilated, and 
 formed a tumour which extended from the liver to the pelvis ; 
 its secreting substance had almost disappeared ; its capsule was 
 adherent to the surrounding parts ; and its interior was loculated, 
 and lined by a slaty grey-coloured membrane. The left kidney 
 was in a similar but less advanced state. 
 
 A further analysis of cases from the records of the Middlesex 
 Hospital between the years 1884 and 1897 gives seventeen cases 
 of uncomplicated pyo-nephrosis in 3,926 cases. These records 
 show that pyo-nephrosis is sometimes associated with suppurative 
 nephritis, and between instances of pyelo-nephritis with very 
 slight dilatation of the renal pelvis and large-pouched pyo-nephrotic 
 cysts there is every intermediate degree. 
 
 In twelve other cases taken from the Middlesex Hospital 
 records during . the same period, pyo-nephrosis was complicated 
 with well-marked suppurative nephritis. 
 
 The causes of the disease in these cases were : 
 
 Cancer of the uterus and vagina .... 2 
 
 Epithelioma of bladder ...... 1 
 
 Stricture of urethra, with cystitis .... 5 
 
 Vesical calculus, with cystitis .... 1 
 
 Enlarged prostate, with, cystitis .... 1 
 
 Tubercular disease of bladder and kidneys . . 1 
 
 Cause unstated ....... 1 
 
 In nine out of the twelve cases the disease affected both kidneys. 
 
 Of sixteen cases of renal calculi observed during the same 
 period there was pyo-nephrosis in eleven. In three of the eleven 
 the kidney was extremely sacculated. In a fourth it was con- 
 verted into a membranous sac, the lower half of the organ being 
 wholly membranous, whilst the upper half retained only a slight 
 trace of renal tissue. In a fifth, the left kidney had lost all 
 its glandular substance, was enormously distended, loculated, 
 and filled with pus and many uric acid calculi, and formed a 
 tumour G^ inches long, and 9 inches in circumference ; the right 
 kidney was enlarged, but healthy; the bladder was inflamed, 
 and phosphatic deposits studded its lining membrane. The 
 patient was a man, aged sixty, who died of the pyo-nephrosis and 
 pelvic cellulitis. 
 
 Dickinson tabulates ten cases of pyo-nephrosis ; in six of
 
 PARTIAL PYO-NEPHROSIS FROM PARTIAL OBSTRUCTION. 449 
 
 them there was calculus in the affected kidney, and in two 
 stricture of the ureter. 
 
 Pyo-nephrosis occasionally occurs in a movable kidney, and 
 from some of the more recent foreign writings it would appear 
 as if this were not an unfrequent consequence of the mobility. 
 From my own experience I think the mobility is often a conse- 
 quence of the weight of the organ, and not the cause of the 
 renal distension and suppuration. Pyo-nephrosis is more often met 
 with on the right side when associated with movable kidney. 
 
 Pregnancy leads to pyo-nephrosis as well as to simple renal 
 distension, i.e. hydro-nephrosis. I have elsewhere referred to 
 suppurative pyelo-nephritis as a result of pregnancy and par- 
 turition. Pyo-nephrosis when caused by pregnancy is almost 
 invariably on the right side, the gravid uterus being inclined 
 to the right, and the foetal head, owing to the occipito-f rental 
 obliquity, pressing most on the right ureter and compressing 
 it against the brim of the pelvis. 
 
 Strumous diseases of the kidney occasionally lead to blocking 
 of the ureter and dilatation of the pelvis of the kidney ; but 
 these cases are characterised rather by the caseating deposits in 
 the substance of the kidney than by atrophy of the glandular 
 substance and distension of the calyces. 
 
 Partial pyo-nephrosis, like partial hydro-nephrosis, 'occurs if 
 the obstacle affects only one portion of the renal pelvis, or the 
 opening of only one or t\vo calyces into the infundibulum. 
 
 Ewart records a case of sacculation of the lower half of each 
 kidney: each kidney possessed two ureters. The cause of the ob- 
 struction was found to be tuberculous disease of the two lower ureters. 
 
 The cause of pyo-nephrosis is not always ascertained ; it was 
 not discovered in the case of pyo-nephrosis affecting one half of a 
 horse-shoe kidney (Fig. 19, p. 74 ante), the specimen of which 
 is in the Middlesex Hospital Museum. 
 
 Erichsen mentions gonorrhoea as an occasional cause of pyc- 
 nephrosis, and alludes to a case in which an abdominal tumour 
 was thus formed. Bayer speaks of gonorrhoea as being a not 
 uncommon cause of pyelitis. There is no proof, however, that 
 these were other than instances of post-gonorrhosal invasion of 
 the kidney by ordinary pyogenic organisms, but Dr. Arpad 
 Gerster has recent!}' reported a case in which the gonococcus 
 and the staphylococcus albus were found in the kidney pus, and 
 VOL. i. 2 D
 
 450 SURGERY OF THE KIDNEY AND URETER. 
 
 Dr. Bransford Lewis * has published a case in which no organisms 
 were present except the gonococci, which had readied the renal 
 pelvis and tubules along the mucous membrane of the bladder 
 and ureter. 
 
 Pyelitis followed by pyo-nephrosis sometimes results from 
 wounds and contusions in the renal region. A case of an 
 enormous pyo-nephrotic cyst from injury to the loin occurred 
 in a boy, aged sixteen, who was admitted into the Middlesex 
 Hospital under Murchison.t The tumour first showed itself 
 about eight months after .the injury, and went on slowly in- 
 creasing for seven years. 
 
 Morbid Anatomy. The outline and volume of pyo-iiephrosis 
 vary considerably, as do those of hydro-nephrosis. 
 
 The tumour may be reniform in outline, and more or less, 
 or not at all, enlarged ; or it may be globular or elongated. 
 Sometimes the enlargement of the kidney is accompanied by an 
 incurving of its two extremities, which tend to embrace the dilated 
 renal pelvis, and thus the kidney acquires somewhat the shape 
 of a horse-shoe. 
 
 The renal surface may be lobulated, the lobules forming large 
 rounded cysts, and the pelvis of the kidney is often enormously 
 expanded. In colour it may be in large part the same as the 
 kidney, or it may be greyish-yellow from the proximity of the 
 purulent contents to the renal surface. By gradual absorption 
 or actual destruction, first the pyramids and then the cortex may 
 disappear, until at length the whole organ is reduced to a mere 
 many-chambered sac (Figs. 65 and 66). 
 
 The cortex differs very much in character, being in places; 
 tough, thick, and resisting, and in other specimens, or in other 
 parts of the same specimen, being so thin as to allow pus to 
 be seen through it, and to admit of an elastic or even a fluc- 
 tuating sensation being communicated to the finger. 
 
 Perinephritis has in most cases been excited, and has led 
 to considerable change in the surrounding cellular tissue, which is 
 often densely adherent to the renal capsule. In some instances 
 the perinephric tissue has undergone considerable fibro-lipomatoue 
 increase, and this sclerosed fatty tissue may project far into the 
 renal hilum and between the calyces (Fig. 66). 
 
 * Journ. of Cutaneous and Genito-urinary Diseases, September, 1900. 
 t Sec Murchison's " Lectures cm Diseases of the Liver, p. 11 ">.
 
 SUBCAPSULAR ABSCESS A RARE COMPLICATION. 
 
 451 
 
 In other instances, suppurative periiiephritis is present, and in 
 others, again, the kidney may be encased or " set," as it were, 
 in a dense, tough, and enormously thick mass of fibre-fatty sub- 
 stance, which it is impossible to remove except by detaching the 
 proper capsule of the kidney with it (see Fig. 34, p. 272 ante). 
 
 Albarran refers to a rare form of subcapsular abscess as 
 
 Fig. 65. Section of a left Kidney in a very advanced stage of calculous Pyo- 
 nephrosis, and showing numerous cavities. Symptoms of renal trouble for 24 
 years. Nephrectomy. Author's case. (Middlesex Hospital Museum.) 
 
 occurring in exceptional cases of pyo-nephrosis. The pus in these 
 cases may form an extensive collection between the kidney and 
 the proper renal capsule, without having any communication with 
 the pyo-nephrotic cavity or cavities. Albarran gives references 
 to three cases of this sort which were brought before the Societe 
 de Chirurgie in 1889 and 1890. 
 
 On section the tumour is found to consist of a number of more or
 
 452 
 
 SURGERY OF THE KIDNEY AND URETER. 
 
 less separate loculi or cysts, which communicate with the venal 
 pelvis and, by means of the pelvis, with one another. These 
 loculi, cysts, or pouches, which represent the dilated renal calyces, 
 vary greatly in numbers and dimensions in different cases. 
 
 The cortical and medullary portions of the parenchyma are 
 often indistinguishable from each other, having undergone a con- 
 
 Fig. 66. Pyo-nephrosis, with fibro-fatty deposit in the Hilum. Removed 
 during life. Author's case. 
 
 siderable amount of sclerosis as well as atrophy. Indeed, in 
 some instances, their consistence is almost cartilaginous, and may 
 be even calcareous or osseous. In many cases the parenchyma 
 lias suffered changes common in suppurative nephritis, and 
 small abscesses are found in the partitions between the en- 
 larged calyces. The partitions between the pouches are formed 
 by the partially atrophied, or often by greatly sclerosed columns of 
 Bertini. These septa may be (1) thick, tough, and inelastic, and 
 may so surround the loculi that their communication with the 
 renal pelvis is reduced to a very narrow opening, or is closed
 
 PYO-NEPHROSIS COMPLETELY OR INCOMPLETELY CLOSED. 453 
 
 altogether, thus converting the loculi into distinctly isolated cysts 
 or abscess chambers (Fig. 65). 
 
 (2) Or the septa may be imperfectly developed, and represented 
 only by radiating, slight ridges or projections on the wall of large 
 sacculi (Fig. 66). 
 
 (3) Or they may be actually destroyed in places, so that the 
 adjacent pouches communicate. 
 
 In advanced cases the septa 
 may have quite disappeared, 
 and one large, smooth-walled 
 sac, with a dense fibrous capsule 
 and no trace of renal sub- 
 stance, is the result (Fig. 68). 
 
 The internal surfaces of the 
 cysts are often smooth ; but at 
 other times they have a rough 
 woolly appearance ; or a false 
 membrane of a grey colour, 
 which may be easily detached, 
 lines them.- This membrane not 
 very uiifrequently is calcined. 
 
 Just as some of the pouches, 
 may be entirely shut off from the 
 renal pelvis as well as from one 
 another, so the whole pyo-ne- 
 phro tic cyst may be shut oft' from 
 communication with the bladder ; 
 or there may be a slight perma- 
 nent communication allowing of 
 the constant passage of a small 
 amount of pus, or pus and urine, 
 to the bladder ; or the communi- 
 cation may be an intermittent one, allowing of the occasional emptying 
 of the sac, and thus an intermittent discharge of a large quantity 
 of pus ; or again, a pyo-nephrosis which has for a time been 
 quite closed may subsequently become patent by the shifting of a 
 calculus or the giving way of a partition. 
 
 As is so often seen after iiephrotomy, most of the pyo-ne- 
 phrotic kidneys, whether packed with condensed pus, or distended 
 with fluid pus, or pus and urine, are able to secrete . urine 
 
 Fi{*. 67. Great destruction of the Kidney 
 from calculous Pyo-nephrosis. Symp- 
 toms of renal trouble for nine years. 
 Removed during life. (Author's case.)
 
 454 SURGERY OF THE KIDNEY AND URETER. 
 
 after being opened and evacuated. And it is important in this 
 connection to bear in mind that the microscopic lesions of the 
 renal parenchyma are of more consequence than the dimensions 
 of the pouches or the thickness of their walls. Pyo-nephrosis, 
 with thick partitions and a thick rind of parenchyma, may not 
 be able to secrete so much urine, or urine of so good a quality, 
 as those with a much smaller amount of rind and much thinner 
 partitions. 
 
 The causes of renal retention, whether calculous or otherwise ; 
 and whether situated in the kidney itself, or in the ureter in 
 the form of stricture, curves, twists, or abnormal states, or at the 
 renal or vesical orifice of the ureter, do not influence the cha- 
 racters of the suppurative changes. 
 
 The changes in the ureters vary considerably according to the 
 mode of onset of the disease. In cases where the pyo-nephrosis 
 has been preceded by hydro-nephrosis both ureters are frequently 
 affected ; they look twisted and tortuous like varicose veins ; they 
 are dilated unequally, so that they present a moniliform appear- 
 ance, especially marked as a rule at the two extremities of the 
 duct and most pronounced at the upper end ; they are also increased 
 in length and . thus present enlargements, constrictions, and folds. 
 The ureteral walls are in places thin, and are surrounded by 
 loose cellular tissue. The mucous membrane is much inflamed, 
 and glaridular cysts are sometimes developed upon it, and there 
 is an increase of the muscular fibres at the situation of the 
 valvular folds which project into the lumen of the tube. 
 
 In other cases, where hydro-nephrosis has not been a prominent 
 antecedent, one ureter alone is often affected, there is no elonga- 
 tion of the tube, and the peri-ureteral tissue is tough and ad- 
 herent : sclerosis and rigidity of the ureteral walls are the prin- 
 cipal characters, the dilatation being irregular and comparatively 
 slight. The points of stricture are due to thickening of the wall, 
 not to folds and twists of the ureter. These different changes in 
 the ureter are more fully described in the chapter on Ureteritis 
 and Peri-ureteritis, to which the reader is referred for further 
 details (Vol. II.. p. .'Wl et scq.}. 
 
 The relation and connection of the cyst with the structures 
 surrounding it vary. Sometimes it forms adhesions on all sides, 
 with the liver or spleen above, with the small intestines on the inner 
 side, with the ascending or descending colon in front or on the
 
 PRIMARY OR SECONDARY CALCULI IN PYO-NEPHROSIS. 455 
 
 inner side, and with the deep structures of the abdominal parietes 
 behind and on the outer side. The surrounding parts are dis- 
 placed in proportion to the size of the tumour ; if this is con- 
 siderable, the cyst may push up the liver or spleen several inches 
 and extend a very long way upwards beneath the ribs (adding often 
 considerably to the difficulties and dangers of nephrectomy), as well 
 as displace the intestines inwards, and the parietes at the loin 
 outwards and backwards. Ulceration. of the cyst wall, or suppu- 
 rating tracks formed through what remains of the renal substance, 
 sometimes end in fistulous openings into the parts around ; it 
 may be into the cellular tissue of the loin, or into the stomach, 
 duodenum, colon, or peritoneum. Sometimes only one, sometimes 
 several fistulous openings occur in the same case (see p. 376 ante). 
 As soon as a fistula forms, the purulent urine escapes and gives rise 
 to perinephritis, peritonitis, or the discharge of pus and urine by 
 the mouth or rectum, or through the loin. A fistula may form, 
 as a consequence of pyelitis, before the calyces and pelvis have 
 become much dilated, or the kidney otherwise enlarged ; but, 
 except in tuberculous kidney, atrophy of the renal substance, 
 and more or less complete retention of pus or purulent urine 
 in the cavity of the kidney, generally precede renal fistulse. 
 
 In pyo-iiephrosis of the left side, the cyst wall may form ad- 
 hesions directly with the diaphragm ; and if the diaphragm 
 becomes adherent to the base of the left lung a fistula may open 
 directly through the muscle into the lung. Urine and pus from 
 the left kidney in this manner come to be expectorated. 
 
 The fluid contained in the distended kidney varies in 
 different cases, and even in different pouches of the same speci- 
 men. Sometimes it is pus mixed with urine or blood, or pus 
 so concentrated that there is scarcely a trace of urine. The pus 
 may be of a greenish colour or largely mixed with gritty lime 
 salts. If the iluid has become changed by decomposition and the 
 development of ammonia, it is more or less thready and glairy, 
 containing little masses of gangrenous debris; and phosphates are 
 often deposited on the walls of the cysts and renal pelvis. At 
 other times the contents consist of a soft mortar}' material, of a 
 white or yellowish- white colour, and of the consistence of butter. 
 
 Calculi, either primary or secondary, are found in many cases in 
 pyo-nephrosis. Primary calculi are often the sole cause of the pyo 
 iiephrosis. Secondary calculi may be situated in any part of the
 
 456 
 
 SURGERY OF THE KIDNEY AND URETER. 
 
 tumour, either fixed or loose in the pelvis or calyces, or fixed 
 in the cortex near the surface. Often these calculi are covered with 
 a thick layer of cheesy pus, or muco-pus, which may be of a 
 brownish colour from the presence of blood, 
 instances a most foetid, feculent odour. I 
 to stink most horribly for many days 
 nephrotomy and exposure to the air. 
 
 In other cases the fluid may be simply urine which contains 
 
 They have in some 
 have known calculi 
 after extraction by 
 
 Fig. 68. Kidney of which the Pelvis is 
 blocked by a Calculus. 
 
 The chambered and enlarged cavity of the kidney 
 was filled with thick greenish pus .and 
 calculous material. (Prom specimen in St. 
 George's Hospital Museum.) 
 
 Fig. 69. The same Kidney as shown in 
 Fig. 68. 
 
 It has been converted into a chambered cyst six 
 or seven times larger than the normal kidney, 
 with thick fibroid walls and septa. Lithatic 
 calculi are contained in the chambers and 
 embedded in the septa. The cavities in the 
 recent state, as well as part of the ureter, 
 were filled with pus. From a man, aged 43, 
 who died of oedema sdottidis. 
 
 very little, if any, urea ; or it may be urine mixed with a very 
 small quantity of pus, and it is this variety which has been 
 termed uro-pyo-nephrosis. The micro-organisms which are most 
 commonly found are bacillus coli, staphylococci and streptococci, 
 and proteus. Melchior has shown that the bacillus coli is much 
 the most frequent of all forms of urinary infection. In a large 
 number of samples examined, this bacillus alone has been found, 
 but it is often present with other micro-organisms. 
 
 When a calculus is formed in the kidney it often assumes 
 a branched shape which exactly fits the pelvis and calyces ; in 
 other instances, one calculus blocks the ureter, and more or less
 
 THE 1NTERLOCULAR PARENCHYMA MAY BE NORMAL. 457 
 
 tills the pelvis, whilst other independent calculi occupy one, two, 
 three, or more of the calyces (see Figs. 08 and <i!M. 
 
 It does not always happen that a calculus which is large 
 and branched, occupying pelvis and calyces too, obstructs the 
 urine altogether. In such cases the kidney does not become 
 nilurged, though the mucous membrane of the pelvis and calyces 
 is much inflamed. On the other hand, when a small stone is 
 impacted in the ureter the kidney is likely to suffer quite as 
 seriously, to become the subject of a general pyelitis and to be 
 rapidly distended with urine mixed with mucus, pus, and blood. 
 Le Dentu in two cases observed the presence of gas, and Tuffier, like 
 myself, has found pyo-iiephrosis complicating a polycystic condition 
 of the kidney. In such cases pus is found in many of the cysts. 
 
 In some cases, although the kidney becomes completely sac- 
 culatecl and loculatecl, and left without a trace of glandular 
 tissue, the organ, instead of being enlarged, is actually reduced 
 in size below normal, owing to shrinking of the cyst. 
 
 Microscopically, the renal tissue is found to contain an excess of 
 connective tissue and often presents appearances like those of diffuse 
 suppuration of the kidney. The septa between the pouches are 
 fibrous, and the walls of the arterioles running in them are much 
 thickened and their lumen diminished, and may be actually ob- 
 literated. In old pyo-nephrosis even the vessels of the pedicle 
 may be obliterated ; they are very commonly diminished in 
 calibre and have thickened, rigid walls. In rare cases all trace 
 of renal tissue has disappeared ; but, on the other hand, there are 
 often present patches of true hypertrophy, or, at least, parts in 
 which the renal tubules and glomeruli, well preserved, are lined 
 with normal epithelium and secrete urine freely. 
 
 Symptoms. In the early stages of the development of pyo- 
 nephrosis the symptoms will be those excited by the cause of the 
 obstruction, whatever that may be, whether calculus, or stricture 
 of the urethra, or enlarged prostate, etc. ; after wards there will be 
 added those of renal distension and pyelitis. In pyo-nephrosis due to 
 some cause in the lower urinary organs, cystitis very frequently 
 precedes it, and in the cases in which the cause of the pyo-nephrosis 
 is in the kidney itself, reflex vesical symptoms such as frequent and 
 painful micturition are very common and are too often attributed to 
 cystitis. When the pyo-nephrosis is the result of an obstruction 
 following pyelitis or pyelo-nephritis, the symptoms of this disease
 
 458 SURGERY OF THE KIDXEY AND URETER. 
 
 will be followed by other and often well-marked symptoms, such 
 as fever accompanied by the development of a tumour, by pain 
 caused by renal distension, and possibly by the occasional evacu- 
 ation of large quantities of pus followed quickly by the subsidence 
 of the tumour. In intermittent evacuations of the contents of 
 the kidney, whether complete or partial, it is during the complete 
 retention that the characters of the urine improve, whilst the 
 general symptoms of the patient become worse. If the obstruction 
 is not complete there will be pus in the urine ; if complete but 
 intermittent, there will be intervals when no pus is discharged ; 
 whilst if the obstruction is both complete and permanent there 
 will be an entire absence of pus in the urine. 
 
 General symptoms. There will be constitutional symptoms 
 of suppuration ; sometimes shivering, sometimes a high tem- 
 perature at night without rigors ; emaciation, great prostration 
 of strength, loss of appetite, perhaps sickness and diarrhoea, and 
 often a dusky pallor or sallow tinge of skin. When the pyelitis 
 is very chronic and severe there may be all the symptoms of hectic 
 fever. When pyo-nephrosis occurs as the result of pregnancy, 
 it is usually during the period from the fourth to the sixth month 
 that symptoms set in ; these consist of frequent and painful 
 micturition, severe pain in one or the other loin, purulent 
 urine, high temperature, perhaps rigors and generally consider- 
 able gastric and nervous disturbances, such as sickness, vomiting 
 and restless excitement. The same symptoms are, however, caused 
 by pyelonephritis without pyo-nephrosis ; so that in the ab- 
 sence of proof that hydro-nephrosis had previously existed, and 
 had become infected, the diagnosis of suppurative diffuse ne- 
 phritis is even more probable than that of pyo-nephrosis during 
 pregnancy. 
 
 Tumour. The presence of a tumour together with fever and 
 the other general symptoms mentioned is characteristic of pyo- 
 nephrosis; but various conditions may prevent the detection of a 
 tumour such as the configuration and obesity of the patient, 
 the subcostal position of the enlargement, or, chief reason of all, 
 because of the absence of any marked enlargement of the kidney. 
 On the other hand, in thin persons and where the increase takes 
 place below the ribs, medium sized or even small tumours may 
 be easily detected. Variations often occur in the volume of the 
 tumour, and I have seen and collected a number of cases in which
 
 ADHESION OF TUMOUR TO LIVER OR SPLEEX. 459 
 
 the tumour has subsided once or oftener and finally never again 
 reappeared. 
 
 When a pyo-nephrotic swelling presents itself in one or the 
 other loin it possesses the same characters as a hydro-nephrotic 
 tumour. It is elastic or fluctuating, or nodulated and hard, 
 and bulging backwards into the flank as well as occupying more 
 or less of the abdomen. If the tumour is not large, there will 
 l^e no actual prominence or bulging of the loin, but merely a 
 slight fulness, or it may be even only just the loss of the natural 
 incurvation of the region. As the kidney becomes more distended 
 and enlarged, the flank may become more and more prominent, 
 until at length a tumour can be both seen and felt projecting the 
 abdominal walls of the ilio-costal space outwards and backwards. 
 In many cases the tendency is for the tumour to increase 
 towards the thorax, pushing upwards the liver or spleen and 
 reaching to a height beneath the ribs which has sometimes quite 
 astonished me. In some cases a pyo-nephrotic kidney may so 
 expand in this direction, and in this direction only, that scarcely 
 any, if any, enlargement is detected by palpating the loin or 
 the abdomen. In other cases, when it is of very large size, 
 the tumour may reach the iliac fossa, or even Poupart's liga- 
 ment or the hypogastrium, and may weigh from ten to thirty 
 pounds or more. On percussion there is as a rule dulness in 
 the flank and not unfrequently the want of resonance extends for 
 some distance forwards ; but the extent of anterior dulness varies, 
 because if the colon is distended with flatus there may be re- 
 sonance for some distance outwards as well as over the front 
 and inner side of the tumour. 
 
 Unless pyo-nephrosis occurs in a movable or horse-shoe kidney, 
 as is sometimes the case, there is always dulness posteriorly. 
 When the tumour is not of great size there may be a line of 
 resonance in front, above it, on the left side between it and 
 the spleen, and on the right side between it and the liver ; but 
 if it be of considerable dimensions it may have formed adhesions 
 with the under surface of the liver or spleen, and so simulate 
 a tumour or hypertrophy of one or other of those organs. If 
 very large the tumour has almost always a more or less bossy 
 or lobulated outline; when this is the case, and fluctuation is" 
 also distinct, hydro- or pyo-nephrosis is clearly indicated. 
 
 When the cause of the obstruction is intermittent in its action,
 
 460 SURGERY OF THE KIDNEY AND URETER. 
 
 the lumbar tumour will diminish, or may even disappear altogether 
 after the discharge of a large quantity of pus. 
 
 Pain. Pain is by no means a constant or a pronounced 
 symptom. It is often abst-nt altogether throughout a long part or 
 the whole of the course of a case. It is due when, present to 
 intra-renal tension, or to dragging, or pressure upon surrounding 
 parts. The pain may be nothing more than a dull aching with 
 or without exacerbations of acute suffering, radiating along the 
 coui-se of the ureter to the penis, and down the thighs. There 
 are in some cases paroxysms of great severity. As in perinephric 
 abscess and other renal enlargements, the patient may bend to 
 the affected side or keep the thigh bent upon the abdomen in 
 order to relieve the suffering caused by making tense the psoas 
 muscle. 
 
 The pain experienced depends greatly on the size of the tumour, 
 pressure over the front of which nearly always aggravates 
 or provokes pain if it was not present before. Pressure over the 
 flank, in some cases, is not only well borne but actually gives 
 relief. If the abdomen is carefully palpated there may be tender- 
 ness along the course of the ureter, and a rectal or vagina] 
 examination often causes pain and reveals marked thickening of 
 the ureteral walls. 
 
 Urine. The urine should be carefully and frequently examined. 
 Pus, and occasionally a little blood, are the abnormal substances 
 it contains. If the ureter is completely blocked, the total 
 quantity of urine excreted for a time, at least, after the occlu- 
 sion will be markedly diminished. The compensatory function 
 of the other kidney may, however, soon bring the amount 
 excreted up to normal. If partially blocked, the quantity of pus 
 and urine will vary from time to time, even during the same 
 day. If the cause of the obstruction shifts so that the ureter, 
 from being quite blocked at one period, becomes patent at another, 
 large quantities of purulent urine will be passed during the patency 
 periods only, the urine in the intervals of occlusion being quite 
 clear and natural provided the opposite kidney is healthy. In the 
 case of pyo-nephrosis in one half of a horse-shoe kidney, from 
 which Fig. 10 (p. 74 ante) was taken, the patient, seven years 
 before his death, complained of severe abdominal pain and constipa- 
 tion. Fourteen days after the onset of these symptoms there was a 
 rise in his temperature, and two days later, when at stool, he
 
 URINE NORMAL WHEN PVO-NEPHROSIS IS CLOSED. 461 
 
 felt something give way in his belly. On the day but one after 
 this sensation a large quantity of pus was passed in his urine 
 (one-fourth to one-third) ; pus continued for a few weeks, and 
 then ceased. He began to feel quite well as soon as the pus 
 began to pass. The patient died, aged fifty-five, of syphilitic 
 disease of the brain ; but though his urine during the seven 
 years' interval was several times examined, it was not purulent. 
 At the post-mortem examination, tlje left part of the kidney was 
 distended with pus. 
 
 It is well to watch the urine continuously and carefully, 
 the total quantity passed during twenty-four hours being col- 
 lected and measured. In suppurative pyelitis there may be more 
 or less dysuria, but though the urine contains pus and may be 
 glairy and alkaline as it comes from the affected kidney, yet that 
 which is voided may not contain any marked quantity of mucus, 
 and will probably give an acid reaction. 
 
 In pyelitis, associated with renal obstruction (i.e. in pyo- 
 nephrosis), the urine decomposes in the calyces, becomes alkaline 
 and then glairy, like the urine in cystitis, but when passed, being 
 mixed with that from the opposite kidney, it is less markedly 
 glairy and less alkaline than in cystitis. Indeed, it may not be 
 at all alkaline, but neutral or even acid if the opposite kidney is 
 healthy. 
 
 In cases of pyo-nephrosis with ascending uretero-pyelitis it is 
 more than probable that the characters of the urine excreted 
 will be changed by co-existing cystitis or suppurating pyelo- 
 nephritis of the opposite kidney. 
 
 The quantity of pus passed from a pyo-nephrotic kidney, as 
 previously stated, varies much in quantity according to the degree 
 of patency of the passage, and the intensity of the suppurating 
 process ; but it forms usually a considerable deposit at the bottom 
 of the urine glass, and after standing many hours the supernatant 
 urine is still rendered opaque or turbid by the pus suspended 
 in it. 
 
 Diagnosis. It is very necessary in pyo-nephrosis, as in 
 hydro-nephrosis, to correctly diagnose the nature of the tumour, 
 because the operative treatment, which is so beneficial in them, 
 might be disastrous in tumours of a different nature. 
 
 The tumours which may be mistaken for pyo-nephrosis are 
 thus enumerated by Raver : " On the left side of the abdomen,
 
 462 SURGERY OF THE KIDNEY AND URETER. 
 
 all those which result from morbid enlargement of the spleen ; 
 on the right side the tumours of the liver and gall-bladder ; 
 on either side the various renal tumours of another nature, such 
 as hydro-nephrosis, haemorrhage into the cavity of the pelvis, 
 cancer of the kidney, tubercle, kidneys containing hydatid cysts ; 
 extrarenal abscess, either idiopathic or consecutive to perforation 
 of the kidney or of the colon or caecum ; abscess arising from 
 caries of the spinal column ; tumours of the suprarenal capsules ; 
 aneurysms of the aorta ; encysted tumours of different contents, 
 hydatid or otherwise ; and lastly, faecal tumours from the ac- 
 cumulations of faecal matter in the colon or caecum." 
 
 For the distinguishing characters of these I must refer the 
 reader to the chapters on renal tumours (p. 529), hydro-nephrosis 
 (p. 398 et seq.), and perinephric abscess (p. 270 et seq.) 
 
 It must suffice here to state that pyo-nephrosis is usually 
 preceded and accompanied by febrile symptoms ; that the tumour 
 is more or less tender and the pain is increased by pressure over 
 it, and by movements of the trunk ; and that when the ureter 
 is not absolutely occluded there is the presence in the urine of 
 more or less pus. 
 
 When pyo-nephrosis affects a horse-shoe kidney there may 
 be no tumour, and the diagnosis may be impossible. It was so 
 in the case from which Fig. 19 (p. 74 ante) was taken. 
 
 In hydro-nephrosis there is an absence of febrile symptoms 
 and of pus in the urine. In perinephric abscess there is more 
 pain than in pyo-nephrosis, the course of the fever is more severe 
 and rapid, and fluctuation succeeds to ill-defined hardness about 
 the loin and iliac region, and not to a gradually developing cir- 
 cumscribed tumour. In periiiephric abscess there is extreme 
 tenderness before there is any sign of fluctuation or elasticity, 
 the thigh is often flexed upon the abdomen, and cannot be ex- 
 tended without great pain ; and there is generally redness and 
 oedema of the skin of the loin ; there is 110 pus in the urine ; 
 and when pus has formed in the circumreiial tissue, fluctuation 
 is more easily made out, and is more superficial than in pyo- 
 nephrosis. 
 
 It is from hydro-nephrosis and perinephric abscess that 
 the diagnosis of pyo-nephrosis is most difficult, and fortu- 
 nately it is of less consequence if a mistake is made between 
 them than in most other cases, because a lumbar incision with a
 
 DIAGNOSIS BETWEEN PYELONEPHRITIS AND PYO-NEPHROSIS. 463 
 
 view to nephrotomy would give vent to the pus of a perinephric 
 abscess, and nephrotomy is equally advantageous for hydro- 
 nephrosis as for pyo-nephrosis. In opening a perinephric abscess, 
 if the discharge has any of the characters of urine it will be safe 
 to infer that the abscess communicates with the kidney. Some- 
 times the sequence of the clinical symptoms will have indicated 
 that pyelitis or pyo-nephrosis preceded the acute symptoms which 
 culminated in perinephric abscess. In other cases a digital ex- 
 amination of the wound will disclose the diseased condition of 
 the kidney, and perhaps detect a perforation in. its capsule. Under 
 these circumstances the surgeon would open the kidney, as in 
 simple hydro-pyo-nephrosis or pyo-nephrosis. 
 
 If, on the other hand, no symptoms which suggest disease 
 of the kidney itself, such as nephritic colic, or the passage of 
 blood or pus with the urine, have preceded or accompanied the 
 formation of the swelling in the lumbar region ; and if the 
 kidney, with the finger in the wound, is felt to be of normal 
 size and character, there will be no reason to suppose that the 
 case is other than an abscess in the perinephric tissue uncom- 
 plicated at least by renal disease. 
 
 It must, of course, be understood that the diagnosis should be 
 pushed not only to the making out of the nature of the tumour, 
 but also of the character of the obstruction which has led to 
 the renal distension. To this end the urethra, prostate, and 
 bladder must be carefully interrogated ; and the various parts 
 of the abdomen and pelvis must be examined by palpation and 
 percussion so as to detect or exclude the several extrinsic causes 
 of occlusion of or pressure upon the ureter. It will seldom 
 be necessary to perform nephrotomy for an accumulation of urine 
 or pus in the pelvis and calyces of the kidney if the distension 
 has been caused by cancel 1 of the penis, stricture of the urethra, 
 enlargement of the prostate, paralysis of the bladder, a stone 
 impacted in the vesical orifice of the ureter, or by an ovarian 
 cyst or a uterine myoma or other form of tumour which was 
 itself removable. 
 
 Pydo-ncphritis without retention of urine may sometimes 
 be mistaken for a pyo-nephrosis, especially if the kidney is 
 much increased in volume and a large amount of pus is in 
 the urine. The diagnosis mav sometimes be made easv bv 
 
 O / v 
 
 the presence of sudden large discharges of pus in the urine.
 
 464 SUKGERY OF THE KIDNEY AND URETER. 
 
 which, as AVO. have seen, occur in cases of pyo-nephrosis, but do 
 not do so in suppurative pyelo-nephritis. The quantity of pus 
 in the urine apart from the sudden discharges is generally much 
 larger in pyo-nephrosis than in pyelo-nephritis, and there is a greater 
 admixture of mucus ; the urine, too, may be neutral or slightly 
 alkaline, at any rate during the time of the great purulent out- 
 flows. 
 
 The diagnosis of pyo-nephrosis of tuberculous origin may often 
 be determined by the presence of caseous masses and tubercle 
 bacilli in the urine, and in doubtful cases the detection of tuber- 
 culosis of other organs will further strengthen the diagnosis. 
 
 A suppurating cyst or abscess opening into the bladder will 
 sometimes give rise to a purulent discharge resembling pyo- 
 nephrosis, but a careful pelvic examination, aided by an inspection 
 of the abnormal opening into the bladder through the cystoscope, 
 will generally make the nature of the case clear. 
 
 In the rare cases where a collection of pus opens into the 
 ureter at any point in its course the diagnosis from pyo-nephrosis 
 may be impossible. 
 
 TJreteral catheterisatioii is occasionally a useful adjunct in 
 ascertaining (1) on which side the pyo-nephrosis is situated, and 
 (2) the condition of the urine coming from the opposite kidney. 
 The difficulties of the operation, especially in the male, are, however, 
 great so that it must not be by any means regarded as a routine 
 method of diagnosis, though occasionally it may be very useful. 
 
 It will be borne in mind that pyo-nephrosis of ascending origin 
 is often associated with cystitis, and with pyelo-nephritis and 
 ureteritis of the opposite side. In pyo-nephrosis from causes 
 independent of aft'ections of the lower urinary organs, the 
 characters of the urine together with a unilateral renal en- 
 largement, if present, and of sudden intermittent discharges of 
 large quantities of urine and pus if such occur, make the diagnosis 
 clear. If there i a previous history of renal calculus, if there 
 are crystals in the urine, and if renal pain and h.pmaturia are 
 brought on by movement and appeased by rest, then the diagnosis 
 of calculous pyo-nephrosis is indicated. 
 
 If, with the characters of urine previously described, there 
 is a movable or misplaced kidney, with localised pain of an aching 
 kind, or with acute painful crises, and nervous or digestive 
 troubles, the diagnosis will be pyo-nephrosis from movable kidney.
 
 RESULTS OF NEGLECT OF SURGICAL TREATMENT. 405 
 
 If renal pain and swelling, purulent urine, feverishness, loss of 
 appetite, with or without frequent or painful micturition, occur 
 during pregnancy or after parturition, and if the urine has not 
 the characters of cystitis, either pyelo-nephritis or pyo-nephrosis 
 will be present. The diagnosis between these two conditions is 
 very difficult and depends chiefly upon the degree and rate of 
 development of the renal tumour. The swelling in pyelo- 
 nephritis is more rapid, but does not attain to so great a size as 
 pyo-nephrosis. The two conditions sometimes exist simultaneously. 
 
 Prognosis. To a considerable degree the prognosis depends 
 on what has caused the renal distension, whether cancer of the 
 pelvic organs, stricture of the urethra, enlarged prostate, vesical 
 calculus, or the impaction of a calculus in one ureter with or 
 without disease of the opposite kidney. In all these and such- 
 like cases the prognosis is mainly decided by the nature of 
 the determining cause. When, however, pyo-nephrosis of one 
 side only is produced in a person with previously healthy kidneys 
 by some cause which occludes the ureter and does not interfere 
 with the opposite kidney, the prognosis as regards life at least 
 is good if early relief to the pent-up urine and pus be given ; 
 otherwise the tumour may cause death by dyspnoea or other 
 effects of pressure, or by sapraemia or other form of septic infection, 
 or may burst at the surface of the body and give rise to a per- 
 manent fistula in the loin or groin ; or into the colon or small 
 intestine, the stomach, or through the diaphragm into the pleura 
 or a bronchus, and death will occur sooner or later from ex- 
 haustion, diarrhoea, vomiting, blood poisoning, empyema, or 
 suffocation ; or, again, it may burst into the peritoneum and 
 cause death rapidly by peritonitis, or slowly after having formed 
 a circumscribed peritoneal abscess. 
 
 Dr. E. H. Bennett* of Dublin showed a left kidney on the 
 anterior surface of which a small opening allowed pus to escape- 
 freely into the peritoneum from a large abscess due to distension 
 of the pelvis of the organ by a calculus impacted in the left 
 ureter. The bladder showed signs of acute cystitis. The man 
 (a sailor) had, seventeen months before, had an injury to his peri- 
 iiaeum (probably ruptured urethra), and numerous small calculi 
 u came away through a stricture of the urethra." 
 
 The most favourable result is when the obstruction gives way 
 
 * British Medical Journal, p. 361 (March 13, 1875). 
 VOL. I. 2 E
 
 466 SURGERY OF THE KIDNEY AND UKETER. 
 
 and does not recur, and the contents of the tumour discharge 
 themselves along the ureter. Even in this case the affected 
 kidney may be permanently damaged and continue for the rest 
 of the patient's life to discharge pus as well as secrete urine. 
 In such circumstances death from lardaceous or septic disease 
 may take place unless the suppurating cavity is removed by 
 nephrectomy. 
 
 In cases in which the opposite ureter is already blocked or 
 the opposite kidney is destroyed, complete anuria and death 
 take place. Temporary anuria has been known to occur when 
 one kidney only was obstructed. 
 
 If suppression of urine is prolonged beyond three or four 
 days a fatal issue must be looked for ; though there are numbers 
 of cases in which not a drop of urine has been secreted for 
 nine days and more, and yet recovery has followed. 
 
 Treatment. Suppuration of the kidney or the renal pelvis, 
 especially when associated with obstruction, is always a serious 
 condition, and too much stress cannot be laid upon 'the desir- 
 ability of using every* care to prevent its occurrence. 
 
 If suppuration has occurred, the lines of treatment to be 
 adopted, as far as possible, are 
 
 1. To remove the cause. 
 
 2. To cure cystitis, if existing. 
 
 3. To attack the infective organisms. 
 
 4. To establish a free outlet for the pus. 
 
 The methods by which these principles are to be carried out 
 vary with the cause of the distension and suppuration of the 
 kidney, and whether it is situated within the kidney itself or 
 in some part of the lower urinary passages. 
 
 1. Attention must be directed to any morbid condition 
 which may be affecting the lower urinary organs. If the cause 
 i 5 a removable or remediable one, such as stricture of the urethra, 
 prostatic enlargement, vesical calculus, etc., appropriate surgical 
 treatment must be addressed to it. Tumours of the ovary, 
 uterus, or of the bladder, should be removed when possible. 
 If a calculus can be felt in the vesical orifice of the ureter, 
 it should be extracted through the bladder if possible ; and if 
 a calculus be impacted in the ureter, too high to be felt from the 
 bladder and too low to be reached through the kidney, it must 
 be excised by one of the methods described in the chapter on
 
 THE THREE OBJECTS OF PALLIATIVE TREATMENT. 467 
 
 ureterotomy ; or possibly nephrectomy may have to be performed 
 if the calculus is in the ureter, below the brim of the bony pelvis, 
 and the kidney itself is very much disorganised. 
 
 2. If chronic cystitis exists, daily irrigation of the bladder 
 will be necessary, both to obviate decomposition of urine and to 
 restore the mucous membrane to a healthy state. In many 
 cases this has been followed by the most marked improvement 
 in the state of the kidney. 
 
 3. Free irrigation of the kidneys must be facilitated by giving 
 mild diuretics and bland fluids, such as milk, distilled water, 
 and other diluents in the form of mineral waters. 
 
 Attempts may be made to influence the micro-organisms 
 by mildly antiseptic drugs, such as cystamine, urotropine, salol, 
 boric acid, and biborate of soda ; but these medicines, unfortunately, 
 have but little definite effect upon the kidney. If, however, 
 the urine is alkaline, cystamine or benzoic acid frequently pro- 
 duces, within a short time, an acid reaction of the urine. 
 
 Astringents, such as tannin, alum, acetate of lead, are given 
 with a view of controlling the flow of pus, especially in the 
 chronic cases, but with not very encouraging results. The tincture 
 of the perchloride of iron is, however, sometimes useful. 
 
 The constipation, flatulence, atony of bladder, and general 
 arterial and muscular feebleness which so commonly exist, suggest 
 remedies which will give tone and contractile force to the muscular 
 fibres of the viscera and blood-vessels. 
 
 When fever assumes the remittent form, 5 grs. of quinine 
 in ^j of lemon juice, and IT\XV of Liq. morph. Hydrochl. are 
 sometimes very efficacious in checking the attacks. 
 
 The bowels should be kept well opened, and for this purpose 
 warm abundant enemata, containing from %iv to %vi of glycerine, 
 are of great and special service. 
 
 The diet should be light and moderate, and should consist 
 chiefly of fish, milk, chicken, or game, light farinaceous and milk 
 puddings, and well-cooked vegetables ; uncooked vegetables or fruits 
 and much butcher's meat should be avoided. Stimulants should 
 be taken, if at all, in very small quantities ; and if during their 
 administration the pulse is quickened, the temperature raised, 
 or the urine becomes more purulent, they should at once be 
 discontinued. 
 
 In acute cases, accompanied by pain, haematuria and frequent
 
 468 SURGERY OF THE KIDNEY AND URETER. 
 
 micturition, relief may be obtained by hot fomentations, cupping, 
 or the application of leeches to the loins. 
 
 4. When a definite diagnosis of pyo-nephrosis has been made, 
 or when in the absence of a renal tumour this condition is 
 believed to exist, the question of operation has to be considered. 
 Prior to the formation of a tumour the development of pyo- 
 nephrosis can only be conjectured by the presence of pus in the 
 urine and the associated symptoms due to the obstructing cause. 
 If the obstruction prevents altogether the downflow of the con- 
 tents of the kidney, there will be nothing but the diminution 
 in the daily quantity of urine to indicate distension of the cavity 
 of the kidney, and the question whether the fluid retained therein 
 is urine or urine and pus can only be answered by the presence 
 or absence of febrile symptoms. 
 
 When the cause of the obstruction has not long existed, and 
 is probably due to a small calculus or a plug of mucus, pus, 
 blood, or false membrane in the ureter, it may be displaced if 
 time is allowed and hot liquids, such as weak tea or other 
 simple diluents, are freely imbibed. Palliative treatment of the 
 tumour is permissible (a) when there is not complete obstruction, 
 and the pus and urine can escape by the ureter ; (b) when there 
 is neither septic fever, diarrhosa, emaciation, nor pain, and the 
 tumour is not of such a size as to threaten rupture ; (c) when the 
 tumour, from having been of large size, has diminished, by the 
 emptying of the cyst along the ureter into the bladder ; (d) when 
 the surrounding organs and tissues are not excited to inflam- 
 mation ; and (e) when the advanced age of the patient, or some 
 serious complication of bladder, uterus, or other organ 
 renders any operation a danger in itself. Under these 
 circumstances we shall help to diminish the suppuration, and 
 prevent the occurrence of acute inflammatory action in the cyst, 
 by rest in bed or on the couch, frequent hot baths, anodyne 
 and emollient applications to the loin and abdominal walls, 
 gentle compression by belladonna plasters, the avoidance of con- 
 stipation or the accumulation of fiscal matter in the colon 
 and caecum, and by a light digestible diet, properly regulated 
 according to the constitution of the patient. 
 
 Neplirotomy. In most instances, however, the only safe treatment 
 is an operation, palliatives being useless, and delay in operating 
 dangerous. The circumstances which indicate operative treatment
 
 NEPHHOTOMY AND DRAINAGE BEFORE NEPHRECTOMY. 409 
 
 are constant pain, increasing size of the tumour, continued fever 
 and evening elevations of temperature, or serious interference with 
 the functions of the stomach and intestine by reflex irritation 
 or by direct pressure of the tumour. An operation is also 
 requisite when the surrounding structures are inflamed or 
 are becoming adherent to the tumour, or when the tumour 
 threatens to rupture or ulcerate. 
 
 The objects of the operation are to evacuate the pus, and 
 to remove if possible the cause of the obstruction. As simple 
 puncture is not efficacious and cannot be recommended, even 
 for the puqDOse of evacuating the contents of the kidney, nephrot- 
 omy is the operation which ought to be performed. In many 
 cases, however, the question of nephrectomy has also to be con- 
 sidered. Lumbar nephrotomy with drainage possesses in the 
 majority of cases very great advantages over all other forms 
 of treatment ; it is simple, rapid, attended with but little shock, 
 and any secreting substance which remains is free to resume 
 its functions. Eapid amelioration of the patient's condition, 
 therefore, often follows, for not only is the pent-up pus evacuated, 
 but the remaining kidney tissue, relieved from pressure, becomes 
 more active, and a freer secretion of urine takes place, with general 
 benefit to the patient. 
 
 Primary nephrectomy may at first sight appear the sounder 
 procedure, since it deals with the root of the evil, but practical 
 experience proves its results to be inferior to those of nephrotomy ; 
 and there is often the unknown condition of the opposite kidney 
 to be considered. Nephrectomy should therefore be reserved for 
 those cases in which the kidney substance is totally destroyed, 
 or in which drainage of the multilocular organ is imperfect; and 
 even then it should only be performed when the general state of the 
 patient is capable of bearing the shock of the operation which 
 is often undeniably great. Each case must be considered on 
 its own merits, and the decision will be made easier if there is 
 any guide to the condition of the opposite organ. Nephrec- 
 tomy is, for instance, often advisable in advanced tuberculous 
 pyo-nephrosis, for if nephrotomy only is performed, the remainder of 
 the diseased kidney will be of but little use, and there is always 
 the risk of tuberculous infection extending to the ureter or to the 
 perinephric tissues. On the other hand, a simple pyo-nephrosis 
 is nearly always best treated by nephrotomy.
 
 470 SURGERY OF THE KIDNEY AND URETER. 
 
 Calculous pyo-nephrosis varies so much in its nature and sur- 
 rounding circumstances that no absolute rule can be estab- 
 lished ; but in the great majority of cases iiephrotomy is the 
 operation which ought to be performed. Nephrectomy should be 
 reserved for the most extreme cases of renal destruction and 
 distension. I have in some cases contented myself with nephrot- 
 omy and the extraction of the calculus when the kidney has 
 been well-nigh converted into a congeries of abscess sacs, filled 
 with pus of the consistence of cream cheese. I have scooped 
 out and washed out these sacs and drained the kidney with 
 the happiest results, the patients recovering without fistula, and 
 though for a long time the urine has continued purulent, the 
 amount of pus has diminished as the patients have become 
 robust. 
 
 When the contents of the distended kidney have infiltrated 
 the perinephric cellular tissue, and set up perinephritis or peri- 
 nephric abscess, there is increased reason for the lumbar incision. 
 The depth at which the pus is situated from the surface, the 
 length of time requisite for the parietal tissues to become thinned 
 by the suppurative process, and the comparative readiness with 
 which the abscess can open into the peritoneum, or at any rate 
 in some direction less favourable than externally, render waiting 
 for pointing or even for fluctuation most injudicious. Nephrotomy 
 in such cases as these gives great and instant relief, and in 
 individuals with fairly, good constitutions it may be said to be 
 quite free from danger. 
 
 What has been said under the treatment of renal abscess 
 respecting the shutting off of one abscess space from others, 
 and of the necessity of opening each suppurating chamber, 
 should be borne in mind in operating on a case of pyo-nephrosis. 
 After opening the kidney, the interior of the loculated cyst should 
 be examined with the finger and with the probe, in order to break 
 down the septa, and to ascertain the presence or not of a cal- 
 culus in the pelvis or upper end of the ureter. This procedure 
 ought not to be omitted. If a calculus be found in the kidney 
 it should be removed. The extraction, though sometimes difficult, 
 may be generally effected by forceps, or by the curette and finger ; 
 sometimes with a blunt hook the calculus may be drawn into a 
 part of the cyst from which it can be easily extracted, or it 
 may thus be brought quite up to the external wound. If no
 
 CONDITIONS OF PYO-NEPHROSIS REQUIRING NEPHRECTOMY. 471 
 
 stone is found in the kidney there may be one in the ureter ; 
 and indeed in every case, whether a calculus is extracted from 
 the kidney or not, the ureter should be tested by passing a 
 bougie along it from the kidney to the bladder. 
 
 In any case in which the pyo-nephrotic kidney is unduly 
 movable, it should be fixed by sutures in its proper position, 
 provided that the passage along the ureter is free and has not 
 become permanently more or less obstructed by flexures, or curves, 
 which are fixed by peri-ureteritic adhesions. 
 
 Nephrectomy. When after nephrotomy a fistulous opening 
 remains permanent, and a considerable quantity of pus daily 
 escapes through it, especially if the matter discharged is very 
 offensive, or when prolonged suppuration or lardaceous disease 
 threatens, nephrectomy should be performed. 
 
 If the cause of obstruction is irremovable, either nephrot- 
 omy, which will be necessarily followed by a fistula, at any rate 
 for a time ; or primary nephrectomy, if the condition of the 
 kidney is such that no useful amount of secreting tissue remains, 
 must be performed. I would again point out, as I did with 
 regard to hydro-iiephrosis, that after an uncertain interval in 
 a few cases a lumbar fistula which has followed nephrotomy 
 may close, owing to the gradual reopening of a good channel 
 through the ureter: this, however, cannot be relied upon, as 
 we have no data at present to guide us as to the cases hi 
 which this may be expected to happen. Should the fistula per- 
 sist, secondary nephrectomy can be performed if the other kidney 
 shows itself reliable. 
 
 In pyo-nephrosis occurring during pregnancy it may be neces- 
 sary to produce abortion or induce premature labour. In the 
 case of a lady referred to me by Dr. Cullingworth, and whom 
 I saw in consultation with Dr. Wilcox, we were able to tide 
 the patient on to the beginning of the eighth month, when labour 
 had to be induced. Many months after recovering from her 
 confinement, however, nephrectomy had to be performed on 
 account of the supervention of acute suppurative pyelo-nephritis. 
 It is open to question whether it would not have been greatly 
 to the patient's advantage if premature labour had been 
 induced at the outset of the disease : in this case I think 
 it possible that the kidney might have been saved had that 
 been done.
 
 472 SURGERY OF THE KIDNEY AND URETER. 
 
 Ureteral catheterisation and irrigation have been employed in 
 the treatment of pyo-nephrosis in three or four cases by Pawlik 
 and Albarran. It consists in catheterising the ureter of the 
 affected kidney daily or well-nigh daily, the catheter being passed 
 as far upwards as the renal pelvis, and the cavity of the kidney- 
 irrigated at the time through the catheter. This treatment, 
 which it would be impossible to employ in many cases, and which 
 it would be very dangerous to attempt in others, is not needful 
 or desirable in any. When the obstruction is in or near the 
 pelvis of the kidney it is unsurgical and unscientific ; when 
 in the lower urinary passages it is fraught with the great danger 
 of carrying a worse infection to, or increasing the infection of 
 the ureter and kidney. When the obstruction is in the ureter 
 at or near the vesical orifice the treatment if it can be 
 tolerated by the patient is too tedious in performance, too 
 indirect in its action upon the kidney, and too little per- 
 manent in its effect upon strictured tissue to be recommended. 
 Though two cures have been claimed, and two cases are said to 
 have been ameliorated after many weeks of this treatment, the 
 objections to it are overwhelming, and cannot be better de- 
 scribed than by one of the surgeons who has employed it, and 
 who extols ureteral catheterisation in certain other cases either 
 as a palliative or a curative measure. 
 
 Partial nephrectomy has been successfully employed in some 
 exceptional cases by Kummel, Bardenheur, Tuffier, Wartz and 
 Albarran, either to minimise a very large sac or to remove 
 a portion of the kidney expanded below the level at which 
 the ureter joins the infundibulum ; or because the lesion involved 
 only a part of the organ. 
 
 Plastic operations. In some cases of hydro-pyo-nephrosis the 
 various plastic operations for overcoming obstructions to the 
 course of the urine, recommended and successfully practised 
 for hydro-nephrosis, may be performed. But in pronounced pyo- 
 nephrosis these operations are not usually, if at all, applicable as. 
 primary surgical methods, owing to the febrile condition and 
 marked debility of the patients. Even as secondary measures 
 they are not indicated when the kidney is converted into a many- 
 chambered abscess cavity with rigid septa : or when the ureter is. 
 thickened, tortuous and rigid from long-standing ureteritis and 
 peri-ureteritis.
 
 URO-H.EMATO-NEPHROSIS SUPERVENING ON HYDRO-NEPHROSIS. 473 
 
 IV. HJEMATO-NEPHROSIS AND URO-HJSMATO-NEPHROSIS. 
 
 Besides hydro-nephrosis and pyo-nephrosis there is another 
 variety of nephrectasis. namely that in which the calyces and 
 pelvis of the kidney are distended with blood, either in the 
 fluid or coagulated form ; or with blood largely mixed with urine. 
 
 The term " haemato-nephrosis " should not be applied to those 
 subcapsular haemorrhages in which the blood is extra vasated 
 between the fibrous capsule and the renal parenchyma instances 
 of which I have related (see pp. 150 and 151, ante) and a good 
 example of which was reported some years ago by Nelsen. 
 Still less should cases of extravasation of blood or blood and urine 
 into the perinephric tissue be described as haemato-nephrosis and 
 uro-haemato-nephrosis : such a designation even with the prefix 
 " false " (false haemato-nephrosis) is entirely a misnomer. 
 
 Etiology. This variety of nephrectasis is rare, but there are 
 several conditions which give rise to it. Injun*, renal calculus, 
 a new growth in the renal pelvis, movable kidney, chronic 
 nephritis with or without small cysts (Poirier's case), continued 
 fevers, purpura (Fig. 70, p. 475), or in fact any condition which 
 provokes renal haematuria may give rise to hsemato-nephrosis. 
 
 Uro-haemato-nephrosis when it occurs is generally due to the 
 giving way of some one or more of the congested vessels in the 
 wall of a hydro-nephrotic kidney (Albarran, Andersen, Ailing- 
 ham, Bazy, Loison, and others). It is more likely to occur 
 when the hydro-nephrosis is intermittent owing to the sudden 
 loss of* the hydrostatic pressure when the renal retention ceases 
 and the renal cavity is suddenly emptied. The escape of blood 
 into the hydro-nephrotic sac under these circumstances resembles 
 the haemorrhage which takes place occasionally into the urinary 
 bladder after too suddenly emptying that viscus of retained urine ; 
 and also the haemorrhage which sometimes quickly fills the sac 
 of a large old hydrocele after the withdrawal of the fluid. 
 
 The haemato-nephrosis which follows an injury may be one 
 of two varieties. (1) It may be caused by haemorrhage from 
 small vessels in the wall of a calyx or in the parenchymatous 
 substance bordering a calyx. In this case the accumulation of 
 blood takes place slowly and the renal substance may by degrees 
 become entirely atrophied. (2) The blood may come from a
 
 474 . SURGERY OF THE KIDNEY AND URETER. 
 
 ruptured branch of the renal artery in which case the kidney 
 is most likely to dilate rapidly. Such cases form one of the 
 varieties of traumatic renal aneurysm which I have previously 
 described (p. 239), and examples of which I have quoted in my 
 paper on " Eenal Aneurysm " in the Lancet of October 6th, 1900. 
 
 The haemato-nephrosis caused by calculus may attain very 
 large dimensions. It is, so far as my personal experience goes, 
 associated almost invariably with calculi of long standing and 
 great size. The general health and strength of the patient are 
 very greatly impaired, he becomes of a sallow and malignant 
 aspect, and the tumour formed is prone to be mistaken for 
 carcinoma of the kidney, or liver, or spleen. 
 
 A small rough calculus may however be both the immediate 
 and the indirect cause of haemato-nephrosis ; it may lead to 
 haemorrhage by bruising or laceration of the renal mucous 
 membrane, and may be the cause of complete obstruction to 
 the escape of the blood by falling over and entirely blocking 
 the upper ureteral orifice. 
 
 New growths in the renal pelvis or ureter, whether simple 
 papilloma, or malignant, are very prone to excite considerable 
 haemorrhage, and may, like a calculus, also be the means of 
 obstructing the passage down to the bladder (cases are recorded 
 by Turner and Paiitaloni). 
 
 In the case of movable kidney the repeated kinking of the 
 ureter may have induced hydro-nephrosis ; and haemorrhage into 
 the hyclro-nephrotic sac may subsequently occur, the blood 
 being derived from the vessels in its wall. 
 
 In other cases, either as the effect of slight injury, or of 
 the congestion produced by torsion of the pedicle of a movable 
 kidney ; or by the catamenial, pregnant, or parturient states, the 
 blood which escapes into the renal cavity may fail to find an 
 outlet to the bladder, owing either to the displacement itself or 
 to the blockage of the ureter by blood-clot. 
 
 Nephritis, which often co-exists with a stricture or valve of 
 the ureter, or with a calculus, is the immediate cause of the 
 haemato-nephrosis in a certain number of instances. 
 
 In haemorrhage from nephritis the obstruction to the outflow 
 of the blood may be due to the same cause as the nephritis 
 itself. In other cases of haemato-nephrosis from nephritis, or 
 from injury, continued fever, or purpura, the coagulation of
 
 H.EMATO-XEPHROSIS A POST-MORTEM SURPRISE. 475 
 
 the blood in the renal pelvis or ureter, or the blockage of the 
 ureter by a small detached clot may be the cause of the 
 obstruction. 
 
 Symptoms and diagnosis. The symptoms of haemato- 
 nephrosis will depend greatly on the cause. They will most 
 likely be rapid and severe when due to a ruptured artery, to 
 a new growth in the kidney or ureter, to haemorrhage during 
 
 Fig. 70. Right Kidney of a man, set. 25, who died of Purpura ; the Pelvis and 
 Calyces filled with a blood-clot. (St. Bartholomew's Hospital Museum.) 
 
 continued fever or purpura, or to that which ensues upon the 
 emptying of a hydro-nephrosis. The}' may be slow and in- 
 sidious, taking years to develop, when due to slight central 
 lacerations or contusions from injury or from calculus. 
 
 In some cases there will have been haematuria, either con- 
 tinuous, relapsing, or intermittent, with long intervals between 
 the discharges of blood. In some cases there has been pain 
 with haematuria ; in some instances of uro-haemato-nephrosis such 
 attacks of haematuria and pain have extended over many years, 
 as in Laueiisteiii's case. In other instances there have been 
 no symptoms whatever ; the patients have died from other than 
 renal causes, the tumour has been found as a surprise at the 
 post-mortem examination, and inquiry has elicited no history 
 whatever of any urinary symptoms. This was so in Loisoii's case.
 
 476 SURGERY OF THE KIDNEY AND URETER. 
 
 The characters of and variations hi the tumour formed by 
 blood within the renal cavity are those of nephrectasis from 
 obstructed urine, or pus, and having been described under hydro- 
 nephrosis and pyo-nephrosis they need not be repeated. 
 
 Pathological anatomy. The condition of the kidney and 
 the character of the contents of the renal cavitj r differ in different 
 cases. The extent to which the pyramidal and cortical substance 
 is atrophied, the size of the tumour, if any exists, the 
 relative proportion of distension of the several calyces and of 
 the infundibulum, and the partial or complete obliteration of 
 the ureter, all vary as in hydro-nephrosis and pyo-nephrosis. 
 The contents may be pure blood, black or treacle-like and semi- 
 liquid, or partly coagulated and partly liquid, or decolorised and 
 deposited in concentric layers ; or blood largely mixed with urine, 
 in which case the fluid will be more or less limpid and of a 
 brownish or blackish colour, very like thin coffee mixed with the 
 dregs of coffee. If the condition has existed long, the renal paren- 
 chyma may have disappeared entirely, and the blood may have 
 consolidated into a hard, nearly decolorised mass. 
 
 Prognosis. The prognosis as to life depends upon the cause 
 of the nephrectasis, and the severity and duration of the disease. 
 If the ureter and renal pelvis remain patent, prolonged and 
 frequently recurring haematuria may threaten or actually destroy 
 life. When malignant disease is the cause of the haemato-iiephrosis 
 death is likely to occur from the development of metastatic new 
 growths. When the haemorrhage comes from a large branch 
 of the renal artery, extravasation of blood into the perinephric 
 tissue is likely after a time to take place, owing to the rup- 
 ture of the sac : this may lead to an enormous tumour and 
 to death from the pressure effects of the tumour or from de- 
 generative changes in the tumour itself. Life is best protected 
 by sacrificing the kidney, or what remains of it, by performing 
 nephrectomy. As regards the kidney, the prognosis is most 
 unfavourable. The whole organ becomes irreparably destroyed 
 if the blood accumulates in the renal pelvis, none of it being 
 able to escape by the lower urinary passages. Even when the 
 exit is not barred by obstruct on in the ureter, the coagulum 
 retained within the calyces impedes or prevents the renal func- 
 tion, besides forming a culture medium for bacteria, and predis- 
 posing to septic disorganisation of the kidney.
 
 THE OPERATION REQUIRED FOR HJSMATO-NEPHROS1S. 477 
 
 Nephrotomy for the removal of the blood from the renal 
 cavity and for the purpose of restoring if possible the patency 
 of the ureter may save the kidne}* for the time or altogether. 
 But unless the primary cause of the nephrectasis can be re- 
 moved, and a recurrence of the intrarenal hemorrhage 
 prevented, the subsequent destruction of the kidney or its 
 removal by nephrectomy will be only temporarily avoided by 
 opening and draining the renal cavity (see cases Xos. 38 and 
 39, Table IV., " Hunterian Lectures "). 
 
 Treatment. It will be nearly always requisite if the 
 kidney is to be preserved, and very often if life itself is to be 
 saved, to resort to surgical treatment. If the hsemato-nephrosis is 
 due to a remediable cause, such as a movable kidney, or a calculus ; 
 or to a cause which, having once produced its effect, 'will not 
 reproduce a similar effect after the extravasated blood has been 
 removed, such as continued fever or purpura nephrotomy fol- 
 lowed by drainage and the fixation of the kidney, the removal 
 of a calculus, or the division of a ureteral stricture or stenosis 
 may effect a complete and permanent cure. 
 
 If, on the other hand, the cause of the condition is an intra- 
 renal false aneurysm, or a new growth in the infundibulum 
 or in the ureter, nephrectomy or nephro-ureterectomy will 
 alone avail. 
 
 In other cases of traumatic haemato-nephrosis in which the 
 blood is not derived from a ruptured artery but from torn 
 parenchyma or a ruptured vein, and in cases in which chronic 
 nephritis of an obstructed kidney is the source of haemorrhage, 
 nephrectomy is the proper treatment if the opposite organ is 
 sound. 
 
 If the patient's condition is not favourable to an operation, 
 and if life is not for the time being threatened, it may be the 
 surgeon's duty to stand by and watch the patient, well knowing, 
 however, that the affected kidney will become ultimately destroyed ; 
 but if nothing centra-indicates the operation, and the cause of 
 the haemato-nephrosis is a persistent and irremediable one, 
 nephrectomy had much better be performed. If the cause is 
 one dangerous to life, such as papilloma or carcinoma of the 
 renal pelvis, nephrectomy at an early stage is the only chance of 
 prolonging or saving the life of the patient.
 
 478 
 
 CHAPTER XVI. 
 TUBERCULOSIS OF THE KIDNEY, 
 
 THE recent history of Renal Tuberculosis shows a very remarkable 
 advance in the pathology and the treatment of this serious disease. 
 
 When I wrote on this subject sixteen years ago (" Surgical 
 Diseases of the Kidney ") tuberculous kidney was regarded more 
 as a constitutional than as a local disease ; " strumous " and 
 "scrofulous" were terms applied to certain affections of joints, 
 glands, the skin, and other parts and organs, as well as of the 
 kidney and the rest of the genito-urinary tract, and the same 
 words were used to express a certain constitutional tendency. 
 Our knowledge of the pathology of these affections, although 
 approaching towards correctness, was at that time far from being 
 by any means precise ; whilst the surgical treatment of renal 
 tuberculosis was but tentative, and opinions were quite unsettled 
 as to whether any operation whatever was justifiable, and if any, 
 what operation was suitable for different kinds of cases. 
 
 The lesions grouped under the vague term scrofulous were not 
 only ill-defined, but their relation etiologically, clinically, and 
 pathologically to miliary tuberculosis was very imperfectly under- 
 stood. 
 
 The results obtained by Yillemin, from the inoculation of 
 crude tubercle, had years before pointed to the infectiousness of 
 tuberculosis. Klebs in 1877 had found that tubercle in human 
 beings invariably contained bacteria, and that he could cause the 
 same disease in other animals by inoculations of the cultures 
 obtained from the bacteria. Other investigators found other 
 microbes which they regarded as having a direct etiological bear- 
 ing on tuberculosis, until at length Koch in 1882 made known 
 to the profession that he had positively identified the special 
 bacillus of tubercle. Koch's earlier investigations had reference 
 to affections of the skin (lupus), glands, bones, and joints, though 
 he subsequently found the bacilli in tuberculous pyelo-nephritis. 
 In the same year (1882) Cohnheim pointed out that man could 
 bv means of his renal excretion eliminate the bacilli of tubercle
 
 HISTORICAL SURVEY OF TUBERCULOSIS OF KIDNEY. 479 
 
 as well as other poisons; and lie maintained that these bacilli 
 could be transported from the lungs into the urine by the blood, 
 and after reaching the bladder, could there excite tuberculous 
 lesions without causing injury to, or infection of, the kidney 
 in their passage. Kahlclen, Cavazzani, Wyssokowitch, and Sher- 
 rington subsequently also affirmed that the bacillus of tubercle 
 could lilter through the kidney without causing tuberculous 
 disease therein. Kahlden affirmed that this could happen without 
 the kidney tissue being in the least changed by the bacilli ; 
 Cavazzani and Wyssokowitch that the bacilli could not pass 
 without causing haemorrhage and a lesion of the renal epithelium ; 
 whilst Sherrington, disagreeing with these views, considered that 
 the requirement to make the excretion of the bacilli possible 
 was a change in the secreting tissues, whereby these tissues 
 were made permeable, and that this change was effected by the 
 virus of the micro-organisms. Sufficient attention, from the 
 point of view of surgical prognosis, had not been given to the 
 question whether renal tuberculosis is a local or general affection ; 
 whether, in other words, from the point of view of treatment, 
 tuberculosis is an operable or an inoperable disease. 
 
 Bayle and Haver, it is true, had, in the early part of the 
 nineteenth century, recognised the disease more or less as a local 
 one. Lancereaux, in his work published in 1871, began to dis- 
 tinguish miliary tuberculosis originating through the circulation, 
 from breaking-down tuberculous depots in the kidney commencing 
 in the apices of the pyramids and spreading upwards towards the 
 cortex, i.e. between medical and surgical forms of tuberculosis. 
 Sayre and other surgeons were pointing out in reference 
 to morbus coxae and other so-called strumous joints that too 
 much attention had been given to the constitutional aspect, to 
 the exclusion of the importance of the local causes. Still, the 
 constitutional element dominated the mind of the profession, 
 and the exclusive localisation of tubercle in organs other than 
 the lungs was barely recognised. 
 
 As to treatment, Bryant in 1870 had performed nephrot- 
 omy for tuberculous pyo-iiephrosis. Clement Lucas in Feb- 
 ruary, 1880, performed nephrectomy on a case presumably, 
 though not actually stated to have been, tuberculous ; and the 
 younger Gross of Philadelphia in July, 1885, collected twenty cases 
 of nephrectomy for renal tuberculosis, of which twelve recovered
 
 480 SURGERY OF THE KIDNEY AND URETER. 
 
 and eight died (a mortality of 40 per rant.). In January, 1885, 
 appeared Part III. of Dickinson's great work on "Kenal and 
 Urinary Affections," in which he fully recognised that renal 
 tuberculosis is a localised affection limited to one kidney about 
 -as frequently as it involves both kidneys ; but, after stating that 
 advanced renal tuberculosis was complicated with similar disease 
 in other organs in six out of every seven cases he expressed his 
 opinion about nephrectomy for tuberculous affections in these 
 words : " These facts would appear enough to discourage and prob- 
 ably to prohibit the operation." 
 
 The points which I endeavoured to indicate in " Surgical 
 Diseases of the Kidney," written in 1884, were the follow- 
 ing :- 
 
 1. Miliary tuberculosis of the kidney more frequently affects 
 children, whereas the caseous form is generally met with in 
 young, and middle adult life. 
 
 2. On post-mortem examinations the caseous form of renal 
 tuberculosis is found to be unilateral nearly as often as bilateral. 
 
 3. Polyuria is sometimes a symptom of the early stages of 
 tuberculous disease of the kidney. 
 
 4. Vesical irritation causing frequent micturition is a very 
 usual, and often the most prominent symptom even when the 
 bladder itself is not affected. 
 
 5. The ureter is often thickened and indurated in tuberculous 
 disease to such an extent as to be clinically detectable, and even 
 to be mistaken for impacted ureteral calculus. 
 
 6. Nephrectomy on the whole would prove to be the best 
 operation for unilateral caseous renal tuberculosis; but in slight 
 cases, erosion of the isolated abscesses or tuberculous foci ; and 
 in very advanced stages of the disease in debilitated persons, 
 nephrotomy would be preferable to primary nephrectomy. 
 
 These views have been amply confirmed by subsequent in- 
 vestigations and experience. 
 
 In 1884 I also alluded to the fact that the bacillus of tubercle 
 had been found in the urine of patients suffering from tuber- 
 culosis of the kidney ; but at that time tuberculosis in all its 
 forms had not come to be generally recognised as due to thus 
 particular micro-organism. Within the following two years, how- 
 ever, Duraiid Fardel (These de Paris, 1886) and Cayla (These de 
 Paris, 1887) had demonstrated the mode of infection of the
 
 HOW TUBERCLE BACILLI REACH THE KIDNEY. 481 
 
 kidney by the circulation, and the penetration of the bacilli from 
 the blood-vessels into the renal parenchyma. The writings of 
 Guyon, Vigneron, and others showed renal tuberculosis to be 
 a localised disease often limited for a long period to one kidney. 
 Tuffier in several literary contributions since 1891 has confirmed 
 the teaching, now definitely accepted on all hands, that tuberculosis 
 of the kidney is frequently a primary disease; whilst the opera- 
 tions of Tuffier, Kiister, Israel, myself, and others have succeeded 
 in establishing the operative treatment of caseous tuberculous 
 kidney upon a sound basis. 
 
 To-day, thanks to bacteriology, to the high value of many 
 research experiments, and to the number of admirable articles 
 and theses which have been devoted to the subject, more especially 
 by the French school, and thanks also to the great progress 
 made in surgical therapeutics, tuberculosis of the kidney forms 
 one of the best understood chapters in pathology and bacteriology ; 
 and great unanimity prevails amongst surgeons as to the treat- 
 ment best suited for the disease. 
 
 Etiology. Renal tuberculosis is due to the presence of 
 the tubercle bacillus, which may reach the kidney through the 
 circulation or the lymphatics, or by way of the ureter by 
 continuity from the bladder, prostate, seminal vesical, or urethra ; 
 or across the capsule of the kidney by extension from a neigh- 
 bouring or distant organ. When the infection is conveyed by the 
 circulation, as it may be during either intra- or extra-uterine 
 life, the disease may either run an acute course as a part of 
 a general miliary tuberculosis, or a chronic form may occur and 
 caseation result. In the latter case the caseated nodules may 
 remain confined to the kidney substance, or they may extend 
 into the calyces and give rise to a tuberculous pyelo-nephritis. 
 
 When the disease reaches the kidney from some of the lower 
 parts of the geni to - urinary tract by way of the ureter, which 
 is a well-recognised process, but according to Tilden Brown not 
 the most common mode of origin of the chronic forms, an ascend- 
 ing tuberculous uretero-pyelo-nephritis occurs, in which the kidney 
 itself is the last portion of the urinary system to be affected. 
 The disease may be conveyed along the walls of the ureter by 
 continuity, or it may pass up along them by the lymphatic 
 channels. It is important, however, to bear in mind that 
 before the ascending mischief reaches the kidney, distinct foci in 
 VOL. i. 2 F
 
 482 SURGERY OF THE KIDNEY AND URETER. 
 
 the cortical substance may be formed independently by infection 
 through the blood stream. More rarely the infection may be 
 directly communicated to the ureter through some tuberculous 
 focus situated altogether outside the genito-urinary tract, as was 
 the case (to be again referred to under tuberculous disease of the 
 ureter) in which an abscess arising from spinal caries penetrated 
 the upper end of the ureter and finally reached the kidney. 
 
 Lastly, the kidney may become affected through direct con- 
 tinuity, as in a case recorded by Newman in which a tuberculous 
 empyema perforated the diaphragm and gave rise to secondary 
 renal infection. This mode of origin is certainly rare, and by 
 some authors is not considered to be clearly proved. The renal 
 capsule is said by Tilden Brown to offer the same protection 
 against invasion as the dura mater does in cases of tuberculous 
 disease of the bones of the skull. He points out (a) that 
 sarcoma and adenoma most frequently affect first the upper 
 part of the kidney, and that in a certain proportion of 
 cases this invasion of the kidney across its fibrous cap- 
 sule spreads from the supra-renal capsule ; (&) that autopsies 
 show often enough that an advanced tuberculosis of the 
 supra-renal capsule gives no indication whatever of spreading 
 through the fibrous capsule of the kidney to the renal parenchyma, 
 yet that perinephric tuberculosis takes its rise frequently from 
 disease in the supra-renal capsule ; and (c) that one ought to be 
 careful as to performing radical operations upon the kidney 
 when a perinephric abscess of tuberculous nature has to be 
 opened. 
 
 Any conditions which lower the resisting power of the in- 
 dividual either generally or locally will, as in tubercle elsewhere, 
 act as predisposing causes. Thus retention of urine, as we have 
 already seen in the chapter on pyelo-nephritis, favours the passage 
 of micro-organisms through the ureter, while injury, such as a 
 blow on the loin, will favour the growth of organisms which may 
 reach the kidney through the circulation. In connection with 
 the effects of injury it is important to note that the healthy 
 kidney possesses a considerable amount of power of getting rid 
 of various organisms which reach it by the blood stream; and 
 among others tubercle bacilli may be excreted in this way. It 
 will thus be seen that tubercle bacilli may possibly be found 
 in the urine when there is no actual tuberculous lesion of the
 
 TUBERCLE BACILLI IN URIXF. 483 
 
 genitourinary tract. Fortunately, however, this possibility is 
 not a fact of frequent importance in the diagnosis, because in 
 tuberculous kidney a careful and if necessary oft-repeated 
 examination of the urine in which bacilli have been found will 
 almost always show some other abnormal constituents which 
 will further support the diagnosis. When tubercle is suspected 
 in any case of chronic renal disease, the presence of tubercle bacilli 
 in the urine, together with pus or blood, may be fairly con- 
 sidered as pathognomonic of the disorder. But, although the 
 experiments previously referred to (see p. 479) indicate that a 
 patient the subject of general tuberculosis may have bacilli in 
 his urine without having renal tuberculosis, there must not be 
 too great a readiness to adopt this view in any particular case, 
 even when no renal or urinary symptom exists ; for the kidney 
 may be considerably affected with tubercle without there being 
 any other indication than the presence of the bacilli in the urine.* 
 
 Age. The disease is most frequent in the young This is 
 more especially the case with the miliary form, since general 
 tuberculosis is so frequent among children. The caseating form 
 is also more frequent in youth and young adult life, but it may 
 occur before five and after fifty years of age. 
 
 Sex. The comparative frequency of renal tuberculosis in the 
 two sexes is given differently by different authors. Fagge's, 
 Tilden Brown's, Watson's and my own tables show men to be 
 more frequently affected than women. 
 
 The joint statistics of Guillard, Tuffier and Albarran concern 
 246 cases of chronic tuberculosis, of which 117 were females and 
 69 males. 
 
 Fagge says, " It is at least twice as common in men as in 
 women," and as to age he says, " Of twenty-nine cases at Guy's 
 Hospital in which renal disease was the principal cause of death, 
 in three death occurred between the ages of ten and twenty, 
 in twelve between twenty-one and thirty, in eight between thirty 
 and forty, in five between forty-one and fifty, and in one between 
 fifty-one and sixty." 
 
 Albarran found that of 203 patients who were operated upon 
 
 for tuberculous kidney, 148 were women and fifty-five men. 
 
 This disproportion is probably due to the fact that the frequent 
 
 co-existence of renal with vesical tuberculosis, or with the disease 
 
 * Tilden Brown: Ann. des Mai. des Org. Genito-urinaires, 1898, p. 587.
 
 484 SURGERY OF THE KIDNEY AND URETER. 
 
 in some other part of the male genito-urinary organs, renders 
 many men unfit subjects for operation. 
 
 The following statistics show the influence of various etiolo- 
 gical factors. In ten years at the Middlesex Hospital forty-four 
 cases of tuberculous disease of the kidneys were met with in 2,610 
 examinations. Of these forty-four cases t\venty-nine were of the 
 miliary and fifteen of the caseating form. 
 
 Of the twenty-nine cases of miliary tuberculosis eighteen were 
 males, eleven females. 
 
 12 occurred in persons under 10 years of age. 
 8 between 10 and 30 years. 
 
 6 over 30 years of age. 
 
 3 ,, whose age is not stated. 
 
 In two of the twenty-nine cases there was a spot or two (but 
 not several) in one kidney, where small caseating nodules had been 
 formed by the merging together of numbers of the miliary tubercles- 
 In none of the twenty -nine cases were the kidneys the only 
 organs affected ; in the greater number there was acute tuber- 
 culosis of the viscera and serous membranes generally ; in some 
 the lungs, or lungs and larynx, were the only parts besides the 
 kidney which were involved ; the brain and its meninges were 
 frequently complicated. 
 
 Of the twenty-nine cases both kidneys were diseased in twenty- 
 eight ; the right kidney alone in one. 
 
 Of the fifteen cases of caseating tuberculosis nine were males, 
 six females. 
 
 7 occurred in persons over 30 (3 of them were over 50). 
 
 3 in adults whose ages are not stated. 
 
 5 ,, in persons between 11 and 30 years of age. 
 
 There was not one instance in a child younger than eleven 
 years. 
 
 In 4 of the 15 cases there was chronic tuberculosis. 
 
 In 5 general tuberculosis of the genito-urinary organs existed ; in only 
 
 one of these were the kidneys the only organs affected, and in 
 
 this case there was a large perinephric abscess ; in the other 4 cases 
 
 the lungs were affected with chronic tuberculosis. 
 In 2 there was caries of the spinal column, with more or less general 
 
 tuberculosis of the other organs. 
 In 1 there was a suppurating elbow joint. 
 
 In 1 acute bronchitis and hypertrophy of the heart were present. 
 In 2 acute tuberculosis, chiefly involving the lungs and the liver, had 
 
 supervened upon the longer-standing disease of the kidneys.
 
 TUBERCULOSIS EITHER UNILATERAL OR BILATERAL. 485 
 
 Of the fifteen cases both kidneys were diseased in eight, the 
 left kidney only in four, and the right only in three. 
 
 In a further analysis of 3,331 cases from the post-mortem 
 records of the Middlesex Hospital, there were only ten out of 
 seventy-four cases in which the condition was limited to the 
 kidney, while there were sixty-four in which the tuberculous deposit 
 was part of a general infection. In nine of the ten cases in which 
 the disease was limited to the kidneys, one organ only was affected, 
 while in the sixty-four in which the deposit in the kidney was 
 part of a general tuberculosis both kidneys were affected in 
 forty-three; it will therefore be seen that the chances of one 
 kidney only being diseased are very much less when there is 
 tuberculosis of other organs of the bod}*. Occasionally the kidney 
 is found at an autopsy to be the only organ actively involved, 
 but old foci of cured tubercle are found in the prostate, the 
 testis, or the lungs. Israel also records such an instance. 
 
 Fischer, in " Ureterite Tuberculeuse " ("These de Paris," 1892), 
 records that in sixty-one cases of tuberculous disease of the kidney 
 both kidneys, the ureters, and the bladder were affected in seven- 
 teen, and one kidney together with its ureter and the bladder 
 were affected in twenty-eight cases (fifteen right side, thirteen left). 
 
 Dickinson tells us that " both kidneys are affected together 
 in about as many instances as one separate!}*. If only one be 
 affected, it is more often the right than the left in adults, though in 
 childhood this difference is not apparent. Of ninety-five cases, 
 both kidneys were affected in forty-seven, one only in forty-eight." 
 
 Taking childhood apart from other periods of life, of twenty- 
 eight children under twelve years of age, nineteen had both 
 kidneys affected, five the light only and four the left only. 
 Of sixty-seven persons over twelve years of age, twenty -eight 
 were affected in both kidneys, twenty-two in the right only, 
 and seventeen in the left only. 
 
 It must lie borne in mind, however, that the multiple con- 
 ditions found at death do not prove that the tuberculous disease 
 was not for a time limited to one kidney and that from this 
 source the disease was not disseminated to other organs and 
 parts. 
 
 Tildeii Brown found tuberculous lesions in sixty-eight out of 
 567 bodies examined at the Presbyterian Hospital between Feb- 
 ruary, 1893, and May, 1896; of the total number presenting any
 
 486 SURGERY OF THE KIDNEY AND URETER, 
 
 tuberculous lesions whatever the kidney was affected in twenty- 
 three, and of these thirteen were males and ten females. In 
 twelve of the sixty -eight subjects the spleen, and in nine the 
 liver was involved. He remarks that the kidney in young 
 children is less frequently affected with tubercle than either 
 the spleen or the liver ; whereas in adults it is the contrary ; 
 the reason assigned being the special function of excretion and a 
 smaller power of antagonism to the action of the microbes and 
 their toxines, which are eliminated by the kidneys. 
 
 The extremes of age at which the disease was observed in the 
 kidneys were two and a half months and sixty-four years. Four- 
 teen out of the twenty-three subjects were between the ages of 
 twenty and fifty. 
 
 These figures contrast strongly with the statistics made in the 
 middle of the century and for some years later when the post- 
 mortem observation of tubercle was less careful and errors as to 
 its recognition were more common. Thus, during 1849-50 Engel 
 of Prague found only one case of renal tuberculosis in ninety-four 
 autopsies on tuberculous subjects ; and Willingk in 1850-52 
 found only seven in 452 tuberculous subjects. Chambers, on the 
 other hand, in 1852 found ninety -one cases of renal tuberculosis 
 in 503 tuberculous subjects. 
 
 Watson* was able to determine the primary seat of the tubercle 
 in fourteen out of twenty-one cases of tuberculous disease of 
 the genito-urinary organs which he had an opportunity of ob 
 serving. Of these fourteen, seven commenced in the epididymis, 
 four in the prostate or vesiculae semiiiales, and three in the kidney 
 itself ; in the remainder the exact origin could not be determined. 
 Of these twenty -one cases there were fifteen males and six females. 
 The oldest was a man of fifty who developed symptoms of 
 prostatic disease two years before his death ; the youngest was 
 a girl of six in whom the disease was primary in the kidney. 
 
 Vigneron's t collected statistics, which include those of Eoberts, 
 Dickinson, Gaultier, Guyon, and my own earlier ones, show that 
 in the caseatiiig form of the disease one kidney is affected in 
 about half the total number of cases. Thus in 205 cases the 
 disease was unilateral in ninety-nine. 
 
 The late results of many nephrectomies and of some partial 
 
 * Boston Medical and Surgical Journal, 1895, p. 121. 
 t "These de Paris," 1892.
 
 PROOFS OF UNILATERAL RENAL TUBERCULOSIS. 487 
 
 iiephrectomies have proved that if the disease was not limited to the 
 excised kidney the other tuberculous focus (if any) which may have 
 been present has given no trouble, as perfect health has been for 
 many years enjoyed by the patients after the operation. It would 
 certainly seem from these results of operations that renal tuber- 
 culosis is much more frequently a local primary disease of the 
 kidney than the results of autopsies, made as they necessarily 
 are at a very late stage of the affection, formerly led us to 
 believe. 
 
 Albarran states that in twenty-one out of thirty-two specimens 
 of renal tuberculosis preserved in the Musee Guyon, with refer- 
 ence to which the condition of both kidneys is stated, one kidney 
 only was affected. 
 
 In fifty consecutive cases of renal tuberculosis of all varieties 
 taken from the post-mortem records of the Middlesex Hospital, 
 the cortex was alone affected in eight, the medulla alone in seven, 
 while both parts were attacked in the remaining thirty -five. 
 
 It would appear from these various figures (a) that miliary tuber- 
 culosis is twice as common as the caseating form ; (6) that miliary 
 tuberculosis affects children under ten years of age in a large 
 proportion of cases, whereas the caseous variety is at least some- 
 what exceptional in children below ten years of age ; (c) that miliary 
 tuberculosis with rare exceptions affects both kidneys, though 
 not to an equal degree in all cases; whereas the caseating form 
 affects both kidneys only a little more often than it does one 
 kidney alone ; (d] that the caseating form of the disease is more 
 especially an affection of young and middle adult life, but occurs 
 also in persons past middle age. 
 
 Pathology. Pathological anatomy teaches us that the 
 kidney is often affected with tubercle without either the ureter 
 or the bladder being involved. It also teaches us that when tubercle 
 commences in the kidney the disease may spread in a descending 
 manner along the ureter to the bladder. It shows us also that 
 miliary tubercle follows the course of the blood-vessels of the 
 parenchyma, often starting about the vessels of the Malpighian 
 tufts. Experimental pathology also has demonstrated the 
 circulatory origin of renal tuberculosis, and has shown furT 
 ther that dead micro-organisms, as well as living active bacilli, 
 may be the cause of the early cellular proliferation of the tuber- 
 culous process. Pathological anatomy shows us also that the
 
 488 SURGERY OF THE KIDNEY AND URETER. 
 
 ureter and kidney can be secondarily invaded in an ascending 
 manner by the extension of tuberculous disease from the bladder, 
 and that when this is the mode of origin of the disease in the 
 kidney the morbid process spreads from the apices of the pyra- 
 mids into the renal parenchyma, until at length the whole organ 
 may be converted into a number of vomicae. Albarran and Cottet 
 (Soc. Anatomique, 1898) have recorded a very beautiful example 
 in proof of this mode of extension from the bladder. 
 
 A man, with advanced widespread vesical tuberculosis had 
 three ureters, two of which opened into the bladder where the 
 tuberculous affection was very pronounced ; along each of these 
 ureters the disease had ascended and had attacked the whole of 
 the kidney with the single ureter, and the part of the kidney 
 with the double ureter which had been drained by the affected ureter. 
 The third ureter opened upon a healthy part of the bladder 
 and was itself, as also was the corresponding part of the 
 kidney, quite healthy. 
 
 Israel met with two post-mortem subjects in which the tuber- 
 culous lesions were limited to one kidney, its ureter, and the 
 area of the bladder about the corresponding ureteral orifice. 
 
 Tuberculous lesions may also occur simultaneously and in- 
 dependently in the kidney and in the bladder or some other part 
 of the genito-urinary apparatus ; the renal lesions are then neither 
 the cause nor the consequence of the vesical lesions, and the 
 disease cannot be placed in either of the two categories ascending 
 or descending tuberculosis though it is possible that the blood 
 by which the bacillus is conveyed to the kidney has been infected 
 by the lesion in the lower organs. 
 
 It is not difficult, generally, when examining a tuberculous 
 kidney which has been removed from the body, to say what 
 has been the mode of infection. When by the blood, miliary 
 tubercles are found in the cortical substance ; the caseous nodules 
 are older and wider about the bases of the pyramids than at 
 the apices ; and if they are broken down and have opened into 
 the calyces, the openings of the vomicse are small, even though 
 the parenchyma may be almost entirely destroyed. Moreover, 
 there may be little or no extension of the diseased process into 
 the renal pelvis or the ureter. 
 
 When the disease is of the ascending type the ureter and renal 
 pelvis are indurated, thickened, and perhaps ulcerated, with a
 
 TUBERCULOUS PERINEPHRITIS FROM KIDNEY PERFORATION. 489 
 
 quantity of cheesy material in their walls or in their lumen. 
 The calyces share in these changes : the connective tissue and 
 urinary tubes become invaded from below upwards; the vessels 
 become obliterated, minute haemorrhages occur into the tissue, 
 and the breaking-down process spreads upwards along the pyra- 
 mids from apices to bases till large vomicae are formed in the 
 kidney which communicate wih the renal pelvis by wide openings. 
 
 As soon as the bacilli or their proteids have excited the con- 
 nective tissue corpuscles and the endothelial cells to proliferate, 
 epithelioid and giant cells are produced which often enclose one 
 or more of the bacilli of Koch, and lymphoid- corpuscles and 
 leucocytes are multiplied and scattered thickly at the circum- 
 ference of the little mass, the centre of which is formed by 
 an occluded vessel stuffed with endothelial cells. In this way is 
 formed the typical miliary tubercle ; and these uniting form 
 grey and yellow nodules of various sizes ; then coagula- 
 tion necrosis following caseating masses result. These masses, 
 sometimes involving the whole kidney, are not unlike in appear- 
 ance to the contents of some dermoid cysts. Where these caseous 
 masses have sufficiently increased at the expense of the surround- 
 ing tissues and softened down, they may break through into 
 the calyces and discharge into the renal pelvis and ureter, or 
 more rarely through the fibrous capsule of the kidney, and give 
 rise to tuberculous perinephritis. 
 
 In other cases the disease, owing probably to. the impaired 
 virulence of the bacilli in relation to the tissues of the individual 
 attacked, may take the form of an infiltrating intertubular 
 tuberculous cirrhosis. If the tuberculous foci are invaded by 
 pyogenic organisms, large abscesses may result ; if the ureter 
 becomes occluded either by ascending ureteritis or (when the 
 tuberculosis is primarily renal) by the impaction in the lumen of 
 the ureter of caseous material or lime salts, tuberculous pyo- 
 nephrosis may thus be caused. 
 
 Tuberculous hydro-nephrosis is most likely to arise from obstruc- 
 tion of the ureter by ascending tuberculous ureteritis. It can be 
 ascertained by the microscope and inoculation that the clear yellow 
 urine which is pent up within a hydro-nephrotic kidney in cases of 
 ascending tuberculosis contains the tubercle bacilli, but no other 
 micro-organism. Klippel has reported a case in which the whole 
 kidney was transformed into a poly cystic mass and a tuberculous
 
 490 SURGERY OF THE KIDNEY AND URETER. 
 
 " cystic degeneration " existed without there being any obstruction 
 of the ureter. 
 
 Certain very rare forms of renal tuberculosis have been 
 described. Kayer mentions an ecchymotic variety of renal tuber- 
 culosis ; Johnson a renal epithelial tuberculosis ; Coffin a special 
 tuberculous nephritis caused by compression of the uriniferous 
 tubules by sclerosis. Cornil and ' Brault, and Durand-Fardel 
 describe a glomerulo-tuberculosis in which the glomeruli alone 
 are invaded by the tubercle, the capsule of Bowman being stuffed 
 with endothelial cells by which the Malpighian tufts are com- 
 pressed and finally obliterated. 
 
 It is not always easy when operating, or even when making a 
 post-mortem inspection, to be sure by microscopic examination that 
 a lesion is tuberculous. This is especially the case if the lesions 
 are small in size, or if suppuration has supervened and altered, 
 as it is pretty sure to do, the character of the initial lesion. 
 
 The lesions most likely to be mistaken for tubercle are those 
 wrought by the bacillus coli communis and staphylococcus ; 
 the minute suppurating foci met with in kidneys wrongly known 
 as " surgical kidneys " ; and, more rarely, the disseminated foci 
 of carcinoma and epithelial adenoma and some of the changes 
 made in the kidney by syphilis, malaria and lepros}'. 
 
 The malarial foci are of the size of pins' heads and are formed of 
 embryonic cells and leucocytes infiltrating the cellular tissue around 
 the obliterated blood-vessels ; they never caseate or suppurate. 
 They are often associated with hsematuria during life. Osier 
 speaks of occlusion of the small renal arteries by the parasite 
 of malaria as being comparatively frequent. 
 
 It is important for the surgeon, when operating, to remember 
 that a kidney may be the seat of extensive discrete miliary tuber- 
 culosis without any evidence of the tubercle appearing on the 
 surface of the organ. Occasionally it is only on section of the 
 kidney and after compressing the renal artery that miliary foci 
 are seen, and then only on the cut surface. 
 
 Acute miliary tuberculosis of the kidneys as part of a general 
 infection is very common in young children who are very prone 
 to general tuberculosis. The tubercles appear as minute trans- 
 lucent grey granulations the size of a pin's head and vary in 
 number from one or two up to any number. The infection 
 is brought to the kidneys by the blood-stream and the tubercles
 
 SECOND KIDNEY INVADED FROM BELOW. 491 
 
 tend to follow the lines of the arterioles. The earliest deposits 
 are usually found in the cortex, but later the}- may be scattered 
 throughout the entire organ and tend to spread downwards 
 into the ureter and bladder and also to involve the vesiculae sem- 
 inales, prostate and testes. This variety of the disease does not 
 give rise to any symptoms directly referrible to the kidney, nor 
 does it come within the scope of surgical treatment. 
 
 Infiltrating or caseating tuberculosis. This form runs a 
 chronic course and is characterised bv the formation of caseous 
 
 Fig. 71. Tuberculous Kidney showing numerous caseous deposits. (Middlesex 
 
 Hospital Museum.) 
 
 nodules within the kidney substance. The disease may for a 
 time be localised in the kidney, but post-mortem examinations 
 show that in. the majority of cases some adjacent parts of the 
 genito-uriiiary tract are ultimately also affected ; where both 
 kidneys are affected the disease in the second usually arises as 
 an ascending tuberculous uretero-pyelo-nephritis, and is generally 
 much less extensive than in the first. 
 
 The bod}' of the kidney is often enlarged, and may become 
 lobulated by the extension of cheesy infiltration into the cortical 
 parts of the organ ; and 011 section, conical masses of this cheesy 
 material in different stages of softening are found to correspond 
 to the prominences of the lobules (Fig. 71). The pelvis of the 
 kidney and its ureter, on the other hand, may be contracted by the
 
 492 SURGERY OF THE KIDNEY AND URETER. 
 
 thickening of their mucous and submucous membranes ; and at 
 a later period the mucous membrane ulcerates, and the lumen of 
 the tube is choked by the softened caseous or putty-like sub- 
 stance which escapes into it. Thus, often both the mucous 
 membrane lining the pelvis and infundibulum and the secreting 
 and tubular substance of the kidney are affected ; and the organ 
 is converted into a huge abscess cavity, or into a series of large 
 irregular abscess cavities with softened caseous or puriform debris 
 for contents. These contents can be readily washed away, and 
 leave exposed white shaggy ulcerated walls in which there is scarcely 
 any, if any, renal structure traceable. In some cases the kidney 
 becomes a mere shrunken putty-like mass in which abundance of 
 cholesterine or calcareous nodules are formed in 'the lobulated spaces. 
 
 The renal parenchyma between the tuberculous foci may be 
 in some places quite or almost healthy, in others interstitial 
 sclerosis may exist, and in others the tubules may be dilated 
 and stuffed with degenerated epithelial cells. The ultimate shape 
 and condition of the kidney in these cases vary considerably, 
 and depend to some extent upon the condition of the ureter. 
 
 When there are only a few discrete caseous nodules scattered 
 throughout the organ the progress is often very slow, and in 
 some cases it may become arrested by calcification of the nodules, 
 or by fibroid changes taking place around them, just as tuber- 
 culous foci in the lung are arrested. Some amount of calci- 
 fication in these cases is not at all uncommon, but it is rare 
 for fibroid changes to be sufficiently marked to exert any definite 
 influence on the course of the disease. When the ureter is 
 occluded the kidney often becomes greatly enlarged, and even- 
 tually is converted into a mere sac partially loculated and tightly 
 distended with a thick white putty substance which has en- 
 tirely replaced the kidney substance proper ; it is to this variety 
 that the term " massive tuberculous degeneration " has been 
 applied. 
 
 Much more rarely, occlusion of the ureter is followed by 
 tuberculous hydro-nephrosis. It is, however, more common to find 
 a pyelo-nephritis with a considerable distension of the renal pelvis. 
 
 Chronic tuberculous disease of the kidney, if it spreads 
 beyond the capsule of the organ, may sometimes, invade the 
 liver or the spleen. In the patient from whom the organs 
 illustrated in Figures 72 and 73 were taken, the upper half
 
 SUPPURATION SUPERVENING ON TUBERCULOSIS OF KIDNEY. 493 
 
 of the right kidney had been completely destroyed, and the 
 disease had spread by contiguity to the under surface of the 
 liver. The lower half of the right kidney was quite health}-. 
 The presence of tubercle in the kidney and the congested 
 condition of the parts which tubercle induces create a ground 
 admirably suitable for the growth and multiplication of secondary 
 infective agents, such as the coli bacillus, the staphyloeoccus and 
 
 Fig. 72. Tuberculous Right Kidney, from the same patient as Fig. 73. Only 
 the upper half of the organ is involved. 
 
 streptococcus, and the bacillus septicus liquefaciens, which is also 
 found in the kidney in cases of secondary infection ; so that 
 if there is present cystitis or suppuration in any of the lower 
 urinary organs, or in any more remote part, the kidney, even 
 though but slightly tuberculous, becomes thereby all the more 
 prone to secondary infection, by the micro-organisms ascend- 
 ing the ureter or circulating in the blood. The tuberculous 
 and the pyogenic infection re-act unfavourably to the patient 
 on one another : the clinical course of the tubercle is rendered 
 more acute, and on the other hand the lesions caused by the 
 pyogenic infection are more serious and persistent than in ordi- 
 nary cases of suppuration. Hence we find very extensive changes
 
 494 SURGERY OF THE KIDNEY AND URETER. 
 
 not only in the kidney, ureter, and bladder themselves, but in 
 the cellular tissue enveloping them. Peri-ureteritis and peri- 
 nephritis are often present in a very aggravated form. 
 
 Other variations in the external and internal appearances 
 are produced by secondary infections becoming imposed upon 
 the primary tuberculous lesions. 
 
 Complications. The most important point for consideration 
 in every case of chronic renal tuberculosis, more especially 
 when a surgical operation is contemplated, is the probable 
 condition of the opposite kidney. As \ve have already seen 
 
 Fig. 73. Portion of Liver involved by contiguity with the Tuberculous Right 
 Kidney shown in Fig. 72. 
 
 from post-mortem records, both kidneys are affected in about 
 half the total number of cases, but not to an. equal degree, so 
 that when patients first come under treatment, unilateral renal 
 tuberculosis is no doubt much more frequent than bilateral. 
 When considered in relation to the possibilities of relief being 
 afforded by operation, figures taken from post-mortem records 
 must be considerably modified, and Tuifier and Albarran are of 
 opinion that tuberculosis of the second kidney is only a contra- 
 indication to operation in about 17 per cent, of the cases. But 
 besides tuberculosis of the second kidney, the possibilities of other 
 forms of renal disease must also be borne in mind, such as pyelo- 
 nephritis, nephritis, and lardaceous disease, which is not at all 
 unfrequent in long-standing cases. There are also often present 
 tuberculous deposits in other parts of the yenito-urinary tract;
 
 INFECTION OF THE PERINEPHRIC TISSUE. 495 
 
 the vesicular seminales, vas deferens, and epididymis are all frequently 
 the seat of such deposits. The bladder is also often affected, 
 and Vigneron found it diseased in twelve out of twenty-three cases. 
 Lastly, there may be old or recent tuberculosis of other organs 
 of the body, such as the lungs, pleura, or intestines. 
 
 Unilateral renal tuberculosis co-existed with epithelioma of the 
 same kidney in a case observed by Albarran. A tuberculous 
 kidney was found in an elderly man in whom, eighteen months 
 before death, I had established a supra-pubic fistula on account 
 of carcinoma of the bladder. 
 
 In cases of renal tuberculosis of long standing, there are 
 usually considerable changes produced in the peri-nephric 
 tissue, which result in the formation of a chronic peri- 
 nephritis of either the sclerosing type or, what is very common, 
 the fibro-lipomatous variety. In some of these cases the peri-renal 
 tissue becomes greatly increased in volume, forming enormous 
 masses which may give rise to a very definite tumour, though 
 the kidney itself is but little if at all enlarged. Tuffier has 
 described under the name of " fungatiiig " a tuberculous peri- 
 nephritis which arises by direct infection of the surrounding 
 tissues after nephrotomy has been performed. A tuberculous 
 abscess of the peri-renal tissue is rare, and when it occurs it often 
 communicates directly with an abscess cavity in the kidney. 
 Firm adhesions may occur between the renal pelvis and sur- 
 rounding parts, and one case has been recorded (Bang) in 
 which an enormously distended pelvis formed a fistula with 
 the duodenum. The kidney may be fused with the vena cava 
 or aorta by means of the sclerosing perinephritis, and when 
 this is so, though the kidney can be easily enucleated from 
 its own capsule, the capsule itself cannot safely be removed from 
 its surroundings. 
 
 The lymphatic glands at the hilum of the kidney may also 
 become infected and form firm adhesions with the organs around. 
 
 Changes in the ureter caused by ascending and descending 
 tuberculous ureteritis are the almost habitual accompaniments of 
 renal tuberculosis. 
 
 Symptoms. Taken together, the symptoms in a typical case 
 of renal tuberculosis are very characteristic, though it must be 
 allowed that in many cases in which some or all of the symp- 
 toms are entirely absent or but little marked, the difficulty of
 
 496 SURGERY OF THE KIDNEY AND URETER. 
 
 diagnosis is considerable. There are cases in which persons who are 
 known to be tuberculous and who die from this disease have 
 never had any symptom referrible to the kidney, and no change 
 in micturition or in the urine (except possibly the occasional 
 presence of bacilli), and yet both kidneys have, been the seat of 
 tubercle. A striking and well-recorded case has been published 
 by Tilden Brown. 
 
 The various symptoms to which renal tuberculosis may give 
 rise are the following : lumbar pain, dysuria, polyuria, frequent 
 micturition by night as well as by day, pyuria with acid urine, 
 haematuria with acid urine, the presence of tubercle bacilli in 
 the urine, pallor, loss of flesh, night sweats, some elevation of 
 temperature especially in the evening, oedema of feet, the occa- 
 sional presence of albumen apart from that due to pus or blood, 
 and the reaction to the injection of tuberculin. 
 
 The symptoms, in the early stages of the disease, vary accord- 
 ing to the mode of invasion. The infection through the blood 
 may cause no local or urinary symptoms for a time, at least, 
 until the calyces become invaded or a tumour is formed. Thus 
 acute miliary tuberculosis of the kidney, occurring as part of a 
 widespread tuberculosis, produces no characteristic symptoms 
 referrible to that organ. 
 
 The symptoms of the chronic infiltrating or caseating form 
 (the so-called strumous kidney) are often slow in developing and 
 may not be at all severe until the disease is well advanced. 
 
 Pain in the loins is sometimes the earliest symptom complained 
 of ; it is long-continued, of moderate intensity, and not as a rule 
 particularly influenced by movement. When the disease becomes 
 well advanced the pain is usually greater and forces the sufferer 
 to seek relief, so that when a patient is first seen the common 
 history is that he has suffered from pain in the loins for a 
 variable length of time it may be for some months or some 
 years which has lately increased very much in intensity. The 
 pain is often referred to one loin, occasionally it is referred to 
 the pelvis, or there may be acute exacerbations accompanied by 
 vomiting which closely resemble nephritic colic due to calculus. 
 Colic is sometimes caused by the passage of small caseous masses 
 along the ureter, which is sometimes temporarily blocked by them. 
 There is usually tenderness on palpating the affected region. 
 
 Tumour. Some increase in volume of the kidnev is exceed-
 
 PERINEPHRIT1S SIMULATES ENLARGED TUBERCULOUS KIDNEY. 497 
 
 ingly common ; and in a large number of cases, though there 
 is no hydro- or pyo-nephrosis, the tuberculous kidney causes a 
 tumour which can be detected on palpation by the movement 
 known as ballottement). A tumour may form insidiously and be 
 the only symptom. There may be an indistinct swelling or sense 
 of resistance, accompanied by an increased area of renal dulness, 
 and in many cases a definite tumour can be felt. In others, there 
 are no local signs to be made out at any period of the disease. 
 In some cases a tumour seems to exist when there is no actual 
 enlargement of the kidney itself : this is due to the effects of peri- 
 nephritis, and it explains the surprise sometimes expressed at 
 operations when the kidney which has been thought to be greatly 
 enlarged is found of normal size on exposure. 
 
 When the kidney is enlarged by tubercle the tumour may 
 be regular and retain the outline of the organ ; or it may be 
 irregular on its surface from the prominence of masses of caseous 
 material in the parenchyma. A large chronic tuberculous abscess 
 may expand at one part of the organ and give it an abnormal 
 outline. An enormous hydro- or pyo-nephrosis may destroy 
 the renal shape and give the tumour a rounded, smooth, and 
 elastic character. 
 
 The tumour may be painless, or on the other hand tender and 
 painful. The pain may be local, or radiate to the groin and 
 thigh and in various directions in the loin and abdomen. It 
 may be continuous or intermittent, spontaneous or only invoked 
 by movements, pressure, or manipulation. 
 
 Tumour is more commonly a symptom of the middle and 
 later stages of both forms of tuberculous kidney. When the 
 infection proceeds upwards, however, partial obstruction of the 
 ureter may give rise to an intermittent or continuous hydro- 
 nephrosis before the kidney becomes affected with tubercle. 
 
 If the disease be on the left side the spleen may be so much 
 pushed forward as at first sight to give the impression that the 
 tumour is an enlargement of that organ. In one instance 
 which I have seen a small ague-cake existed and masked 
 a large tuberculous kidney. 
 
 The urine. Polyuria is a frequent and early symptom of renal 
 
 tuberculosis ; it shows itself sometimes in fits and starts, and its 
 
 occurrence is often accompanied by dysuria. There may be no 
 
 other symptom of any kind hi the early stage of the disease, 
 
 VOL. i. 2 G
 
 498 SURGERY OF THE KIDNEY AND URETER. 
 
 and when it occurs in a patient of weakly constitution and of a 
 tuberculous stock and no other cause for it is assignable, sus- 
 picion of incipient renal tuberculosis ought to be aroused. In 
 the late stage of the disease the quantity of urine passed is often 
 below the normal. 
 
 The urine may .not show any definite alterations in quantity 
 or quality during the early stages, but later it becomes cloudy 
 and contains varying quantities of pus and blood, and sometimes 
 debris of renal tissue and minute cheesy masses. The polyuria 
 sometimes met with in the earlier stages may cease, or give 
 place to anuria in the late stages. The reaction is nearly always 
 acid, but may become neutral or slightly alkaline, especially in 
 the later stages. The quantity of urea and of the phosphates is 
 often much diminished. Epithelial cells from the tubules or 
 pelvis of the kidney, and occasionally hyaline or granular casts, 
 are found ; but these if present in quantity point to nephritis, 
 which not very rarely co-exists with renal tuberculosis. 
 
 A partial occlusion of the ureter which not unfrequently 
 accompanies ascending tuberculosis may for a time become com- 
 plete, and in this way the appearance and composition of the 
 urine may show great variations : at one time being thick and 
 at another clear according to whether the duct from the diseased 
 kidney is partially or completely blocked. 
 
 Pyuria. Although the bacilli of tubercle are non-pyogenic, 
 still in nearly every case of renal tuberculosis there comes a 
 period when pus is present in the urine, or at any rate leuco- 
 cytes resembling pus. The urine containing the pus is acid, 
 and the pus is frequently sterile. When the disease begins in 
 the kidney, pus may be absent for a long time, until the tuber- 
 culous process reaches the calyces, and then pyuria will appear. 
 In the ascending form of renal tuberculosis, pus will be present 
 in the urine before the tubercular affection involves the kidney. 
 According to Watson, the pus differs from that of other forms 
 of pyuria in that it has a peculiar dirty grey colour, and also 
 n the fact that tuberculous urines even when loaded with pus 
 do not often have the exceedingly foul smell that is so generally 
 noticed in the urine of cases of chronic cystitis due to stricture, 
 enlarged prostate, and malignant disease of the urinary organs. 
 Mixed with the pus sometimes there may be small mortary 
 phosphatic masses in some of which bacilli may be found.
 
 SLIGHT ILEMATURIA USUAL IN RENAL TUBERCULOSIS. 499 
 
 Haimaturia is not ^infrequently the earliest symptom of the 
 disease, and in most cases traces of blood can be found in the 
 urine from time to time ; the blood is intimately mixed through- 
 out with the urine. It is often present with pyuria. Occasion- 
 ally the haemorrhage is very severe, and may be prolonged for 
 weeks or months. It has been known to be so violent and 
 persistent as actually to endanger life, but this is most exceptional. 
 The cases of excessive haematuria have often been those in which 
 the disease is not far advanced, or is of the miliary type. But it 
 occurs also in advanced cases where the kidney is dilated and 
 breaking down, as in those recorded by Habershon in 1880, and 
 Czerny, which were the first of the kind published. It is said to be 
 more frequent and abundant in tuberculosis of circulatory origin 
 than of the ascending form. It may be so small in quantity 
 as to require the microscope for its detection ; or it may be only 
 faintly visible to the naked eye when the urine is first passed, 
 and become evident enougli after being deposited as reddish 
 streaks or as a reddish layer in the thick purulent sediment. 
 Fagge says, " Haematuria is neither constant nor profuse. Among 
 eighteen fatal cases, with notes of the symptoms during life, which 
 occurred at Guy's Hospital, in only ten is blood said to have 
 been at any time observed in the urine ; and in most of these 
 cases the bladder was likewise affected with tuberculous disease, 
 so that the exact source of haemorrhage was, after all, doubtful." 
 Sometimes clots of blood are voided, and their passage down the 
 ureter is often attended with much pain or with actual colic. 
 The haematuria is in man}' cases intermittent and quite inde- 
 pendent of rest or exercise. 
 
 The presence of bacilli of Koch is of the very first import- 
 ance ; not so their absence. Tilden Brown points out that 
 it is just after an attack of haematuria that the condition of 
 the urine is most favourable to the discovery of the bacilli. 
 Tuffier thinks it is in the deposit of purulent urines that 
 they ought to be searched for; whilst Albarran. on the other 
 hand, emphasises the necessity of searching for them whilst the 
 urine is fresh and acid, and says that it is best to ceiitrifugalise 
 the fresh urine and examine carefully the caseous particles brought 
 down. 
 
 It is absolutely necessary to examine many specimens, for 
 no matter what mav be the state of the urine which is examined
 
 500 SURGERY OF THE KIDNEY AND URETER. 
 
 the bacilli will often escape detection. They may he found in 
 several slides of the same specimen, or in only one out of a dozen, 
 or they may elude a prolonged and careful search in one sample 
 and be readily found in another. They are often absent from 
 the urine in cases of primary renal tuberculosis and in cases of 
 descending tuberculosis if the ureter is blocked. 
 
 They are sometimes detected by inoculation experiments with 
 urine in which they are not found by staining and microscopical 
 examination. In the case of a man upon whom I performed 
 partial, and afterwards total nephrectomy the urine was examined 
 by Mr. Foulerton before the first operation. Two hundred 
 cubic centimetres of the urine were centrifugalised for fifteen 
 minutes, the machine running at about 1,500 revolutions per 
 minute. From the small sediment thus obtained twelve cover- 
 glass films were prepared and examined ; on one only of these 
 cover-glasses a few specimens of bacilli tuberculosis were found. 
 
 Three guinea-pigs, of about 250 grammes weight, were in- 
 oculated in the inguinal region with portions of this sediment. 
 Of these animals one died on the fourth and another on the 
 fourteenth day after inoculation, neither of them showing any 
 sign indicative of tubercular infection. The third guinea-pig 
 was killed, whilst still apparently well, on the thirty-second day 
 after inoculation. The spleen contained a large number of 
 small tubercles in which bacillus tuberculosis was identified on 
 microscopic examination. There was no obvious tuberculous 
 lesion at the site of inoculation. The cover-glasses had been ex- 
 amined, and a negative report sent to me before the results of 
 the inoculation experiments were known, and it was only after 
 some of the cover-glasses had been re-examined that the bacillus was 
 discovered by the microscope in just one of the specimens. The 
 above case shows the difficulty of detecting the bacillus with the 
 microscope, and the necessity, when making an inoculation ex- 
 periment, of injecting several guinea-pigs instead of only one. 
 
 Besides the bacillus of Koch, there may be present in the 
 urine in the advanced stages of the disease the ordinary bacilli 
 of suppuration the coli bacillus, the staphylococci, and the 
 streptococci. When none of these other microbes are present 
 in acid purulent urine the diagnosis of tubercle becomes greatly 
 strengthened if other symptoms of tuberculous kidney exist, even 
 without the evidence afforded bv the bacilli of tubercle.
 
 VES1CAL PAIN AND IRRITATION FAIRLY CONSTANT. 501 
 
 The smegma bacillus may be mistaken for the bacillus 
 of Koch. Leyden, Koch, Konig, and others have failed in dis- 
 tinguishing them by colouring and the microscope. Inoculation 
 is the only sure test. Fraenkel, however, claims that they can 
 be distinguished by the method of Ehrlich the bacillus of 
 smegma being decolorised when the preparation is treated by 
 nitric acid. The mistake is most likely to occur in females and 
 in males with very long prepuce. 
 
 It has been previously stated that sometimes persons with 
 general tuberculosis have bacilli in their urine without having 
 tuberculous kidneys. 
 
 Albuminuria. When the tuberculous deposits in the kidney are 
 in connection with the renal infundibulum and ureter, albuminuria 
 is almost a constant symptom as representing the admixture of 
 serum and blood corpuscles and leucocytes which then escapes 
 with the urine. But when the lesions are limited to the renal 
 parenchyma albuminuria is rare, and if present indicates 
 a degree of nephritis superadded to the tuberculosis. This 
 nephritis may be brought about by the strain upon the still 
 uninvolved tubules owing to the extra work forced upon them 
 and the large amount of septic products they have to eliminate. 
 
 It has been thought that if we could distinguish clearly 
 between globulin and true albumen in urine, we should have 
 an aid in making a diagnosis between Bright's disease and tuber- 
 culous nephritis. 
 
 Frequent micturition and Jysuria. Without the presence of 
 any disease in the lower urinary organs, there may be an undue 
 sensitiveness, sometimes amounting to actual acute pain, when 
 passing water. This is in some cases, perhaps, the result of the over- 
 activity and consequent hyperaemia of the neck of the bladder 
 when polyuria or frequent micturition are present; but there 
 is pain at the neck of the bladder and along the urethra also 
 complained of by patients who have neither polyuria nor vesical 
 disease. 
 
 Vesical irritation is quite usual, and in some cases has been 
 the most prominent and a very early as well as a very distressing 
 symptom. A man was under my care who passed water with 
 much pain and spasm on an average 160 times in twenty -four 
 hours. At the post-mortem examination there was found tuber- 
 culous disease of the kidneys and ureter, the bladder having only
 
 502 SURGERY OF THE KIDNEY AND URETER. 
 
 quite recently become affected. In another case micturition was 
 incessant until the kidney was opened and drained. Dickinson 
 goes so far as to say that the absence of vesical symptoms in the 
 presence of pus from the kidney would indicate pretty certainly 
 that the case is not tubercular. The converse of this, however, 
 is certainly not true. 
 
 Frequency of micturition, besides being often the earliest 
 symptom, may for a long time be the only one. It occurs during 
 the night as well as in the daytime. Nocturnal frequency of 
 micturition in a person between twenty and forty years of age 
 should always excite the suspicion of renal tubercle. 
 
 Instead of frequent and painful micturition being caused by 
 either polyuria or reflex irritation, it may be due to co-existing 
 tuberculous deposit in the bladder, or to tuberculous cystitis, or 
 to an ordinary cystitis caused by infection with pyogenic 
 microbes. These vesical conditions may be secondary to the 
 renal disease or independent of it. Daily experience, however, 
 proves that the bladder may be for a very long period in con- 
 tact with urine infected with the bacilli of Koch or with other 
 micro-organisms without itself becoming infected. 
 
 Another cause of frequent and painful micturition is the 
 accumulation in the bladder of masses of soft phosphatic particles 
 blended with muco-pus, or caseous material and debris of renal 
 tissue. In the case of a young wranan whose left kidney I re- 
 moved for tuberculous disease micturition continued to be frequent 
 and painful after the operation until I discovered and removed 
 from the bladder about ten days after the nephrectomy several 
 masses of this material, the size of or larger than dried raisins, yet 
 this lady's bladder had been inspected and these masses over- 
 looked only a clay or two before the operation by a skilled 
 cystoscopist. 
 
 The reaction of tuberculin has been but rarely employed 
 as a means to diagnosis of tuberculosis in man ; its use should 
 be very restricted, and the results of Escherich's clinical obser- 
 vations would lead us to attach very limited importance to its 
 diagnostic power in man, whatever may be its value in bovine 
 tuberculosis. 
 
 General symptoms. -The evening temperature even in the 
 early stages of latent renal tuberculosis is in some cases con- 
 stantlv somewhat elevated. If the tuberculous kidnev is also
 
 TUBERCULOUS MATTER BLOCKING THE URETER. 503 
 
 suppurating the evening temperature may be much higher 
 though one or more chronic or cold abscesses may occur with- 
 out any rise of temperature. In general tuberculosis and in 
 tuberculosis localised in the kidney, when there is much de- 
 struction of tissue and septic infection, the evening temperature 
 may rise to 103 or 104 F., and the morning temperature to 
 1 or 1^ above normal. 
 
 Loss of flesh, loss of appetite, diarrhosa, a sallow or pale skin, 
 and, very rarely, oedema of the feet are symptoms indicative 
 of a general anaemic state, which may precede any local or urinary 
 symptom ; but they are more likely to occur after the disease has 
 existed for some time, and to increase as the disease progresses. When 
 frequent and painful micturition occurs the patient rapidly loses 
 ground owing to the pain and loss of rest which it entails. 
 
 In the advanced stages there are marked rigors and exhaust- 
 ing sweats or hectic temperature. The temperature may be such 
 as is seen in ague or septicaemia, or there may be intermittent 
 periods of high fever lasting for two, three, or four consecutive 
 days. 
 
 These attacks of high fever are indicative of temporary obstruc- 
 tion in the ureter, and are apt to be associated with lumbar 
 pain, general malaise, loss of appetite, an increase of dulness 
 and resistance, or possibly the presence of a distinct tumour in the 
 renal region, together with a marked improvement in the urine 
 which, if the opposite kidney and the bladder are unaffected, will 
 become quite normal and remain so until the ureteral block is 
 removed. Retention of the urine may follow obstruction of the 
 ureter by caseous masses, and if the opposite kidney is absent or 
 destroyed by disease, or if there is but a single kidney, a con- 
 dition of anuria analogous to that produced by a calculus will 
 result. 
 
 Intermittent pyo-nephrosis from partial obstruction of the 
 ureter is important clinically from the fact that some knowledge 
 of the state of the opposite kidney may be obtained by exam- 
 ination of the urine passed in the intervals between the attacks 
 of pyuria. 
 
 When suppuration is superadded to renal tuberculosis the 
 greater part of the general symptoms may be due to the 
 secondary and not to the tuberculous infection. In fact, it is 
 difficult to say how much of either the local or general phenomena
 
 504 SURGERY OF THE KIDNEY AND URETER. 
 
 is due to the one cause or to the other ; and yet it is a matter 
 of importance to know this when considering the question of 
 surgical treatment. For example, in the case of pyo-iiephrosis 
 in a slightly tuberculous kidney nephrotomy and erasion may 
 suffice, whereas if the disease be entirely tuberculous iiephrectomy 
 would be requisite. So in the case of the ureter and the bladder, 
 a septically infective state of either may be entirely and rapidly 
 recovered from, whereas a tuberculous ureter will require re- 
 moval, and a tuberculous bladder will probably contra-indicate any 
 operation. 
 
 Diagnosis. The early diagnosis of renal tuberculosis is of 
 very great importance ; and if this is made, the patient may be 
 saved the necessity of subsequent partial or entire iiephrectomy 
 by being sent to a suitable climate and placed under proper 
 dietetic and hygienic conditions. 
 
 The diagnosis is, however, frequently very difficult, and it is 
 only by an accurate knowledge of the various symptoms above 
 related that it can be arrived at correctly. When there is fre- 
 quent micturition, or polyuria, or pyuria, or haematuria in an 
 acid urine, together with an elevation of the evening temperature ; 
 when the pyuria is persistent and the haemorrhage uninfluenced 
 by rest or movement; when the patient is pallid and losing flesh, 
 and especially if he comes from a tuberculous family, and if there 
 is fulness or a tumour with or without pain in the renal region, 
 and tubercle bacilli are found in the urine, we have an assemblage 
 of symptoms which are sufficiently characteristic. On the other 
 hand, all these symptoms may be absent in the early stages of 
 the disease and occasionally throughout its whole course ; and 
 the bacilli of Koch, though positively proved by inoculation to be 
 ^uch and not the bacillus of smegma, may be present in the 
 urine without either of the kidneys or ureters or the bladder 
 being the seat of tubercle. 
 
 In the diagnosis of tuberculous kidney from simple or suppura- 
 tivc pyelo-nephritis much assistance will be given by the ante- 
 cedent history of the patient, by family history, by the develop- 
 ment of the disease, by the discovery of other tuberculous 
 lesions, by careful examination of the lungs, the testes, prostate, 
 and seminal vesicles, by finding a thickened irregular nodular 
 state of the ureter, by abdominal rectal or vaginal palpation, 
 and above all by discovering the tubercle bacilli in the urine.
 
 DIAGNOSIS FROM CALCULUS : OFTEN VERY DIFFICULT. 505 
 
 Blocli of Copenhagen has proposed cutting out and microscopi- 
 cally examining a portion of the affected parenchyma, after expos- 
 ing the kidney by lumbar incision. This might be done with 
 advantage in exceptional cases before sacrificing a very doubtful 
 kidney to nephrectomy ; but it is rarely feasible in practice. 
 
 From renal calculus. In the early stages of the disease it is 
 difficult if not impossible in the absence of the bacilli of tubercle 
 to diagnose tuberculous kidney from renal calculus. The chief 
 reliance must be placed on the constitutional signs of tuberculosis : 
 a poor and weakly physique with existing or threatening or past 
 lung symptoms, in a person between ten and fifty years old who 
 is suffering from suppurative pyelitis with an irregular and 
 occasionally high temperature, and with vesical irritation, are 
 pretty sure indications of tuberculous kidney. The bladder 
 symptoms are often the most prominent, and no relief from pain 
 in the hypogastrium and the neck of the bladder is experienced 
 except when the bladder is empty. In stone there is more likely 
 to be haematuria brought on by exercise or exertion and ceasing on 
 resting or lying down, and the pyuria is generally intermittent ; 
 whereas in tuberculous kidney blood is usually found only in small 
 quantity, the haematuria is unprovoked by exercise and not abated 
 by rest, and purulent urine is continuous, or if it ceases the 
 cessation is the result of occlusion of the ureter. Sometimes 
 there is considerable induration and thickening about the ureter ; 
 and if the patient is thin and has lax abdominal parietes this 
 condition may give rise to the impression that a calculus is im- 
 pacted in the ureter. I have known this error made ; and even 
 at a post-mortem examination with the peritoneum alone inter- 
 vening between the indurated ureter and the finger the impression 
 may be maintained till dissection shows the real state of things 
 to be tuberculous, and not calculous at all. Nor is a palpable renal 
 tumour sufficiently common in tuberculous disease for its absence 
 to influence the diagnosis. Still, the kidney is sometimes so 
 enlarged as to cause a tumour which in all respects resembles 
 a iiephrectasis due to calculus or any other obstruction. In the 
 early stages before it becomes purulent the urine may be al- 
 buminous ; but this is indicative of nephritis rather than of 
 tuberculosis. In renal calculus the urine is often charged with 
 uric acid and urates, in tuberculosis with little masses of caseous 
 material and little phosphatic lumps.
 
 506 SURGERY OF THE KIDNEY AND URETER. 
 
 In all doubtful cases the urine should be carefully examined 
 for tubercle bacilli, and if these are found the diagnosis is facili- 
 tated. Unfortunately, however, the bacilli are much more difficult 
 to find in urine than in sputum, and therefore a negative 
 result even after a large number of specimens have been ex- 
 amined has not so much significance in regard to the former as 
 to the latter. But if systematic and careful examinations of the 
 urine are made many cases can be definitely settled as being 
 tuberculous in nature which must otherwise have continued 
 doubtful. As previously stated, care must be taken not to confuse 
 the tubercle bacillus with the smegma bacillus, which it closely 
 resembles in its appearances and staining properties. The in- 
 oculation of several guinea-pigs with the sediment of the centri- 
 fugalised fresh urine is a test which should always be resorted to 
 in doubtful cases. When the bladder is inflamed, as it so 
 frequently is, the urine is ammoniacal and ropy and as this 
 condition of urine is known not to occur in simple renal tuber- 
 culosis it often misleads the practitioner into regarding a case 
 as one of simple cystitis, when it is really one of tuberculous 
 disease of the kidney with the addition of cystitis. 
 
 In renal calculous affections descending ureteritis and peri- 
 ureteritis are much less likely to reach so low down along the 
 tube as the}* are in tuberculous disease, and therefore a thickened, 
 nodulated, and indurated ureter below the brim of the bony 
 pelvis, as felt per vaginam or per rectum, is much more indicative 
 of renal tuberculosis than of a renal calculous disorder. 
 
 In the male, tuberculous disease of the kidney is frequently 
 associated with the same disease in other parts of the genito- 
 urinary tract ; so that an examination of the testes, the prostate, 
 and the vesiculre seminales should be made, and if either of 
 them be found to be nodular or irregularly indurated additional 
 weight will be thereby given to the diagnosis of tuberculous 
 kidney. 
 
 From renal new growths tuberculous kidney differs commonly 
 by the hsematuria being far less abundant, by the persistent 
 pyuria, by the family history and personal antecedent history, 
 by the discovery of the bacilli in the urine, and possibly by the 
 presence of co-existing tuberculous lesions elsewhere in the body. 
 The occurrence of a high temperature with other symptoms would 
 IDC in favour of tuberculosis, though it should be borne in mind
 
 UNCERTAINTY AS TO WHICH KIDNEY IS INVOLVED. 507 
 
 that a slight elevation of one degree is quite consistent with rapidly 
 growing neoplasm. 
 
 In renal new growth, in renal calculus, in movable kidney, 
 and in suppurative pyelo-nephritis and pyo-nephrosis, as well as 
 in renal tuberculosis, there may equally be present a tumour 
 or fulness in the renal region, tender on pressure and accompanied 
 by local and radiating pain ; together with reflex bladder irritation, 
 nephritic colic, and pyuria, and hsematuria in acid urine. The 
 differences between the symptoms in these different disorders men- 
 tioned have been described under the symptomatology of these 
 several subjects, and need not be here repeated. 
 
 As to which kidney is affe-cted. The diagnosis as to the 
 tuberculous nature of the disease being settled, there may yet 
 be doubt as to which kidney is the seat of the affection, or as 
 to the condition of the opposite kidney if one of the organs 
 is known to be affected. The presence of a tumour and of 
 pain in one loin and not in the other goes far to settle the 
 question as to the side, and if there is intermittent pyuria 
 with increase in dulness, pain, or tumour when the pus ceases 
 to be present in the urine, there is not only a further indica- 
 tion of the organ involved but good proof that the other 
 organ is not affected. If the kidney supposed to be healthy 
 is not enlarged and has never been the seat of pain, and 
 if a good quantity of healthy urine is voided at times when 
 there is reason to think from colic and lumbar enlargement 
 that the ureter of the affected organ is blocked, the indications 
 are sufficiently clear that the second organ is sound. It must 
 not be forgotten, however, that the normal kidney, especially 
 in women during the catamenial periods, may be enlarged and 
 even painful owing to temporary congestion, and also that a 
 healthy kidney may be hypertrophied ; and these facts must be 
 taken into consideration in judging of the state of the second 
 kidney. Methylene blue, as recommended by Castaigne and 
 Achard, may be of use by proving one kidney to be healthy 
 if the blue appears without undue delay in the urine. The 
 cystoscope and the ureteral catheter should be employed with 
 reserve and with great caution in tuberculous disease. 
 
 There are sometimes 'seen on the mucous membrane of the 
 bladder in persons with tuberculous renal disease, one or many 
 hypersemic patches which are apt to be ascribed to disease
 
 508 SURGERY OF THE KIDNEY AND URETER. 
 
 in the bladder itself. Tilden Brown has pointed out that after 
 nephrectomy these patches disappear with the vesical troubles 
 with which they are associated, and therefore that they are not 
 the sites in which tubercle develops. I have elsewhere referred 
 to other mistakes in diagnosis which are liable to be made with 
 the cystoscope (see Vol. II., p. 323 et seq.). 
 
 AVith the ureteral catheter the urine from the two kidneys 
 can be collected separately and examined for the bacilli. From 
 what is known of the uncertainty and difficulty of finding the 
 bacilli in any given specimen of urine, this form of catheter- 
 isation may have to be repeated many times before it affords the 
 desired information. If employed at all in this disease the ureteral 
 catheter ought not to be passed into a healthy ureter without 
 having previously well irrigated the bladder with antiseptic solution. 
 Even then there is the risk of urine coming into the bladder 
 from the affected organ and passing upwards along the side of 
 the catheter in the sound ureter. If the bladder be healthy 
 and one kidney is known to be affected, Albarran advises that 
 the ureter of the affected organ should be catheterised with a 
 catheter which exactly fills the ureteral opening, and the urine 
 from it collected whilst the urine from the doubtful organ is 
 allowed to collect in the bladder. To avoid error in the result 
 of this procedure Albarran injects an. antiseptic fluid through 
 the ureteral catheter when the catheter is in position, and at 
 the same time watches through the cystoscope to see if any 
 of the fluid passes back into the bladder along the outside of 
 the catheter. If the bladder is itself the seat of tuberculous 
 disease, the ureters ought on no account to be catheterised even 
 after the bladder has been well irrigated. 
 
 Prognosis. Unless the disease is strictly localised, and as 
 such is diagnosed early enough to be radically removed, the 
 prognosis is most unfavourable. This is especially so when both 
 kidneys, or one kidney with its ureter and an extensive tract of 
 the bladder, are involved. 
 
 The course of the infiltrating caseous form of renal tuber- 
 culosis (as distinct from the acute miliary disease) is much more 
 chronic than is often supposed. The disease progresses often 
 by fits and starts, periods of activity being succeeded by long 
 periods when it is comparatively or entirely quiescent. It is 
 bv no means unusual for the disease to extend over four or
 
 SPONTANEOUS CURE OF RENAL TUBERCULOSIS VERY" RARE. 509 
 
 five years ; its duration in fact varies much, from a few months 
 to several years. Its course is hastened by the supervention of 
 secondary pyogenic infection ; and occasionally, though very 
 rarely, by profuse hsematuria. Keference has been previously 
 made to certain rare hsemorrhagic cases in which the patients 
 have rapidly become anaemic, and a fatal result even has been 
 threatened, by excessive hsematuria. 
 
 The complication of suppurative pyelo-nephritis is one of the 
 gravest significance. 
 
 It is not impossible, but it is rare, for this disease to subside, 
 either by the tuberculous material undergoing cretification or by 
 the whole kidney atrophying owing to the complete occlusion of 
 the ureter. Neither prognosis nor treatment, however, ought to 
 be influenced by these improbable events. 
 
 Certain well-marked cases of renal tuberculosis have been 
 temporarily or permanently benefited, and some actually cured, 
 by change of residence, a suitable climate, and under a suitable 
 hygienic and dietetic regime. Good results of this sort are much 
 more likely to be accomplished in the rich and well-to-do classes, 
 by whom these advantages can be obtained to the full, than 
 in the poorer classes of patients. 
 
 The prognosis of surgical treatment has greatly improved 
 with operative experience during the last fifteen years. The 
 mortality after nephrectomy has been reduced from 40 per cent, 
 when Gross published his statistics in 1885, and 38' 18 according 
 to Palet's and to Vigneron's figures in 1891 and 1893 respectively, 
 to 18 per cent, as recorded by Israel in 1896 and 7 per cent, 
 by Tilden Brown in 1898. 
 
 The following are Vigneron's figures in detail : 
 
 Vigneron* collected 1 04 cases of nephrectomy for renal tuber 
 culosis which gave a general mortality of 3 8 '40 per cent, and an 
 operative mortality of 29 '80 per cent. 
 
 They were divided into the following groups : 
 
 (i.) Primary lumbar nephrectomies ; 65 cases yielded a general 
 mortality of 40 per cent, and an operative mortality of 29 per cent. 
 
 (ii.) Secondary nephrectomies, 20 cases ; general mortality, 
 35 per cent. ; operative mortality, 25 per cent. 
 
 (iii.) Primary abdominal nephrectomies, 19 cases ; general 
 mortality, 36'84 per cent. ; operative mortality, 36'84 per ent. 
 * Gazette des Hupitaux, June 24, 1893.
 
 510 SURGERY OF THE KIDNEY AND URETER. 
 
 Tuffier* gives the following results of 16 cases : 
 
 C Operative mortality, 2. 
 
 Nephrotomies, 7 cases -J Amelioration with fistula, 3. 
 
 ( Cure, 2. 
 
 ( Y Total nephrectomies, 
 
 -n 3 6 cured. 
 
 XT L n Prunarv, 7 cases -< T> ,. , , 
 
 JN ephrectomies, 9 cases I 1 artial nepnrectomy, 
 
 V 1 cured. 
 I Secondary, 2 cases cured. 
 
 With regard to the ultimate result of these cases, Tuffier was 
 able to state that three were in good health for varying periods 
 after the operations, one six years and a half (nephrectomy), 
 another five years and a half (nephrectomy), and the third five 
 years (nephrotomy). The others had finally been lost sight of, 
 but one nephrotomy case was known to have been well two 
 years, and another fifteen months after the operation ; two 
 others (nephrectomies) were well nine and six months respec- 
 tively after the operation, while two others upon whom ne- 
 phrectomy had been performed had been too recently operated 
 upon at the time of writing to be able to judge of the final result. 
 
 The following analysis of all my operations, thirty -seven in 
 number, for tuberculous disease of the kidney, between February 
 1888 and the end of the year 1899, shows the nature and 
 result of the operation in each case : 
 
 Of eighteen total nephrectomies thirteen recovered and five died. 
 
 Of the five fatal cases, in one the opposite kidney was found 
 on post-mortem examination to be fatty and the spleen and 
 intestines lardaceous ; in a second the patient died soon after the 
 operation from general tuberculosis ; and in a third in which 
 the disease of the kidney had set up a perinephric abscess which 
 was the immediate cause of operative treatment, the opposite 
 kidney was found after death to be tuberculous. In the other 
 two cases death was due to causes independent altogether of the 
 operation : in one case to broncho-pneumonia and emphysema, 
 and in the other to perforation of a gastric ulcer. Of the thirteen 
 cases which recovered from the operation, two died shortly after- 
 wards : death ensued in one case seven weeks after the operation 
 owing to advanced cystic degeneration of the opposite kidney, 
 
 * Trait>'' de Chirimjic ; Duplay and Reclus, -2nd oil. (1899), tome vii., 
 p. .-304.
 
 RESULTS OF OPERATIONS FOR REXAL TUBERCULOSIS. 511 
 
 and in another from convulsions one month after the operation, 
 the opposite kidney being found on post-mortem examination in 
 an advanced state of hydro-nephrosis. A third recovered from a 
 subcapsular nephrectomy, but the capsule became distended with 
 blood-stained serum and formed a large abdominal tumour which 
 was subsequently successfully removed. A fourth died four months 
 after the nephrectomy from tuberculous disease of the lungs. The 
 other cases recovered, and most of them have since been heard 
 of as remaining well. Some of them were known to be well several 
 years afterwards. 
 
 In seven cases partial nephrectomy was performed, but in three 
 of them total nephrectomy had subsequently to follow. The 
 other four patients were known to be well at considerable periods 
 after the operations. One of them was heard of in March, 1898, 
 three years and three months after the operation, and is believed 
 to be still quite w T ell. Another was known to be well in September, 
 1896, four and a half years after the operation. Another whose 
 opposite kidney had been explored by another surgeon (a fistula 
 being left) was alive in 1896, two and a half years after the 
 operation. The fourth case had previously had one kidney 
 removed in Canada, and I subsequently excised about one-third 
 of the remaining kidney. She is still alive and actively engaged 
 in domestic service, now nearly four years after the partial 
 nephrectomy.* 
 
 In one case just referred to the renal capsule and the ureter 
 down to the broad ligament were removed several weeks after 
 subcapsular nephrectomy had been performed. The patient made 
 an excellent recovery and was known to be well some months later.* 
 
 In four cases nephro-ureterectomy was the operation. One 
 of the operations followed a partial nephrectomy ; the patient 
 recovered from the operation, but died five weeks afterwards from 
 haemoptysis and tuberculosis of the lungs and peritoneum. 
 
 The other three patients made good recoveries, and were 
 known to be well many months later : one has been lately 
 heard of as well, now three years and a month after the operation. 
 
 In seven patients the operation was nephrotomy. Of these 
 one died from disease of the opposite kidney soon after being 
 
 * December llth, 1900: This patient was seen to-day in very good 
 health. She is now earning her living as a working housekeeper. 
 t See Lancet, January 1st, 1898, p. 19.
 
 512 SURGERY OF THE KIDNEY AND URETER. 
 
 operated upon ; two recovered from the operation but died soon 
 after from tuberculosis of other organs; in two others neph- 
 rectomy was subsequently performed ; and in the remaining two 
 the wounds healed well, and in one of them the opposite kidney 
 was afterwards operated upon. 
 
 The remote results of nephrectomy and of partial iiephrectomy 
 are in a large majority of cases excellent ; patients are known 
 to be alive and in good health three, five, and eight years or 
 more after undergoing the operation. 
 
 The commonest cause of death is asthenia due to the gradual 
 progress of the disease and to the exhaustion and cachexia con- 
 sequent upon the discharges, upon the frequent painful micturition 
 and loss of sleep, and upon fever, anorexia, and diarrhoea. Sep- 
 ticaemia is an occasional result of suppurative changes in a kidney 
 the ureter or renal pelvis of which is occluded so that the natural 
 channel no longer affords a means of escape for the septic matters. 
 When only one kidney is present, or when both kidneys are 
 diseased, anuria and uraemia are causes of death. 
 
 A fact which should not be overlooked is that not only are 
 the immediate and remote or permanent results of total or com- 
 plete nephrectomy good when the operation is undertaken in good 
 time, but that when the operation is performed as a tentative measure 
 of relief in very advanced local disease the patients being in 
 a state of very marked cachexia some most surprising recoveries 
 have followed. 
 
 Treatment. The treatment of tuberculous kidney should 
 be carried out on the same principles as those which govern 
 the treatment of tuberculosis elsewhere. 
 
 The objects to be aimed at are twofold : (1) To keep up 
 the general nutrition of the patient, and (2) to remove the 
 source of infection whenever possible. 
 
 To attain the first of these objects the patient should have 
 plenty of fresh air and good nourishing food, and should take 
 maltine, cod-liver oil, and plenty of other fatty articles of diet, 
 such as cream and butter. Creosote gradually increased to 15 
 or 20 minims three times a day is recommended. If there is 
 much pain relief may be obtained by the application of fomenta- 
 tions and other anodyne preparations to the loin. 
 
 Residence in a dry bracing climate, sheltered from cold and 
 damp, and especially in a locality where pine wood abounds, should
 
 NEPHRECTOMY IN RENAL TUBERCULOSIS. 513 
 
 be obtained if possible. A sea voyage is often of great benefit ; a 
 residence at Arcachon, Sydney, or Colorado is highly advantageous. 
 
 The question of surgical treatment has to l)e carefully con- 
 sidered in each case. If the renal tuberculosis is only a part 
 of an advanced widely spread infection, it is clear that no operation 
 should be undertaken ; but if, on the other hand, the disease appears 
 to be localised, at any rate so far as its activity is concerned, 
 then there is a good prospect that an operation may not only 
 relieve the symptoms but even effect a permanent cure. 
 
 But, as has already been seen, the disease too often affects 
 both kidneys, and therefore it becomes of the greatest importance 
 to gain knowledge of the condition of the opposite kidney before 
 deciding the nature of the operation ; for it would be unwise 
 to perform* a nephrectomy if it were certain that the kidney 
 on the opposite side was in an advanced stage of disease. Unfor- 
 tunately it is in some cases very difficult to ascertain the actual 
 state of the opposite kidney. Careful and systematic examination 
 of the urine should be made in every case, as it sometimes happens 
 that the ureter on the affected side becomes blocked for a time 
 an event which is usually accompanied by attacks of colic), 
 and the condition of the urine escaping from the opposite ureter 
 may under these circumstances yield very positive information. 
 In some cases, especially in females, the diagnosis may be assisted 
 by a cystoscopic examination or by catheterisation of the ureter, 
 but the restrictions of and precautions for this mode of investiga- 
 tion have just been indicated. 
 
 Xephrectomy. Xephrectomy, partial or complete, is the ideal 
 operation for a tuberculous kidney, since the local infection is 
 thus completely removed ; but, unfortunately, the number of 
 cases upon which it can be practised is limited 011 account of dis- 
 ease of the opposite organ. Nephrectomy alone, however, is very 
 frequently insufficient to effect a complete cure, and it is of the 
 greatest importance to examine the condition of the ureter, which 
 also in a large proportion of cases is diseased. That so many 
 primary iiephrectomies for tuberculous disease have in the past 
 been followed by fistultp is owing to the fact that an infected ureter 
 has been left unremoved. It is not sufficient in such cases to 
 ligature the ureter just below the kidney, but as much of its 
 length as is diseased should if feasible in the particular case 
 be completely taken away. In the male the duct may be 
 VOL. i. 2 H
 
 514 SURGERY OF THE KIDNEY AND URETER. 
 
 traced down and divided close to the bladder ; in the female 
 it can seldom be so completely extirpated, owing to the difficulties 
 of manipulation in the neighbourhood of the broad ligament; 
 but it can always be traced with safety below the brim of the 
 pelvis where it should be severed and ligatured, care being taken 
 that none of its infective contents escape during the process. 
 The cut end should be well scraped and then thoroughly rubbed 
 with an emulsion of iodoform. 
 
 The question as to whether a nephrotomy should be first 
 performed, to be followed by secondary nephrectomy in cases suitable 
 to the latter operation, has been much discussed. The advantages 
 that have been claimed for this practice are (1) that the patient, 
 later on, will be better prepared for a severe operation, and (2) 
 that after a nephrotomy the tumour may shrink* and make 
 nephrectomy more easy to perform. 
 
 With regard to the first of these points, it may be said that, 
 with due precautions, most (not all) of the patients who can bear 
 a nephrotomy -can undergo a nephrectomy ; and with regard to 
 the second point, experience has shown that the diminution hi 
 volume of the kidney, except in some cases of tuberculous pyo- 
 nephrosis, is not likely to be such as to render a subsequent ne- 
 phrectomy more easy. In most cases no very appreciable diminution 
 in size really occurs, owing to the number or extent of the caseous 
 infiltrating masses ; or if these have broken down, to the loculated 
 nature of the tumour. Moreover, the difficulty and danger of 
 secondary nephrectomy are sometimes made greater than those of 
 primary nephrectomy by the increased toughness and adhesions of 
 the perinephric tissues which follow nephrotomy and drainage. 
 
 The surgeon must bear in mind that it is in tuberculous dis- 
 eases of long standing especially that the probability of the second 
 kidney being diseased is so great; and he must be on his guard 
 against the catastrophe of removing a kidney and losing his 
 patient within a few days from uraemia, and then finding on 
 the post-mortem table that the opposite kidney had likewise been 
 destroyed . 
 
 It would appear from the figures mentioned on pp. 484-5, 
 that the chances of such a catastrophe are very .much greater 
 in operating upon children with tuberculous kidney than upon 
 adults. 
 
 Albarran has pointed out the advisability of cutting into a
 
 CASES IN WHICH XEPHRECTOMY IS REQUIRED SUDDENLY. 515 
 
 tuberculous kidney before removing it, after previously protecting 
 with sponges or swabs the perinephric tissues, because it is 
 often impossible before doing so to tell how much of the disease 
 is due to secondary infection and how much to tubercle, and 
 that by taking this precaution a kidney may sometimes be saved.* 
 
 Nephrectomy is required in certain rare and exceptional cases 
 as an operation of emergency. This is so when haemorrhage is 
 profuse and threatening the life of the patient ; or when severe 
 and frequently recurring attacks of colic confine the patient to 
 bed, and necessitate the administration of large quantities of 
 narcotics or prolonged and repeated inhalations of chloroform ; 
 such attacks may be caused by the passage of masses of debris 
 in cases in which abscess cavities and breaking down caseous 
 masses open into the renal pelvis, and in cases of inter- 
 mittent hydro- or pyo-nephrosis from tuberculous ureteritis. The 
 operation may be urgently required, also, when a sudden access 
 of fever and suppuration supervenes upon chronic tuberculosis of 
 the kidney, whether this happens in pyo-nephrosis or abscess 
 formation or diffuse suppuration in connection with caseous foci, 
 and whether the foci or abscesses communicate or not with the 
 renal pelvis. 
 
 In the last group of cases, nephrotomy, if care be taken to 
 open up all the independent abscesses or vomicee, may suffice 
 to reduce the fever and the risks of septicaemia, and to remove 
 the other more serious general symptoms caused by the se- 
 condary pyogenic infection ; but primary iiephrectomy is the 
 operation to choose in these cases, if we know the condition 
 of the other kidney to be good, and if the strength of the patient 
 will allow. If nephrotomy is the operation immediately resorted 
 to in such a case an excellent temporary result may follow ; but 
 secondary iiephrectomy will be required, providing the opposite 
 kidney will permit of it, if abundant suppuration continues, if 
 the drainage of the several abscesses or vomicae is incomplete, if 
 general septic infection threatens, or if a troublesome fistula persists. 
 
 The indications for nephrectomy are controlled also, though to 
 a less degree than by the state of the opposite kidney, by the 
 integrity or otherwise of the rest of the genito-urinary organs : 
 thus, as Tildeii Brown states, when unusual or very severe 
 symptoms occur in the course of renal tuberculosis even if there 
 * Ann. des Mai. des Org. Genito-urinaires, 1897, p. 17.
 
 516 SURGERY OF THE KIDNEY AND URETER. 
 
 exists in another organ of the patient an appreciable tuberculous 
 deposit, provided it be not in the opposite kidney immediate 
 nephrectomy is not only legitimate, but is even strongly indicated. 
 Tuffier points out also that, whereas a simple tuberculous nodule 
 in the prostate is not a contra-indication if the patient is suffering 
 from a pyo-nephrosis with severe constitutional symptoms ; yet 
 that, on the contrary, if a similar nodule is formed in a patient 
 affected with chronic renal tuberculosis, without febrile symptoms, 
 one would hesitate before undertaking, and probably should refuse 
 to undertake, an operation. 
 
 Concomitant disease of the bladder is an almost insuperable 
 contra-indication. If the vesical disease is quite confined to the 
 area immediately around the ureteral orifice, and if the kidney 
 and ureter of one side only are tuberculous, nephro-ureterectomy, 
 including the removal of the affected piece of the bladder, may 
 be performed in some unique cases. Trendelenburg has successfully 
 performed this operation. 
 
 The cases in which nephrectomy is inappropriate or out of 
 the question are those in which the opposite kidney is certainly 
 or probably the seat of tuberculous or of some other advanced 
 or advancing disease, though it may be less extensive than in the 
 kidney upon which operation is contemplated ; cases in which any 
 one of the lower urinary organs, especially the bladder, is the seat 
 of tuberculosis ; those in which the state of the peritoneum is in 
 doubt, or the lungs are extensively affected ; and in the female 
 when the Fallopian tubes or ovaries are tuberculous. But, as stated 
 above, even in some such cases, under conditions not easy to define 
 in general terms, if the principal disease is in the kidney, and is 
 progressing or is not abated by iiephrotomy and drainage, ne- 
 phrectomy may be tried, and its performance is often justified by the 
 marked, even though temporary, improvement which it affords. 
 
 The technique of the operation is the same in tuberculosis as 
 in other cases. The lumbar method is the method for choice. The 
 sub-capsular operation is often compulsory in tuberculous cases, and 
 piecemeal removal may be the only thing possible. This mode of 
 operating was very early employed by Lucas, Morrant Baker, 
 and other English surgeons, as the Transactions of the Inter- 
 national Congress in 1881 and the medical journals show. As 
 the capsule may be itself infiltrated with tubercle its removal 
 with the kidney when possible is decidedly to be preferred ; and
 
 WHEN NEPHRECTOMY WITH DRAINAGE IS UNSUITABLE. 517 
 
 when the renal substance has had to be enucleated from the capsule, 
 as much of the latter as can be separated from its adhesions to 
 the surrounding structures should be trimmed away afterwards. 
 
 Partial resection of the kidney is perhaps the operation 
 which gives the most promise for the future, if only operations 
 are undertaken at an early period, and when the disease is limited 
 and localised : for in suitable cases this method possesses the ad- 
 vantages of iiephrectomy, inasmuch as the source of infection 
 is completely removed without the risk of being followed by 
 a fatal result should the opposite kidney be defective. When 
 partial resection is practised the patient is still left with a con- 
 siderable amount of secreting tissue, which is thus able to counter- 
 balance disease of the opposite kidney, should such be present. 
 As I have mentioned 011 an earlier page (p. 511), there is a woman 
 living, and leading an active life from whose second kidney 
 four years ago I excised about one-third for tuberculous disease. 
 Her other kidney had been previously removed for the same disease. 
 
 Xephrotomy in tuberculous disease ought to be regarded 
 simply as a palliative operation for the relief of symptoms due to 
 pyo-nephrosis ; and it is only otherwise indicated in cases where 
 the patient's condition is too extreme to bear the more severe 
 operation of iiephrectomy, or in which the disease is advanced 
 or widespread in other organs, or where the local adhesions 
 are so great that no attempt at iiephrectomy is desirable. 
 
 Nephrotomy, although inferior in its curative results to ne- 
 phrectomy, is nevertheless very useful in cases where free drainage 
 can be obtained and where the more radical operation cannot 
 be performed. 
 
 When the disease is not far spread it may be checked 
 altogether by giving a free and direct means of escape for the 
 pus of a solitary abscess. The relief which has sometimes followed 
 an incision of the kidney in search for a stone, in cases in which 
 no stone has been found, is to be explained in this way. The 
 unsatisfactory points with regard to iiephrotomy in cases of abscess, 
 in addition to the very important fact that foci of the disease are 
 apt to be left behind in the kidney, are the danger of infecting 
 the wound by the discharge, and the difficulty in many cases of 
 securing free drainage for multiple abscesses without which a cure 
 cannot be attained. 
 
 To cut into one of several abscess spaces and to drain it,
 
 518 SURGERY OF THE KIDNEY AND URETER. 
 
 leaving others unopened and unable to discharge their contents, 
 is unsurgical in theory and unsuccessful in practice. It is true 
 that after the evacuation of one abscess others do sometimes 
 partly empty themselves through the wound into the renal pelvis ; 
 but this mode of relief is uncertain and, usually, insufficient, 
 and it is far better in such a case to remove the kidney at once. 
 I have opened and scraped out as many as seven tuberculous 
 abscesses in the same kidney, with the best possible immediate 
 and remote results : the man was alive and well several years 
 afterwards. 
 
 Summary as to surgical treatment. No strict rules can 
 be laid down with regard to the adoption of any particular 
 operation in the treatment of tuberculous kidneys, for while each 
 has its special applications, the best results will be obtained by 
 a judicious selection in individual cases. The whole kidney must be 
 carefully examined, close search must be made for separate caseous 
 deposits, for scattered miliary tubercles, and for independent ab- 
 scesses and vomicae. The condition of the ureter also must be 
 ascertained. 
 
 By a careful exploration it may be discovered that 
 what at first sight seemed to require complete nephrectomy 
 may be successfully treated by partial nephrectomy ; or what 
 is much more probable is that an intended nephrotomy must 
 be changed for a nephrectomy or a nephrectomy for a nephro- 
 ureterectomy, owing to the occlusion or very advanced state 
 of disease of the ureter. To obtain a complete cure, partial 
 resection and nephrectomy are both far in front of nephro- 
 tomy, but their application is necessarily limited; and it is 
 just in those cases where the more radical operations cannot 
 be carried out successfully that the wisdom of choosing nephro- 
 tomy is 'shown ; for where from disease of the opposite kidney 
 or other reasons nephrectomy would probably be followed rapidly 
 by a fatal result, nephrotomy may great!}' relieve the symptoms 
 and prolong life, although a permanent cure cannot be expected.
 
 519 
 
 CHAPTER XVII. 
 RENAL SYPHILIS. 
 
 THE occurrence of syphilitic affections of the kidney was first 
 pointed out by Rayer in 1840, but the condition had not received 
 much attention till within the last few years, and indeed the 
 albumimiria and acute forms of nephritis which occur during 
 the secondary stage of syphilis were until recently thought by 
 many to be the effects of the mercurial treatment. 
 
 Syphilitic affections of the kidney may be divided into three 
 classes, according to whether (1) they occur during the early or 
 secondary stage, or (2) during the late stage, or (3) are associ- 
 ated with the congenital type of the disease. 
 
 During the secondary period of syphilis it is not uncommon 
 to find some albumen in the urine and more rarely there may 
 be a definite nephritis. The albuminuria is generally transient, 
 and appears about the same time as the secondary rash ; it is not 
 usually accompanied by any definite symptoms, and is doubtless 
 very frequently overlooked. 
 
 Less commonly, a definite acute nephritis occurs, which runs 
 the clinical course of acute nephritis due to other causes, and 
 terminates in resolution or in the chronic tubular nephritis which 
 gives rise to the large white kidney. Microscopically, the secreting 
 structures are the parts chiefly affected, and in some instances 
 the appearances closely resemble those found in the kidneys from 
 cases of scarlet fever. 
 
 The symptoms of these acute cases are similar to those accom- 
 panying Bright's disease from other causes, and have nothing 
 specific in their character. They may run an acute course 
 terminating in uraemia, but frequently the symptoms are inter- 
 mittent with well-defined intervals, and the albumen often per- 
 sists long after all other symptoms have disappeared. 
 
 Although the exact causal relation between nephritis and the 
 early stage of syphilis is somewhat obscure, it is now established 
 beyond doubt that some definite relationship does exist, for careful 
 observations have shown that the cases cannot be explained as mere
 
 520 SURGERY OF THE KIDNEY AND URETER. 
 
 coincidences of nephritis occurring during the course of syphilis. 
 Neither is the exact cause of the condition known : it may be 
 due to the presence of a micro-organism or a toxine, or it may 
 be due to a congestion similar to that which occurs in the skin 
 and mucous membranes during the secondary stage of the disease. 
 
 Typical cases have been recorded by Mauriac,* Hudelo,{ For- 
 dyce^ and many others ; but the frequency with which the 
 condition occurs cannot be said to be accurately determined. 
 Mauriac collected twenty-three cases, in eight of which the 
 symptoms appeared two months after the chancre. Harrison 
 states that albuminuria occurs in from 3 to 8 per cent, of 
 secondary syphilides ; and Petersen places it at about 3' 8 per 
 cent. Furbringer || found albumen and casts during the roseola 
 stage in twelve cases out of a hundred. As already stated, the 
 nephritis of early syphilis attacks the secreting structures, and 
 microscopically the lesions are seen to affect chiefly the paren- 
 chymatous tissue. The epithelial cells are swollen, granular, 
 and in some instances detached and undergoing fatty changes, 
 while the interstitial tissue suffers but little in proportion. There 
 is nothing specific in the onset, course, or post-mortem appear- 
 ances of these cases. The diagnosis rests only on the relationship 
 between the two diseases, and therefore great care must be taken 
 in every individual case to exclude all other possible causes of 
 the nephritis before its direct dependence upon syphilis is accepted 
 as the fact. 
 
 It is probable that the careful and moderate use of mercury 
 does not produce albuminuria ; on the other hand, many patients 
 appear to derive direct benefit from anti-syphilitic treatment. 
 The prognosis in these cases is difficult, but a large amount of 
 albumen, the presence of epithelial and fatty casts, and the onset 
 of respiratory or other complications are grave signs. 
 
 Renal disease appears 011 the whole to be considerably more 
 common during the later stages of syphilis than in the earlier 
 ones. The interstitial and amyloid forms are most frequent during 
 the late period, but occasionally the parenchymatous variety occurs, 
 
 * Archives Gen. de Mcd., Oct., Nov., and Dec., 1886. 
 
 t Semaine Mcd., 1893, p. 358. 
 
 I Journ. Cut. and Gen.-urin. Disease, April, 1897. 
 
 Brit. Med. Journ., Oct. 3rd, 1891. 
 
 ij Quoted in " Manuel de Medicine,'' by Debove and Achard.
 
 INTERSTITIAL NEPHRITIS, GUMMA AND AMYLOID DISEASE. 521 
 
 as also do mixed varieties, so that beyond stating that the inter- 
 stitial forms predominate nothing more definite can be asserted. 
 
 In forty-nine cases of late renal syphilis, Bamberger found four 
 cases of acute nephritis, twenty-nine of chronic parenchymatous 
 nephritis with large white kidneys, and sixteen of the chronic 
 atropliic variety. 
 
 In sixty-three cases, examined microscopically by Wagner, there 
 were eight acute cases, four chronic parenchymatous cases, and 
 eight small granular kidneys ; in the other cases atrophy was 
 limited to one kidney alone, while the opposite organ was either 
 hypertrophied or normal. 
 
 Sometimes the interstitial change is localised without forming 
 definite gummata ; thus M. Key* found sclerosis of the inferior 
 parts of both kidneys associated with gummata of the heart and 
 hypertrophy and dilatation of the ventricles. 
 
 The kidneys in which interstitial changes are present are 
 usually considerably diminished in size, and are often irregular in 
 shape, with scars on their surfaces. 
 
 Lancereaux, in twenty observations on cases of visceral syphilis, 
 found an interstitial nephritis present in four, waxy degenera- 
 tion in two, and small gummata in one, while several other 
 kidneys showed some amount of scarring and atrophy. Micro- 
 scopically, the interstitial tissue is found to be greatly increased 
 and the walls of the arterioles are thickened ; the tubules are 
 affected secondarily, many are obliterated, and there is fatty 
 and granular degeneration of their epithelial cells. 
 
 Though gummata of the kidney are admittedly rare, they are 
 recorded by Lancereaux, Klebs, Moxon, Greenfield and others. 
 In Moxoii's case the gumma was the size of a small potato, firm, 
 hard, tough and of a yellowish colour. Morell Mackenzie also 
 recorded a case of gummata in the liver and right kidney in 
 which the renal capsules were adherent. Gummata usually 
 exist as small deposits either in the cortex or medullary region, 
 and they vary very much in number and size. There are often 
 several not much larger than a pin's head, while at other times 
 the presence of one or two may give rise to a considerable swelling 
 and cause the same general symptoms as renal tumours of 
 other kinds. Thus Legrain { has recorded a case of hereditary 
 
 * Quoted by Mauriac. 
 
 t Annales des Malad. des Organes Gen.-urinaire, 1898, p. 1155.
 
 522 SURGERY OF THE KIDNEY AND URETER. 
 
 syphilis, in which a painful varicocele was a prominent symptom, 
 a fact of importance since this effect is most commonly pro- 
 duced by malignant tumours. Gummata occur in the inter- 
 stitial tissue between the tubules and the glomeruli ; they are of 
 a yellowish colour, and often show some softening and tendency 
 to break down in the centre ; this tendency to undergo softening 
 is not, however, nearly so great as in the case of tubercular deposits, 
 and Baumgarten has compared their consistency to bacon, in 
 contradistinction to the yellow caseous necrotic deposits which 
 occur in tuberculosis. Their histological characters are the same 
 as those of gummata elsewhere. 
 
 Gummata, if not very numerous, may not of themselves give 
 rise to any alteration in the urine, nor need they cause any 
 symptoms ; but their presence is frequently accompanied by some 
 diffuse interstitial changes upon which the general and local 
 symptoms often depend. 
 
 They not unfrequently disappear, and their previous existence 
 is then betrayed by a scar which if near the surface may cause 
 a very considerable depression of the renal substance. 
 
 The chief surgical interest with regard to gummata lies in the 
 fact that they sometimes cause such gross changes in the kidney 
 that they are mistaken during life for malignant or tuberculous 
 disease, and 011 that supposition have been operated upon. 
 
 An interesting case of this description has been recorded by 
 Bowlbv.* The patient, a female aged forty, noticed a swelling in 
 the right renal region, and on examination it was found that the 
 right kidney was movable, unusually hard, and a little enlarged ; 
 the urine was normal except for a trace of albumen. A year 
 later the tumour had increased in size, and formed a definite 
 renal tumour which was exceedingly hard and easily movable. 
 The urine still contained a trace of albumen, but there was no 
 hsematuria at any time during the illness. There was a history 
 of syphilis having occurred twenty-one years previously. 
 
 Nephrectomy was advised and duly performed, the kidney being 
 easily shelled out of its capsule. The \v hole organ was very enlarged 
 and exceedingly hard : it weighed seventeen ounces. The surface 
 was nodular, and there was no dilatation of the calyces or pelvis. 
 It cut like fibrous tissue, and on section showed areas of wash- 
 leather-like gummatous masses embedded in dark-coloured fibrous 
 * Trans. Path. Soc., 1897, p. '128.
 
 GUMMA MISTAKEN FOR MALIGNANT TUMOUR. 523 
 
 4 
 
 tissue. All trace of cortex and pyramids had disappeared and, 
 except for its shape, the mass of tissue bore but little resemblance 
 to a kidney. Microscopical examination showed typical gumma- 
 tous areas, with small-celled infiltration and caseous degeneration, 
 much new fibrous tissue, and very scanty remains of secreting 
 structure. 
 
 Israel* has also recorded two interesting cases of a similar 
 nature, which led to a mistaken diagnosis. 
 
 The first case was that of a woman, aged twenty -three, who 
 suffered from frequency of micturition, thirst, and pain in the 
 back. There was also considerable loss of flesh. An examination 
 showed the right kidney to be much enlarged and hard, but not 
 especially tender ; it was not movable, and did not descend during 
 inspiration. The urine sometimes contained a small quantity 
 of albumen, and microscopically renal epithelium and pus cells 
 were present, and on one occasion a hyaline cast was observed. 
 A careful consideration of all the symptoms taken in con- 
 junction with the past history of the patient led to the true 
 nature of the condition being suspected, and the patient was 
 placed upon anti-syphilitic treatment. This was for a time 
 followed by improvement and some decrease in the size of the 
 tumour, but collections of masses of flattened cells appeared in 
 the urine as a white deposit, and it was thought advisable to 
 explore the kidney under the idea that the tumour might be 
 of a malignant nature. This operation was accordingly per- 
 formed and the kidney, which was greatly altered, was removed. 
 The renal capsule was much thickened and very nodular, espe- 
 cially on the outer surface, and was very firmly adherent to 
 the kidney substance. The kidney itself, which was not much en- 
 larged after the capsule was removed, was chiefly affected in its 
 lower half, and was the seat of gummatous infiltration. 
 
 The second case occurred in a man of thirty-nine, and was 
 mistaken for tuberculous disease. There was a tuberculous 
 family history, and also a history of syphilis. The percussion 
 note was diminished under the right clavicle and there was a 
 scar with a fistulous opening between the eleventh and twelfth 
 ribs on the left side. The urine contained albumen and pus, but 
 no tubercle bacilli were found. Exploration, followed by nephrec- 
 tomy, was performed ; the kidney was separated from its adhesions 
 * Deutsch. Med. Woch., 1892, Xo. 1.
 
 524 SURGERY OF THE KIDNEY AND URETER. 
 
 
 
 with some difficulty, and was found to be the seat of extensive fibrous 
 degeneration and gummatous swellings, in parts undergoing caseation. 
 Kelynack in his work on '" Renal Growths," mentions and 
 figures a case of diffuse fibroid induration of the kidney 
 which at first sight resembled a diffuse malignant growth ; it 
 proved, however, 011 closer examination to be an example of 
 
 Fig. 74. Gumma of Kidney. (St. Bartholomew's Hospital Museum, 2343 A.) 
 
 diffuse syphilitic cirrhosis, and a somewhat similar gummatous 
 mass was also found in the liver. 
 
 The following case, illustrated in Fig. 75, occurred under 
 my own care. The patient, a man aged sixty-four, came to me 
 on account of persistent haematuria and frequent micturition 
 of fifteen months' duration. The micturition occurred about 
 every hour and was attended with very great pain and spasm. 
 An examination showed the presence of a growth in the bladder 
 which proved to be a villous carcinoma with a hard infiltrating 
 base extending from al)ove the left ureteral orifice up to the 
 fundus. Supra-pubic eystotomy was performed on October 25th, 
 IMDH, and the bladder drained through a tube. The operation gave 
 great relief, the patient slept well, the urine became clearer, and 
 alxmt twenty ounces drained off every twelve hours. Some diarrhoea, 
 unattended by sickness, bad existed before tbe operation and con-
 
 DESCRIPTION OF CASE OF RENAL SYPHILIS. 
 
 525 
 
 tinned after it. The improvement continued till October 30th, 
 when the patient became restless and disinclined to take nourish- 
 ment, and this together with diarrhoea and vomiting which super- 
 vened made him very weak ; his pulse was regular and of fair 
 tension and there was a free flow of urine. The next day there 
 was some improvement, which continued till November 5th, when 
 he again became very restless and sleepless and attempted to 
 get out of bed. From this time 
 onward the condition got rapidly 
 worse and hallucinations and de- 
 lusions were a marked feature ; 
 he was very violent in his deli- 
 rium and resisted furiously the 
 changing of his dressings. The 
 quantity of urine diminished, 
 but it became very difficult to 
 measure it. The restlessness 
 and incoherence increased, but 
 were relieved by hyosciii ; the 
 skin was quite dry and there 
 was still diarrhoea. During the 
 last few days of the illness there 
 were marked muscular twitch- 
 ings, and the pupils reacted 
 sluggishly to light. After the 
 delirium had been relieved by 
 the hyoscin the patient became 
 drowsy, but was easily roused 
 by turning up the light or 
 calling loudly. He turned rest- 
 lessly in his bed from time to time, every now and again mum- 
 bling in an incoherent manner. He resisted feebly when the 
 dressings were changed and would take no food, appearing to have 
 some difficulty in swallowing. Eespirations were regular and the 
 highest temperature registered was 99 '6 ; it was often subnormal. 
 The breath had a peculiar odour which could not definitely be 
 described as urinous. The urine still gradually diminished in 
 quantity and the patient died on November 13th. 
 
 At the autopsy made by Dr. Voelcker no growth was found 
 in any other organ but the bladder, but there was extensive dis- 
 
 Fig. 75. Syphilitic left Kidney. Author's 
 case. (Middlesex Hospital Museum. )
 
 526 SURGERY OF THE KIDNEY AND URETER. 
 
 ease of the kidneys. Both kidneys were very firm and enlarged, 
 measuring 4^ inches in. length ; their surfaces were pale yellowish- 
 grey speckled with red, and were markedly irregular on account 
 of numerous depressions of various sizes ; their capsules stripped 
 with difficulty. On section they presented a greyish-yellow ap- 
 pearance in the cortical region, which was increased in thickness, 
 measuring over a quarter of an inch. The medullary portion 
 was congested and showed uratic deposits in some of the straight 
 tubules. Sections stained with iodine and methyl violet showed 
 very marked waxy disease of the glomeruli, of the vasa recta, and 
 of the walls of the straight tubules. There was also some fatty 
 degeneration of the renal epithelium and overgrowth of interstitial 
 fibrous tissue. There .was no dilatation of the renal pelves and 
 no pyelitis ; the ureters were not dilated and there was no 
 evidence of any ascending uretero-pyelo-nephritis. There was 
 no focus of suppuration anywhere in the body (except a small 
 recent superficial abscess in the abdominal wall) and there was 
 no evidence of any suppuration having existed at a former time. 
 
 The liver was rather large, pale and very firm, with rounded 
 edges. Numerous irregular puckered scars were present in the 
 right lobe ; the left lobe was small and puckered. The depressed 
 scars corresponded to areas of cicatricial tissue and were evidently 
 old gummata. The spleen was much enlarged, measuring seven 
 inches in length ; it was dark, firm and smooth on the surface, 
 showing no scars ; on section the surface was dark red, smooth 
 and glistening. Sections of both liver and spleen showed marked 
 waxy disease 011 staining with iodine and methyl violet. 
 
 The actual cause of death must be ascribed to the advanced 
 renal disease, which was undoubtedly of specific origin, and the 
 case therefore is especially interesting on account of the clinical 
 symptoms associated with it. The later stages of this case, which 
 depended upon the renal disease, bore some superficial resemblance 
 to anuria from calculus or obstruction to the ureters by pelvic 
 cancer, and had the patient been seen for the first time in this 
 later stage these possibilities might have entered into the question 
 of diagnosis. The symptoms, however, in reality differed very 
 materially from those of anuria in the following points : (1) 
 The presence of violent delirium and (2) continued wakefulness ; 
 (3) there was no urinary obstruction, but a gradual increasing 
 suppression without any interference in the flow ; (4) there
 
 ALBUMINOID DEGENERATION A LATE EFFECT. 527 
 
 was 110 lumbar pain whatever ; (5) the skin was dry, with entire 
 absence of sweating ; (6) diarrhoea was present and persistent to 
 the end ; (7) there was great increase of pulse tension which 
 only gradually failed during the last few days of life. 
 
 Albuminoid degeneration is not unfrequently a late effect 
 of syphilis, and may co-exist with the other forms of the disease. 
 The possibility of its presence must be remembered as a factor 
 in renal diagnosis, and its influence must also be taken into account 
 when considering the advisability and prognosis of operations; 
 but for a detailed account of its symptoms the reader is referred 
 to works on medicine. 
 
 Diabetes mellitus and insipidus have occasionally been recorded 
 in syphilis, but their origin in such cases usually depends upon 
 the effects of gummata in the central nervous system and not 
 to any direct action of syphilis on the kidneys. 
 
 The kidneys may occasionally suffer from the effects of con- 
 genital syphilis, which usually shows itself by an increase of 
 interstitial tissue. A case of this kind has been recorded by Cou- 
 pland in a female child of three months. There were very 
 extensive syphilitic manifestations in the viscera, including gum- 
 mata of the liver and lungs. The kidneys to the naked eye 
 appeared pale and unduly firm. Microscopically, the cortical 
 region was the seat of an interstitial infiltration of small round 
 cells which were most abundant round the arterioles and especially 
 round the Malpighian bodies. The renal epithelium was unaltered. 
 
 Diagnosis. The diagnosis of renal syphilis is difficult and 
 often cannot be made with any certainty, since the symptoms 
 do not present any specific qualities. Difficult even in those 
 cases which arise in the early stages of syphilis, it becomes far 
 more so in the later stages when no direct relations between the 
 disease and its effects can be traced. 
 
 The diagnosis of acute syphilitic nephritis occurring in the 
 early stage of the disease can only be made after all other pos- 
 sible causes have been rigorously excluded, and therefore each 
 case must be considered on its own merits ; in some the relations 
 appear fairly obvious, while in others they are very obscure. In 
 the nephritis of late syphilis. Avhich generally assumes the chronic 
 interstitial or gummatous form, a diagnosis will depend upon 
 a definite history of syphilis and the presence of tertiary symp- 
 toms elsewhere, other causes being excluded. The diagnosis is
 
 528 SURGERY OF THE KIDNEY AND URETER. 
 
 sometimes further strengthened by improvement under anti-syphilitic 
 treatment. The difficulty of placing syphilis as the definite cause 
 of these chronic cases is further intensified by the fact that in 
 many instances other possible causes cannot be absolutely excluded ; 
 and many mixed cases occur as, for instance, chronic alcoholism 
 following a previous history of syphilis. If the kidney is much 
 enlarged it cannot with certainty be diagnosed from other tumours 
 unless the evidence of co-existing lesions elsewhere is exceptionally 
 strong. The cases recorded above show that renal syphilis is 
 very liable to be mistaken for malignant disease. 
 
 Treatment. The treatment of the different forms of syphilitic 
 nephritis must be carried out on the general principles which govern 
 the treatment of nephritis due to other causes. The occurrence of 
 albuminuria and even the more definite forms of nephritis during 
 the early stages of syphilis are not usually coiitra-indications to 
 the administration of mercury provided its effects are carefully 
 noted, for it must be remembered that the diseased kidneys 
 cannot eliminate the drug as they do in health. In some cases 
 mercury appears to have a direct beneficial action, the renal 
 symptoms subsiding rapidly under its influence. In the cases 
 arising during the late periods potassium iodide may be given, 
 especially if the presence of gummata is suspected, but in most 
 of these cases the connective tissue changes are so advanced 
 before symptoms arise that but little benefit can be expected 
 from medicinal treatment.
 
 529 
 
 CHAPTEE XVm. 
 TUMOURS OF THE KIDNEY. 
 
 THE kidney is liable to many morbid growths of a cystic and 
 solid character, both benign and malignant. Several of these 
 do not attain to any great size, or cause the kidney to become 
 appreciably, if at all, enlarged. Thus adenoma, which occurs in 
 three forms in the kidney (the tubular, the papillary and the 
 alveolar), is usually the size of a hazel-nut or walnut, but seldom 
 if ever as large as an egg or smaJl orange ; angeiomata cavernosa, 
 though distinct formations or new growths of reticulated caver- 
 nous tissue, are of quite small size not often exceeding that of a 
 marble, and though called tumours the parts which they affect are 
 shrunken, rather than projecting or enlarged; leukJicemic tumours 
 are small, scattered, roundish patches of lymphoid cells following 
 the course of the capillary vessels, and looking not unlike extra- 
 vasated white blood cells, though they are sometimes actively 
 growing tumours of a truly malignant character ; lymphadenoma 
 is found in the kidney associated with similar disease of the 
 glands, liver, and intestine ; fibroma occurs " in the form of 
 small white knots of fibrous tissue near the bases of the pyra- 
 mids,"* but occasionally in the kidney there has been found a 
 very large simple fibrous tumour ; tumours consisting of fatty 
 tissue or of a mixture of fatty tissue and unstriped muscular fibres 
 are small growths, single or multiple, which rarely surpass the 
 size of a cherry. True lipomata, the heteroplastic lipomata 
 of Virchow, are found sometimes in the cortical substance im- 
 mediately beneath the capsule. Villous papilloma occurs in the 
 pelvis of the tidney, as it does in the urinary bladder, and in 
 a case met with in the post-mortem room of the Middlesex Hos- 
 pital, there were villous growths in the kidney f and bladder 
 of the same person. Syphilitic giimmata occur occasionally, but 
 do not often attain such a bulk as greatly to increase the 
 
 * Moxon. 
 
 t There is also a specimen in the Middlesex Hospital Museum (see 
 Catalogue, No. 1822). 
 VOL. I. 2 I
 
 530 SURGERY OF THE KIDNEY AND URETER. 
 
 dimensions of the kidney. Cysts varying in size and number 
 occur, as for example in granular kidney, without adding to the 
 size of the organ. 
 
 Though pathologically of the nature of " tumours," some of 
 the above-mentioned new formations never, others only rarely, 
 give rise to tumours clinically speaking. 
 
 Clinically, any enlargement of the kidney which can be de- 
 tected by physical examination at the bedside is spoken of as a 
 tumour of the kidney. Some of these enlargements have been 
 already considered ; namely, hydro-nephrosis, pyo-nephrosis, renal 
 abscess, and the enlargement of the kidney caused by tuberculous 
 disease. There remain for description, however, other renal tumours, 
 cystic and solid ; amongst the solid are carcinoma, sarcoma, and 
 rhabdo-myoma, all of the nature of malignant new growths ; and 
 amongst the cystic are various forms serous, polycystic, clermoid, 
 and hydatid. 
 
 Some idea of the relative frequency with which the different 
 tumours occur may be gathered from the following table of 
 159 cases which I collected from British, American and foreign 
 literature during a period of ten years from 1884 to 1893 inclusive. 
 
 Sarcomata 63 
 
 Carcinoma ta 41 
 
 Cystic degeneration . . .21 
 
 Hydatid cysts 11 
 
 Adenomata 10 
 
 Papillomata 3 
 
 Myxomata 2 
 
 Lipomata 2 
 
 Dermoid cyst .... 1 
 
 154 
 Of the remaining five cases, in one the tumour was due to a 
 
 collection of cholesterine, one was of doubtful nature, and the other 
 
 three were tumours of the suprarenal body. 
 
 The following are the ages at which the tumours occurred in 
 
 148 of the cases : 
 
 Under 5 years, 5-10, ' 10-20, 20-30, 1 30-40, 1 40-50, 50-CO, I 60-70, | 70-80 
 39^ 2 6 14 20 30 22 11 4 
 
 Of the 39 cases occurring under 5 years of age, there were 
 31 sarcomata, 2 carcinomata, 1 cystic degeneration, 1 fibre-cystic 
 tumour, 1 rhabdo-myo-sarcoma, while two were tumours of the 
 adrenal and one was of doubtful nature.
 
 EMPTY COLON FORMING A ROLL ON TUMOUR. 531 
 
 Renal tumours are amongst the most difficult of abdominal 
 enlargements to diagnose correctly. They therefore demand 
 close study, and it will save repetition if I make some general 
 remarks on the clinical characters of these tumours as a 
 class. . By way of preface, I will draw the reader's notice to a 
 passage from Spencer Wells's paper " On the Diagnosis of 
 Eenal from Ovarian Cysts and Tumours."* That brilliant ovari- 
 otomist wrote, " I quote the following remark of one of the 
 greatest clinical teachers of any age or country Bright : ' I 
 have known the enlarged kidney to be mistaken for disease of 
 the spleen, of the ovary, of the uterus, and for a tumour 
 developed in the concave part of the liver ; nor is it perhaps 
 possible, by the greatest care and the most precise knowledge, 
 altogether to avoid such errors.' " 
 
 The chief distinctive points about tumours of the kidney 
 are the following : 
 
 1. The large intestine is in front of the tumour. Normally 
 the right kidney, unless enlarged, lies a little way from the lateral 
 wall of the abdomen, behind and to the inner side of the ascend- 
 ing colon ; not in close contact with the abdominal wall and 
 outside the ascending colon as the liver does. When the kidney 
 is enlarged the ascending colon is usually placed in front of and 
 towards the inner side of the tumour. On the left side, the 
 descending colon is in front of, and inclines towards the outer 
 side of, the kidney below; in some cases coils of small intestine 
 may overlie either right or left tumour if the enlargement is 
 not sufficient to bring the kidney into direct contact with the 
 front abdominal wall. When the colon is empty, or non-resonant, 
 it can be felt as a roll on the front surface of the tumour. 
 Clifford Allbutt in a private letter referred to this last statement 
 and said that he was able to confirm it by a case then under 
 his observation. These relations of the small intestines and the 
 colon to a renal tumour are met with in the child as well as in 
 the adult. Fagge described and illustrated them in the case of 
 a carcinomatou? tumour weighing four and a half pounds which 
 affected the left kidney of a child aged four and a hah* years.t 
 
 Bowel is never thus placed in front of a splenic tumour, 
 and only very occasionally in front of one of hepatic origin. 
 
 * Dublin Quarterly Journ. of Med. Science, Feb. to May, 1867. 
 t Path. Soc. Trans., vol. xxi., p. 250.
 
 532 SURGERY OF THE KIDNEY AND URETER. 
 
 If ascites is present and the liver is enlarged in an irregular 
 and misshapen manner the small intestines may float between 
 the liver and the abdominal parietes. 
 
 2. There is no line of resonance between the kidney dulness 
 and the vertebral spines ; and no space between the kidney and 
 the spinal groove into which the fingers can be dipped with but 
 little resistance, as there is between the spleen and the spine. 
 
 3. Renal tumours do not project or protrude backwards 
 to any marked extent. They fill up the hollow of the loin and 
 may even cause some actual fulness there-; but often there is 
 nothing more than the effacement of the natural hollow of the 
 loin. When the tumour attains a large size the parietes may 
 be projected laterally to a degree sufficient to be observed by a 
 superficial glance. Sir William Jenner says : " Renal tumours 
 never cause enlargement behind. A renal tumour is not visible 
 
 n the back, it expands in front. A little greater fulness of the 
 loin there may be, but nothing like tumour. . . . Tumours 
 due to disease of the kidney enlarge in front ; whilst abscesses 
 and other lesions which may simulate renal tumours often cause 
 considerable posterior projection."' 
 
 This ' is an important feature in relation to diagnosis, and if 
 stated a little too absolutely it will serve the more to impress 
 a pretty general fact. There are exceptions, however, as I shall 
 show further on. 
 
 Auscultatory percussion, assisted by the phonendoscope, has been 
 recommended by some of the French cliniciens, but has not 
 found much favour with or proved of practical use in the hands 
 of London physicians or surgeons. 
 
 4. "The kidney is rounded laterally, rounded in front, rounded 
 at its inner border, rounded at its upper border, rounded at its 
 lower border. The inner border is usually lost against the spine, 
 and the upper border cannot be felt unless the kidney is dis- 
 placed. The kidney has no sharp edges. It is rounded on 
 every side, and in disease never loses this peculiarity " (Jenner). 
 Whether solid or cystic, and of whatever size,, a kidney tumour 
 is prone to retain some, often much, of its natural outline. The 
 absence of any sharp edges marks off renal from many hepatic 
 and splenic enlargements. 
 
 5. Renal tumours descend in inspiration less frequently and 
 less markedly than hepatic, splenic, and adrenal swellings.
 
 SOME RENAL TUMOURS FIXED. 533 
 
 Hepatic and splenic, and more especially splenic enlargements, are 
 depressed by the contraction of the diaphragm ; whereas kidney 
 swellings are sometimes quite unaffected by respiratory movements. 
 If the kidney and circumrenal tissues have been, inflamed the kidney 
 will be bound down in its natural situation and there fixed. 
 Sir W. Jenner remarks : " When the kidney is enlarged by disease 
 it is rarely movable by respiration or palpation. When chronic 
 changes, sufficient to enlarge the organ, have occurred, whatever 
 their nature, adhesions sufficient to prevent movement usually 
 form between the capsule and adjacent parts." Without doubt 
 this is often so ; but in cases of new growths, where the organ 
 and parts around have not been the seats of inflammation, there 
 may be a considerable degree of movement. I have more than 
 once seen a renal tumour descend an inch and more by a deep 
 inspiration and fall forwards or backwards by its own weight 
 with the movements of the body, passing in front of the spinal 
 column \vhen. the patient has lain on the side opposite to the 
 tumour, and falling against the anterior abdominal wall when 
 he has stooped or assumed the knee-elbow position. In one 
 recorded case a renal tumour was, on account of its mobility with 
 respiration, diagnosed as an hydatid of the liver.* I therefore 
 agree with Dr. Dickinson when he says : " No certain inference is to 
 be drawn from the fact that a tumour descends with inspiration," 
 and I would add, " or can be moved forwards and backwards 
 by palpation." 
 
 Bright pointed out this variation as to fixity and mobility 
 of renal enlargements in conformity with the nature of the 
 swelling ; and he says, speaking of one of his cases : " On 
 pushing the anterior part of the tumour backwards, the motion 
 of the tumour was felt by the hand placed at the loin." It 
 is to this kind of movement, long ago recognised by British 
 physicians, that Guyon has more recently given the name 
 battottement. 
 
 6. When the pelvis of the kidney is dilated the resulting 
 tumour may press upon the liver so as to be indistinguishable 
 from it ; it may, and often does, reach down into the iliac fossa ; 
 and occasionally it extends inwards beyond the middle line of the 
 abdomen. I have opened a hydro-nephrotic swelling which 
 crossed the linea alba fully two inches. As a rule, however, 
 * Deutsche Zeitschr. f. Cliir., xxiv., 1886.
 
 534 SURGERf OF THE KIDNEY AND URETER. 
 
 renal enlargements never invade the bony pelvis, rarely reach the 
 median line, and frequently are separated from the hepatic dulness 
 by a resonant area. 
 
 7. When the tumour is large enough to reach the front 
 wall of the abdomen, the point at which it comes into contact 
 with the anterior parietes is commonly about the level of the 
 umbilicus, or a little higher ; the lateral wall between the costal 
 margin and the crest of the ilium is then also bulged outwards. 
 In a case formerly under my care, the tumour a suprarenal 
 capsular tumour involving the kidney presented a well-defined 
 prominence the size of an apple immediately below the left costal 
 margin ; this prominence looked like a tumour situated in and 
 projecting frrm tfie parieues, with its centre in the linea 
 semilunaris, anu its inner edge reaching the median line along 
 a distance of one r.^d a half inches ; it was, however, only a 
 part of a large tumour weighing four pounds, and completely 
 filling the left ilio-costal space. By palpation it could readily be 
 moved ; and it fell bodily against the anterior abdominal parietes 
 when the patient turned from the recumbent position on to his 
 right side ; it also moved freely with respiration. Fig 76 shows 
 the outline of the tumour after its removal by abdominal 
 nephrectomy. 
 
 8. A symptom in the particular case referred to in the last para- 
 graph is one which might be expected to occur in large renal 
 tumours, especially of the left kidney, and not in splenic enlargements. 
 There was a large varicocele of the left side, which had been gradually 
 increasing with the growth of the tumour ; and at the operation 
 it was seen to be directly due to distortion and distension of the 
 spermatic vein, which, with the inferior mesenteric vein, curved 
 over the front and inner side of the tumour, and was enlarged 
 to the size of the ring finger. When writing the " Surgical 
 Diseases of the Kidney " in 1884 I had only met with varicocele 
 in association with renal or suprarenal tumour once, and that on 
 the left side. In September, 1894, I removed a large, smooth- 
 surfaced, very movable, papillomatous epithelial new growth of 
 the right kidney from a gentleman aged fifty -four, in which 
 there was right varicocele which had quite disappeared on the 
 second day after the operation. At that time I believed I was 
 the first who had ever called attention to this symptom in con- 
 nection with renal tumour, but I afterwards found that Guyon
 
 VARICOCELE CAUSED BY GROWTH OF TUMOUR. 
 
 535 
 
 had described this curious coincidence of varicocele with tumours 
 of the kidney, and had proved them to stand in relation of cause 
 and effect by observing the oncoming of the varicocele after the 
 discovery of the tumour, and noticing the increase of the 
 varicocele as the tumour developed. He had met with it three 
 times on the right and three times on the left, and the veins of 
 
 Fig. 76. Tumour of the Adrenal, with Kidney pushed forwards upon its surface. 
 Removed by operation. Author's case. 
 
 the scrotum on the same side were also enlarged in one case, and 
 hydrocele co-existed in two others. 
 
 There are a few exceptional features connected with renal 
 tumours which must be remembered. 
 
 1. A right renal tumour may push the ascending colon down- 
 wards, instead of forwards or inwards. A left renal tumour is more 
 likely to push the descending colon outwards, but Bright, in two 
 of his figures, represented it as lying vertically over the front of 
 the tumour. A tumour of either kidney may push the bowel 
 to its inner side towards or even beyond the median line, in which 
 case there is no resonance in front of the tumour.* In the case 
 just mentioned there was sometimes a line of resonance over a 
 curved area of the tumour outside the dull and prominent portion, 
 
 * iMncet, Aug. 29th, 1885.
 
 536 SURGERY OF THE KIDNEY AND URETER. 
 
 and when resonance was wanting a roll of bowel could be 
 grasped with the finger tips. The tumour had grown forwards 
 on the inner side of the descending colon, so that in the operation 
 the bowel had to be drawn inwards quite across the front of 
 the mass, after dividing the outer layer of the mesocolon. 
 
 In a case under Lawson in the Middlesex Hospital some 
 years ago, a sarcomatous tumour springing from the cellular 
 tissue at the hilum of the left kidney bulged forwards below 
 the umbilicus on the left of the median line and was entirely 
 in front of the bowel. The kidney, probably as the result of 
 the drag of the tumour, had elongated the peritoneum into a 
 mesentery, and had then floated forwards in front of the descend- 
 ing colon, sigmoid flexure, and small intestine. It in some 
 respects, therefore, resembled an ovarian tumour.* In connection 
 with this case I may allude to one, the notes of which I extracted 
 from the Guy's Post-mortem Eecords, and which I have pre- 
 viously mentioned amongst the causes of acquired misplacement 
 of the kidney ; the left kidney of a woman, aged fifty-seven, 
 who died of phthisis, was displaced on to the brim of the pelvis 
 by a large cyst in its lower part which contained a pint of fluid. 
 The cyst had dragged down the kidney and occupied the greater 
 part of the pelvic cavity. 
 
 2. Either a cystic or solid renal tumour may attain such 
 a size as to occupy the greater part of the abdomen. Roberts 
 quotes such a case of encephaloicl left kidney in a boy aged six ; 
 Spencer Wells, an encephaloicl in a girl aged four years ; and 
 Dickinson, a fluctuating sarcoma in a girl aged three years, 
 which was mistaken for ascites ; and a second in a girl of the 
 same age which roughly resembled in appearance the swelling 
 of pregnancy. I have recorded a case of cystic tumour of the 
 left kidney in a man, which nearly filled the abdomen. In the 
 Middlesex Hospital Museum there is a cancerous tumour weighing 
 thirty-one pounds from the left kidney of a boy aged eight years.* 
 
 3. There are but few, if any, exceptions to the rule laid down 
 by Sir W. Jenner, that renal tumours retain the rounded outline 
 and never present a sharp edge ; but this does not at all imply 
 that the normal outline of the kidney is retained in all cases. 
 
 * Lancet, vol. i., 13GG. 
 
 t See No. 18-27, Mid. Hosp. Catalogue ; and Path. Soc. Trans., vol. iii., 
 p. 203.
 
 SIZE OF TUMOURS ASCERTAINED BY PALPATION. 537 
 
 On the contrary, when the tumour involves only a part of the organ 
 and not the whole, and therefore does not expand the entire 
 capsule as it grows, it is unusual for it to have the renal outline. 
 
 4. Mobility of the tumour in respiration and by palpation 
 ia so far from being rare that it ought hardly to be enumerated 
 amongst the exceptional symptoms. 
 
 5. A renal tumour may, as quite an exceptional thing, cause 
 pointing on the posterior aspect of the body. Mr. Holmes has 
 reported a case* of pulsating cancer of the left kidney in a man 
 forty-nine years of age. The disease was almost confined to the 
 left kidney, but presented a swelling over the sacrum, and caused 
 oedema of the back as high as the neck. The tumour weighed 
 thirty ounces and had so destroyed the natural structure of 
 the kidney that not a trace remained. 
 
 When renal growth or abscess affects only part of the 
 kidney, the abdominal tumour may appear to be somewhat 
 removed from the strict limits of the renal region. Thus, when 
 the upper part of the kidney is alone involved there is much 
 upward bulging, and the tumour may be felt in the part usually 
 occupied by the liver or the spleen. In malignant disease of the 
 right kidney I have seen the tumour occupy a great part of the 
 right hypochondriac region, and simulate an hepatic tumour. 
 
 6. Little or no reliance can be placed on. the absence of changes 
 in the urine. Solid tumours do not always cause hsematuria, nor 
 do accumulations of pus in the kidney always cause a discharge 
 of purulent urine.^ The tumour may not involve the cavity 
 of the kidney ; or the ureter may be temporarily or permanently 
 plugged, so that the urine which is passed may be quite normal. 
 On the other hand, however, hsematuria and pyuria associated 
 with the physical signs of renal tumour are valuable adjuncts 
 in forming a diagnosis. 
 
 The best way of estimating the size of a renal swelling has been 
 described by Eayer, Bright, Jenner, Freund, and others. As the 
 patient lies on his back, place the fingers of one hand flat upon 
 the ilio-costal space just outside the erector spin* muscle, and those 
 of the other hand flat on the front of the abdomen just, over the 
 hand which is behind. Then, during expiration, and whilst the 
 patient's attention is diverted, a very fair idea will be obtained of 
 
 * Path. Soc. Trans., vol. xxiv., p. 149. 
 
 1 See "Hunterian Lectures," 1898, Case No. 15, Table VI.
 
 538 SURGERY OF THE KIDNEY AND URETER. 
 
 the size and weight of the organ by depressing the fingers in 
 front as much as possible, and tilting forward those of the 
 hand behind. In thin persons and with the aid of an anaes- 
 thetic, this mode of examination is very effective. By its adoption 
 a renal swelling too small to give rise to dulness on percussion 
 will often be detected. Excepting in children and in persons with 
 abnormal configuration or much emaciated, it may be stated general!}* 
 that a kidney which is recognisable by the touch is either movable, 
 misplaced, or enlarged by disease. Sir W. Jenner pointed out, that 
 when the lower dorsal and lumbar parts of the spine are curved 
 well forwards the kidney, even though only of natural size, may 
 be sufficiently prominent to be seen through the abdominal 
 parietes. He remarked that this condition is not uncommon 
 in women, and added that he once gave such a case, for examina- 
 tion, to the candidates for the degree of the University of London, 
 and was told that the tumour (a healthy kidney, though probably 
 somewhat larger than normal) was an ovarian tumour and should 
 be cut out. A spinal or a perinephric abscess, or an effusion 
 of blood or urine behind the kidney, may raise the kidney hi 
 front of it into a prominence which can be easily felt if not 
 actually seen. 
 
 Solid faeces in the ascending or descending colon may be mis- 
 taken for the kidney ; but perhaps a more frequent error is 
 to mistake an actual tumour for faecal accumulations. 
 
 Having mentioned the usual and exceptional symptoms of 
 renal tumours as a class, it will be well next briefly to state 
 how they differ from other tumours with which they are likely 
 to l)e confused. 
 
 (A) Tumours of the abdominal parietes are rare. Though 
 sometimes difficult to distinguish from intra-peritoneal swellings 
 they are but little likely to be mistaken for renal enlargements. 
 Their mobility is affected by deep respiration only as that of 
 the abdominal walls is. They are either rendered less defined or, 
 on the contrary, more prominent by the forced action of the 
 muscles of the abdominal walls, according as they occupy the 
 deeper or more superficial planes respectively of the parietes. 
 Sometimes these tumours are adherent to the skin. 
 
 (B) Enlargements of the liver. Renal tumours often dip 
 down or fade off so as to allow the fingers to be depressed 
 between the edge of the costal cartilages and the upper
 
 ABNORMAL SHAPE OF LIVER OR SPLEEN. 539 
 
 border of the tumour. They develop an area of dulness com- 
 paratively early in the lumbar region ; whereas tumours of the 
 liver or the spleen only do so very late, if at all. Hepatic tumours 
 pass downwards from beneath the ribs, and so rarely do they 
 have any intestine hi front of them that the presence of bowel 
 in front of a tumour may be regarded as a strong indication 
 that it has not its origin in the liver. There is an absence of 
 baUottement. When the tumour is of the right side a jaundiced 
 tint of eye, or skin, or urine, and stools deficient in bilious 
 colouring, are suggestive, to say the least, of its having an hepatic 
 origin. A tongue-shaped lobe of the liver or a tumour developed 
 in the concave part of the liver is very likely to cause error 
 in diagnosis; especially so are hydatids in the left lobe of the 
 organ. 
 
 There are rare cases in which a floating hepatic lobe closely 
 simulates in appearance and relations, and in the presence of 
 well-marked ballottement , a movable kidney. Such an abnormal 
 lobe of the liver may be prolonged downwards in front of the 
 kidney and give rise to a true baUottement in the costo-iliac 
 region. 
 
 (C) Enlargements of the spleen. The enlarged spleen has 
 not bowel in front of it ; it generally presents a sharp or 
 well-defined edge, beneath which the fingers can be depressed; 
 this edge is in some cases notched. There is resonance between 
 the posterior edge of an enlarged spleen and the spinal column , 
 and the tumour is traceable upwards beneath the ribs. A splenic 
 tumour is movable ; a renal tumour may be so, but in some 
 cases it is fixed in the loin. Splenic tumour will not cause 
 varicocele, a renal tumour may do so. 
 
 A case of " reniform spleen " has been published by Lefas in the 
 Bulletin de la Socitte Anatomiquel , 1896. Splenic tumours increase 
 and are displaced not vertically, but downwards and inwards, 
 and in rare instances almost horizontally or transversely inwards. 
 This is especially the case with leukhaemic spleens ; but malarial 
 spleens sometimes take a vertical direction, become elongated, 
 and have their lateral borders parallel somewhat after the 
 manner of some tumours of the kidney (Trinkler). The spleen 
 when enlarged by a hydatid tumour may be very irregular. 
 
 (D) Tumours of the suprarenal capsule are not usually 
 of sufficient size to form an abdominal tumour, but when they
 
 540 
 
 SURGERY OF THE KIDNEY AND URETER 
 
 do so it is not easy, if it be possible, to distinguish them from renal 
 tumours. Nor is it clinically of importance to do so, since new 
 growths of the suprarenal capsule (see Figs. 76 and 77), when of 
 any clinical importance from their dimensions, involve the kidney 
 and sometimes completely efface it. 
 
 A case in which a new growth of the suprarenal capsule 
 formed an abdominal tumour is recorded by Dr. John Ogle.* It 
 
 Fig. 77. Adrenal Tumour removed from patient during life. A, Flattened area 
 of tumour ; B, lower portion of kidney unaltered ; c, vessels at the hilum. 
 Author's case. (See Brit. Ned. Journal, Jan. 7, 1893.) 
 
 was a hard, globular, movable, " encephaloicl " tumour, 6 inches 
 in diameter, in. a girl aged three years. It lay immediately 
 beneath the abdominal wall, uncovered by any bowel, and 
 extended between the concave margin of the kidney, which 
 was turned forwards with the tumour, and the front wall of 
 the abdomen. It had assumed the position but not the relations 
 of a renal enlargement. Dr. Dickinson (who made the post- 
 mortem examination) remarked that this suprarenal tumour 
 was not crossed by bowel as renal tumours almost invariably 
 are. This is a point of importance to remember, namely, that 
 adrenal tumours are not necessarily crossed by bowel. They 
 present in either hypochondriac region, and may be hard, rounded 
 * Path. Soc. Trans, vol. xvi., p. 250.
 
 DIAGNOSIS OF OVARIAN 1 FROM RENAL TUMOURS. 541 
 
 and movable. The skin may be hyperaemic and sallow or bronzed ; 
 on the other hand, it may not be changed at all in appearance 
 
 (E) Ovarian Tumours. Both solid and cystic tumours of 
 the kidney may be mistaken for ovarian tumours. " Solid 
 renal tumours, whether cancerous or innocent, may resemble 
 the malignant, pseudo-colloid, or cysto-sarcomatous tumours of 
 the ovaries ; while different varieties of ovarian cysts may be 
 closely simulated by different forms of pyelitis, and p} r o-nephrosis, 
 hydro-nephrosis, cystic degeneration, and the growth of hydatids 
 in the kidney" (Spencer Wells). Attention to the following 
 points will facilitate the diagnosis : With an ovarian tumour 
 the intestines lie behind ; both loins are resonant ; the tumour 
 grows from below upwards, and either drags up the uterus or 
 can be felt as a swelling in the pelvis by vaginal or rectal exam- 
 ination. An ovarian tumour exceptionally has intestine in front 
 of it : (1) if of small size the bowel may not be displaced back- 
 wards by it ; (2) adhesions may have formed between a coil 
 of intestine and the front surface of the tumour, so that the 
 bowel retains an anterior position. A careful examination of 
 the urine should be made in every case of doubtful tumour of 
 the abdomen. Although it is possible that a renal tumour may 
 be present and the urine be quite normal either because the 
 tumour does not alter the character of the secretion, or because 
 the healthy kidney alone secretes, or because the ureter of the 
 diseased kidney is blocked yet the rule is that blood, albumen, 
 renal epithelium or pus is detected, or that there is some 
 history of one or other of these abnormal constituents having 
 been previously detected in the urine, in any case of renal 
 swelling ; whereas, the probability is that they will be, and 
 will have been throughout, absent in the case of an ovarian 
 tumour. There are, however, many exceptions to the last part 
 of this statement. If a correct history can be obtained it may 
 be expected that an ovarian tumour will in all probability have 
 been first noticed in one inguinal or iliac region and will have 
 extended upwards and inwards. A renal tumour will have been 
 first discovered between the false ribs and ilium, and will have 
 extended first towards the umbilicus, next into the hypochondrium, 
 and lastly downwards towards the groin (Spencer Wells). 
 
 I operated upon a case of deep interest in 1891, in which 
 from the gouty tendency and the previous urinary symptoms
 
 542 SURGERY OF THE KIDNEY AND URETER. 
 
 as well as from the clinical symptoms of the tumour, an ovarian 
 dermoid with a twisted pedicle was mistaken for a hydro- 
 nephrosis, due as was thought to an impacted ureteral calculus or 
 to the pressure of a uterine myoma. The patient, a lady, aged 
 forty-seven, had for six or seven years suffered from occasional 
 attacks of pain in the left side of the abdomen ; the attacks 
 lasted several days, and were associated with increased frequency of 
 micturition, highly acid urine, and the passing of a large quantity 
 of urates and uric acid. On September 29th, 1891, she was 
 suddenly seized with agonising pain in the left side of the 
 abdomen where a tumour was detected attended with collapse, 
 and attributed by her medical attendants to renal colic and hydro- 
 nephrosis. When the pain had subsided sufficiently to allow 
 the abdomen to be examined, a uterine myoma the size of a 
 small melon was detected in the hypogastrium, and a large tumour, 
 rounded and elastic, was found in the left flank and extending 
 into the left iliac fossa. This tumour was the size of a large 
 cocoa-nut, was almost fixed in its position, with complete dulness 
 on percussion in the loin and resonance over the whole of its 
 front surface. On the second day after the attack the tumour 
 was tapped through the loin and many ounces of fluid were 
 drawn off. This fluid was found to be full of cholesterine crystals, 
 squamous epithelial debris, and neutral fats. 
 
 Its dermoid nature was then diagnosed, and its connection 
 with the ovary was proved by abdominal section, performed on 
 November 16th, 1891. The dermoid had a long pedicle connected 
 with the left ovary, and this pedicle was rotated two and a half 
 times round its own axis. The cyst, engorged with blood, was 
 quite fixed in the left loin by adhesions to the lumbar parietes, 
 and over its front and inner surfaces the small intestines and 
 part of the omentum were connected by recent adhesions of a 
 vivid crimson colour. A fringe of omentum and the cyst 
 were removed, so also were the right Fallopian tube and right 
 ovary, which contained several small cysts. The myoma was 
 not removed. The patient made an excellent recovery from the 
 operation, but died subsequently of sloughing and suppuration of 
 the myoma. 
 
 A sub-peritoneal uterine myoma in a pregnant uterus may 
 lie carried upwards, fall back into the loin and get partly covered 
 in front and on its inner side bv small intestine giving a resonant
 
 OVARIAN TUMOURS MAY INTERMIT OR VANISH. 543 
 
 note. A case of this sort in a lady between four and five 
 months advanced in pregnancy was sent to me by a dis- 
 tinguished physician as a probable renal tumour. It, together 
 witli the increasing size of the uterus, was causing great in- 
 convenience, sickness, and obstruction by pressure. I removed the 
 tumour by lateral laparotomy. The patient made a good recovery 
 and was subsequently delivered of a large child at full term. 
 
 In connection with the diagnosis of cystic tumours it must 
 be remembered that ovarian cysts, after forming adhesions, some- 
 times discharge their contents through the Fallopian tube, vagina, 
 intestines or bladder, and so by their variations in size can 
 closely simulate those cases of hydro-nephrosis which periodically 
 empty themselves through the ureter, or after once or oftener 
 doing so permanently disappear. 
 
 A very small ovarian tumour with a long pedicle may be 
 mistaken for a floating kidney, but a floating kidney can gene- 
 rally be recognised by its characteristic shape, its greasy feeling, 
 and its tendency to slip upwards and backwards into the loin. 
 
 (F) Enlargements of the lymphatic glands in the near 
 neighbourhood of the kidney when they give rise to a swelling have 
 relations to the colon very similar to those of a renal tumour. The 
 diagnosis may be made sometimes by the independent enlarge- 
 ment of one or more lumbar glands not forming part of the 
 tumour ; by the abruptness of the outline of the swelling ; -and 
 possibly even by a protrusion from the growth along the spermatic 
 cord into the scrotum. 
 
 (G) From flatulent or faecal accumulations in the caecum, 
 sigmoid flexure, or colon, renal tumours may be diagnosed 
 by the absence of intestinal disturbance, of general abdominal 
 pains and colic, and of the enlargement by flatus which 
 characterise over-distension, of the bowel. 
 
 The proximity of the colon to the kidney renders the diagnosis 
 between nephritic colic and intestinal colic sometimes difficult. 
 Sir AVilliam Jenner wrote : " Nephritic colic will cause loss of 
 power in the colon, and so induce constipation, thus favouring 
 the idea that the patient has intestinal colic. Again, collections 
 of stools in the colon may be mistaken for an enlarged kidney ; 
 a large enema will solve all doubt on this point." 
 
 Before the surgeon commits himself to a definite opinion in 
 any doubtful case of abdominal tumour, the bowels ought to have
 
 544 SURGERY OF THE KIDNEY AND URETER. 
 
 been well opened and the examination of the tumour made im- 
 mediately afterwards. It will be well to remember that just 
 as there is incontinence of urine in retention, and incessant out- 
 pouring of fluid through the mouth in pyrosis, so there may 
 be frequent discharge of small stools from a bowel over-loaded 
 with faeces. An opinion should be deferred in some cases until 
 after a second or third examination has been made, and until 
 full time has been allowed for the removal of fsecal accumulations 
 if there are any. 
 
 (H) Fsecal abscess, appendicitis, or inflammation of the 
 cellular tissue about the sigmoid flexure will be distinguished 
 by the marked febrile disturbance, the associated intestinal 
 symptoms, the tenderness over the front surface of the part 
 affected, and the lower position of the swelling, which will be in 
 the iliac rather than in the renal region of the belly. 
 
 (J) Malignant growths of the large intestine. There is 
 a close resemblance between a malignant growth of the ascending 
 or descending colon, less frequently also of the caecum and sig- 
 moid flexure, and a tumour of the kidney. I vividly recall at 
 least six cases in which this confusion in diagnosis occurred, 
 and I have been consulted about others. In three of my cases 
 the cancer of the gut set up large abscesses in the perinephric 
 tissue (see Lancet, April 25th, 1895). In two other cases which 
 I have explored within the last three years there was cancer of 
 the caecum in one, and cancer ,of the ascending colon in the other. 
 I have at the moment of writing a gentleman under treatment 
 with what was diagnosed to be a renal tumour, but which on 
 exploratory examination proved to be a malignant mass in the 
 descending colon involving the hilum of the left kidney. 
 
 Other cases of a somewhat like nature are reported in the 
 same issue of the Lancet (April 25th, 1895) by TV. Anderson and 
 E. Owen. 
 
 The features of resemblance between cancer of the large 
 gut and renal tumours are the following. First, the situation 
 and mode of increase ; the growth in the colon presents in the 
 loin, then extends forwards as far as or even beyond the semi- 
 lunar line, then descends towards or for two or three inches into 
 the iliac fossa, and afterwards may bulge somewhat backwards 
 between the lower ribs and the iliac crest. When the growth 
 ]s in the ascending or descending colon, the tumour may reach
 
 CANCER OF COLON SIMULATING RENAL TUMOUR. 545 
 
 upwards beneath the costal border, when in the caecum or sigmoid 
 flexure it is likely to be separated from the costal border \yy a 
 line of resonance. There is dulness in the loin and an un- 
 certain resonance in front of the tumour. Sometimes the note 
 is distinctly resonant, at others less resonant or completely dull. 
 The mass may move freely in a lateral or in an antero-posterior 
 direction between the two hands placed one on the loin and 
 the other on the front of the abdomen. When this movement 
 is .possible, the swelling is likely to be mistaken for a movable 
 kidney. This mobility may exist even when the growth has 
 commenced to infiltrate the antero-lateral parietes of the abdomen 
 if the parietes are relaxed. There may be no pain whatever, 
 or, on the contrary, there may be dull aching or radiating pains 
 caused by pressure of the tumour on the branches of the lumbar 
 plexus. If these symptoms of tumour and pain are associated with 
 blood or albumen in the urine, malignant renal tumour or hydro- 
 nephrosis due to renal calculus will be suspected. Sometimes 
 albuminuria or haematuria is present. Albumen was occasionally 
 found in the urine of one of my patients ; this was due to pres- 
 sure on the renal vessels, the cellulo-fatty tissue surrounding 
 and extending into the hilum having been invaded by the new 
 growth. Variable albuminuria and occasional haeinaturia with 
 steady diminution hi the amount of urea were marked symptoms 
 in W. Anderson's case of tumour in the left loin already referred 
 to ; the condition simulated hydro-nephrosis and was caused by 
 carcinoma of the descending colon. 
 
 Cancer of the large gut rarely has the form of the kidney. 
 It should be suspected if, as is very likely to be the case, the tumour 
 is associated with diarrhoea or possibly with loose blood-stained 
 actions of the bowels or other intestinal symptoms. In some cases 
 ball-like masses due to portions of bowel distended with flatus and 
 causing marked peristalsis have been noticed ; in others incomplete 
 obstruction of the bowel has occurred and has led the surgeon to 
 think the growth was not renal, but intestinal. Even this symp- 
 tom is fallacious, because partial or even complete obstruction 
 may be due to displacement of and pressure on the colon by 
 a renal growth, or by constriction due to adhesions of the me- 
 sentery to the front of the tumour. 
 
 An exploratory incision in the loin will reveal the kidney 
 unaffected, or involved only indirectly by the extension of the 
 VOL. i. 2 j
 
 546 SURGERY OF THE KIDNEY AND URETER. 
 
 growth in the surrounding perinephric tissues, and it may not 
 be possible entirely to expose the mass from the lumbar wound. 
 Such cases teach us to approach these tumours in a cautious 
 manner, giving a guarded diagnosis, and undertaking an operation 
 in a spirit prepared for a surprise and ready to meet with con- 
 ditions of an inoperable kind. 
 
 It is noteworthy that in three cases these growths of the colon set 
 up extensive perinephric abscesses, probably by ulcerating through 
 the intestinal walls at a spot uncovered by peritoneum. Sometimes a 
 renal tumour, on the other hand, ulcerates into the colon and 
 causes faecal extravasation into the peritoneal cavity. 
 
 (K) Tumours of the mesentery are more median, nearer the 
 umbilicus and the anterior parietes, more movable, especially in 
 a lateral direction, and have a zone of resonance all around them 
 due to their relation to the small intestine. A movable kidney 
 would have more vertical and less lateral movement, and would 
 lie capable of being pushed back into the recess of the loin. 
 
 (L) Tumours of the omentum are very movable laterally and 
 in an upward direction. They project prominently against the 
 anterior abdominal wall, and give a dull note on percussion. 
 
 (M) Tumours of the pancreas, whether cystic or cancerous, are 
 more median in position, their chief mobility is vertical, and they 
 may cause obstruction of the pancreatic and common bile-ducts. 
 Pancreatic cysts fluctuate and give a hydro-aerial bruit in front 
 of them (Le Dentu). It is only with left-sided renal tumours that 
 the confusion with those of the pancreas is likely to arise. 
 Hydro-nephrosis of the left kidney when it causes a tumour 
 is placed more -in the loin and descends more into the iliac fossa 
 than does a cyst of the pancreas, and the distended colon passes 
 vertically over its front surface or is displaced to its outer side 
 instead of crossing it transversely or lying below it, which is the 
 usual relation of the colon to a cyst of the pancreas. 
 
 (N) Enlargements of the gall-bladder are liable to be mis- 
 taken for renal swellings, and more especially perhaps for movable 
 kidney (sec p. 123, " Movable Kidney "). 
 
 (0) Perinephric lipomata are liable to be mistaken for renal 
 tumours. Their symptoms and diagnosis are discussed in Chapter 
 XXIII., Vol. IL, p. 14.
 
 547 
 
 CHAPTER XIX. 
 
 TUMOURS OF THE RENAL PARENCHYMA. 
 
 WE have to study renal new growths, (1) of the renal paren- 
 chyma ; (2) of the renal cavity, i.e. within the calyces and pelvis 
 of the kidney ; and (3) of the renal capsule, and of the tissue 
 around it, comprising what have been called the perinephric 
 and paranephric tumours. 
 
 We will first consider the new growths affecting the renal 
 parenchyma, and afterwards separately describe those of the 
 renal cavity, the renal capsule, and the perinephric tissue. 
 
 Three classes of new growths affect the substance of the kidney : 
 (A) The malignant, including the epithelial and sarcomatous 
 tumours ; (B) the non-malignant solid tumours, i.e. lipoma, fibroma, 
 myo-lipoma, myxoma, angeioma, et cetera; and (C) the cysts of 
 the kidney, i.e. cysts consecutive to nephritis, serous cysts, der- 
 moids, hydatid cysts, and the polycystic kidney. 
 
 (A) MALIGNANT TUMOURS IN THE ADULT. 
 
 The malignant tumours tend to infiltrate contiguous structures, 
 invade the lymph tracts, and generalise in the system, or, in 
 other words, set up secondary growths in near and distant organs 
 and parts. They are thus distinguished from the other class of 
 solid tumours the non-malignant which merely interfere by 
 direct pressure with neighbouring tissues or organs. The whole 
 class of malignant renal tumours have sometimes been erroneously 
 denominated cancer of the kidney. 
 
 The class, however, includes, both the epithelial and the meso- 
 blastic growths. The epithelial comprise the adenomata and the 
 epitheliomata ; whilst the mesoblastic growths, i.e. those of con- 
 nective tissue origin, include all the sarcomata, whether pure or 
 mixed with striped or unstriped muscular fibres, or with cartilage, 
 or with angeiomatous or other forms of tissue. According to 
 several observers, a certain number of new growths are com- 
 posed of connective and of epithelial structures blended in 
 different proportions, thus forming adeno-sarcmna. 
 
 Malignant tumours include also tumours less virulent than
 
 548 
 
 SURGERY OF THE KIDNEY AND URETER. 
 
 epithelioma and sarcoma, namely, lymphadeiioma ; as well as 
 the pathological development of supernumerary adrenals included 
 within the capsule of the kidney, first described by Grawitz in 
 1883, and to which the names struma renalis and supra^renalis 
 have been given. 
 
 Etiology. Carcinoma, sarcoma, struma supra-renalis and myo 
 sarcoma or rhabdo-myoma occasionally occur as primary new 
 growths in the kidney. Carcinoma and sarcoma are much more 
 frequently secondary than primary. Injury and the irritation of 
 
 Fig. 78. Two Views of the same (right) Kidney removed after death from a 
 Woman who died of Cirrhosis of the Liver. (Middlesex Hospital Museum, 
 No. 1795.) 
 
 A sarcomatous tumour, the size of a fist, is attached to the hilum and completely surrounds the pelvis 
 and commencement of the ureter. The pelvis of the kidney is dilated, and contains two rough 
 dark calculi, one, of which is spherical and the other branched. 
 
 a calculus (Fig. 78) have, in several recorded cases, been the 
 cause of primary cancer (Pollard, Shattock, Newman). Second- 
 ary carcinoma has, in quite a considerable number of recorded 
 cases, been preceded by carcinoma testis ; in other cases it has 
 followed cancer of the liver, stomach, breast, or uterus. 
 
 As a primary disease malignant new growths affect one organ 
 alone, except in some cases of congenital sarcoma, in which 
 both kidneys are affected without at iirst other organs being in- 
 volved. As a secondary disease, usually both kidneys are invaded. 
 The instances to the contrary, according to (luillet amounting to 
 seven in seventy-eight cases derived from autopsies, are probably
 
 SECONDARY MALIGNANT DISEASE MORE COMMON THAN PRIMARY. 549 
 
 instances of secondary infection long delayed. Sarcoma occurs 
 as a primary disease in children, before the fourth or fifth year; 
 and in adults in advanced life. As a result of stone or laceration 
 it has caused death at the age of twenty-five. Though somewhat 
 rapidly fatal after it has once commenced, a malignant neoplasm 
 may take a long time before it is excited into existence : thus, 
 twenty years have elapsed between a fall which gave rise to a 
 renal calculus with a blood-clot for its nucleus, and death from 
 primary cancer of the kidney in which the calculus was situated. 
 
 Of thirty cases of malignant disease, including cancer, sarcoma, 
 adenoma, and lymphadenoma of the kidney, found in 2,610 post- 
 mortem inspections at the Middlesex Hospital, twenty-five were 
 secondary and five primary. 
 
 Of the five primary growths two were hard carcinoma and 
 three encephaloid. In one case (a male aged seventy-six) the 
 right kidney was infiltrated with a firm white growth ; it was 
 enormously enlarged, weighed forty-nine ounces, and contained 
 several large irregular calculi. Probably the calculi had been the 
 exciting cause of the disease. In this case, and in one other 
 (a male aged sixty -four), in which the right kidney was converted 
 into a mass of encephaloid cancer as large as a melon, the disease 
 was confined to the kidney ; in the other three cases there was 
 secondary disease in other organs. In one the liver and colon, 
 in another the liver and retro-peritoneal glands, and in the third 
 the pancreas and omentum, were the parts thus secondarily 
 affected. 
 
 Of the twenty-five cases in which the kidney was affected 
 secondarily, ten were in males, fifteen in females. The primary 
 seats of disease were the female breast in five ; the female genital 
 organs and bladder in four ; the rectum in two ; the omentum, 
 duodenum, and liver each in one ; lympfiadenoma of the stomach 
 in one, and of the prostate in one ; sarcoma of the arm, of the axilla, 
 of the pleura, of the orbit, of a fibroma of the uterus, and of 
 the spinal dura mater each in one ; epithelioma of the tongue in 
 one, and of the cervical glands in one. In a further survey of the 
 more recent records of the Middlesex Hospital, sixty-nine cases 
 of malignant disease of the kidney were found in 3,926 post- 
 mortem examinations. Of these, fifty-four were secondary and 
 fifteen primary new growths. Of the fifteen primary tumours 
 of the kidnev thirteen were carcinoma and two adenoma.
 
 550 SURGERY OF THE KIDNEY AND URETER. 
 
 Pathology. 1. The Adenomata. Kecent histological re- 
 searches appear to show the malignancy of certain forms of 
 adenomata, and especially of the form denominated by Grawit/ 
 struma supra-renalis. Sturm in 1875 pointed out that renal 
 carcinoma may take the form of adenoma, consisting of a true 
 proliferation of convoluted tubules, which ultimately may be trans- 
 formed into cancer. Grawitz, Sudeck, Sabourin and OEttinger 
 have reported cases of adenoma of the kidney followed by secon- 
 dary deposits of like nature in the lung ; and with them PiUiet, 
 Senator, Sottas, and Albarran all agree that certain renal 
 adenomata behave like malignant tumours, both in their local 
 and distant effects ; that distinction between adenoma and 
 carcinoma is sometimes most difficult ; that transition forms 
 occur in the kidney more especially and more markedly than in 
 any other organs ; that it is impossible either from the micro- 
 scopical or from the macroscopical characters to establish precise 
 limits between adenomata and epitheliomata ; and further, that 
 an adenoma is sometimes only the beginning of an epithelioma. 
 There are several instances in which tumours of the kidney have 
 from their histological characters been described under the name 
 of adeno-carciiioma, and from their clinical and histological fea- 
 tures combined as " malignant adenoma." From the clinical point 
 of view, adenomata often increase in size, and give rise to meta- 
 static growths, and provoke cachexia and death like other malig- 
 nant new growths. 
 
 An example of congenital cystic adenoma in an infant of ten 
 months, which proved to be malignant, has been recorded by Edgar 
 Willett in the Transaction* of the Pathological Society (1895). The 
 cut surface showed a large tumour projecting from the outer border 
 of the kidney, and pushing the cortex, nearly the whole of which was 
 involved, to one side. A well-marked capsule separated the kidney 
 substance from the tumour, which was glandular in appearance and 
 consisted of minute cysts just visible to the naked eye. On the outer 
 surface the capsule of the kidney was thinly spread out over the new 
 growth. Microscopically the structure consisted of numerous minute 
 cysts, of various sixes, each of which was lined by a single layer 
 of short cubical epithelium. The essentially glandular look of the 
 tumour seemed at the time (the tumour was removed by opera- 
 tion) to warrant its being considered an adenoma, especially 
 as there was a definite limiting membrane to the growth. Sub-
 
 INTRARENAL LIPOMA IDENTICAL WITH ADRENAL ADENOMA. 551 
 
 sequently, it proved to be malignant, and eleven months later a 
 recurrence took place, and the child died. 
 
 The struma supra-renalis of Grawitz, or the development of 
 a supernumerary adrenal enclosed within the capsule of the 
 kidney into a renal tumour, has sometimes been considered a 
 benign tumour, but many of them are in course and termination 
 malignant. The nature of some primary tumours of the kidney 
 is similar to the normal adrenal tissue, but in others, " while some 
 portions simulate suprarenal tissue, other parts closely resemble 
 an alveolar sarcoma, and some districts have an appearance 
 which, I believe, many would be inclined to term carcinomatous " 
 (Kelynack). Some are identical in structure with adrenal adeno- 
 mata. These, when of small size, are the tumours described by 
 Robin as intrarenal lipomata. Grawitz, hi 1883, pointed out that 
 these so-called renal lipomata have the structure of the suprarenal 
 capsules, and he propounded the theory that they are small 
 adenomata arising from small masses of the suprarenal gland 
 included within the kidney. He proposed to call them strumce 
 lipomatodes aberratce renis. He supported his opinion by the 
 following arguments : (1) The sub-capsular situation ; (2) the 
 complete difference between the cells of the tumours and the 
 cells of the uriniferous tubes ; (3) the presence of fat globules 
 within the cells, and their morphological resemblance to those 
 of the adrenal cortex ; (4) the separation of these tumours 
 from the renal parenchyma by a connective tissue capsule ; (5) 
 the characteristic arrangement of cells in the tumour in single 
 or double layers separated by capillary vessels, which gives it the 
 appearance of the cortical part of the suprarenal capsule ; (6) the 
 simultaneous occurrence of amyloid degeneration of the vessels 
 of the tumour and of the capsule of the adrenals. Grawitz's 
 ingenious hypothesis that certain tumours of the kidney arise 
 from small adrenal "rests" embedded within or beneath the 
 capsule of the kidney has been pretty generally accepted. In- 
 deed, as Mr. Targett suggests, it is a question whether it has 
 not been somewhat too frequently applied, with the result that 
 some ordinary renal carcinomata have been referred to this ex- 
 traordinary class. Such a mistake is quite compatible with the 
 opposite one, namely, that some primary tumours of the suprarenal 
 gland have been regarded as primary tumours of the kidney. 
 Lubarsch, in support of Grawitz's view, insists also upon other 
 
 LC
 
 552 SURGERY OF THE KIDNEY AND URETER. 
 
 similarities in the cell formation of these tumours and the supra- 
 renal capsule, and especially on the presence of glycogen in both. 
 Horn concludes that all the adenomata of the kidney have this 
 origin. Sudeck, on the other hand, energetically disputes the 
 theory of Grawitz. In answer to the question to what class of 
 tumours do the struma supra-renalis of Grawitz belong, Strubing 
 and Resenstein recognise some as benign, some as malignant, 
 but clinically the local symptoms do not permit of a distinction 
 being made between the two sets of cases. Some speak of them 
 as adenomatous, some as carcinomatous, some as sarcomatous, and 
 Driessen considers they are endotheliomatous. Thus their nature 
 is far from being settled, though it is a recognised fact of great 
 importance that they have in many instances all the characters 
 of malignancy. Israel, Perthes, Lotheissen, and Askanazy give 
 cases, some in men, some in women, between the ages of forty-two 
 and sixty-four, of renal tumours of this kind which have been 
 removed and have subsequently recurred locally and in the lungs 
 and pleura and bones within periods varying from four months 
 to a year and a half.* Bayard Holmes has recorded a case 
 of adrenal tumour in a man aged fifty-six, with marked con- 
 stitutional symptoms and secondary growths, and this same author 
 stated that about one-third of all tumours of the kidney appearing 
 in adult life are of adrenal origin, but only a small proportion 
 of them show a tendency to metastases, and that these metastatic 
 foci are usually confined to the lungs or bones, and only rarely 
 are they found in both. There is unquestionable evidence to 
 show that instances, by no means very rare, of tumours 
 named by the German observers struma supra-renalis are very 
 malignant, from the point of view both, of quick recurrence and 
 of wide diffusion ; and consequently that the}', like some other 
 forms of adenomata, ought to be included amongst malignant 
 new growths of the kidney. It is conceded, however, that many 
 instances of the struma supra-renalis, and many of the other 
 varieties of adenomata, are benign ; but at the same time it is 
 held to be impossible to distinguish clinically or microscopically 
 the benign tumours from those which assume all the characters 
 of malignancy, and it is considered, therefore, that they ought 
 to be grouped with the malignant tumours in considering them 
 from the point of view of treatment. 
 
 * Amer. Med. Assoc. Journ., 1898, p. 405.
 
 ADULTS ALMOST EXCLUSIVELY AFFECTED BY CARCINOMA. 553 
 
 Adenomata are spheroidal in shape, encapsuled, often of con- 
 siderable size, forming a prominence on the outer surface of the 
 kidney as large as an orange, or larger; or they may 
 occupy the kidney above or below the hilum, leaving the other 
 part of the organ quite normal. There may be many cysts, 
 and also haemorrhages seen on section. The capsule is often thick 
 and fibrous, and sends processes across the tumour. The stroma 
 is frequently very scanty. The microscopical appearances are 
 those of spaces or tubes lined with epithelial cells like renal 
 epithelium ; in other parts there may be masses of cells of the 
 
 Fig. 79. An Adrenal " Rest " Tumour, described in the Catalogue as a Spheroidal- 
 celled Carcinoma of Kidney ; encysted form. (Guy's Museum.) 
 (See Targett, Trans. Path. Soc. Loud., vol. xlvii., p. 123, 1896.) 
 
 same type, and delicate branching papillary out-growths covered 
 with the same kind of cubical epithelium may fill the tubes. 
 
 2. Carcinoma ta. Renal cancer is found almost exclusively 
 in adults and those advancing or advanced in life, most fre- 
 quently between forty and sixty. Primary cancer of the kidney is 
 more common on the right side than the left. Where the point 
 is mentioned in the twenty-eight cases collected by Guillet, it is in 
 the proportion of seven to three. In cases recorded in my own 
 lists, collected from English literature (1884 to 1893), it was in 
 the proportion of ten to six, and in American journals during 
 the same period, four to three. It is also more frequently met 
 with in men than women, thirteen to three in the English
 
 554 
 
 SURGERY OF THE KIDNEY AND URETER. 
 
 cases, though in the American it is as two to five, and in 
 Guillet's cases about twice as frequent in men as in women, 
 sixty-four men to thirty-five women out of ninety-nine cases. 
 
 Cancer affects the kidney in two forms, the diffused and the 
 encysted (Figs. 79, 80). It is rare for the tumour tissue 
 so completely to replace the renal parenchyma that the latter 
 entirely disappears ; and it is also seldom that it is diffused 
 uniformly throughout the organ. Commonly, one finds that it 
 
 Fig. 80. Section, showing Alveolar Carcinoma. The Capsule of the Kidney is 
 continued over the surface of the Tumour. (St. Thomas's Hospital Museum.) 
 
 has destroyed a more or less considerable part of the organ 
 the superior or inferior third or half leaving the rest of the 
 kidney tissue unaltered in appearance to the naked eye. The 
 proper capsule of the kidney, often much thickened, is continued 
 over the surface of the tumour (Figs. 80, 81). On section, the 
 margin of the tumour projecting into the parenchyma is rounded 
 and regular in outline, and is limited frequently on this aspect by a 
 capsule ; but the capsule may be wanting, and then the new growth 
 infiltrates the tissue and has not a definite outline. In some cases 
 two or more separate encapsuled masses occupy the kidney. 
 
 When, the cancer infiltrates the kidney, it may increase its 
 volume without altering its shape, the capsule being thickened 
 and having large veins ramifying upon it. In the more
 
 RENAL CARCINOMA SPREADING TO THE BLADDER. 555 
 
 advanced stages the capsule may rupture or become perforated 
 by the growth at several points ; or the growth may invade the 
 renal pelvis and the ureter, and spread along the latter even as 
 far as the bladder, which it has been known to enter. The size 
 attained by epithelial cancer is very variable, ranging from less 
 than that of a nut to tumours larger than the adult head. 
 They do not often reach such large dimensions as the sarcomata. 
 The shape of the kidney is maintained when the cancer is 
 
 Fig. 81. From the same Kidney as Fig. 80, showing the continuation of the 
 Renal Capsule, or what looks to he so, over the Hilum. 
 
 small or of only moderate size (Fig. 82), but it is lost when 
 the tumour attains a large size and when it becomes irregular 
 and nodular in outline (Figs. 79 and 81). The tumour 
 may give rise to dilatation of the stomach by pressure or by 
 displacement of the pyloric end ; the fatty capsule adheres more 
 or less intimately to the growth and as the tumour increases 
 it comes into relation and forms adhesions with neighbouring 
 organs, viz. the liver, spleen, colon, duodenum, inferior vena cava 
 (Elliott, Lancet, 1879, vol. xi., p. 423), or aorta. Pescher* 
 records a case in which there were extensive adhesions between 
 a primary carcinoma of the kidney and the colon, with numerous 
 perforations of the colon, allowing of the escape of faecal matter 
 * Pescher, tfa/ott's Annual of the Medical Sciences, 1889, p. 30.
 
 556 
 
 SURG1ERY OF THE KIDNEY AND URETER. 
 
 into the peritoneum. Piegne also records a somewhat similar 
 case (Bull, de la Soc. Anat., Avril 30, 1888). Raver published 
 a case hi which the duodenum was invaded. 
 
 The renal capsule may contain secondary isolated nodules, as 
 in my case, illustrated below, Fig. 82. 
 
 The adhesions to the vena cava of tumours of the right 
 kidney are more frequent than those of the tumours of the left 
 
 Fig. 82. Epithelioma of Kidney, with Clot in the Renal Vein. Removed by Author. 
 
 kidney to the aorta, and they are particularly dangerous, being 
 likely to result in rupture of the vein if an attempt be made to 
 perform iiephrectomy. Quenu (Bull, de la Soc. Chir., Juillet, 1888) 
 speaks of the occurrence of peritonitis dependent on renal cancer. 
 Some of the cancerous tumours of the kidney, which on the 
 surface are more or less smooth, present on section an enormous 
 cyst, with shaggy llocculent walls containing soft greyish or 
 yellowish-white or brain-like new growth, into which blood ex- 
 travasations have occurred, so that the tumour-tissue is mixed 
 with blood-clots more or less altered in colour.
 
 CYSTIC CHARACTER OF SOME RENAL CANCERS 
 
 557 
 
 On section, wide bands of fibrous tissue connected with the 
 capsule may divide up the tumour into a series of lobules. 
 Sometimes there are cyst-like cavities containing blood or a 
 semi-gelatinous substance. 
 
 In other cases the tumour has an alveolar appearance, honeycombed 
 in places, the tissue around being 
 firm. Such was the structure of 
 the new growths in two kidneys 
 recently removed by me. 
 
 Case I. A kidney removed 
 from a man in 1899 was much 
 enlarged, measuring ten inches by 
 seven inches. On the surface it 
 was lacerated. 
 
 It was greatly distended and 
 sacculated, and there was but 
 little normal renal tissue left, 
 It had the general appearance 
 of a large tuberculous kidney. 
 
 In the lower half the walls 
 of the sacculi were thickened and 
 nodular, as if composed of new 
 growth. The nodular masses 
 were pale and hard. There were 
 no distinct evidences of tubercle. 
 The interior of each sacculus 
 was roughened and shaggy. 
 
 Microscopical appearances. 
 The tumour was composed of 
 bands of fibrous tissue, so ar- 
 ranged as to enclose alveolar 
 spaces which were occupied by 
 
 epithelial cells, many of them typically squamous. In some places 
 structures like " cell nests " could be seen ; in other places the 
 epithelial columns appeared as tubes with a central lumen. 
 
 Case II. A kidney removed from a woman on June 26, 
 1899, was about the normal size. The capsule was thickened 
 and adherent, and cut as if it were calcified in parts. 
 
 In the lower half, a hard rounded mass could be seen, which 
 on section measured about two and a quarter inches in diameter. 
 
 Fig. 83. Kidney with Clot enlarged and 
 measuring 6-^ inches in long axis, and 
 3 inches in transverse axis, u, renal 
 pelvis ; v, renal vein : A, renal artery. 
 Author's case. (From same specimen 
 as Fig. 82.)
 
 558 SURGERY OF THE KIDNEY AND URETER. 
 
 This mass was not encapsuled, was pale and mottled, and gener- 
 ally firm. It appeared to be an infiltrating new growth. The 
 upper part of the organ was healthy. 
 
 Under the microscope the main mass of the tumour 
 was seen to be composed of very delicate flattened cells (either 
 epithelial or endothelial), which were embedded in a very delicate 
 connective tissue stroma. In places the arrangement was roughly 
 alveolar, in others it was very indistinct. 
 
 The naked-eye resemblance of renal carcinomata to caseous 
 tuberculous deposit is in some cases very close indeed. 
 
 I removed on one occasion from a very thin, spare, middle- 
 aged man a tumour which filled more than half the belly and 
 from which a large quantity of diffluent or nearly fluid contents 
 escaped, leaving a large collapsed cyst to be removed. It gave 
 at the time more the impression of a huge, almost completely 
 liquefied, tuberculous cyst, but on microscopic examination it 
 proved to be an epitheliomatous cancer, which recurred and 
 killed the patient within four months from the date of the 
 nephrectomy. Horn, Strubing, Le Dentu, and others have 
 recorded somewhat similar cases. 
 
 Cancer spreads by invasion of, i.e. by continuity into, the sur- 
 rounding tissues, as well as by forming adhesions with the neigh- 
 bouring organs as stated alx)ve. The size of the tumour does 
 not necessarily imply adhesions; some tumours of very large size 
 have been quite free from them. 
 
 The growth may invade the renal vein, causing thrombosis, 
 and giving rise to simple and infective emboli ; it may spread 
 along the renal vein into the inferior vena cava, and thence 
 extend along the large trunk vein a considerable distance, en- 
 larging it in doing so to an enormous degree* (see Fig. 85). 
 From the vena cava the growth may also spread into the renal 
 vein of the opposite side.t 
 
 In some cases, what looks like the invasion of a vein by new 
 growth is only decolorised blood-clot, as in Fig. S3. The aorta 
 is very rarely affected in this way ; but the renal artery is often 
 enlarged, hypertrophied and dilated. The vertebral column has 
 been destroyed, causing neuralgia of the cauda-equina and para- 
 plegia, as in cases recorded by Lepine (Lyon Medical e) and Cornil 
 
 * Coyne and Troisier (Bid. tie la Soc. M<'d., 1871, p. -239). 
 t Lepine, Revue, de M>'d., ISSs viii., 102 1.
 
 ADENOMA CAUSING SECONDARY INFECTIONS. 559 
 
 (Bull, de 1'AcadJm. de Med., 1866) ; and also in a case I attended 
 with Dr. Cambridge of Finsbury Park. The calyces, pelvis, and 
 upper part of the ureter may be invaded and filled with a foetid, 
 semi-solid mass composed of blood, urine, and cancerous debris. 
 
 Albarran records a very interesting case in which a button of 
 the new growth obstructed the ureter and caused a hydro-nephrosis. 
 Not detecting the presence of this growth in the renal cavity, he 
 })erformed nephrotomy, and let out of the sac a quantity of quite 
 clear liquid and a small fragment of tissue which looked like false 
 membrane ; he then fixed the kidney. The microscope showed this 
 fragment to have the characteristic structure of epithelioma of 
 the kidney, and thirty days later he performed nephrectomy, and 
 ascertained the presence of a central new growth. Hildebrandt 
 has published a similar case (Arch, fur Klin. Chir., Bd. Ivii., 
 1896, p. 224). 
 
 Secondary infections occur through the lymphatics, and most 
 frequently involve the lungs and liver. Metastases sometimes 
 occur with renal carcinoma of small size, and with tumours 
 having the microscopic characters of adenoma. The lymphatic 
 glands along the vertebral column and at the renal pelvis some- 
 times attain a very large size and form a tumour larger than 
 the renal tumour, and with which they may be amalgamated. 
 
 If the spermatic vein is compressed by the renal tumour or 
 by the enlarged glands, or if the left renal vein is plugged by 
 thrombus, a varicocele is developed on the corresponding side. 
 
 Besides the renal epitheliomata having the ordinary struc- 
 ture of carcinoma, Albarran describes a second variety of tumours, 
 which he has named epithelioma a cellules claires, and which 
 he considers are very characteristic. A great number of new 
 growths of the kidney present, according to him, an alveolar 
 structure and clear cells, such as are described as occurring in 
 adenomata of the large tubular form. 
 
 Some of the tumours, even when of large size, are uniformly 
 so composed, whilst others consist partly of epithelioma with clear 
 cells, and partly of portions having the tubular structure exactly 
 like the ordinary form of epithelioma. 
 
 3. Sarcomata sometimes infiltrate the whole of the kidney, 
 which meanwhile preserves its ordinary form, at other times 
 they commence in the centre of the parenchyma, being surrounded 
 by a thin layer of renal tissue ; rarely, when commencing in
 
 560 
 
 SURGERY OF THE KIDNEY AND URETER. 
 
 the capsule, they surround the kidney, the normal tissue of which 
 is preserved ; but most frequently the sarcoma forms a tumour 
 which is developed at one point and rapidly destroys the rest 
 of the. organ. It may commence in or invade the wall of a large 
 cyst without invading the renal parenchyma, as in the case of 
 adrenal tumour from which Fig. 86 was taken. 
 
 At its outset the sarcoma appears in certain cases separated 
 
 Fit 
 
 Si. Multiple Sarcomata of Kidney, encapsuled with fibrous bands passing 
 inwards from capsule and dividing the growth into lobules. (Guy's Hospital, 
 Xo. 1658.) 
 
 by a capsule from the kidney (Fig. 84) ; but often there is 
 no capsule ; and where it exists the capsule often bursts at some 
 small point and the tumour infiltrates, through this point of 
 rupture, the rest of the renal tissue. 
 
 Sarcomata sometimes form enormous tumours which fill more 
 than half the belly ; they are lobulated, being firm in some cases 
 and partially or totally softened in others. On section they 
 often show hsemorrhagic foci and pseudo-cysts. 
 
 Perhaps two of felie most remarkable features in connection
 
 SARCOMA REACHING AN ENORMOUS SIZE. 
 
 561 
 
 with sarcomata are the enormous size to which such growths attain 
 and the fact of their occurrence in earlv childhood. Tumours of 
 
 as much as 20 Ibs. weight have been found in quite young 
 children* occurring and proving fatal between birth and the fifth 
 * Audain (d'Haiti), " Sarcoma du Rein," Union Medicate, May, 1875. 
 VOL. I. 2 K
 
 562 
 
 SURGERY OF THE KIDNEY AND URETER. 
 
 86. Cysts in the Kidney, one at the upper end was developed into a large 
 tumour containing gelatinous grumous fluid, and its wall was the seat of a 
 mixed-celled sarcoma. The tumour originated in the adrenal. There was no 
 new growth in the kidney itself. This same kidney is shown in section in Fig. 
 33. p. 271. (Removed by the Author.) 
 
 Fig'. 87. Melanotic Sarcoma of Kidney and Perinophric tissue. A small growth an eighth 
 of an inch in diameter is seen in the cortex, and a similar growth as large as a 
 filbert in the connective tissue over the kidney. (St. Thomas's Hospital Museum.)
 
 SARCOMA TENDING TO RAPID GENERALISATION. 
 
 563 
 
 year. In a small portion of the cases sarcomata in children are 
 bilateral. Between five and fifteen years of age these growths 
 are not met with, but in later years of adolescence and to the 
 age of sixty unilateral sarcoma is pretty frequent. It is not 
 often seen in persons over sixty. 
 
 Though attaining great size some sarcomata remain circum- 
 
 Fig. 88. Melanotic Sarcomata (probably secondary) in the Perinephric Tissue. 
 Presented by Astley Cooper. There were also melanotic growths in the skin, 
 omentum, and abdominal lymphatics. (Guy's Hospital, No. 166'2.) 
 
 scribed without invading neighbouring organs, or becoming 
 generalised. But as a rule they rapidly invade the vena cava, 
 the ureter, and the lymphatic glands, and generalise themselves by 
 secondary deposits which are found chiefly in the lungs, liver 
 and brain. 
 
 Melanotic sarcomata are almost always if not invariably secondary 
 when met with in the kidney. In each of the cases from which 
 Figs. 87, 88, and 89 were taken the melanotic sarcomata in the 
 perinephric tissue, cortex, and capsule of the kidney were secondary.
 
 564 
 
 SURGERY OF THE KIDNEY AND URETER. 
 
 Melanotic discoloration of cancerous and sarcomatous renal 
 tumours is of occasional occurrence ; and Dickinson has pointed 
 out that melanotic formations may be found in the kidney 
 independently of any morbid growth and simply as a develop- 
 ment of pigment cells in the interstitial tissue of the organ. 
 
 Dickinson gives an illustration taken from a specimen in 
 the Hunter ian Museum which he had examined microscopically, 
 showing black spots unattended with any swelling or displacement 
 of structure scattered throughout the medulla and cortex and 
 in the capsule of the kidney. These were caused by masses 
 
 View of outer surface. 
 
 View of section surface. 
 
 Fig. 89. Portion of Kidney with Melanotic Sarcoma, from a woman, aged 40, who 
 died with ascites. Melanotic growths were also found in the skin, pleura, 
 peritoneum, liver and spleen. (Guy's Hospital, No. 1661.) 
 
 of pigment cells varying in size from a pin's head or smaller 
 to a pea or rather larger. " The cells were situated wholly in 
 the interlobular district of the kidney, leaving the tubes and 
 Malpighiaii lx)dies unaffected, but often strikingly outlined by 
 the black matter. There was no evidence of new fibroid growth 
 or stroma." 
 
 In the Hunterian Museum is another kidney uniformly 
 blackened by a similar change, and at the London Hospital 
 is a specimen " looking as if lampblack had been inserted into 
 round cavities." Dickinson adds, " Clinically the history of 
 melanosis is that of the growth with which the pigment is 
 associated," and he refers to Fagge's cases* to show that in 
 melanotic sarcoma the urine has been proved to contain black 
 pigment either in casts, granules, or solution. 
 
 ' Trans. Path. tioc. Land. vol. xxviii., p. 172 (1877).
 
 LYMPHO-SARCOMA IX KIDXEY ALWAYS SECOXDARY. 565 
 
 There are numerous forms of sarcoma varying according 
 to the different kinds of cells of which the growth may be com- 
 posed, to the arrangement of these cells, and to their admixture 
 with various tissue developments. The round-celled vascular variety 
 is soft and grows rapidly ; it is the most common, and composed 
 twenty-three out of forty -three tumours in children operated 
 upon since 1890. The spindle-celled form is firm, of slower 
 growth and less marked malignancy ; it is much rarer than 
 the round-celled sarcoma. Myxo-sarcoma rapidly attains a large 
 size without giving rise to much pain and often without metastasis ; 
 it occurred in five cases out of forty-three sarcomata operated 
 upon in children since 1890. 
 
 Lympho-sarcoma. Tumours occur in which one part re- 
 sembles a growth of lymphatic origin and another part a small 
 round-celled sarcoma. The cases of so-called lympho-sarcoma 
 of the kidney sometimes resemble large white kidneys. The 
 new growth is diffused throughout more or less of the organ. 
 Both kidneys, and other organs as well, are usually affected. Pro- 
 bably the kidneys are always involved secondarily to the retro- 
 peritoneal or mesenteric glands. The growths are composed, 
 of round cells with large nuclei contained in a delicate network 
 of interlacing fibres, Heresco found only one case of lympho- 
 sarcoma amongst 165 instances in which nephrectomy had been 
 performed for malignant tumours of the kidney. The patient 
 was a girl of two years of age, from whom Bran removed the 
 right kidney. The child died of recurrence three months after 
 the operation. 
 
 Dr. Parkes Weber brought before the Pathological Society in 1896 
 the kidneys of a girl aged five, enlarged to ^hree or four times 
 their natural size by diffuse symmetrical lympho-sarcomatous 
 infiltration, associated with deposits in the caecum, appendix, 
 diaphragm, pericardium, and some of the mesenteric and media- 
 stinal glands. The liver to the naked eye was unaffected. The 
 history of the illness is very defective, but the urine was reported 
 to have contained a considerable amount of albumen, a few casts, 
 but no red blood-corpuscles. 
 
 Mr. Jackson Clarke in a discussion on lymphadenoma and 
 its relation to other morbid growths, introduced by Mr. W. G. 
 Spencer, stated that he found nineteen cases of lympho-sarcoma 
 in 730 consecutive autopsies, as compared with thirty-nine cases
 
 566 SURGERY OB' THE KIDNEY AND URETER. 
 
 of other forms of malignant neoplasms. Of these thirty -nine 
 instances the kidney was only once the seat of disease ; it is not 
 stated how often the kidney was involved in the nineteen lympho- 
 sarcomas. His observation of these nineteen cases, however, 
 led him to attribute the primary seat of the disease to the bronchial 
 glands in ten cases, to the hepatic glands in the small omentum 
 next in point of frequency, then to the lumbar glands, and 
 lastly, to the cervical and axillary glands in the order named 
 (Brit. Med. Journ., 1896, Jan. 18th, vol. i.). Hebb (Trans. 
 Path. Soc., vol. xl., p. 296, 1889) describes a case of primary 
 lympho-sarcoma of the kidney of a girl aged four. 
 
 Lymphadenoma is a growth of tissue closely resembling in 
 structure that of the lymphatic glands. An overgrowth of lymph- 
 adenomatous tissue occasionally occurs in organs and parts such 
 as the kidney, liver, testis and skin, wherein traces only of 
 such tissue are to be found normally ; as well as in the lymphatic 
 glands themselves. Lymphadenoma occurs in the kidney in 
 association with the same affection of other organs. Murchison 
 and Coupland have put on record in the Transactions of the 
 Pathological Society (vols. xx. and xxviii.) extreme cases of renal 
 lymphadeiioma. 
 
 Each kidney may present numerous circumscribed masses of 
 new growth, round in form, soft in texture, white in colour, 
 and varying in size from a walnut to a pea. The deposits may 
 raise the outer surface of the kidney, and also be embedded in 
 the cortical and pyramidal tissue. 
 
 The ureter may be infiltrated, for an inch or two, with an 
 opaque white material contained in its walls but without occluding 
 its lumen. The naked eye characters of the growths are not 
 distinctive, but their microscopical appearances are tbose of 
 lymphadenoma : a strongly - marked fibrous reticulum, blending 
 with the interstitial tissue of the kidney, encloses spaces which 
 contain nucleated cells ; numerous uniformly small and round 
 nuclei pervade the substance of the fibrous stroma. In 
 Murchison's case there are at least a hundred masses shown 
 in the lateral aspect of one kidney. They were yellowish-white, 
 looking somewhat like large masses of tubercle, but less apt to 
 caseate, and harder and closer in texture. 
 
 The question arises as to the primary scat of the disease in 
 these cases. J)oes it start in the lymphatic glands, in the kidney,
 
 RENAL LYMPHADENOMA A GENERAL, NOT LOCAL, DISEASE. 567 
 
 or elsewhere, and thence become generalised ? Or is there a 
 simultaneous development in different organs and regions of the 
 body ? The latter would seem to be the case, where many 
 organs are affected nearly equally ; but occasionally the history 
 of the illness may give a clue as to which organ first showed 
 signs of functional disturbance. 
 
 >l I have had a case of this disease under observation in a gen- 
 tleman, aged seventy -six, who twelve months or more before fell 
 from a bicycle, hurting his left groin in such a manner that, 
 though he could not stand erect or. walk immediately afterwards, 
 he was able to mount his machine and ride home two miles, 
 and after a fortnight in bed all ill effects of the fall seemed to 
 have passed off ; but an enlarged, painless, well-defined movable 
 gland appeared some months later in the left groin, others 
 similar in character subsequently developed in the iliac fossa. Till 
 three months before I saw him he had been an active and 
 wonderfully strong man for his age, cycling and taking other forms 
 of vigorous exercise. He was the father of four healthy children, 
 the eldest being under sixteen years of age. The symptoms 
 were rapid loss of strength, marked emaciation, loss of appetite, 
 complete enervation, and slight albuminuria, but an entire absence 
 of hsematuria and pain. The liver, spleen, retro-peritoneal and 
 meseiiteric glands were enlarged, and there was enlargement 
 with induration and slight irregularity of the surface of each 
 kidney. The urine was sometimes very thick from lithates, at 
 others quite clear and of a pale-yellow colour. In Murchison's 
 case the urine was pale, clear, and free from albumen. 
 
 Dickinson, under the head of "Leukhaemic Tumours or 
 Extravasations/' refers to " white marrow-like tumours, consisting 
 of white blood corpuscles, in a very delicate reticulum, varying in 
 size from a mere dot to a cherry," as having been described as 
 occurring in the kidney in connection with the general condition 
 of leukhaemia. 
 
 He adds, " Sometimes the extravasations, though mainly con- 
 sisting of white corpuscles, present so much the appearance of 
 ordinary haemorrhage that they are not to be distinguished by 
 the naked eye from such sanguineous outbreaks as have been 
 described in connection with some of the varieties of sarcoma." 
 Dr. Greenfield gives an instance of this in the Pathological Society's 
 Transactions (vol. xxix., p. 298, plate xiv.). In this case a girl,
 
 568 SURGERY OF THE KIDNEY AND URETER. 
 
 four and a half years old, died from leucocythemia with multiple 
 haemorrhages and infiltration of the liver and kidneys. 
 
 The kidneys were found enlarged and covered with large 
 purple blotches, and a thin layer of coagulated blood separated 
 the capsule in places from the cortex. Between the haemorrhagic 
 blotches the intervening tissue was of pale dead-w T hite colour. 
 Similar patches were scattered through the cortical substance, 
 some of which had their bases at the surface of the organ ; and 
 around the bases of the pyramids were radiating tracts or bands 
 of haemorrhage. Microscopically, masses of leucocytes, either 
 in distended capillaries or outside their walls, were found to 
 separate the convoluted tubes ; in some places " the tubes were 
 quite isolated, like islands, in a sea of leucocytes. The renal 
 tubules were apparently healthy. There was no sign of stroma 
 or adenoid structure." 
 
 Dr. Greenfield briefly summarises the distinctions which are 
 found between lymphadenoma and leucocythemia. He points out 
 that the two diseases differ in etiology, symptoms, duration, 
 prognosis, and the occurrence of haemorrhages. They are only 
 related in that they both involve the lymphatic and the blood 
 systems ; but there is a closer relationship between lymph- 
 adenoma and tubercle on the one hand, and cancer and 
 sarcoma 011 the other, than, between lymphadenoma and leuco- 
 cythemia. 
 
 In leucocythemia there is excessive and abnormal production 
 of white blood corpuscles, which stuff the capillaries and transude 
 into the surrounding tissues and give rise to haemorrhages. The 
 so-called growths are nothing more than collections of leucocytes, 
 without organisation, and no stroma except coagulated fibrin and 
 the normal connective tissue. 
 
 In lymphadenoma there is a new growth of an adenoid 
 character composed of a well-marked, sometimes coarse, stroma, 
 and well-formed large and sometimes multinucleated cells. 
 
 Rhabdo-myoma or myo-sarcoma. Cases of renal tumour, 
 of probably congenital origin, and composed of striped muscle 
 and sarcoma tissue, have been occasionally met with, especially 
 in children under two years of age. In some instances there 
 has been a tumour of each kidney ; in some, all vestige 
 of normal kidney structure lias been destroyed ; in others, the 
 tumour has lain beneath the renal capsule upon the surface
 
 MYO-SARCOMA OFTEN BILATERAL AND ENCAPSULED. 569 
 
 of the kidney.* Witzel has recorded a case of a child in which 
 the renal pelvis was greatly dilated by numerous peclunculated 
 tumours of this nature growing from its walls. 
 
 These tumours are composed of round and spindle cells ; and 
 mixed with them are elongated and transversely striated cells 
 which are usually considered to be muscular elements. These 
 cells vary very much in size and striation, they have no sar- 
 colemma, and their actual muscular origin has been questioned 
 by some ; spaces resembling kidney tubules are found in the 
 tumours, and the epithelium lining these may undergo proliferation. 
 Paul and some other pathologists think these tumours belong 
 to the teratomata. In some cases there is a large amount 
 of connective tissue, and it is said that the growths often contain 
 glycogeii. Their exact mode of origin is doubtful ; it is generally 
 thought that they depend upon the inclusion of muscular tissue 
 during foetal development. They are regarded by others as being 
 composed of transformed renal elements, in support of which view 
 it may be stated that Eberth f has described a network of smooth 
 muscular fibre on the surface of the kidney ; and, more recently, 
 Jardet 1 demonstrated this tissue in the substance of the gland. 
 
 The sarcomata with striated fibres were first described by 
 Eberth. Windle in 1884 had collected eleven cases, and his 
 paper contained valuable information on primary sarcoma of 
 the kidney. Albarran has added ten to Windle's list. Almost 
 invariably these striped fibres when they occur are met with 
 in sarcomata, but exceptionally they are found in adeno-carci- 
 nomata (Hirschfeld). These tumours are often bilateral, often 
 acquire a great size, and frequently remain separated from the 
 renal tissue by a capsule. If secondary tumours form, striped 
 muscular fibres may be found in them also. 
 
 On section of these myo-sarcomata, fibrous bands are seen, 
 which divide regularly the sarcomatous mass, and it is in these 
 
 * See Trans. Path. Soc. Lond., vol. xxxiii., pp. 312 et seq., for cases 
 by Mr. Eve and Dr. Dawson Williams ; see also Osier's and Windle's 
 papers in the Journ. of Anat. and Physiology, vol. xiv., p. 229, and 
 vol. xviii., p. 160; Paul, Brit. Med. Journal, Jan. 12th, 1884; Med. Press 
 and Circular, Apl. 30th, 1884; other cases are reported in the Lancet 
 Aug. 15th and 29th, 1885. 
 
 t Virchow's Arch., Bd. lv., s. 518 (1872). 
 
 | Arch, de Phys. Norm, et Pathol., Feb. 15th, I860. 
 
 Journal Anat. and Phy?., vol. xviii., p. 160.
 
 570 SURGERY OF THE KIDNEY AND URETER. 
 
 bands that we find muscular fibres, either unstriated or striated ; 
 the latter are often imperfectly developed, being devoid of sar- 
 colemma, and it is often difficult to distinguish the one 
 (unstriated) from the other (imperfectly striated). 
 
 Adeno-sarcoma occurred in seven out of forty-three cases of 
 sarcomata in children operated upon since 1890. 
 
 Alveolar-sarcoma approaches more nearly in structure to 
 carcinoma than the other forms, and is of rapid growth and 
 marked malignancy. 
 
 Vale and Maiiasse speak of eiidotheliomata, and Manasse and 
 Driesseii describe lymphatic eiidotheliomata. Angeio-sarcoma is less 
 rare than either of these two last-named forms. 
 
 Deciduoma malignum. There is in the Huiiterian Museum a 
 kidney affected with this disease, secondary to a deciduoma malignum 
 of the uterus. The growth on section looks like a rounded mass 
 of blood clot partly decolorised in places. 
 
 Pathogenesis. The question as to the origin of tumours 
 is still at this day one about which there is much dispute 
 and uncertainty. Tumours of the kidney are no exception 
 to this statement, however well their anatomical forms and their 
 mode of propagation and generalisation may be established. 
 
 Malignant tumours begin either in the fibrous stroma of the 
 cortex or in the epithelium of the renal tubes. Frequently, 
 however, the proper tissue of the kidney is invaded by a new 
 growth which has had its primary seat in the lymphatic glands 
 or in some other structure about the hilum ; and the disease, 
 putting 011 the form of the kidney after penetrating the hilum and 
 expanding the capsule, is called a "renal" tumour. Moxon thinks 
 this the commonest plan of attack in primary malignant disease 
 of the kidney, and as it may be long before the renal pelvis 
 is penetrated, and as the proper renal tissue remains long intact, 
 we have, he says, the reason, of the frequent absence of diseased 
 products in the urine. The whole organ, in time, becomes in- 
 filtrated, and when the disease begins -within the capsule this 
 process is very rapid, and cysts and bloody or purulent collections 
 form in the organ as the disease advances. 
 
 There is commonly a tumour recognisable during life, and 
 if the tissues around the kidney become adherent to the organ, 
 the growth sometimes advances outwards until it is immediately 
 beneath the skin in the loin.
 
 HISTOLOGICAL BIRTHPLACE OF EPITHELIAL NEOPLASMS. 571 
 
 Ailrnoma and epithelioma. Different views are entertained 
 as to the origin of renal adenoma and epithelioma. Some con- 
 sider them as of eiidothelial origin, others hold that they start from 
 the epithelium of the renal tubules, others from aberrant nodules 
 of adrenal structure enclosed with the renal capsule, whilst 
 Albarran refers the genesis of many of these tumours to aberrant 
 para-renal embryonic tubules. 
 
 Robin, Lancereaux, Sabourrin, Sturm, Waldeyer, Sucleck, 
 Depage, Bellatti, and several others regard the epitheliomata 
 as arising from the proliferation of the epithelium of the 
 renal tubules, especially of the convoluted tubes. The start- 
 ing point of these tumours is generally the cortical area, 
 only exceptionally do they arise from the calyces or renal pelvis. 
 This opinion was expressed by Raver, and has been corroborated 
 by nearly all observers. De Paoli and Driessen, basing their views 
 on the analogy between these tumours and certain tumours of 
 bones, as well as on the relation of the cells of the tumours 
 to the capillaries, have described the "epitheliomata with clear 
 cells " as eiidotheliomata, but this view is opposed by the histo- 
 logical characters of the cells and their arrangement or grouping. 
 
 Sabourin (1882) regards the isolated adenomata, as well as those 
 met with in Bright's disease, as taking origin in the epithelium 
 of the renal tubules, and considers that cirrhosis of the kidney 
 is the cause of the proliferation of the epithelium. He describes 
 two varieties of adenoma, the cylindrical celled and the cubical 
 celled. 
 
 Grawitz (1883) admits that the adenomata with cubical cells 
 (the papillary adenomata) take origin in the renal tubules ; but 
 regards the cylindrical-celled growths (the alveolar adenomata) 
 as well as the epitheliomata with clear cells (strumse lipomatodes 
 Aberrate renis) as originating in the aberrant masses of the 
 suprarenal capsules included during fostal life beneath the fibrous 
 capsule of the kidney. He bases his conclusion on the grounds 
 stated 011 p. 551. Lubarsch in 1894 confirmed the views of 
 Grawitz, basing his opinion on (1) the morphological resem- 
 blance previously pointed out by Grawitz ; (2) the form and 
 colour of the cell nucleus of the tumour, which, with the 
 methods of Weigert and Russell, is variously coloured, as also 
 are those of the cortical substance of the adrenals, whilst the 
 cells of epithelioma of the kidney and of other forms of adenoma
 
 572 SURGERY OF THE KIDNEY AND URETER. 
 
 fail to show the same effects ; (3) the structure of the cellular 
 protoplasm, which contains the fatty globules and the glycogen ; 
 (4) the likeness of the tumours affecting the suprarenals to these 
 tumours of the kidney ; (5) the presence of giant cells in the 
 tumours like those which occur in simple hypertrophy of the 
 suprarenals ; (6) the tendency which these tumours have to 
 penetrate veins, a tendency shared by hyperplastic tumours of 
 the suprarenal capsules. Lubarsch also insists very much on 
 the presence of glycogen, which is constant in the cells of these 
 tumours, but is not found in other new growths of the kidney. 
 Albarran, on the other hand, does not regard the arguments of 
 Grawitz as decisive for the following reasons : (1) The separation 
 of the tumour by a zone of sclerosed renal parenchyma is ob- 
 served in a great majority of renal tumours, even in those which, 
 like the embryonic sarcomata, arise in the middle of the paren- 
 chyma ; (2) the presence of glycogen is of slight consequence in 
 all varieties of renal neoplasms ; (3) the presence of fatty globules 
 has little value, unless it can be shown that the epitheliomata 
 of the kidney do not possess the same character ; and he de- 
 scribes and illustrates a renal tubule, the cells of one part of 
 which have preserved their normal characters, whilst other cells 
 had undergone modifications which made them like to the cells 
 of the tumours under consideration. 
 
 These objections, however, refer to only the least important of 
 the points of similarity indicated by Grawitz. Nor is it necessary 
 to reject Grawit/'s theory with respect to the pathogenesis of 
 certain tumours, in order to accept a theory somewhat similar 
 etiologically though different morphologically, propounded by 
 Albarran with regard to other tumours. It is impossible to 
 deny that tumours of the kidney do occur which there is 
 every reason to believe arise from the aberrant suprarenal 
 nodules. At the same time we ma}' admit that the great ma- 
 jority of renal epitheliomata spring from the epithelium of the 
 renal tubes, and it can be shown that gradations of changes 
 are traceable from the normal tubes to adenoma and epithelioma. 
 Consistently with this view as to the renal epithelial origin of 
 these tumours Albarran advances the theory of aberrant renal 
 lobules embedded in the capsule of the kidney and capable of 
 degenerating into epithelioma. He has discovered, he tells us, 
 collections of embryonic tubes in the capsule of the kidney. They
 
 CARCINOMA ARISING IN TISSUE FUNCTIONALLY ISOLATED. 573 
 
 occur in the greater number of foetuses. They represent aberrant 
 formations derived from branchings of the convoluted tubules of 
 the cortex which do not come into relationship with the glomeruli. 
 He thinks that just as paradental epithelial debris in cancer of the 
 jaw and the tubular formation of the para-ovary in cancer of the 
 ovary, so these pararenal tubes play an important role in the patho- 
 genesis of cancer of the kidney. Pilliet, bearing in mind the de- 
 velopment of the kidney in two parts viz. (1) the collecting canals 
 developed from the upper end of the ureter on the one part, and 
 (2) the Malpighiaii corpuscles and uriniferous tubes on the other, 
 and that subsequently these are joined together points out that if 
 there is not an equality in number between the collecting tubes 
 and the secreting portions, one or more of these secreting seg- 
 ments not finding an excretory canal will remain functionally 
 isolated within the kidney, and will become the nucleus of an epithelial 
 evolution at a variable period in the development of the individual. 
 In reference to Albanian's and Pilliet's theories, it is of in- 
 terest to refer to the results of the experiments by R. Marie,* 
 who inserted beneath the renal capsule fragments of the cortical 
 substance of the kidney and found that in two out of twenty -five 
 cases adeno - carcinomatous tissue was produced. In the other 
 twenty-three cases he observed only phenomena of degeneracy 
 more or less rapid, but in no case did the tissue live as a simple 
 graft. These results seem to square very well w r ith the theory 
 of Albarran and with that of Pilliet, both of whom pre-suppose 
 a functional isolation of a portion of renal tissue as a requirement 
 for the formation of a tumour. The pieces of the renal cortex 
 engrafted by Marie were cylindrical in shape. The two animals 
 were killed on the twenty-first and twenty -fifth day after the 
 grafting respectively. In each case a small mass, rather larger in 
 size than the piece engrafted, of an ovoid, not cylindrical form, 
 and of a reddish-grey colour, was seen firmly fixed to the kidney 
 The microscopic examination of these small masses showed identity 
 of structure in the two cases. There were no Malpighian corpuscles, 
 there was nothing characteristic of the tubular structure of the 
 kidney in these living and growing masses of engrafted renal 
 tissue. They were not, indeed, grafts in the proper sense of the 
 word. The only interpretation which their appearances and struc- 
 ture permitted was that they had become adeno-epitheliomatous 
 * Soc. Anat, Fevrier, 1899, p. 113.
 
 574 SURGERY OF THE KIDNEY AND URETER. 
 
 evolutions developed at the expense of fragments of kidney 
 tissue implanted beneath the renal capsule. 
 
 The small masses were very similar to the tubular type of 
 adenoma, with small cylindrical or cubical cells. The points of 
 resemblance were their being encapsuled and divided into lobules, 
 and the presence in each lobule of epithelial tubes with dark grey 
 cells of the cylindro-cubical form. 
 
 This identity of structure, Marie considers, implies that the 
 process which regulates the spontaneous development of these 
 tumours is analogous with that which led to the formation of 
 the little tumours resulting from his experiments. 
 
 If now the various theories which have been propounded to 
 explain the genesis of adenomatous tumours of the kidney are 
 examined by the light of these two experiments, the parasitic 
 theory must be quite rejected, because of the strictly aseptic 
 conditions under which these experimental tumours were pro- 
 duced. The suprarenal capsular theory of Grawitz is clearly 
 not of universal application ; whilst Sabourin's theory respecting 
 the formation of adenomata in the course of chronic nephritis 
 requires modification. This last-named theory makes the ade- 
 nomata an accidental production of renal cirrhosis, and explains 
 them as being developed either at the expense of the convoluted 
 tubes from the granulations formed in Bright's disease, or from 
 tubes contained in the sclerosed areas. 
 
 The two conditions shown by the experiments to be necessary 
 are (1) the isolation of a certain number of epithelial elements, 
 and (2) a special vitality of these elements which permits them to 
 resist momentarily the suppression of blood supply and to grow 
 feebly afterwards. 
 
 In chronic nephritis certain affected areas become absorbed and 
 are replaced by cicatrices ; these cicatrices separate segments of one 
 or many uriniferous systems, isolating them functionally, as was 
 done by Marie's experiments. These isolated portions, he thinks, 
 undergo modifications analogous to those which occurred in the 
 implanted pieces of renal tissue, and more easily so, seeing that 
 the segment in process of being separated from its functional con- 
 nections by the inflammatory process preserves a certain number 
 of vascular connections, which assure its nutrition, whilst the 
 implanted segments, of course, do not. The conclusions to be 
 drawn from these experimental facts are applicable, Marie thinks,
 
 STRIPED AND UXSTRIPED MUSCLE IN RENAL SARCOMATA. 575 
 
 not only to adenomata of the kidney, but also to epitheliomata of the 
 kidney and to cancer in general. The facts themselves not only 
 tend to make us reject the parasitic origin of tumours, but to 
 regard these tumours as an individualisation of certain fragments 
 of tissues or organs, and as a deviation more or less accentuated 
 from their original type of structure. 
 
 Sarcoma is developed in adults in connection with the 
 renal capsule and from the interstitial connective tissue of the 
 kidney. As unstriped muscle fibres are contained hi the renal 
 capsule, and renal pelvis and calyces which are continuous with 
 the capsule, and are met with in the connective tissue of the 
 parenchyma (Jardet and Albarran), it is easy to understand that 
 similar muscular fibres are found in some of the renal sarcomata. 
 But primary tumours of the kidney are also met with which 
 contain striated muscular fibres or cartilage cells, structures which 
 do not normally exist in the kidney, and their presence is only 
 to be explained by supposing these elements to proceed from the 
 embryonic inclusion of neighbouring tissues beneath the capsule 
 of the kidney. It is possible that aberrant renal nodules play 
 an active role in the development of the adeno-sarcomata 
 (Albarran). 
 
 Sarcoma begins sometimes outsid* the renal capsule in the 
 perinephric tissue, sometimes (and commonly in children) in the 
 cellular tissue of the hilum, and after increasing to a variable 
 size, spreads into and distends or otherwise involves the substance 
 of the kidney. A large sarcoma invading the renal pelvis is 
 seen in Fig. 90. In Fig. 78 (p. 548), a round and oval-celled 
 sarcoma invaded or commenced in the wall of a large renal 
 cyst, without affecting the renal parenchyma at all. 
 
 Symptoms. It is important, from the point of view of treat- 
 ment, that a malignant tumour of the kidney should be recognised 
 as soon as possible. It should be borne in mind that nephrectomy 
 for cancer or sarcoma of the kidney is the more hopeful and 
 efficacious the sooner it is performed after the first onset of the 
 disease. Thus it is essential, in the interest of the patient, for 
 us to know what are the first symptoms by which these tumours 
 make themselves manifest. 
 
 There are three leading symptoms which require examination, 
 namely, haemorrhage, tumour, and pain : besides these there are 
 two others of some importance when they exist, though they are
 
 576 
 
 SURGERY OF THE KIDNEY AND URETER. 
 
 not always or even generally present namely, modifications in 
 the characters of the urine, and varicocele. 
 
 Hccmaturia. Haematuria is not seldom noticed before the 
 detection of a tumour ; in some cases it is slight or altogether 
 absent ; in others it is severe. Long, recently formed blood-clots 
 may be passed per urethram, as in the remarkable case mentioned 
 on p. 9, Vol. II. Sometimes clots of blood partially block the 
 ureter for a time, and then, after all the colouring matter has 
 
 been washed out of them, are 
 passed per urethram as colour- 
 less fibriiious shreds or columns. 
 Haematuria occurs as the first 
 symptom in at least 50 per cent, 
 of all cases of malignant tumour 
 in the adult ; but tumours which 
 commence in the hilum or just 
 beneath the renal capsule, or 
 deeper in the cortical or even 
 in the pyramidal parts of the 
 kidney, without early affecting 
 the papillae, calyces or renal 
 pelvis, may cause a tumour be- 
 fore producing haematuria. 
 
 Denaclara,"* in a collection of 
 409 instances of new growth of 
 the kidney, of which 108 were 
 patients of adult age, found that 
 
 haematuria was the first symptom in G8'8S per cent, of the adult 
 cases. The haematuria occurs spontaneously, without obvious cause, 
 often without pain, and in a way unexpected. Suddenly the 
 patient finds that he is passing blood with his urine without any 
 premonitory or accompanying symptoms. It is often abundant ; 
 it is sometimes recurrent at longer or shorter intervals 
 intervals of days, weeks, months, or even years leaving the 
 patient quite free from bleeding in thy intervals. in some cases it 
 is uninterrupted, lasting days or weeks persistently, causing 
 extreme anaemia by its continuance ; in other cases it is both 
 abundant and persistent, threatening the life of the patient and 
 demanding urgent surgical interference. 
 
 * These dc Lyon, 1899 : " Des Hematuries dans los Xeoplasmes du Rein." 
 
 Fi 
 
 90. Sarcoma invading Renal Pelvis. 
 (Guy's Hospital, No. 1663.)
 
 ILEMATURIA CAUSED BY CONGESTION AND ULCERATION. 577 
 
 Haematuria, according to Guillet, (1) is often spontaneous ; (2) 
 is not influenced by repose or exertion ; (3) occurs at any period 
 of the disease ; (4) is repeated at variable intervals ; (5) is usually 
 profuse ; (6) lasts from one to six days and may subside completely, 
 to recur in a few hours ; (7) is often preceded by pain. The 
 blood is intimately mixed with urine, but may be accompanied by 
 clots. 
 
 The question occurs, to what cause is haematuria in tumour of 
 the kidney directly due ? It is no doubt owing to congestion, caused 
 by the pressure of the tumour on the parenchyma in the early 
 stages, and to congestion or to ulceration into the renal calyces 
 or renal tubules in the later stages. Malignant tumours are 
 very vascular and of soft consistence, so that they readily give 
 way, as shown by the frequency of interstitial haemorrhages 
 into them. 
 
 Denaclara's figures show that in adults haematuria occurs 
 most frequentlv between the ages of fortv and seventv. Xo 
 
 / / / 
 
 instance of new growth of the kidney was met with between 
 ten and eighteen years. 
 
 Haematuria preceded the appearance of tumour in forty-six 
 cases, and there were six in which it was apparently induced 
 by violence. In one case the interval between the occurrence 
 of haematuria and the recognition of the tumour was so long as 
 fifteen years, and in another seven. . 
 
 Thirty-one instances of haematuria were associated with malig- 
 nant growths. In six cases the haematuria and tumour were 
 noted simultaneously. 
 
 Haematuria was the only indication of disease in twenty-three 
 cases, of which nine were benign growths. Lumbar pain without 
 distinctive character accompanied the blood in fifteen of the 
 patients. In six others the pain resembled renal colic, and in 
 five it was preceded by retention of urine. The growth was 
 not recognisable during life in six of the cases. In forty-one 
 cases, hsematuria was the only symptom of the neoplasm, having 
 been in one instance associated with pains which were not dis- 
 tinctive, and in one with pseudo-colic. 
 
 Of the entire series in which haematuria occurred, namely, in 
 
 109 out of 168 cases of new growths of the kidney, movement 
 
 and repose had 110 influence in determining the occurrence 
 
 except in two. In all the others, haematuria was spontaneous 
 
 VOL. i. 2 L
 
 578 SURGERY OF THE KIDNEY AND URETER. 
 
 both in its commencement and cessation, whatever the mode 
 of life of the patient. It was only continuous in seven cases : 
 intermittent for the most part, with short intervals in five in- 
 stances, and very long ones in three others. Ten patients suffer- 
 ing from regular attacks at the commencement noticed the intervals 
 becoming shorter and shorter as the growth developed. Nine 
 others, on the contrary, who commenced with frequent attacks, 
 observed a gradual diminution till they ceased altogether. 
 
 The quantity of blood lost was considerable throughout the 
 disease in twenty-three patients. In three, though copious at 
 first, the haemorrhages amounted to little in subsequent attacks, 
 in seven others it was in small amount throughout, and in 
 one it was only recognisable by the microscope. 
 
 In all the observations the blood was uniformly mixed with 
 the urine, except in one case in which it occurred only at the 
 commencement of micturition. The presence in the urine of 
 moulded or worm-like clots was noticed eight times. 
 
 In children forty-six malignant and thirty-three benign tumours 
 were not associated with haematuria; nineteen malignant and ten 
 benign tumours were so associated. In the other collected cases 
 the nature of the neoplasms was not indicated. Thus there was 
 haemorrhage in a percentage of 41' 3 of the malignant tumours, 
 and in 3O3 per cent, of the benign tumours. 
 
 In some instances the absence of haemorrhage would seem 
 to be rather apparent than real, as for example in a case of 
 rapidly growing cancer reported by Brault,* in which the absence 
 of haematuria was accounted for by contraction of the kidney 
 011 itself through cancerous adhesions to the vertebral column 
 the renal pelvis being rendered impermeable. 
 
 In adults, ninety malignant and forty-three benign tumours 
 presented 110 haematuria, whilst haematuria occurred in sixty- 
 eight malignant (75'5 per cent.) and twenty-four benign (55'8 
 per cent.) tumours. 
 
 Tumour. In twenty-three per cent, of cases in the adult, 
 a tumour was the first discoverable symptom. In the adult 
 the tumour caused by malignant disease is neither so early nor 
 so frequent, nor so easily made out, as in children. It has in 
 adults to be carefully sought for ; the patient is usually in ig- 
 norance of its existence, and complains commonly only of a certain 
 * La Semaine Mi'd., ii., 1891, p. 249.
 
 RENAL TUMOURS PAINLESS UNLESS VERY LARGE. 579 
 
 degree of weight or dragging in the lumbar region. In many 
 instances the tumour has been merely a nodule of new growth 
 in the kidney substance, not exceeding in size a walnut or a large 
 cob nut ; palpation therefore ought to be practised with the most 
 minute care and thoroughness. It is only after a long experience 
 in palpation of the kidneys that one is able to detect tumours 
 of small or medium size within the renal capsule. It is too 
 frequently, the case, therefore, that malignant renal tumours are 
 only discovered when they have attained a size large enough 
 to form evident tumours, and when it is too late to perform 
 nephrectomy ; or if not entirely too late, still at a stage when 
 the operation becomes much more hazardous and the ultimate 
 result much more unpromising. 
 
 The character of the tumour formed by enlargement of the 
 kidney has been described in Chapter XVIII,. p. 531. 
 
 The presence of a tumour in the loin is, at some time in the 
 development of the case, almost a constant feature ; although, 
 as already stated, it is not always the first indication, and is not 
 nearly so common in adults as in children. It is soonest apparent 
 when the enlargement is general or at the lower pole, or when 
 the kidney through undue mobility can be brought readily within 
 reach of palpation below the costal margin. On the other hand, 
 when the upper extremity is affected or the kidney fixed high 
 up, the swelling may only be appreciated after it has attained 
 considerable size. No protrusion in the loin or noticeable asym- 
 metry is to be expected with a growth of small or even moderate 
 dimensions. Sometimes there is a degree of dilatation of the veins in 
 immediate neighbourhood, indicating embarrassment of the deeper 
 circulation. The tumour is only appreciable by careful palpation 
 and is to be detected by bimanual examination or ballottement, 
 that is by being pressed backwards and forwards between the 
 hands placed below the costal margins. With ordinary mobility 
 it can be felt to descend in inspiration on palpating in the manner 
 previously described (see pp. 84, 85). The mass occupies the flank 
 between the costal margin and the anterior superior spine of the 
 ilium, and when fairly defined the colon can be felt between it and 
 the abdominal wall ; allowance however must be made for variations 
 between contraction to a thick cord and great distension with 
 faecal matter or gas. The tumour is, as a rule, painless until by 
 its increased dimensions it exercises severe pressure on surrounding
 
 580 SURGERY OF THE KIDNEY AND URETER. 
 
 structures ; then it may become severe, paroxysmal, and radiating. 
 It is not usually very tender, as is the case with inflammatory 
 swellings, and unlike them is smooth, well defined, and sometimes 
 pulsating. Percussion anteriorly yields a resonant note and pos- 
 teriorly a dull one extending to the vertebral column. The facility 
 with which the tumour may be detected varies considerably with 
 the thickness and tension of the abdominal wall, and in difficult 
 cases is much increased by anaesthesia. The growth is. as a rule 
 rapid, but cases occasionally occur where symptoms have been 
 apparent for some years.* 
 
 (Edema, constipation, vomiting, and jaundice (when the right 
 kidney is affected) may be present ; the last named being due 
 to obsruction of the common bile-duct, f 
 
 Guillet has divided the growth of the tumour into three stages : 
 (1) when it is but little developed and passes undetected, unless 
 very carefully searched for by bimanual palpation. Guy on points 
 out that by means of renal ballottement the diagnosis of renal 
 tumour can sometimes be made before the appearance of any 
 other symptom. (2) When the tumour, having acquired a moderate 
 size, makes an appreciable prominence at the level of one of the 
 antero-lateral regions of the abdomen. It is then discoverable on 
 deep palpation as well as by renal ballottement. There is generally 
 resonance in front, unless the colon is empty, and then the col- 
 lapsed bowel can be rolled under the fingers upon its surface. 
 (3) When the tumour occupies a large part of the abdomen ; when 
 it loses some of its peculiar characters, when ballottement is no 
 longer possible, and palpation and percussion no longer give clear 
 indications as to its connections. 
 
 Pain. Pain is often absent in children ; it was found to be the 
 first symptom in 35 per cent, of adult cases in which the clinical 
 details are sufficiently fully and clearly given. Slight at first, 
 it has the following characters as soon as it definitely attacks 
 the patient. It is situated in the lumbar region and thence 
 radiates to the thorax, where it takes the form of intercostal 
 neuralgia, or towards the thighs, genitals, and abdomen. The 
 pain is spontaneous, uninfluenced by rest or movement, occurring 
 by night as much as by day. It is not generally severe and is 
 often intermittent ; still, in some exceptional cases it has been 
 
 * Bull, de la Soc. Anat., 1889 ; Rev. de M<'d., 1893, p. 727. 
 t G. Aberden, Brit. Med. Journ., May 13th 1876.
 
 PAIN CAUSED BY VASCULAR CONGESTION. 581 
 
 agonising and continuous. In Brault's* case of this painful form 
 of cancer of the kidney, death was induced by the exhaustion 
 caused by the sufferings. 
 
 We have no information as to the relation between the first date 
 of occurrence, or the degree of intensity of pain, and the degree 
 of development of the tumour. The pain is no doubt sometimes 
 due to pressure of the growth or of the secondary glandular 
 enlargements upon the nerve filaments in its neighbourhood ; 
 in other cases it is caused by the vascular congestion of the 
 organ compressed within its capsule; in others by occlusion of 
 the ureter by blood-clot or a fragment of the tumour ; f in others, 
 again, the pains are of the form of nephritic colic due to the 
 transit of a mass of clot along the ureter. In all cases where 
 the cellulo-adipose region around the kidney has been infiltrated, 
 pain occurs from involvement of nerves or extension of growth 
 to the spinal nerve roots ; but in the earlier stages of the dis- 
 ease there may not be sufficient disturbance of sensation to 
 indicate the side affected. The occurrence of pain together with 
 increase in the size of the tumour alternating with hsematuria 
 is of importance from a diagnostic point, indicating as it does 
 a condition of intermitent uro-hsemato-nephrosis. When the pains 
 are caused by the pressure of the tumour or of lymphatic glands 
 secondarily invaded they must be looked upon as a late sign. 
 There is, however, nothing special about the character of the 
 pain of malignant tumour, neither is it constant or characteristic. 
 
 Modifications in the quantity and characters of the urine. 
 As a rule the urine offers no indication of the nature or even of 
 the presence of a tumour, nor is the quantity of urine altered. 
 In other cases, however, at the commencement of a malignant 
 growth of the kidney, the quantity of the urine is sometimes 
 increased (polyuria), sometimes diminished (oliguria), or even 
 temporary stoppage of secretion may occur. The amount of 
 urea is sometimes markedly diminished, and this has in some 
 cases been in itself sufficient to draw attention to the early 
 existence of cancer of the kidney (Kovsing). In many cases, 
 however, the amount of urea is quite uninterfered with. By 
 microscopical examination blood corpuscles (microscopic hsema- 
 turia) have been sometimes discovered long before there has been 
 
 * La Semaine M?d., ii., 1891, p. 249. 
 
 t See case reported by Dr. Leared, Path. Soc. Trans., vol. xxi., p. 252.
 
 5cS2 SURGERY OF THE KIDNEY AND URETER. 
 
 naked - eye evidence of blood. Cancerous particles have been 
 in rare instances discovered, as in the cases of Bonet, Segerus, 
 and G. Little reported in the Dublin Journal of Medical Science 
 for January, 1873. In other cases pieces of villous growth or 
 sarcomatous tissue or calcareous masses have been found. The 
 colour of the urine is normal or not, according to the presence 
 or the amount of blood in it. Pus will rarely be found, it only 
 occurs if there is pyelitis or pyelo-nephritis. The chlorides and 
 acid phosphates are sometimes diminished. The presence of 
 albumen is not constant ; its occurrence and amount are in 
 relation to the presence of blood or pus or of a certain degree of 
 congestion of the affected kidney ; or to an alteration in the 
 epithelium of the opposite kidney. 
 
 Cancer of the kidney, like cancer of the bladder, may cause 
 frequent micturition. Sometimes, when the kidney alone is involved, 
 the irritability of the bladder is so great that the nephritic 
 mischief is overlooked, and primary cancer of the bladder, or 
 vesical calculus is supposed to exist, as in a case recorded by 
 Milner Moore in the Lancet (vol. i., p. 770, 1879). 
 
 Varicocele. When, in 1884, I wrote my former work on 
 the " Surgery of the Kidney " I drew special attention (p. 488) 
 to a varicocele which had appeared and gradually increased with 
 the growth of a left suprarenal malignant tumour. I have 
 since seen varicocele in association with an epithelial cancer of 
 the right kidney, which completely disappeared on the second 
 day after nephrectomy. I did not know till long afterwards 
 that M. Guyon had, in 1881, described this as an occasional 
 symptom of malignant renal tumours. Guyon taught that the 
 existence of a varicocele of relatively recent date ought always 
 to lead us to examine the renal region of the same side, and 
 he tells of a case in which a young musician was about to undergo 
 at the hands of a distinguished surgeon an operation for painful 
 varicocele before the examination of the corresponding flank 
 (left) led Guyon to the discovery of a left renal tumour. Guyon 
 is of opinion that varicocele is a very common consequence of 
 renal malignant tumour, but that it escapes notice owing to 
 patients being for the most part examined when lying down. 
 My own experience, however, leads me to regard varicocele as 
 quite an exceptional though, when it exists, an important symptom. 
 The characters of this varicocele are the following : it may
 
 CHARACTERS OF VARICOCELE FROM RENAL TUMOURS. 583 
 
 be situated on either the right or left side, depending on the 
 side of the renal tumour, its appearance is comparatively sudden, 
 it occurs in persons beyond the ordinary age for varicocele, its 
 progress is rapid and marches with the growth of the renal 
 tumour, and finally it rapidly subsides after removal of the 
 tumour by nephrectomy. It may occur as an early symptom 
 before the tumour has attained a large size. 
 
 An important question regarding this varicocele from the point 
 of view of its being a guide to the surgical treatment is as 
 to the cause of its occurrence with malignant tumour. Is it 
 due to compression of the spermatic veins by the renal tumour 
 itself or by enlarged secondarily affected lymphatic glands ? 
 M. Legueu, who in 1895 wrote a paper on the subject,* 
 considers it due to pressure by enlarged lymphatic glands 
 on the spermatic vein at its entrance into the renal vein 
 on the left side and into the vena cava on the right. If this 
 be so varicocele would centra-indicate nephrectomy, because it 
 would indicate enlarged secondarily invaded lymphatic glands. 
 But it can be shown (1) that varicocele occurs in cases in which 
 the glands are not enlarged (Boinnet, Le Dentu, Israel) ; (2) that 
 varicocele does not occur in all cases in which the glands at the 
 hilum of the kidney are much enlarged ; and (3) that even where 
 varicocele has been present with enlarged glands the glands have 
 not pressed upon the orifice of the spermatic vein but the renal 
 vein has been blocked by blood-clot. Morestin (quoted by Heresco) 
 had a case in which a varicocele was caused by a large tumour 
 of the light suprarenal capsule without any glandular enlarge- 
 ment, and which had disappeared six weeks after the removal 
 of the tumour. This case is a striking proof of the independence 
 of varicocele and glandular infiltration. From our present know- 
 ledge it is impossible to agree with Legueu that symptomatic 
 varicocele is caused in all cases by pressure of the spermatic 
 vein by the enlarged lymphatic glands. It is sometimes due 
 to that cause no doubt, sometimes to pressure on the spermatic 
 vein by the tumour itself, and sometimes on the left side not 
 to either of these causes but to blockage of the renal vein by 
 blood-clot or extension of sarcomatous tissue along the renal 
 vein. It cannot therefore be regarded as a contra-indication of 
 
 "Le Varicocele Symptomatiqiie des Tiuneurs Malignes du Rein," 
 Presse Medicate, Aoilt, 1895, p. 321.
 
 584 SURGERY OF THE KIDNEY AND URETER. 
 
 nephrectomy. In this form of varicocele the veins do not present 
 any marked thickening of their walls. 
 
 The general symptoms of malignant tumour of the kidnev 
 wasting, anaemia and cachexia accompany the development of 
 cancer in the kidney, as elsewhere. But these new growths, whether 
 sarcomatous or epitheliomatous, may exist a long while without 
 giving rise to symptoms dependent on impairment of the general 
 health. Such tumours are known to have existed two, three, or 
 more years without the bearers of them showing any sign of the 
 hopeless disease by which they were being gradually borne to 
 their graves. The digestive functions, the appetite, and the regular 
 action of the bowels may all remain good. But when the general 
 health becomes affected complete loss of appetite, great weakness, 
 and* rapid emaciation soon bring about the condition often spoken 
 of as the cachexia of cancer. 
 
 In rare cases emaciation has been the earliest symptom to 
 lead to the discovery of malignant renal tumour (Guillet) ; and 
 when this condition is present, and is otherwise unexplained, 
 the kidney as well as other organs should always be examined. 
 
 There are a few cases in which the first sign of malignant 
 disease of the kidney is the so-called cachexia. They have been 
 described as latent cancer. Secondary growths in distant parts 
 have occasionally been the first indication. Thus Curtis related a 
 case in which metas,tases in the bones occurred before any other 
 symptom. Hawthorne, Villaret, Stroup, and Tuffier record 
 somewhat analogous cases. 
 
 Israel has recorded a case in which hectic fever of several 
 months' duration, vomiting and nausea, and emaciation were 
 associated with a large renal tumour. All symptoms for a time 
 ceased after nephrectomy ; but recurrence soon took place, and 
 was attended by the same symptoms fever, nausea, vomiting 
 which clearly showed the dependence of these symptoms on the 
 malignant affection of the kidney. This is spoken of as a toxic 
 form of renal sarcoma. 
 
 Sarcoma and carcinoma have many clinical symptoms in 
 common, but some differences. In sarcoma hsematuria is not so 
 common as in carcinoma, but is more profuse. Metastasis, like- 
 wise, is rare. Cachexia does not develop early, partly, no doubt, 
 owing to the absence of these two factors, and the general progress 
 of the disease is slow, extending over five or six years. Tumour
 
 LONG DURATION OF CARCINOMA AND SARCOMA. 
 
 585 
 
 and pain are prominent symptoms of sarcoma in adults. > As is 
 common in carcinoma, pain and haemorrhage occur spontane- 
 ously ; tenderness is not a common feature in connection with 
 the tumour, but may occur from time to time without evident 
 cause. In sarcoma pressure symptoms develop early, and owing 
 to the great bulk attained by the tumour, are ultimately more 
 marked than in carcinoma. 
 
 The urinary changes, if any exist, are much the same in both. 
 The duration of cancer hi the adult, though shorter than that of 
 sarcoma, is long compared with the course of the same disease in 
 other viscera, averaging two and a half years, and sometimes ex- 
 tending to six years. 
 
 When only a single kidney exists the course of the disease 
 is necessarily shortened, as in cases reported by Wood in the New 
 York' Medical Record (1886), and by Manby in the Lancet (1885). 
 
 The following comparative table is given by Guillet: 
 
 CARCINOMA. 
 
 Hcematuria 
 
 Pain . 
 Cachexia 
 
 Duration 
 
 40 to 60 years 
 
 Profuse in two- 
 thirds of the 
 cases 
 
 Usually great pain 
 
 Present early 
 
 3 to 3|- years 
 Generalisation Usually occurs 
 
 SARCOMA. 
 
 Adult. Infant. 
 
 20 to 40 years 5 years. 
 
 In a small fraction In two-thirds of 
 of cases, profuse the cases but 
 
 slight. 
 
 Usually great pain Often absent. 
 Absent for a long Early. 
 
 time 
 5 to 6 years or less Less than one 
 
 year. 
 
 Occurs only in a few Occurs only in 
 cases a few cases. 
 
 Diagnosis. The diagnosis has to be made, first, as to the seat 
 of the tumour ; secondly, as to its precise nature. 
 
 Diagnosis as to the situation of the new growth. 
 The exact locality of the tumour when first seen, its direction 
 of increase, and the line of surrounding dulness or resonance on 
 percussion, will help to fix the renal origin of the swelling, as 
 distinct from an origin in the liver, spleen, or ovary. But errors 
 in this respect are sometimes unavoidable, and I have found, 
 on post-mortem examination, a large cancer in the kidney of a 
 man who had been supposed to be the subject of malignant 
 disease of the liver. Similar errors as to the spleen, when the 
 left kidney has been the seat of a cancer, are on record. Other 
 renal enlargements as well as malignant renal neoplasms give
 
 586 SURGERY OF THE KIDNEY AND URETER. 
 
 rise to the same mistake. Thus I have twice operated upon 
 large calculous pyo-nephrotic kidneys, which had been diagnosed 
 by physicians and treated for months, one as cancer of the 
 liver, the other as a "cancerous tumour either of the spleen or 
 kidney." The rapidity of growth of the tumour, its unequal 
 resistance and nodular outline, and the progressively cachectic 
 aspect of the patient point to cancer ; and when a swelling 
 which begins on one side of the abdomen and in the renal region 
 of a patient either below the age of five or over that of forty 
 years attains rapidly a very large size, its malignant nature may 
 be diagnosed with fair certainty. 
 
 Whether in children or adults, it is no uncommon thing for 
 these tumours to reach a weight of eight or nine pounds ; some- 
 times they attain to thirty or forty pounds. 
 
 From enlarged mesenteric glands renal cancer is distinguished by 
 its one-sided position and less nodular outline; from cancer of the 
 colon or small intestine by the absence of characteristic intestinal 
 symptoms. The reader is referred to p. 538 et seq. for the points of 
 difference between renal tumours and other abdominal enlargements, 
 and for the account of the diagnosis of renal tumours in general. 
 
 We have now to indicate how renal malignant tumours are to 
 be diagnosed from other forms of renal swellings, and how 
 malignant disease of the kidney is to be diagnosed when there 
 is no tumour. It has been stated above that haematuria, tumour, 
 and pain are the three chief symptoms of renal malignant new 
 growth or renal " cancer," if we use the term " cancer " clinically 
 to include all forms of malignant disease of the kidnej r . We 
 now want to ascertain whether one or other of these cardinal 
 symptoms, when present alone or together, is due to "cancer" 
 or to some other renal disease. When haematuria and tumour 
 co-exist the presumption is that the tumour is renal. It may not 
 be so, however, because the two symptoms may co-exist and not 
 be due to a common cause ; and even when the tumour by its 
 own characters points to kidney, we have yet to make sure that 
 it and the haematuria are caused by renal cancer, and not by 
 some other renal affection. 
 
 At its onset "cancer" of the kidney presents symptoms 
 common to it and to other renal affections, such as renal tuber- 
 culosis, renal calculus, pyo-nephrosis, hydro-nephrosis, and to 
 what is called " essential " hoematuria.
 
 BLOOD UNIFORMLY MIXED IN RENAL H^EMATURIA. 587 
 
 It is very difficult indeed to diagnose from early "cancer" 
 these several affections when they themselves are at a stage 
 insufficiently advanced for a clear diagnosis to be made of them. 
 
 When haematuria such as we have described above and an 
 easily ascertainable renal tumour exist together the diagnosis 
 of " cancer " of the kidney is highly probable, and is made more 
 so if, the haematuria being intermittent, clear normal urine or 
 urine with a diminished amount of urea is passed in the inter- 
 vals. With a renal tumour without change in the urine, or 
 with a lessening amount of urea as the only deviation from the 
 normal, cancer is the probable diagnosis in the adult between 
 forty and seventy, or in the child below ten. 
 
 When there is hcematuria without tumour. The difficulties 
 in diagnosis, however, become very great w r hen haematuria occurs 
 with pain, but without tumour ; and they are still further in- 
 creased when haematuria occurs alone, without either tumour, pain, 
 or recent varicocele. 
 
 In this last condition (haematuria as an only symptom) we 
 have first to localise the source of the haemorrhage : (1) that 
 it is renal ; (2) that it comes from one kidney, and not from 
 the other ; and (3) to pass in review all the various causes of 
 renal haemorrhage, and take into consideration the characters 
 of the haematuria, and any other symptom which the patient 
 presents, before deciding that the renal affection is " cancer," and 
 not some other form of renal disease. 
 
 1. The diagnosis as to the renal source of the haematuria 
 is based upon the following features : (a) the blood is 
 thoroughly mixed with the urine throughout, not terminal or 
 chiefly at the end of the act, so that the first urine passed 
 is as equally loaded with blood as the last few drops. This 
 sign is not, however, absolutely pathognomonic or quite in- 
 variable, because in very exceptional cases when the blood 
 comes from the bladder it is uniformly mixed with the urine ; 
 and conversely in renal haematuria the deepest coloured urine, 
 or even pure blood, may come at the end of the act of mictu- 
 rition, if the kidney bleeds so profusely that the blood flows 
 freely from it whilst micturition is proceeding. But these are 
 exceptions, not only as to the cases in which they occur, but 
 as to the particular acts of micturition in the same individual. 
 (6) A second character of renal haematuria is the passage of worm-
 
 588 SURGERY OF THE KIDNEY AND URETER. 
 
 like blood-clots, partially decolorised, which the patients some- 
 times bring to the surgeon thinking they are really lumbrical 
 worms ; in other cases, as Hilton years ago was in the habit of 
 showing to his pupils, the blood -clots instead of taking the 
 mould of the ureter, take that of one or other of the calyces. 
 In most cases in which renal or ureteral blood-clots are voided 
 heir transit along the ureter excites pain or actual colic, and this 
 gives the indication as to the particular organ which bleeds. 
 
 2. The diagnosis of the side from which the renal haemorrhage 
 proceeds is generally determined by clinical signs of some kind, 
 but if not it may in some cases be ascertained by the cystoscope. 
 Constant or profuse haemorrhage, or an irritable state of the 
 bladder, or an enlarged prostate may, however, render cystoscopic 
 inspection of the ureteral orifices unsatisfactory or impossible. 
 
 3. The diagnosis of the nature of the renal disease which is 
 causing the haematuria is often very difficult. Is it cancer, 
 is it calculus, or is it tubercle ? Or is it due to still some other 
 cause than these ? The characters of the haematuria in malig- 
 nant renal disease are described on p. 576. 
 
 The haematuria of renal calculus is provoked by exercise 
 or movement, and is diminished or ceases with rest. It is not 
 usually of long duration, and ceases within a few hours under 
 the influence of rest ; but it is sometimes abundant, and may 
 continue in spite of absolute quietude. If it ceases with rest, it 
 may recur after the least movement. I have known a walk of a 
 few steps from the bed to the sofa, after complete confinement to 
 bed for two weeks, bring it on again. 
 
 The haematuria caused by a stone passing along the ureter 
 generally follows nephritic colic. In rare cases it precedes the colic- 
 
 With renal calculus, equally with renal cancer, we find 
 hsematuria with or without tumour, with or without pain ; but 
 it is the common thing to have pain as well as haematuria, 
 though tumour is a comparatively rare occurrence in renal cal- 
 culous affections, unless hydro-nephrosis, pyelitis, or pyo-nephrosis 
 also exists. In renal calculus the kidney is often tender, and 
 there is frequently history of lithiasis and haematuria of years ago- 
 There are many cases on record to show that long-standing 
 renal calculus is a precursor of carcinoma, but with the super- 
 addition of carcinoma the characters of the hsematuria change. 
 
 The features of the haematuria of tuberculous kidney, as
 
 RENAL CANCER SIMULATING RENAL TUBERCULOSIS. 589 
 
 a rule, are the following. It is spontaneous, small in amount, 
 intermittent, uninfluenced by movement or rest, and repeated at 
 short intervals. In rarer cases renal tuberculosis, especially the 
 miliary form, has excited a hsematuria, sudden in its onset, pro- 
 fuse in quantity, and persistent for weeks together. Even with these 
 characters it is impossible to be sure that the haematuria is 
 due to tubercle, and not to " cancer " of the kidney, unless we 
 find the bacilli of Koch in the urine or evidence of tubercle 
 in some other organ. Even if there is a tumour, our diagnosis 
 may still remain uncertain or prove to be erroneous. Albarran 
 has recorded the case of a female patient with hsematuria which 
 had all the characters of renal new growth. A small nodule 
 the size of a nut was found in the right kidney, and this on 
 microscopic examination was ascertained to be a tuberculous 
 nodule, not a cancer. Conversely, Newman* records a case in 
 which the functional and physical signs suggested tubercle, but the 
 autopsy showed the disease to be cancer. 
 
 In a case of a very large tumour under my care the haematuria, 
 pyuria, and other physical signs, the fever and the emaciation, as 
 well also as the appearances during the operation of nephrectomy, 
 pointed to tuberculous pyo-nephrosis w r ith extensive deposits of 
 tubercle in the cortical substance of the kidney ; but the 
 microscopic examination showed the condition to be a breaking- 
 down cystic epithelioma. Recurrence took place within three 
 months, and the patient was dead within four months of the 
 operation, and nineteen months after the first discovery of a 
 tumour. In another and more recent case in my wards at the 
 Middlesex Hospital the appearances of the large kidney after 
 removal were just those of tuberculous disease; but microscopical 
 examination showed it to be cancer, and the man died with secondary, 
 growth in his brain within three months after the operation. 
 
 In renal tuberculosis there will usually be pyuria, and in 
 the intervals between the haematuria the urine is turbid ; it may 
 also contain the bacilli of tubercle. It must be remembered, 
 however, that tuberculosis limited to the cortical part of the 
 kidney may give rise to irregular, intermittent, apparently un- 
 provoked haematuria without any other change in the urine. 
 We must look, then, to the age, the family and personal history, 
 and the state of the other organs of the patient to aid us in 
 * Glasgow Med. Journ., 1896, p. 179, case 2.
 
 590 SURGERY OF THE KIDNEY AND URETER. 
 
 forming a diagnosis. If with haematuria without pyuria there 
 is a renal tumour, tubercle is improbable, and cancer most likely 
 exists. If with haematuria and pyuria there is a tumour, and 
 if there is also fever, then tuberculous pyo-nephrosis becomes more 
 probable than malignant disease ; though it might be cancel 1 , 
 as in the case just referred to proves. 
 
 Other diseased conditions besides cancer, calculus, and tubercle 
 give rise to hsematuria ; it is also met with after slight injuries, 
 thrombus or embolus in the renal vessels, and even in the absence 
 of any lesion whatever of the kidney. Haematuria in chronic 
 nephritis presents in certain cases all the characters of haematuria 
 from renal tumour. Very abundant one-sided renal haematuria 
 may continue for days or weeks in subacute and chronic nephritis, 
 whether of the form of Bright's disease or following disease of 
 some other kind, such as influenza or pneumonia. I have known 
 severe haematuria occur as an early symptom in subacute neph- 
 ritis induced by a repetition of exposure to damp and cold- 
 The source of the bleeding was at first supposed by the medical 
 attendant to be the bladder, and the cause to be vesical calculus, 
 until it was pointed out that there was more albumen than even 
 the blood explained and that the urine teemed with renal casts. 
 Partial suppression soon ensued, and the patient died within 
 three months from uraemia. It is by the presence of albumen 
 and renal casts either constantly or on some occasions only, and 
 in the intervals between the haematuria when this is intermittent, 
 that the diagnosis of chronic or subacute nephritis will be made. 
 If, however, when the urine is clear of blood it does not present 
 any other abnormality the diagnosis is most difficult. When 
 nephrotomy is had recourse to in these cases the kidney presents 
 signs which indicate the nature of the case it is puckered, scarred 
 and mottled in colour ; in detaching it for examination we find 
 it irregularly and more or less toughly adherent to the sur- 
 rounding tissue in places, and on section some parts of its paren- 
 chyma look pale yellow, whilst for the most part it is deeply 
 congested, and the knife meets with different degrees of resistance, 
 indicating that in some places it is much harder and denser than 
 elsewhere. Nephrectomy should never be resorted to in these 
 cases, as the other kidney may be or may become similarly changed, 
 and more especially as simple exploratory nephrotomy has in 
 several cases been followed bv cessation of the haematuria.
 
 CAUSE OF " ESSENTIAL H^EMATURIA NOT UNDERSTOOD. 591 
 
 There are a certain number of cases of renal haematuria with- 
 out ascertainable renal lesion, the so-called essential hcematuria, 
 which at present are unexplained ; cases in which the haemorrhage 
 is so profuse, so unprovoked, so recurrent or persistent, that no 
 amount of rest, and no remedies which have been tried have 
 influenced it ; and in which no explanation is forthcoming even 
 after a post-mortem examination. The haemorrhage in some 
 of these cases probably depends upon some functional derange- 
 ment or actual lesion of the vaso-motor nervous system, in others 
 possibly upon a morbid condition of the blood or blood vessels due 
 to some toxic cause. 
 
 I have known at least three fatal cases of the sort, two after 
 nephrotomy, and one in which no operation was performed. In the 
 first case* upon which I operated the patient was a young man 
 of twenty, who for six months had suffered from severe attacks 
 of haematuria uninfluenced by exercise or rest, but attended 
 with pain in the loins, chiefly in the right loin. The repeated 
 and considerable losses of blood had rendered him very anaemic, 
 weak and emaciated, and his condition was becoming progressively 
 worse. The right kidney was cut into and thoroughly examined, 
 with negative result ; nothing was found to explain the haematuria, 
 and no improvement in the symptoms resulted. Ten days after 
 the nephrotomy I performed nephrectomy, because of the con- 
 tinuing haematuria and the supervention of haemorrhage from the 
 kidney operated upon. Haematuria, however, continued after 
 the nephrectomy, and the patient died the next day. There 
 was nothing in the naked-eye appearances of the kidney removed, 
 or of the left kidney, or of the bladder, or any part of the 
 urinary system to explain the cause of the haemorrhage. Neither 
 a microscopic nor a bacteriological examination of the kidneys 
 was, I regret to say, made, their naked-eye appearances being 
 so normal that further examination was unfortunately omitted. 
 In the second case operated f upon for similar symptoms there 
 were no naked-eye or microscopical characters existing to account 
 for the symptoms. 
 
 The essential haematuria of hot or tropical countries is caused 
 
 by parasites, such as the bilharzia or filaria or the plasmodium 
 
 malariae ; in the colder countries neither parasites in the blood 
 
 or urinary organs nor any lesion of the kidney is discoverable. 
 
 * " Hunterian Lectures," Table IV., No. 30, and Table VIII., No. 3.
 
 592 SURGERY OF THE KIDNEY AND URETER. 
 
 Some of the German authors, following Senator and Klemperer, 
 describe cases of " essential " renal haematuria under the name 
 of " angeio-neurotic," and to this class I believe the two cases 
 I have referred to belong. Schede, Klemperer, Xitze, Debaisieux, 
 and others have reported cases of the sort for which nephrotomy 
 or nephrectomy has been performed. Nitze speaks of having 
 operated in seven cases of " essential " haematuria four by nephrec- 
 tomy and three by renal incision. In Schede's case the haematuria 
 had lasted many weeks, and the kidney after nephrectomy was 
 microscopically examined and found to be quite healthy.* 
 
 Though the clinical diagnosis of these cases is impossible, yet 
 when there is any indication as to which kidney is the source of 
 the haemorrhage we have exploratory nephrotomy to fall back upon. 
 It is satisfactory to learn that in a good many cases of undiagnos- 
 able haematuria which have been operated upon the haematuria 
 has ceased and has not recurred. The explanation of this is 
 possibly the removal of intra-capsule tension by the relief of renal 
 congestion, \vhether due to blood or nervous cause in the first place. 
 It is, however, difficult to understand why, though the bleeding 
 ceases for a time, it does not in all these cases recur after the 
 kidney is healed. In neither of the cases upon which I performed 
 nephrotomy, was the bleeding controlled by the operation. In 
 one case in which (in March, 1896) I performed simultaneously 
 nephrotomy and nephropexy for haematuria associated with hae- 
 mato-nephrosis in a movable kidney, the haematuria did not cease 
 till some weeks after the nephrotomy, and then after an interval 
 of more than a year, the kidney being well fixed, recurred to a 
 less degree, and has done so two or three times subsequently. 
 In another case in which I performed nephrotomy for haemato- 
 nephrosis and haematuria there were subsequent recurrences of 
 haematuria for a time until the kidney atrophied ; and at the 
 patient's death, fourteen months after the operation, retro-perito- 
 neal carcinoma, unconnected with tjie atrophied kidney, together 
 with secondary deposits in the liver, were found. There was no 
 tumour to be discovered, though often sought for during life. 
 
 In some of the cases of the so-called essential or angeio-neurotic 
 kind there is reason to think the haemorrhage comes from both 
 kidneys, even when there is some other local symptom such as 
 
 * See also Harris, Med. Journ. Philadelphia, March 19, 1898, on 
 cases of Essential Haematuria.
 
 NEPHRALGIC H.EMATURIA DUE TO RENAL IRRITATION. 593 
 
 pain or nephrectasis pointing to one kidney rather than to the 
 other. This clearly was so in the fatal case upon which I 
 operated, and to which I have referred above. 
 
 Nephralgic haematuria. Since the time of Sydenham much 
 has been written and many cases have been published to show 
 that renal neuralgia gives rise to haematuria in the absence of any 
 appreciable lesion of the kidney. Many cases of nephralgia are 
 attributed to malarial poisoning. Tift'any of Maryland speaks 
 of having seen a number of cases of malarial haematuria in which 
 there was apparently no history of intermittent or remittent 
 fever. He seems to have gone some way towards proving the 
 malarial origin of the haematuria and pigmented urine in some 
 of these cases by finding the plasmodium malarias in the blood. 
 Maurice Raynaud, Rolf, Legueu, Broca, Sabatier, and others 
 have attributed haematuria to nerve causes. Nephralgic haema- 
 turia has been ascribed to a profound disturbance of the vaso- 
 rhotor system of the kidney, just as symmetrical gangrene is 
 ascribed to exaggerated vaso-motor disturbance in the fingers 
 and toes and other peripheral parts in Raynaud's disease. 
 
 In many of the cases, however, some other condition, such 
 as oxaluria, lithaemia, movable kidney, and chronic nephritis, has 
 been present by which possibly both the pain and the haema- 
 turia may have been caused. In other cases there have been 
 found adhesions about the kidney and ureter, or calculous particles 
 in the renal calyces, to which rather than to an idiopathic dis- 
 turbance of the vaso-motor system of the kidney the renal 
 congestion and tension and the consequent haematuria and pain 
 were much more probably due.* 
 
 As a correct clinical diagnosis of these cases cannot be made, 
 it is consoling to know that in many of them complete relief 
 follows from lumbar nephrotomy. 
 
 Senator and Klemperer have given evidence as to the exist- 
 ence of very abundant haematuria in cases of proved haemophilia. 
 Senator relates the case of a young girl affected in this way, 
 upon whom Sonnenburg performed nephrectomy. When it occurs 
 it is usually in young men or boys. Sometimes pain is associated 
 with the haemorrhage, but often not. 
 
 Haematuria, with or without pain, but without other ascer- 
 tainable or recognisable cause, in. a member of a family of 
 
 * "Hunterian Lectures," lecture ii., p. 52. 
 VOL. I. 2 M
 
 594 SURGERY OF THE KIDNEY AND URETER. 
 
 " bleeders," should be treated as due to this constitutional ten- 
 dency, and not submitted to nephrotomy but to nephrectomy, 
 if all other remedies have failed and life is threatened, and not 
 ttefore. No operation which can possibly be avoided is per- 
 missible in the case of these persons. 
 
 Hsematuria, in some cases to a rather abundant degree, has 
 been met with in association with movable kidney. I have 
 explored the movable kidney in several instances, on account of 
 pain and hsematuria, and I have found it congested ; and after 
 the operation the symptoms have entirely ceased. In some of 
 these cases I have been uncertain as to how much of the 
 relief ought to be attributed to the fixation and how much to 
 the nephrotomy ; and whether the symptoms were not caused 
 by chronic nephritis. In some instances, where the kidney on 
 exposure and section has had the appearances of chronic 
 nephritis, I have not fixed it, though I found it very movable, 
 and yet the symptoms have ceased after the operation, which 
 looks as if the relief was the result of the nephrotomy. This 
 cannot be positively inferred, however, because after such an 
 operation, the kidney is apt to become firmly fixed, even when 
 no sutures are inserted into its substance or capsule. 
 
 When hsematuria occurs with a movable kidney, lumbar 
 exploration ought to be performed and nephrorraphy practised, 
 after full examination of the kidney and downward catheterisation 
 of the ureter have shown that no other tangible cause for the 
 haemorrhage exists. 
 
 Guyon has pointed out that hsematuria occurs in rare cases 
 during pregnancy. If not caused by direct pressure it is 
 probably due to congestion of the renal vessels, which are apt 
 to be influenced by uterine and ovarian conditions. 
 
 When there is tumour without hcematuria. Having diagnosed 
 a tumour of the abdomen to be renal, how can we decide whether 
 the tumour is due to a malignant new growth or to some other 
 form of renal enlargement ? It is likely to be malignant, if 
 the tumour occurs in a child under ten, and still more so if 
 under six or seven years of age ; or in an adult between forty 
 and seventy ; if it has grown rapidly since it was first discovered, 
 whether preserving the renal outline or not ; if it has not varied and 
 does not vary in size and painfulness, with marked variations in 
 the amount of urine passed ; if there are no crystals, calculous
 
 H.EMATURIA AND TUMOUR IN OTHER AFFECTIONS. 595 
 
 fragments, or pus or casts in the urine ; if by repeated and 
 careful microscopic examination of the urine little masses of new 
 growth are detected ; if there is a progressive diminution in the 
 amount of urea ; if there is no antecedent history of calculus ; 
 if with the growth of the tumour the patient emaciates 
 markedly and becomes sallow ; if enlarged glands, intra-abdominal, 
 pelvic, or inguinal, are discoverable : if there is a recent vari- 
 cocele on the same side as the tumour distinctly increasing with 
 the growth of the tumour ; if there are signs of venous obstruc- 
 tion in the inferior cava ; or if there is any nodule of malignant 
 new growth in any other part of the bod}'. 
 
 Too much reliance must not be attached to any one 
 individually of the indications just mentioned, but if several 
 of them co-exist in any case in which the tumour is diag- 
 nosed as renal the probability of malignant new growth is 
 considerable. 
 
 When hwmaturia and tumour co-exist. In renal calculous 
 affections, in tuberculous affections of the kidney, in cystic 
 disease, in hsemato-nephrosis, and in hydro-nephrosis from various 
 causes, haematuria and renal tumour co-exist, and will have 
 to be diagnosed from malignant renal tumour. 
 
 From calculous affections it is diagnosed by the characters 
 of the haematuria above described ; by the absence of tenderness 
 on pressure, which is so frequent in calculous affections when 
 the kidney is manipulated between the two hands; by the non- 
 occurrence of renal colic after exercise, jolting, or fatigue ; by 
 the want of an antecedent history of lithiasis or of former 
 attacks of hsematuria and pain followed by long periods of 
 quiescence years before the tumour first appeared.* 
 
 From tuberculous affections by the characters of the haema- 
 turia ; by the absence of pus and tubercle bacilli in the urine ; 
 by the absence of tuberculous lesions in other organs ; by the absence 
 of an elevated temperature at night ; and by the absence of 
 the family history of tubercle. 
 
 From poly cystic disease by the abundance of the hsematuria, 
 hsematuria being rare in cystic disease, but when it occurs it 
 resembles the haematuria of malignant tumour by its unprovoked 
 onset and its tendency to recur without assignable cause ; by 
 the absence of polyuria, or anuria, or uraemia, either or all of 
 ' " Himterian Lectures." pp. 70-74.
 
 596 SURGERY OF THE KIDNEY AND URETER. 
 
 which are met with as early symptoms in polvcystic disease, but 
 very rarely indeed occur in cases of new growths of the kidney ; 
 by the absence of that irregular botryoidal outline which is so 
 characteristic of conglomerate cysts ; and by the absence of a 
 tumour on both sides bilateral enlargement being not at all un- 
 frequent in polvcystic disease. In malignant disease the amount 
 of urea may be diminishing but without polyuria or anuria ; in 
 polvcystic disease the lessening amount of urea is associated with 
 a great increase in the amount of water, or on the contrary 
 with a suppression of the secretion in great part or entirely. 
 
 In cases of serous cysts the hsematuria is either absent 
 or slight, the tumour may fluctuate at some stage of its growth, 
 whilst at others it is very dense and hard, and more resembles 
 a rounded circumscribed solid tumour in the abdominal parietes. 
 I have known a case in which there were sudden fainting fits 
 caused by haemorrhages into the cyst cavity.* Cancer may be 
 engrafted upon such a renal cyst.j 
 
 The difficulties which surround the diagnosis of these very 
 rare cases of greatly enlarged simple cysts are considerable, and 
 it is sometimes impossible to distinguish them not only from 
 cases of nephrectasis, but from solid tumours of the kidney or 
 of some other intra-abdominal organ or tissue. 
 
 The diagnosis of hydatid cysts of the kidney, which are 
 very rare, from malignant tumour must in most cases remain 
 uncertain, unless daughter cysts or booklets are discovered in the 
 urine, or the tumour gives the characteristic hydatid fremitus, 
 or fluctuates. 
 
 Another source of error in the diagnosis of malignant tumour 
 is due to the fact that hydro-nephrosis is in some cases ac- 
 companied by haeniaturia, and may therefore be mistaken for a 
 new growth of the kidney. This is especially likely to occur if 
 the cause of the hydro-nephrosis happens to be a tumour villous 
 papilloma or carcinoma of the bladder. I have 011 several 
 occasions been consulted on account of hsematuria with or without 
 renal enlargement, which has been regarded as due to some 
 affection of the kidney, when the disease has really been a new 
 growth in the bladder around the orifice of the ureter of the sus- 
 pected side. Such growths may cause continuous or intermittent 
 
 * Path. Soc. Trans., vol. xxii., p. 171. 
 
 t Ibid., vol. xxi., p. 253 and vol. xxii., p. 171.
 
 RENAL ENLARGEMENT CAUSED BY VESICAL GROWTHS. 597 
 
 hydro-nephrosis, and spontaneous profuse irregularly intermittent 
 hgematuria having all the characters of renal tumour. 
 
 The diagnosis can be made by bimanual examination of 
 the bladder under chloroform after emptying it of its 
 contents ; then with one finger in the rectum and the fingers 
 'of the other hand depressing forcibly the abdominal wall in 
 the hypogastrium, the collapsed vesical walls can be thoroughly 
 felt and any difference in thickness or resistance appreciated. 
 The induration and unyielding feeling of an infiltrating malignant 
 growth is readily detected by the experienced fingers ; and a 
 soft villous papilloma large enough to give rise to the symptoms 
 of hydro-nephrosis can be felt within the vesical cavity like a 
 piece of saturated sponge between the fingers (see a paper with 
 recorded cases by the author in the Lancet, October 31, 1896). 
 The cystoscope may be employed whenever a new growth of 
 the kidney is suspected ; but with the bimanual method of 
 examination just described all the information requisite for a 
 correct diagnosis can be obtained in these cases without re- 
 sorting to the intra-vesical inspection. 
 
 Unless due to the cause just stated it is not common for the 
 hsematuria in hydro-nephrosis to be either abundant or bright red 
 as it is in renal tumour. 
 
 In some of the cases of renal distension from, vesical new 
 growth which have been under my charge high temperature 
 and shivering have been prominent symptoms. 
 
 Diagnosis of the variety of new growth. In the adult it 
 is generally almost impossible to diagnose with any degree of 
 certainty the nature of the tumour. Sarcoma is more frequent 
 than carcinoma in the earlier decades of manhood (twenty to 
 forty), epithelioma in the later (forty to seventy) ; sarcoma causes 
 hsematuria less frequently, secondary growths more slowly, and 
 has a duration of from five to six years, instead of from three 
 to four years as has carcinoma. 
 
 But these distinctions cannot be relied upon. It is impossible 
 clinically to diagnose adenoma from epithelioma, and even with 
 the microscope the distinction is far from easy and not always 
 possible. 
 
 It is often quite impossible to make the diagnosis of malig- 
 nant from benign renal tumours and from pararenal growths 
 except by an exploratory incision, and often a microscopic
 
 598 
 
 SURGERY OF THE KIDNEY AND URETER. 
 
 examination of the growth does not permit of a decisive 
 judgment being formed. Very variable opinions are ex- 
 pressed by equally competent microscopists about the nature of 
 the same tumour. The facts of the tumour being encapsuled 
 and that on section the microscopic characters are those of an 
 adenoma do not prove the non-malignancy of the growth or 
 give a certain guarantee against recurrence. In the case of a 
 lady whom I saw in consultation, a renal tumour removed and 
 
 Necrosis centre of the 
 growth. 
 
 Fig. 91. Carcinoma of the upper half of the kidney confined within the renal 
 capsule. There were secondary deposits in the brain, lungs, and hronchial 
 glands. Pyelitis existed. From a man aged 38. (See also Figs. 92 and 93.) 
 
 described by Mr. Stanley Boyd as an adenoma, recurred within a 
 few months, and formed a tumour much larger than the original mass.* 
 The diagnosis of adhesions and secondary deposits is of import- 
 ance from the point of view of treatment, but it is not always 
 possible to exclude these without an exploratory incision. The long 
 duration of the symptoms, the absence of mobility and ballotte- 
 ment of the tumour, the oedema of the tissues in the loin, vari- 
 cocele, oedema of the leg 011 the affected side, and the detection 
 of enlarged glands within the abdomen along the brim of the 
 * Path. Hoc. Trans., vol. xlix., ]>. 175.
 
 CANCER GRAFTED ON ANOTHER RENAL DISEASE. 
 
 599 
 
 pelvis or in the groin -will indicate extension of the disease and 
 
 make the prospects of an operation unfavourable. A careful 
 
 examination of all the other organs 
 
 of the body for signs of secondary 
 
 growths should be made. 
 
 Prognosis. When once the disease 
 
 has set in, sarcoma and carcinoma and 
 
 other malignant forms of new growths 
 
 advance steadily. The usual causes of 
 
 death are exhaustion, haemorrhage, or 
 
 uraemia ; the more rare are ulceration, 
 
 or bursting of the growth into the 
 
 peritoneum or through the diaphragm 
 
 into the lung causing pulmonary 
 
 abscess, or secondary new growths 
 
 in the brain (Figs. 91, 92, 93), vertebral 
 
 column and spinal cord, stomach or 
 
 intestine. The cases in which the 
 
 course and progress of the disease 
 
 seem to have been arrested for many 
 
 years, and then to have advanced 
 
 again, must be accepted with some 
 
 reserve. It is not improbable that 
 
 the earlier 
 symptoms in 
 these and 
 s u c h - 1 i k e 
 cases were 
 
 due to some other disease, and that the 
 malignant growth was engrafted upon it. 
 This was almost certainly the case in the 
 cancer which was associated with a large 
 renal cyst, and which I reported years 
 ago to the Pathological Society of London 
 (see the Transactions, vol. xxii., p. 172). 
 It is not necessary for the renal 
 
 tumour to have attained a large size before it causes secondary 
 
 deposits in other organs. Thus, in the case from which the speci- 
 mens illustrated in Figs. 91, 92, and 93 were taken, the renal new 
 
 growth was the size of a Tangerine orange, occupying the upper 
 
 Fig. 93. Secondary Tumour in 
 the Right Temporo-Sphen- 
 oidal Lobe. From the same 
 patient as Fig. 91. 
 
 Fig. 92. Secondary Tumour 
 of Brain. Exact size of 
 the tumour. From same 
 patient as Fig. 91.
 
 600 SURGERY OF THE KIDNEY AND URETER. 
 
 pole of the kidney and contained within the renal capsule; the 
 lower part of the kidney was natural and no tumour was detect- 
 able during life ; and cases are on record in which new growths in 
 the neck or in the limbs have been secondary to a growth in the 
 kidney which was only detected during an operation or after death. 
 
 The duration of the tumour between the discovery of the 
 first symptom and the date of death, when no operation has 
 been performed, is from three to four years for carcinoma and 
 five to six years for sarcoma. 
 
 Guillet has collected five cases which survived from four to 
 ten years, and six cases from ten to sixteen year's. 
 
 The liability to secondary deposits, although not so decided in 
 the case of the kidney as in many other organs, is still great, 
 and is of course of extreme importance when considering the 
 advisability of an operation. Likewise, it is also of the greatest 
 importance in considering the prognosis and treatment of a renal 
 tumour to make sure that a primary growth in some other 
 organ has not been overlooked. Death may supervene very 
 rapidly if the mediastinal glands become secondarily affected. 
 In a case sent to me by Dr. Casley of Ipswich, in June, 1899, 
 there was a soft friable carcinoma affecting a portion of the left 
 kidney, the rest of the organ being quite healthy. It was for- 
 tunately decided that no operation was advisable, as the patient 
 died somewhat suddenly eighteen days later from dyspnoea due 
 to the pressure of carcinomatous deposits in the mediastinal 
 glands and the glands at the roots of the bronchi. 
 
 The following statistics will show the frequency with which 
 secondary deposits occur in malignant disease of the kidney. 
 
 Roberts in fifty-one cases found secondary growths in thirty- 
 one, while in the remaining twenty the kidney alone was attacked. 
 Dickinson found secondary growths in fourteen out of fifty-nine 
 cases. Rohrer in 115 cases found secondary growths in fifty, 
 and Guillet in forty-seven out of seventy cases. The lungs appear 
 to be the most frequent seat of secondary deposits, but the liver 
 and lumbar glands are also frequently affected while the suprarenals 
 are often implicated by direct continuity. Guillet has attempted 
 to compare the relative infect ivity between renal carcinoma and 
 sarcoma : he found secondary growths in thirty-two out of thirty- 
 eight cases of carcinoma and in four out of eight cases of sarcoma 
 in adults,, while in sarcoma of children he found secondary deposits
 
 IMPROVEMENT IX THE MORTALITY OF NEPHRECTOMY. 601 
 
 in eleven out of twenty-four cases. From the consideration of 
 numerous statistics, Guillet concludes that secondary deposits occur in 
 about two-thirds of all cases of malignant disease of the kidney, 
 that they are very frequent in carcinoma, and occur in about 
 half the cases of sarcoma. 
 
 Treatment. Death is the inevitable result of every malig 
 riant tumour of the kidney if left to itself ; and so rapid is its 
 advance in children that the fatal termination usually .supervenes 
 very quickly upon the first discovery of the existence of the 
 tumour. If therefore nephrectomy can cure even a large minority 
 the operation would not only be justifiable but would be hailed 
 with satisfaction by surgeons and patients, even though death 
 in some instances is somewhat hastened by it. The chance 
 of cure by operation would be well worth the risk when the 
 alternative is certain death, especially if the chance can be shown 
 to be three or four to one in favour of the operation. This 
 point then ought to l)e first investigated. 
 
 Thanks to the better recognition of the signs of renal tumour 
 a diagnosis is nowadays made at a much earlier period than 
 formerly : at a period, that is, when the growth is yet small or 
 of but medium size. Moreover, the technique of nephrectomy 
 is better understood and better practised, so that the operation has 
 been performed under more favourable conditions than formerly, 
 with the result that not only has the whole of the disease been 
 more frequently removed but the immediate mortality of the 
 operation has been reduced between half and two-thirds. 
 
 Dickinson, writing in 1882, stated that so far as he knew 
 the kidney had been removed in eleven instances for malignant 
 tumour, with these results : six deaths, five recoveries, i.e. a mor- 
 tality of 54'f> per cent., whilst as to the permanence of the cure 
 two of the five were known to have lived and to have been 
 in good health two years and four months and two years and six 
 months respectively after the operation. Of the other three, one 
 died of recurrence alxmt nine months, one of recurrence about 
 six weeks after the operation, and of the other no later history 
 was known beyond the fact that the patient perfectly recovered 
 from the operation. A larger number of cases yielded worse 
 results. Guillet's figures of all the iiephrectomies for malignant 
 renal tumours performed up to 1888 showed a mortality of 72 
 per cent. Chevalier, in 1891, found 58 per cent, mortality, but
 
 602 SURGERY OF THE KIDNEY AND U'RETER, 
 
 his list was weighted by a good many deaths from trans-peritoneal 
 nephrectomy, whereas twenty-one of the more recent lumbar 
 nephrectomies in his collection gave a death-rate of only 25 
 per cent. Other collections of this date showed much the same 
 results : thus in Siegrist's in 1889 there were nineteen recoveries out 
 of sixty-one operations, a mortality of 68'8 per cent. ; Earth's, 
 in 1892, 42 per cent. When we come to later statistics a marked 
 improvement is seen. 
 
 Kiister, in 1896, by his collected cases showed a mortality of 
 24 per cent. ; Max Jordan, in 1895, 20 per cent. 
 
 Kovsing, who reviewed the results of operations performed 
 between 1890-95, found a mortality of between 20 and 25 per cent. 
 
 The results obtained by each individual operator are variable, 
 but show improvement in later years. Czerny, for instance, in 
 his first nine cases had a mortality of 75 per cent., \vhereas 
 his following nine cases all recovered. Tuffier's mortality up to 
 1888 was 65'2 per cent., and it has since fallen to 5 per cent. ; 
 but the number of his cases is not given. My own results 
 in nephrectomy for malignant tumour in the adult have been 
 deaths in the two first cases, namely, in 1885 and 1886, and 
 ten cases since without a death, that is, a mortality of 16 '6 per 
 cent. Kiister lost three patients out of eight, whilst Israel 
 lost three out of twenty-four, i.e. a percentage of only 12. Al- 
 barran has reported upon four cases all of which recovered from 
 the operation. 
 
 The most recent statistics of a large number of cases are 
 those given in the Thesis recently published by Heresco.* Out 
 of 165 nephrectomies for renal malignant disease collected from 
 records published between 1890-98, thirty-two of the patients 
 died within a month of the operation, which, roughly speaking, 
 gives a mortality of 19 '35 per cent. Of these 165 operations, 
 112 were performed on adults and twenty -three of the patients 
 died from the operation, which yields a death-rate of 20'5 per cent. 
 
 From the above statistics we see that the mortality has been 
 reduced from between 68 and 72 per cent., at which it stood 
 till 1889, to between 20 and 25 per cent., which has been realised 
 during the last eight years. So far as we can tell at present 
 it would seem that this death-rate is not likely to be much 
 further diminished if we take all cases and all operators into 
 * "Tumeurs Malignes chi Rein," Paris, 1899.
 
 DOES NEPHRECTOMY PROLONG LIFE ? 603 
 
 account, though the results of individual surgeons, with special 
 experience in renal work, or who are more exclusive in. their 
 selection of cases for operation, may be lower. If this be so 
 nephrectomy for malignant tumours of the kidney must be 
 credited with hastening the end of nearly a quarter of the patients 
 submitted to it. But this, as we said above, would be deemed a 
 far from unsatisfactory result in the case of an absolutely fatal 
 malady if it could be shown that the surviving three-quarters were 
 cured or obtained a considerable prolongation of life by undergoing 
 the operation. 
 
 In order to arrive at a just appreciation of the general effect 
 of nephrectomy 011 life, i.e. at the precise value of it as a means 
 of prolonging life, we want to know, in addition to the risks 
 of the operation itself, (1) what number of the 75 per cent, 
 who survive the operation are permanently cured, and (2) to what 
 extent, if at all, life is prolonged by the operation in those who 
 die after it of recurrence of the disease. 
 
 We know that the mean duration of life of a person affected 
 with cancer or sarcoma of the kidney is from three to four years ; 
 and that it has been in some cases prolonged to six, eight, ten, 
 and even seventeen years. We know, too, that after malignant 
 tumours of the kidney have attained to considerable size life 
 may still last for two or three years. Guyon and Albarran, 
 for instance, testify to the fact that two patients were able to 
 attend to their occupations three years and five years respectively 
 after they were discovered to have very large malignant tumours 
 of the kidney. 
 
 These points must be borne in mind in judging of the thera- 
 peutical efficacy of nephrectomy ; and our experience is not 
 sufficiently large, nor I fear sufficiently precise, to enable us to 
 make a just comparison between the duration of life, from the 
 date of the first symptom to death, of the patients who have 
 not been operated upon, and of those who have been oper- 
 ated upon but who died from recurrence of the disease. 
 
 It is impossible to obtain in all instances the distant results 
 as to the duration of life after the operation and the dates and 
 frequency of recurrences, so that our information is much less 
 accurate and convincing on these points than as to the im- 
 mediate results of the operation. Enough, however, is known 
 to prove that recurrences are very frequent, especially in the
 
 604 SURGERY OF THE KIDNEY AND URETER. 
 
 case of tumours of large size and those which had contracted 
 adhesions. Within six months a great number of recurrences 
 are noted ; and if Bloch, Wagner, Max Jordan, Helferich, Czerny, 
 K iister, Israel, and myself can report recurrences at such 
 long intervals after the operation as three years, ten years, two 
 and a half years, three and a half years, two years, twenty-three 
 months, four years, and three and three-quarter years, still these 
 results ought only to make one the more careful in giving a distant 
 prognosis after nephrectomy, even in the most promising instances. 
 Heresco's figures show that eighty-nine out of 112 adults operated 
 upon survived the operation. But later information was only 
 obtained about sixty-two of them. Of these, thirty-six were alive 
 and well at dates varying from two months to seven years, twenty- 
 two died from recurrence of the disease at periods varying from 
 three months to three and a half years, and four died of inter- 
 current diseases without recurrence of malignant disease, at 
 periods varying from six weeks to four and a half years. 
 
 Of my own operation cases, one out of eight lived for two years 
 and between nine and ten months (i.e. nearly three years) after 
 the operation and then died of recurrence of the disease in 
 the ovary and liver. Of the others, four died of recurrence 
 between six and twelve months after the operation, two within 
 three months, and one is still living and well three months after 
 nephrectomy. 
 
 Many cases are recorded, however, in which recurrences have 
 followed at long intervals after the operation. The following 
 cases are examples : A patient of Bloch's lived three years ; one 
 of Wagner's, ten years ; Max Jordan's, two and a half years ; Hel- 
 ferich's, three and a half years ; Czernv's, two years ; Kiister's, 
 twenty-three months ; Israel's, four years ; my own, about 
 thirty-four months ; Siegrist's, four years. 
 
 Wagner collected twenty -four cases, alive and well, more than 
 two years after the operation ; Billroth had two cases which 
 survived more than two years, and of these twenty-six cases, 
 fifteen survived three years. Israel records patients living six, 
 nine and ten years respectively. Thornton removed a large adrenal 
 tumour weighing eleven pounds from a woman, aged fifty-three, 
 who was alive and well six years after, and His excised an 
 adeno-carcinoma from a woman who was living and well five 
 vears later.
 
 NEPHUEGTOMY ONLY PALLIATIVE IX LATER STAGES. 605 
 
 But, though the mortality of nephrectomy for malignant 
 renal tumours has diminished from one-half to two-thirds, and 
 though in exceptional cases complete cures seem to have occurred, 
 still in the majority of survivors from the operation the duration 
 of life is but short. 
 
 Growths of large size give results less favourable in imme- 
 diate results, and a greater proportion of recurrences. This 
 is because fragments of the tumour or of implicated lymphatic 
 glands have often had to be left behind owing to their intimate 
 adhesions to the large vessels of the abdomen. Still, life has in 
 some few cases been, prolonged after the removal of very large 
 tumours, e.g. Terillon's patient lived two years and three months 
 after removal of a tumour nearly ten inches in length. Schode's 
 patient aged thirty -nine lived four years after the removal of a 
 sarcoma tous tumour the size of an adult's head. One of Israel's 
 patients was alive and well fourteen months after nephrectomy 
 for sarcoma ; in this case a gland which was adherent to the renal 
 vein, and three others which were adherent to the vena cava, 
 were also excised. 
 
 In my earlier work 011 the kidney I remarked as to the treat- 
 ment of malignant tumours of the kidney : " Th^ can only be 
 palliative in the middle and later periods of the disease. In the 
 very early stage, could the growth be recognised then, nephrec- 
 tomy would seem to offer a prospect of postponing the fatal 
 result, perhaps even of considerably prolonging life, and in ex- 
 ceptional cases of securing permanent immunity." The accumu- 
 lated experience of surgeons since 1884, unhappily, does not permit 
 of a more favourable or more precise summary now. 
 
 As stated above, we want more precise information as to the 
 comparative duration of life (from the earliest evidence of the 
 presence of a malignant tumour of the kidney till death) of those 
 in whom the disease has been allowed to take its course on the 
 one hand, and of those who have undergone nephrectomy on the 
 other. 
 
 It is also to be hoped that before long more exact information 
 will be forthcoming both as to the clinical history and histological 
 characters of the tumours which have been removed, so that 
 we may know better which of the kinds of malignant tumours 
 afford the best prospect of complete cure or of longest immunity 
 from recurrence after nephrectomy ; and whether there are any
 
 606 SURGERY OF THE KIDNEY AND URETER. 
 
 diagnostic symptoms characteristic of the different histological 
 varieties of growths the sarcomata, carcinoma ta, and the adrenal 
 or accessory adrenal tumours. 
 
 Heresco has gone some way towards throwing light on the 
 first of these points, but I feel a little hesitation about his 
 figures as giving quite the true results, because there seems 
 to have been a certain amount of selection of the cases in 
 his list. His figures, however, are instructive, and stand as follows : 
 Of sixty-eight cases of nephrectomy for all forms of sarcoma-, 
 fourteen died, i.e. a mortality of 2O5 per cent. ; of fifty-three 
 cases of nephrectomy for carcinoma of various kinds, twelve 
 died, i.e. a mortality of 22'56 per cent. ; of fourteen nephrec- 
 tomies for adenoma all were successful, and of seventeen for 
 struma supra-renalis, five died, i.e. a mortality of 29'4 per cent. 
 Of the sarcomata, fourteen were known to be well at periods 
 varying from two to seven years after the operation. Of the 
 cancers, four were known to be well at periods between two 
 years and five years and three months ; and of the struma 
 supra-renalis cases three were alive and well at periods from two 
 and a half to four and a half years after operation. Thus, the 
 relative numbers of persons who survived the operation and were 
 free from recurrence two years or longer after nephrectomy, 
 for the three separate classes of cases, were 25 '9 per cent, for 
 sarcoma, 25 per cent, for struma supra-renalis, and only 9*7 
 per cent, for carcinoma 33 per cent, of the survivals after 
 nephrectomy for sarcoma had recurrence within one year, 25 
 per cent, of the adrenals, and only 9'7 per cent, of the cancers. 
 
 The principles which must guide us in dealing with any given 
 case are the same as those which we follow in regard to cancer 
 of the mammary gland and indeed of malignant disease generally. 
 
 Are the neighbouring lymphatic glands too widely invaded to 
 be completely removed ? Are there secondary growths in any other 
 organ or tissue ? Has the tumour any important adhesions, or has 
 it infiltrated irremovable structures ? In short, can the whole of the 
 disease be removed and is the patient's strength and general state 
 of health sufficiently good to allow of the operation being well 
 borne ? If these questions can be satisfactorily answered, nephrec- 
 tomy ought to be performed at as early a date as possible. 
 
 Good results may lie hoped for only when the tumour is 
 small, or of but moderate size, when it is not adherent, and
 
 NEPHRECTOMY AND SECONDARY DEPOSITS. 607 
 
 the neighbouring lymphatic glands are not invaded. Some of the 
 larger tumours are also sufficiently circumscribed to allow of 
 complete extirpation, and for such also nephrectomy is the treat- 
 ment to be advised. It is not, however, possible to state with 
 precision what the connections of the tumour or the extent of 
 glandular invasion are without an exploratory operation, and not 
 in all cases even then. When there is doubt on these points 
 and yet the patient's age, general state of health and his wishes 
 are in favour of an operation, a direct examination through an 
 exploratory incision should be made, and the operation abandoned 
 if the conditions which justify nephrectomy are not found to 
 exist. In certain circumstances the exploratory operation may be 
 followed by great benefit. I have twice thus operated on patients 
 in whom the tumour was causing intestinal obstruction, and in 
 both cases complete relief from this state was obtained, in one 
 of them by detaching two processes of omentum which passed 
 across and bound down the colon. 
 
 It is only in exceptional cases where, for instance, death is 
 threatened by haemorrhage or pressure effects, or where the pain 
 caused by the tumour is unendurable that nephrectomy is justi- 
 fiable when we know that infiltrated tissues or infected glands 
 must be left behind. 
 
 It may happen, after the tumour has been removed, that 
 some non-removable infected gland, or mass of secondary growth, 
 may be found, which w T as inaccessible whilst the tumour was in situ. 
 But in order to avoid submitting the patient to the risks of the 
 operation when the whole of the affected parts cannot be removed, 
 a most careful preliminary examination should be made in every case. 
 
 On one occasion I removed the enlarged kidney in the pre- 
 sence of numerous small secondary nodules of the liver, but in 
 that case the tumour was causing very great pain, and was itself 
 very movable and free from adhesions. The result justified the 
 operation, as the patient was quite relieved of his sufferings, and 
 lived for eight months afterwards. 
 
 Nephrectomy. Of the two methods of nephrectomy for malig- 
 nant growths, the lumbar and the abdominal, the lumbar is 
 now by almost universal consent regarded as the operation of 
 choice for tumours of small and moderate size. The earlier 
 statistics, however, show a much larger difference in the mor- 
 tality of the two methods than the later.
 
 608 SURGERY OF THE KIDNEY AND URETER. 
 
 Siegrist in sixty-one cases found 57 per cent, of deaths 
 by the trans-peritoneal and 23 per cent, by the lumbar. 
 
 Chevalier's figures are almost the same, viz. 59 per cent, 
 for the trans-peritoneal and 24 per cent, for the lumbar. 
 
 Heresco's statistics of cases published between 1890 and 1898 
 show forty trans-peritoneal operations with nine deaths, i.e. a 
 mortality of 22'50 per cent. ; and fourteen deaths out of sixty- 
 four cases, i.e. 21*90 per cent., of extra-peritoneal nephrectomy. 
 
 For very large tumours the abdominal method, however, 
 must be adopted ; and it must also be conceded that by the 
 abdominal route a more immediate examination can be made of 
 the hilum and pedicle of the kidney, and of the retro-peritoneal 
 glands along the same and on the opposite side of the spinal 
 column. In the earlier statistics recurrences were less frequent 
 than after the lumbar method. It is, however, by the abdominal 
 method that such fatal accidents as ruptures of the vena cava 
 have occurred. 
 
 Strongly in favour as I am of the lumbar method of nephrec- 
 tomy for other diseases, I have always combined the lumbar 
 with the lateral trans-peritoneal route for malignant tumours of 
 the kidney. I first make an incision into the peritoneal cavity, 
 along the liiiea semilimaris, and through this I examine 
 the connections of the tumour. I then temporarily close this 
 wound and turn the patient over upon his sound side, and 
 through the usual oblique lumbar incision I enucleate the tumour 
 from behind. The patient's position is then again changed, and 
 the peritoneum is raised from the front of the tumour, the ves- 
 sels of the pedicle are secured, and the tumour is then pushed 
 and raised out through the anterior wound. 
 
 This plan possesses the following advantages : (1) It enables 
 the surgeon to make a wide exploration before beginning the 
 separation of the kidney and the tumour from their connections. 
 
 (2) It gives the opportunity of feeling and inspecting the 
 other organs, and the mesentery and peritoneum, and so of detect- 
 ing any early and unsuspected secondary growths. 
 
 (3) It allows of the posterior, the upper, lower, and outer 
 connections of the tumour being detached whilst the tumour 
 itself is being pressed towards the spinal column, instead of the great 
 vessels being dragged and forcibly pulled away from them, as 
 happens when this detachment is made through an anterior
 
 PARTIAL NEPHRECTOMY FOR MALIGNANT TUMOURS. 609 
 
 wound. It thus diminishes the risk of injury to the great 
 vessels. 
 
 (4) The delivery of the tumour through the anterior incision 
 is very greatly facilitated by one hand of the surgeon in the 
 posterior wound. 
 
 (5) The pedicle can be more precisely manipulated than 
 through either wound alone. 
 
 (6) The lumbar wound affords the best means of draining 
 the space from which the tumour has been extracted. 
 
 Partial nephrectomy has been practised at least five times for 
 malignant tumours of the kidney ; but in every case the surgeon 
 thought he was dealing with a benign tumour. Czerny in 1887 
 excised part of a kidney for an angeio-sarcoma which followed a sub- 
 parietal injury to the organ. Recurrence took place, and the 
 kidney was removed two years later, the patient dying five 
 months afterwards. 
 
 Kummel resected a part of the kidney for a malignant neoplasm 
 of the upper end of the organ ; the patient died two and a half 
 months after the operation. Bloch removed half the kidney for 
 an acleno-sarcoma ; the patient was alive two months afterwards. 
 Tuffier did a partial re-section for an adeno-carcinoma ; the 
 patient recovered from the operation, but I do not know the 
 ultimate result. 
 
 Albarran resected part of the kidney for a sarcoma, and the 
 patient was alive more than two years after, but recurrence was 
 then probable as she had haematuria. Mayo Robson excised part 
 of the kidney with a supra-renal tumour.* 
 
 The results of partial nephrectomy are not encouraging. Total 
 nephrectomy should be practised for cases of even very small 
 tumours, if their malignant nature is evident. Nothing less than 
 total nephrectomy should be resorted to in the cystic forms of 
 malignant tumours. Grawitz, Klaatsch, and Rudolphi, after 
 incising such tumours, packed them with gauze, but each of the 
 patients quickly died. Leopold, after opening one of these cysts, 
 resected it, and his patient recovered. 
 
 MALIGNANT TUMOUR OF THE KIDNEY IN CHILDREN. 
 
 Etiology. Malignant disease of the kidney is not unfrequent 
 in children. Duran, in the " These de Paris," 1876, says that the eye 
 
 * Brit. Med. Journ., Oct. 21, 1899. 
 VOL. I. 2 N
 
 610 SURGERY OF THE KIDNEY AND URETER. 
 
 and the kidney are the two organs most frequently affected ; out of 
 124 cases of malignant disease in children, he found the eye in 
 seventy and the kidney in forty-five the seat of the disease. 
 
 Guillet, out of 132 cases of malignant disease of the kidney, 
 found forty-five in children. 
 
 Out of 347 cases of cancer (using the term in its widest sense) 
 of the kidney operated upon between 1890 and 1897, collected by 
 Albarran, sixty-three of them were in children. 
 
 The maximum frequency is between one and five years of age, 
 but Seibert, Weigert, Semb, and others have published cases in 
 which the tumours were congenital. It is during the first five 
 years of life that children are exceptionally prone to renal sarcoma. 
 
 In the adult, cancer of the kidney is more frequent in 
 men than in women, in children there is no difference in fre- 
 quency in the two sexes. There have not been any cases to show 
 that calculus is either an exciting cause or a result of renal 
 tumour in children. 
 
 Pathological anatomy. The renal sarcoma of early life 
 originates commonly in the connective tissue of the hilum and 
 gradually spreads into and expands the renal tissue. It rarely 
 obstructs the ureter or ulcerates into the calyces, and thus does 
 not cause hydro-nephrosis, and very rarely haematuria ; in some 
 cases, however, the renal cavity shows signs of compression, the 
 pyramids being flattened and the sides of the infundibulum in 
 contact, as in a case of cancer in a child four and a half years 
 of age recorded by Fagge in the Pathological Society's Transac- 
 tions (vol. xxi., p. 261). The yielding nature of the infant tissues 
 and the absence of renal distension explain the rarity with which 
 pain becomes a symptom in these little patients. 
 
 Adenomata and epitheliomata are rare in children. Sarcoma 
 is the form of malignant tumour commonly met with. Shattock, 
 in the Lancet, 1894 (vol. ii., p. 1219), has published a case of solitary 
 adenoma. Albarran. gives eight to forty-three as the proportion 
 of epithelioma to sarcoma in children. The structure and patho- 
 genesis of malignant tumours in the child is the same as in 
 the adult (see pp. 550 and 570). 
 
 When once the lymphatic glands are invaded the tendency 
 of the disease to spread in them is not confined to the glands 
 of the same side and along the median line of the body, but 
 aftects also the glands about the hilum of the opposite kidney,
 
 SARCOMA IN CHILDREN OFTEN BILATERAL. 
 
 611 
 
 and in this manner the growth becomes bilateral. Fig. 94 shows 
 a round-celled sarcoma arising about the hilum of the right 
 kidney, which is partly stretched over the surface of the tumour. 
 It was removed from a male infant nine months old ; the glands 
 at the upper part of the hilum of the left kidney, as well as those 
 about the aorta at this level, were found to be infected, as shown in 
 Fig. 95. 
 
 Sarcomata have a tendency, no doubt, to attack independently 
 
 Lobulated growth. 
 
 K 
 
 Kidney. 
 
 Fig. 94. Sarcoma of the right Kidney arising at the Hilum. See also Fig. 95. 
 From a male, aged 9 months. (Middlesex Hospital Museum.) 
 
 both kidneys, either simultaneously or consecutively, just as they 
 have to affect both eyes or both ovaries ; but the affection of the 
 opposite organ by continuous extension either along the retro- 
 peritoneal tissue or the lymphatic glands is probably more common. 
 In a case of a child, fourteen months old, under Abbe, one kidney 
 was successfully removed for sarcoma, and four years and a half 
 later the remaining kidney became similarly diseased. In this 
 case the sarcomata of the two organs most probably been quite 
 independent, and both, so to speak, primary growths.
 
 612 
 
 SURGERY OF THE KIDNEY AND URETER. 
 
 Symptoms. In the great majority of cases the first symptom 
 is tumour. Heresco states that this was so in 81 per cent., 
 whilst pain was the first symptom in 14 per cent., and hsema- 
 turia in only five. This contrasts strongly with the relative 
 frequency of these same symptoms at the outset of malignant 
 disease of the kidney in the adult. As the result of the infre- 
 quency of pain and haematuria the tumour does not attract 
 early notice. It is not until the child emaciates or the tumour 
 attains a large size, causing the abdomen to be protuberant, that 
 
 the nurse's or parent's attention is 
 drawn to the abdomen. 
 
 Not only is the tumour the earli- 
 est symptom, but except for wasting, 
 pallor, and general debility it is the 
 only one. The size attained by it 
 is in some cases enormous. Its 
 local characters are the same in the 
 child as in the adult. 
 
 Pain is rare at the outset and 
 occurred in only six out of forty-three 
 cases collected by Heresco. When it 
 is present it is vaguely referred to 
 the loin or over the side of the abdo- 
 men on which the tumour is situated, 
 right Kidney, being from the Qr it may radiate to the tn igh and 
 from same subject as Jig. 94. 
 
 (Middlesex Hospital Museum.) along the course of the gemto-crural 
 
 nerve. The passage of clots of blood 
 'may cause renal colic, but very rarely does so. 
 
 Hcematuria. The most divergent statements have been made 
 by different authors as to the frequency of and importance to be 
 attached to hsematuria as a symptom of malignant renal disease. 
 Only those based upon actual figures will be referred to here. 
 
 It may occur as an early or late symptom. There may be 
 one attack or several. It may entirely disappear before the end 
 of the disease, even when there have been several attacks. The 
 quantity of blood passed may be much or little ; sometimes it is 
 only microscopic in amount, but generally when present at all it 
 is sufficient to colour the urine. 
 
 It is like the haematuria from malignant renal growths in 
 adults : spontaneous, sudden, intermittent, occurring without 
 
 Fig. 95. The left Kidney showing 
 disease about its vessels and in 
 the glands along the aorta. 
 From a case of Sarcoma of the
 
 H^MATUBIA RARELY AN EARLY SYMPTOM. 613 
 
 premonitory or accompanying symptoms. The attacks of haema- 
 turia usually last four or live days ; in one case it continued 
 for fourteen consecutive days (Lotheissen). 
 
 Haematuria has seemed to relieve or remove pain when pain 
 has preceded the haemorrhage. When haematuria is an early 
 symptom it is probably due to congestion of the kidney caused 
 by the presence of the tumour.; when a late one, by ulceration 
 or bursting of the growth into the renal tubules or calyces. 
 
 Heresco found it as an early symptom in only two out of 
 forty-three cases. G-uillet noted it as occurring at some period 
 during the course of the disease in only ten out of thirty -eight 
 east's of sarcoma. Albarraii found it mentioned in nine only 
 out of fifty-six cases operated upon for malignant tumour. 
 
 Denaclara, out of 409 cases of all kinds of new growths in chil- 
 dren and adults, found haematuria recorded in 146 of them; 132 of 
 these cases were in children below ten years of age, of whom 
 thirty-seven had haematuria, i.e. nearly 39 per cent. It was 
 much more frequent in children under five years of age than 
 over ; twenty-seven out of the thirty-seven patients were under 
 five, and in one the age was not stated. In five cases of malignant 
 tumour and in three of non-malignant, the haematuria appeared 
 before the tumour ; in three instances haematuria followed the 
 tumour. The periods in relation to the tumour at which haema- 
 turia was first observed, varied from two months before to three 
 months after the discovery of the tumour. In two other cases 
 haematuria was an early symptom, though not preceding the 
 tumour. In three cases there was only one attack of haematuria, 
 and in one case the haemorrhage lasted as long as the disease. 
 
 The rapid growth and frequent bilateral development lead to 
 early pressure symptoms. Varicocele has not been noted amongst 
 the pressure effects. Metastasis is not a marked feature. Cachexia 
 is developed early, and is much more rapid in the child than 
 in the adult. Death, which is postponed in the adult till be- 
 tween the third or fourth, or even fifth or sixth year, occurs usually 
 in the child within one year. 
 
 Diagnosis. This is the same as in the adult (see p. 585)- 
 The tumour is the leading symptom, and in any case of an 
 abdominal tumour in a child we ought to think of sarcoma of 
 the kidney and investigate the swelling and the urine from that 
 point of view.
 
 614 SURGERY OF THE KIDNEY AND URETER. 
 
 Renal tuberculosis and vesical tumours, the other diseases of 
 the child in which haematuria occurs, are very rare. The 
 characters of the urine in tuberculosis, and the detection of a 
 tumour within the bladder by bimanual examination, i.e. rectal 
 and hypogastric palpation combined, will enable the diagnosis to be 
 made. Haematuria, peristent and abundant, due to Bright's disease, 
 has been met with in a boy (Albarran), but is exceptionally rare. 
 
 Treatment. Jessop, in 1877, first successfully removed a 
 malignant tumour of the kidney from a child. The patient 
 died afterwards from recurrence of the disease. Heuter, in 1876, 
 had previously removed a sarcoma of the kidney from a little 
 girl, aged four, but the patient died of haemorrhage. 
 
 Before 1890 the mortality from extirpation of the kidney 
 in the child for malignant disease, as given by Heresco, was 60 
 per cent. ; this is based on the collected cases of Taylor, Guillet, 
 Dohrn, and Chevalier. Fischer quotes thirty cases of nephrec- 
 tomy with a mortality of 48 per cent., and the longest survival 
 after operation was one year and a half. In 1894, Doderlein found 
 a mortality of 40 per cent, in forty-nine collected cases of 
 operation for malignant tumour in children.* Ardle in the same 
 year gave a mortality of 20 per cent, in twenty-six cases. Al- 
 barran brings the figures down two years later with ninety -seven 
 cases to the end of 1896, and a mortality of 30 per cent. Lewy in 
 sixty-two cases found an operative mortality of 28 per cent. 
 Heresco has collected 165 nephrectomies for malignant disease 
 performed between 1890 and 1898, with a mortality of thirty-two, 
 or 19 '3 5 per cent. He has considered as deaths from the opera- 
 tion all those dying within one month from the date of its per- 
 formance. Of these operations fifty-three were performed upon 
 children, with nine deaths, i.e. a mortality of 17 per cent. The 
 method of operating in these fifty-three cases is stated in forty, 
 viz. the trans-peritoneal in thirty-four cases, with seven deaths, 
 i.e. a mortality of 20'6 per cent., and the extra-peritoneal in 
 six cases, without a death. 
 
 Heresco further gives the distant results in twenty -four out 
 of the fifty-three children operated upon. They are as follows : 
 eight had no recurrence, and sixteen died from recurrence. 
 Of the eight who were living, three were alive after five years 
 (two of them after six years) ; three were alive between two years 
 
 * Centralblatt fi<r Krank. d. Harn. it. Sexual Org., 1S94, H. 1 and 2.
 
 IMPROVEMENT IN OPERATIVE MORTALITY. 615 
 
 and three months and three years and six months; one, fourteen 
 months and another nine months after operation. Of the sixteen 
 children dead of recurrence, one died at the end of three years 
 and six months, three between twelve and twenty -two months, 
 and the rest between two months and ten months (Heresco, p. 25). 
 
 The important fact deducible from these elaborate statistics is 
 this, that with improvements in operating and increased ex- 
 perience in renal surgery the mortality has in recent years been 
 reduced more than two-thirds, viz. from 60 per cent, in 1890 
 to 40 per cent, in 1894, and thence to 17 per cent, in 1898. 
 Chevalier concluded that nephrectomv would have to be rejected 
 in children. Gross and Fischer inclined to this same opinion. 
 But this position requires reconsideration, and the greater im- 
 provement in results of nephrectomy warrants Heresco, Albarran, 
 and others in thinking that the advantages of nephrectomy 
 in children will only be known later, and that for the present 
 all we can say is that the improved results of nephrectomy suffice 
 to guide us in counselling the operation in any case in which after 
 careful investigation AVC are unable to discover signs of dissemina- 
 tion, and when the general condition of the little patient encourages 
 us to hope that the shock of the operation will be well borne. 
 
 With the refusal to operate upon cases in which the tumour 
 has attained to a great size, and has infiltrated surrounding 
 tissues, and with the restriction of operations to the earlier stages 
 of renal growths, better results still will be obtained ; and whilst 
 operations upon small and medium sized and freely movable growths 
 will become the rule, surgeons will decline to operate at a late 
 stage and upon tumours of large size which have infiltrated 
 the perinephric tissues and lymphatic glands. 
 
 The result of this change in practice has not only been to 
 diminish the actual operative mortality, but also to improve the 
 distant results, and to increase the number of patients who sur- 
 vive not only one but several years after the operation without 
 recurrence. This end can only be attained and advanced b}' 
 prompt diagnosis and early operation. 
 
 D. K. Abbe recorded in the Annals of Surgery (Xovember 22, 
 1895, p. 269) two cases of sarcoma of kidney cured by nephrectomy. 
 
 Case 1. A girl, when two years old, was operated upon on 
 April 12, 1892. She was still quite well at the age of five years. 
 The weight of the tumour was two and a quarter pounds.
 
 C16 SURGERY OF THE KIDNEY AND URETER. 
 
 Case 2. A child was operated upon November 20, 1892, when 
 fourteen months old. She was alive in April, 1895, and quite 
 well. The weight of the tumour was seven and a half pounds, 
 or just one-half the weight of the child immediately after operation. 
 
 The fatty capsule was not removed in Abbe's cases ; there was 
 no blood in the urine in either case, and albumen only in one 
 of them. In one case, part of the kidney, being healthy, was not 
 removed. Both were round -celled sarcomata, one containing a 
 good deal of unstriped muscle. In a third case there was re- 
 currence after five months. 
 
 Coley mentioned a case of large sarcoma of the kidney in a girl 
 aged five years, removed in September, 1894 ; seven months later 
 there was no sign of relapse. Other successful cases might be quoted. 
 
 The results 011 patients who survive nephrectomy have been 
 shown above to a certain extent. Of the sixty-six cases collected by 
 Albarran who survived the operation, recurrences are known to 
 have taken place in forty-three, no late information was obtained 
 about eleven, and eleven cases had been seen free from recurrence 
 and in good health at periods varying from one year to two and 
 a half years after the operation. 
 
 But recurrences have in some cases taken place late. Thus 
 Trencleleiiburg records a case of a child, two and a half years of 
 age, operated upon for myo-sarcoma, who died of recurrence 
 one year and a half after the operation. In another case of a 
 child of nine years of age operated upon by the same surgeon 
 for an acleiio-carcinoma, the patient died of recurrence five and a 
 half years after the nephrectomy. 
 
 The operation may be followed by success 110 matter at what 
 age it is performed ; from six months old upwards the child may 
 recover from it. Of eighteen children of two years old and under 
 operated upon since 1890 only two died from the operation, but 
 only five were known to lie living and well at periods varying from 
 seven months to two and a half years afterwards (Albarran). Nor 
 does the size or nature of the tumour prevent success following 
 nephrectomy. Amongst the recoveries there are several cases in 
 which the tumours were very large and some of these have not 
 been followed by recurrence. 
 
 As regards the bearing of the nature of the tumour on the 
 remote results of nephrectomy, Albanian's figures give some clue. 
 Five out of the eleven cases of non-recurrence were epitheliomata,
 
 RULES FOR GUIDANCE AS TO NEPHRECTOMY. 617 
 
 and the case which died at the longest date after operation, viz. 
 five and a half years after, was one of adeno-carcinoma. The prog- 
 nosis would seem indeed from these results to be more favourable 
 hi epithelioma than in sarcoma, because whereas epitheliomata form 
 barely a quarter of the total number of all the malignant renal 
 tumours in children, they give nearly half of the best results. 
 
 Considering the very rapid growth and early certain death if the 
 tumour is left to take its course, the conclusions to be drawn from 
 the latest information at hand are in my opinion the following : 
 
 1. Xephrectomy should be recommended in every case in 
 which the surrounding tissues and the neighbouring lymphatic 
 glands are not invaded and in which there are no secondary deposits 
 discoverable, if the general constitutional state of the child gives 
 fair hope of its withstanding the shock of the operation. 
 
 2. The operation should be performed at as early a period 
 as possible, before the tumour has attained a great volume. 
 
 3. In the commencement, the operation should be undertaken 
 in the way of an abdominal exploration, and only proceeded 
 with if it is found that the lymph glands are not involved and 
 that the whole of the growth can be removed. 
 
 4. The operation should be by the trans-peritoneal method, 
 for the following reasons : the ilio-costal space is too small to 
 permit of the necessary manipulations ; and although the opera- 
 tive results are somewhat inferior to those of the lumbar method, 
 the abdominal route allows of a complete examination of the 
 state of the surrounding tissues, of the renal pedicle, and of the 
 vessels and glands along the spinal column and on the opposite 
 side of the column. 
 
 The statistical results given by Heresco of the two operations 
 on children are thirty-four cases with seven deaths, i.e. 20'60 per 
 cent., for the trans-peritoneal, and six cases without a death by the 
 extra-peritoneal method. Albanian's figures are, 21 per cent, for 
 the abdominal and 29 per cent, for the lumbar. As they are only 
 the smaller tumours that would be attempted by the lumbar 
 method, Heresco 's six cases without a death make this operation 
 compare too favourably with the trans-peritoneal. In actual 
 operative results there is probably little or no difference ; but the 
 chief advantage of the abdominal operation lies in the fact stated 
 above, that it gives incomparably greater facility of exploring the 
 abdominal cavity before deciding on the removal of the tumour.
 
 618 
 
 CHAPTEE XX. 
 TUMOURS OF THE RENAL PARENCHYMA. 
 
 (Continued.) 
 
 (B) NON-MALIGNANT TUMOURS OF THE KIDNEY. 
 
 BENIGN new growths in the kidney are very rare, and scarcely 
 form 6 per cent, of renal tumours. Of fifty-one collected cases 
 Aldibert found forty-eight were malignant and only three benign. 
 They are of perhaps pathological rather than clinical interest, 
 inasmuch as they are usually discovered in post-mortem ex- 
 aminations, and do not often give rise to hgematuria, tumour, 
 pain, or other sjanptoms. When they attain to a size large 
 enough to form a tumour they ma}" cause discomfort from pres- 
 sure by their weight and volume, and they are then likely to be 
 mistaken for ovarian or hydatid tumours. The treatment is 
 either partial or total iiephrectomy, according to the extent to 
 which the kidney is involved. When the tumour is certainly 
 benign (a point upon which the naked eye is far from being 
 a sure guide) it should be removed, and a large portion of the 
 healthy kidney left behind ; this ought to be done in preference 
 to total iiephrectomy. The prognosis after recovery from the 
 operation is good in the case of simple fibroma and simple lipoma, 
 but not so when sarcomatous or myxomatous elements are com- 
 bined with the fibrous or the fatty tissue. 
 
 ADENOMA. 
 
 Simple adenomata occur in two forms, the papillary and the 
 alveolar (Weichselbaum and Greenish). They may be single or 
 multiple, solid and glandular, or cystic. 
 
 The papillary variety originates in the tubules of pyramids, 
 and consists of tubules and acini lined with more or less cubical 
 epithelium, together with papillary formations. 
 
 The alveolar adenoma is said " to arise in the convoluted tubes, 
 and closely resembles the true secretory epithelium " (Kelynack). 
 
 The simple adenoma presents itself as a small yellowish nodule
 
 VARIATION IN TYPES OF RENAL ADENOMA 619 
 
 of the size of a pea, or larger, in the cortex of the kidney. It 
 is round, circumscribed and encapsuled. It may be either 
 single or multiple, it usually occurs in persons of adult age, 
 and may be found in both kidneys of the same subject. Several 
 writers speak of adenomata as occurring frequently in kidneys which 
 have been the seat of interstitial inflammation, but others regard 
 the little yellowish bodies found in such organs as being more 
 of the nature of gland proliferation than true new growths. 
 Simple adenomata present great variations in the proportion 
 between their cells and stroma, and in their degree of vascularity. 
 In some the fibrous and connective tissue is very abundant. They 
 may undergo fatty degeneration or actual necrosis. 
 
 The pathogenesis of simple adenoma is obscure and uncertain. 
 Some are probably of accessory adrenal origin. Bicker speaks 
 of having seen them in the central parts of infarction cicatrices, 
 having originated apparently from tubules isolated by the cica- 
 tricial tissue. Some arise probably, as Albarran suggests, from 
 " rests " of the renal tubules or, as Pilliet indicates, from func- 
 tionally isolated elements due to an error in development, others 
 possibly from remnants of the Wolffian body. Allen and Cherry 
 state that all their cases seem to have originated in renal tubes 
 and not in adrenal or Wolfnan inclusions, and that in not 
 a single instance was there the least resemblance to adrenal 
 tissue. 
 
 As stated under epithelial tumours, the types of renal 
 adenomata vary exceedingly, and no definite line can be drawn 
 between them. Some, especially those which are very vascular 
 and those with papillary ingrowths, have a marked tendency 
 to become malignant and enlarge indefinitely. Delafield, Bicker, 
 Ivlebs, Ziegler, Thoma, and many others all emphasise the fact 
 that adenomata may develope into tumours of a malignant type. 
 They may pass from adenoma into carcinoma, and be followed 
 by the formation of metastatic tumours. 
 
 Papillary ingrowths are specially apt to develope in the cystic 
 forms of adenomata (Fig. 97) ; so also are the hsemorrhagic or an- 
 geiomatous conditions ; and in some of the latter, in spite of the 
 absence of true blood-vessels, the blood itself is of so normal a cha- 
 racter as to suggest that it had been freely circulating up to the last. 
 In other cases the peripheral part of the tumour has presented 
 large blood spaces occupied by coloured blood-clot, and if such
 
 620 
 
 SURGERY OF THE KIDNEY AND URETER. 
 
 a tumour encroaches upon the renal pelvis, haematuria and 
 haemato-nephrosis may occur. 
 
 An interesting example of papillary adenoma has been recorded by 
 Parkes Weber,* in a man aged seventy -two, who was suddenly 
 attacked with hsematuria and died a day or two afterwards. In each 
 kidney there were two or three little whitish tumours of a more or 
 less globular form; the largest was six or seven mm. in diameter. 
 Sections showed the tumour to consist of tubes lined by small 
 epithelial cells of more or less cubical form. The tubes were 
 
 Fig. 96. Adenoma of Kidney. From a girl aged three years. The tumour chiefly 
 consists of three spheroidal portions separated and intersected by films and con- 
 nective tissue. The remains of the renal tissue are seen stretched over the 
 tumour. (St. Thomas's Hospital Museum, Xo. 2095.) 
 
 lined with delicate branching papillary outgrowths covered with 
 the same kind of cubical epithelium. Most of the tumour was 
 surrounded by a fairly thick fibrous capsule formed apparently 
 from the surrounding renal tissue which had been compressed 
 by the growth. Parkes Weber has since recorded another case of 
 multiple papillary adenomata in a contracted kidney from a man 
 aged fifty-seven, the other kidney being free from the growths. 
 His view is that such tumours may be regarded as analogous to 
 multiple warty growths developing upon a chronically irritated 
 
 * Trans. Path. Soc. Land., 1898.
 
 CASES OF NEPHRECTOMY FOR ADENOMA. 
 
 skin, and that in certain kidneys as in certain skins and mucous 
 membranes and not in others, chronic inflammation tends to 
 the formation of multiple warty growths.* 
 
 K. P. Weir of New York removed the kidney of a man aged 
 thirty-five by the trans-peritoneal route for adenoma in 1887.f 
 The patient recovered. The kidney weighed twenty-one ounces 
 and measured nine by five and a half inches. The tumour was 
 encapsuled, of the size of a man's fist, and it encroached upon 
 but did not burst into the renal pelvis. Microscopical examination 
 
 A second small cyst with three or four 
 apparently solid intra-cystic growths. 
 
 Fig. 97. Cystic Adenoma of Left Kidney. Removed from a girl aged eighteen, in 
 whom it had existed as a movable tumour for two years. A thin layer of renal 
 tissue is spread between the tumour and the capsule of the kidney. Renal tissue 
 normal. (St. Thomas's Hospital Museum, No. 2096.) 
 
 showed it to be an adenoma. Albert J also successfully removed 
 the kidney from a woman aged forty-two years for an adenoma 
 the size of a child's head, by the posterior incision. The tumour 
 followed a fall two years previously ; the fall caused hoematuria. 
 
 * Path. Soc. Trans., 1899, vol. 1., p. 179. 
 
 t See Annals of Surgery, 1887, July-Dec., p. 37. 
 
 I Wiener Med. Presse, 1885, No. 9.
 
 622 SURGERY OF THE KIDNEY AND URETER. 
 
 Czerny* performed nephrectomy in a child eleven months old for 
 a large adenoma of the right kidney; death from peritonitis 
 followed. Schonborn also has successfully removed the kidney for 
 adenoma from a child aged two years. 
 
 The indefinite gradation between the various types is no- 
 where more concisely or more clearly stated than by Allen and 
 Cherry in the following passages from their excellent pamphlet x 
 on "The Histology of Twenty-nine Cases of Primary Neoplasms 
 in the Kidney contained in the Pathological Museum of the 
 University of Melbourne" : 
 
 "The simplest adenoma consists of tubes or alveoli lined 
 or filled with large epithelial cells, which may become hyaline, 
 colloid, or fatty. The softer forms are often composed of cysts 
 with papillary ingrowths, the core of the ingrowths being some- 
 times fibrillar, sometimes embryonic and cellular, while the 
 epithelial lining varies from a single layer of columnar cells to 
 heaped-up layers of large flattened endothelioid plates. In some 
 cases, many of the ingrowths are pedunculated, and grow freely 
 in the cystic spaces, so as to produce pseudo-glomeruli. All 
 stages may be traced of transformation from simple tubes into 
 papilliferous cysts. Some adenomata are encapsuled, while others 
 abut directly on renal tissue. The adjacent tubes are partly 
 atrophied, fibroid, or otherwise degenerate, but partly show 
 signs of epithelial activity, the nuclei staining deeply. In en- 
 capsuled adenomata, similarly active tubes, or cylinders of 
 epithelium derived from tubes, may be found in the capsules. 
 These capsular developments are worthy of close study, for 
 sometimes the epithelial growth is so extensive and so irregular 
 as to produce an alveolar structure resembling carcinoma or 
 alveolar sarcoma, while the main tumour in its macroscopic 
 characters continues perfectly innocent. In other cases, round 
 and spindle cells may be so abundant in the capsule as to re- 
 semble sarcoma, but without any corresponding malignity. 
 
 " The pseudo-carcinomatous development, just described in the 
 capsule of certain adenomata, may be the main histological type 
 throughout a tumour. In this case the tubules or cysts are 
 replaced by alveolar formations, the alveoli being bounded by 
 
 * Deutsche Med. Woch., 1882, No. 32. 
 
 t Reprinted from the Proceedings of the Intercolonial Medical Congress 
 of Australasia, Fourth Session.
 
 ISOLATED ADENOMATA IN HEALTHY KIDNEYS. 623 
 
 finely fibrillar tissue with spindle cells, and being more or less 
 completely filled with large irregular epithelioid cells, sometimes 
 extensively colloid. These pseudo-carcinomata may remain small, 
 inactive, and distinctly encapsuled. Such alveolar formations 
 may occur side by side with the most typical papillary cysts. 
 Xot one of our cases of renal adenoma has passed into typical 
 carcinoma, with corresponding malignant history. 
 
 " Adenomata of either the tubular or the papillary cystic type 
 may grow freely and become hsemorrhagic. In some of these 
 cases there is an admixture of ordinary sarcoma tissue, but pro- 
 gressive growth is not necessarily dependent on such admixture." 
 
 The adenomata are met with either consecutively to nephritis, or 
 independently of chronic inflammatory conditions of the kidney, as 
 isolated growths, single or multiple, between the capsule and the 
 renal substance, or penetrating more or less deeply into the 
 parenchyma. 
 
 The epithelial new growths (papillary adenomata) consecutive 
 to Bright's disease have only an anatomico-pathological interest. 
 They are met with in kidneys the subject of advanced interstitial 
 nephritis, and are found in the parenchyma immediately beneath 
 the capsule as small grey or red nodules from the size of a pin's head 
 a marble. Sometimes there are only one or two of these minute 
 tumours ; in other cases there are very many in different stages 
 of development, and it is by no means unusual for both kidneys 
 to be affected in the same way. They penetrate to a variable 
 extent the renal parenchyma, are generally encapsuled, and have a 
 homogeneous structure, in some cases being tough in texture, 
 in others friable and even haemorrhagic. They easily undergo 
 degenerative changes, and in doing so probably sometimes give 
 rise to small cysts filled with pultaceous material in the renal cortex. 
 
 The isolated adenomata occur in kidneys healthy in appear- 
 ance or but slightly sclerosed. There may be one or more, rarely 
 two or three, separate tumours. They vary in size from a cherry 
 to a mandarin orange or larger, though occasionally they are 
 as small as a hemp-seed. They are usually situated just beneath 
 the renal capsule, which they somewhat elevate, though they 
 are also partly imbedded in the renal substance and are occasionally 
 entirely surrounded by it. They have distinct, often thick cap- 
 sules, and on section white bands pass inwards from this capsule, 
 dividing the tumour up into distinct rounded lobules independent
 
 624 SURGERY OF THE KIDNEY AND URETER. 
 
 of one another (Fig. 96). The tissue of these little tumours 
 is greasy white, soft and friable, with frequent haemorrhagic ex- 
 travasations or cystic formations more or less marked in their 
 substance. 
 
 From the point of view of structure Albarran distinguishes 
 three varieties of adenomatous tumours, the canalicular, the 
 tubular, and the alveolar. 
 
 The canalicular type is the rarest; it is a mimicry of the 
 renal tubules completely developed or on their way towards 
 complete development, and large epithelial nests separated by a 
 delicate stroma. 
 
 The tubular (camtaire) type of Albarran includes the papillary 
 adenoma of Weichselbaum and Greenish, and the cubical-celled 
 adenoma of Sabourin, and other forms not described by those 
 observers. These tumours are composed of cavities more or 
 less regularly arranged in the form of tubes, and lined by cubical 
 epithelium with or without intra-cystic papillary growths. They 
 are generally multiple, very small, and correspond to the ade- 
 nomata met with in Bright's disease. Exceptionally they are 
 solitary. 
 
 The alveolar type corresponds to the "strumse lipomatodes 
 aberrate renis" of Grawitz. They are nearly always solitary 
 tumours, and much larger than the preceding varieties. They 
 are encapsuled, and from the inner surface of the capsule proceed 
 thick bands of connective tissue containing some imstriped mus- 
 cular fibres, while from these bands other very slender partitions 
 proceed which subdivide the larger alveoli into a great number 
 of small, very regular secondary alveolar spaces. Numerous 
 capillary vessels occupy the stroma. These tumours contain 
 much fat, which led to their being called renal lipomata, 
 but when the fat is dissolved out of them their identity in 
 structure with the suprarenal capsule becomes evident enough. 
 The epithelium contained within the alveoli approaches the 
 cylindrical form, and is infiltrated with fat ; the cells, when 
 deprived of this fat, appear like vesicles limited by a fine mem- 
 brane. Other cells are granular and not fatty. Glycogen 
 is often found in the cells. Tumours of this type sometimes 
 commence in the suprarenal capsule itself, and either involve the 
 kidney secondarily by sheer extension of growth or destroy it by 
 pressure and absorption, as shown in Figs. 76 and 77 (pp. 535, 540).
 
 FIBROMA FORMING A CLINICAL TUMOUR. 625 
 
 FIBROMA. 
 
 Fibromata occur usually as small white nodules near the 
 bases of the pyramids, but occasionally a very large simple fibrous 
 tumour has been met with in the kidney. Tumours of large 
 size have been found to be composed of fibrous tissue, in some in- 
 stances mixed with muscular tissue, in others containing cysts. In 
 some cases the tumours have appeared to be developed at the 
 expense of the capsule rather than of the kidney itself, in others 
 to be of truly renal origin. 
 
 Wilks, in 1869, described a case in which the right kidney 
 of a man, aged fifty-three, was converted into a very hard, trans- 
 lucent fibro-cartilage-like mass the size of a child's head. It 
 consisted of nothing but fibrous tissue. The renal pelvis was 
 enormously distended. The new growth had invaded and de- 
 stroyed the renal tissue, and by gradual distension of the renal 
 capsule had preserved the general form of the kidney. In this 
 case a tumour on the right side of the abdomen had been noticed 
 for six years before death, and haematuria and lumbar pain four 
 years before the tumour, so that the growth had probably com- 
 menced ten years before death. 
 
 Dickinson records a case in which a large tumour, weighing 
 six pounds seven and a half ounces, and consisting of inter-branch- 
 ing masses of white fibrous tissue holding a quantity of fatty 
 matter unenclosed in cells, replaced the greater part of the right 
 kidney, and formed a perceptible enlargement in the right hypo- 
 chondrium. 
 
 Bristowe reported a case, very similar to Dickinson's, of a 
 globular, soft, buff-coloured tumour, yielding a cream-like juice, 
 affecting only part of the kidney, and covered with large tor- 
 tuous veins. On section it was divided by fibrous septa into 
 segments varying in size from a walnut to a bean. 
 
 Both of these tumours w r ere probably degenerated sarcomata. 
 Indeed, Dickinson states that, by means of methods of section 
 not in use when these growths were presented to the Pathological 
 Society of London, he subsequently arrived at the conclusion 
 that his own specimen had the characteristic structure of a small- 
 celled sarcoma in which extensive fatty degeneration had occurred. 
 
 Billroth removed a large fibro-myomatous growth, which 
 weighed nearly forty pounds, from a woman thirty-five years of 
 VOL. I. . 2 o
 
 626 SURGERY OF THE KIDNEY AND URETER. 
 
 age, but the patient died of peritonitis. Thomas successfully 
 removed a very large fibro-cystic growth from a woman aged 
 twenty-one. It had apparently originated from the capsule of 
 the kidney, and had attained the size of a gravid uterus at eight 
 months. 
 
 Bruntzel successfully removed a fibrous tumour, weighing 
 thirty-seven and a half pounds ; and nephrectomy for similar fibrous 
 tumours of the kidney has been performed by Peaslee, Wahl, 
 and Bardenheuer. 
 
 These tumours may undergo degenerative changes; and simple 
 softening may cause extensive cystic transformation. 
 
 The small fibrous tumours the size of a pea or less are not 
 so very rare, and are said to be formed in connection with diffuse 
 interstitial nephritis (Ebstein and Virchow) ; but Sabourin has 
 shown that many of them at least are not fibrous tumours 
 at all, but adenomata, and consist of glandular tissue resembling 
 the true renal parenchyma. Small encapsuled fibromata are 
 often present in the midst of healthy renal tissue, cortical or 
 medullary. Fragments of tubules have been traced into them. 
 
 OSTEOMA AND CHONDROMA. 
 
 Roberts stated that a fibrous tumour growing in the substance 
 of the kidney may ossify and transform a large part of the 
 organ into a bony mass. The fibroois capsule of the kidney has 
 also been known to undergo ossification, as in the historical 
 specimen which Elliston sent to Rayer of two ossified renal 
 capsules taken from a man who died with symptoms of apoplexy. 
 
 Newman points out that many of the so-called bony growths 
 are in reality calcified inflammatory products. Dickinson says : 
 " There are many preparations in museums which show formations 
 within the kidney of bony hardness ; these appear to be usually 
 derived from the transformation of hydatids " ; and he refers to 
 specimens in the museums of Guy's and the Royal College of 
 Surgeons in support of his statement. 
 
 Roberts, referring to changes which take place in pyelitis and 
 pyo-nephrosis, says : " Sometimes the fibrous septa which separate 
 the compartments are extensively calcified. In an example of 
 this kind which was handed to me for examination, a saw was 
 required to cut the kidney across, .and a piece of one of the 
 bony septa which was ground down displayed under the micro-
 
 RENAL LIPOMA DIFFICULT TO DIAGNOSE. 627 
 
 scope the characters of true bone, though in a rudimentary 
 state. A line specimen of similar transformation is preserved 
 in the museum of the Owens College."* 
 
 Cartilaginous growths are still less frequent than bony, and 
 it is really doubtful if such ever occur. Gluge, however, speaks 
 of a growth apparently consisting mainly of cartilage in a hydro- 
 nephrotic kidney, and there is in the Arch. f. Path. Anat., 1886, 
 a note of a chondro-sarcoma having been recorded by Hoisholt of 
 San Francisco. 
 
 LIPOMA. 
 
 True lipomata of the kidney are very rare. They must 
 be distinguished from circumrenal lipomata, which take origin in 
 the substance of or outside the capsule ; as well as from fibro- 
 fatty deposits in and about the kidney, seen after long-standing 
 retention of urine, pyelitis, and inflammation due to calculus. 
 Cases recorded by Weir, Godard, Hullett Brown, and others 
 are examples of fatty transformation associated with calculus, 
 but these and the similar cases associated with septic pyelo- 
 nephritis are degenerative changes, and not new growths. 
 Some of the so-called lipomata described by Robin and Virchow 
 and afterwards studied by Lecampe-Lousteau and by Hartmann 
 have been shown by Grawitz, Lubarsch, Manasse, Miiller, and 
 others to be small sub-capsular inclusions of aberrant adrenal 
 tissue, or of fatty tissue mixed with muscular fibres. Grawitx, 
 however, admitted the occasional occurrence in the kidney of 
 genuine lipomata. Small renal lipomata are apt to be mistaken 
 for metastatic abscesses in persons dying from some suppurative 
 disease, or for secondary new growths in persons dying from some 
 malignant primary disease such as glioma of the brain. Two 
 such cases have been recorded by Dr. Lazarus-Barlow,* one being 
 a man aged seventy years and the other a woman aged thirty 
 years. The lipomata were about the size of a Spanish nut, pale 
 yellow in colour, composed of fatty tissue of the ordinary kind, 
 and were not surrounded by a capsule. 
 
 Various minute tumours fibromata, lipomata of the renal 
 cortex may easily be set down, as Parkes Weber has pointed out, 
 as adenomata if no microscopic examination be made. 
 
 The true lipomata are small, sometimes the size of a millet 
 
 *" Urinary and Kenal Diseases," p. 509 (1885). 
 ]Brit. Med. Journ., Sept. 29, 1900, p. 24.
 
 628 SURGERY OF THE KIDNEY AND URETER. 
 
 seed, seldom larger than a cherry; single or multiple: situated in 
 the cortex, and frequently immediately under the capsule, and not 
 in the region of the hilum where fat is normally present. They 
 are rounded in form, sometimes lobulated, and of a grey colour. To 
 the naked eye they look like papillary adenomata. When mul- 
 tiple and numerous, though each individual tumour is small, 
 they may increase the volume of the kidney to that of a child's 
 head. Renal lipomata are sometimes associated with granular 
 disease of the kidney, and this fact has been used as an argu- 
 ment in support of the view that they originate in a fatty 
 modification of masses of connective or ordinary fibrous tissue. 
 Only a few of the lipomata are composed entirely and purely 
 of fatty tissue. In most, numerous fibrous or muscular fibres 
 are found on microscopic section. " Heteroplastic " lipomata (as 
 Virchow called them, there being no true fatty tissue normally 
 present in the renal parenchyma) result from the fatty trans- 
 formation of connective tissue or fibro-blastic cells. 
 
 Manasse, Lubarsch, and Miiller describe myo-lipomata and 
 lipo-myo-sarcomata, Manasse reported two cases of lipo-myoma 
 in women of eighty -six and forty -four years of age respectively. 
 
 A large amount of fat may be mixed up in a sarcoma, 
 and true malignant growths may undergo fatty degeneration. 
 Fagge uses the term carcinoma lipomatosum to describe a variety 
 of cancer. 
 
 Ebstein records a case of lipoma occurring in the left kidney 
 of an elderly woman, which doubled the natural size of the organ. 
 The patient died of marasmus. 
 
 Warthin, quoted by Kelynack, has recorded a remarkable 
 case of fibro-Hpoma of the left kidney of a woman, aged thirty-one, 
 which caused an irregular tumour the size of a child's head. 
 This growth extended into the pelvis, was fixed and very sensitive 
 on examination. The uterus was anteverted, its cervix patulous, 
 and the vaginal wall on the left side was very tense. The 
 tumour was 14 inches long, 8 inches wide, and 6 inches thick, 
 and weighed two pounds. It was removed by operation, and 
 the patient entirely recovered. It had the appearance of a 
 dilated cystic kidney and ureter, filled with a solid elastic mass. 
 It had grown from the interstitial tissue of the kidney substance 
 and not from the kidney capsule, and in such a manner that 
 the atrophied renal substance, exhibiting the changes of chronic
 
 NEPHREGTOMY FOR LIPOMA RARELY REQUIRED. 029 
 
 nephritis with amyloid degeneration, was spread like a capsule 
 over the tumour. The external surface of this capsule resembled 
 that of the kidney capsule, presented no fatty tissue, but was 
 covered with stringy portions of the perinephritic connective tissue 
 from which it had been separated. The tissue of the tumour 
 passed directly into the connective tissue surrounding the larger 
 blood-vessels between the cortex and the medulla, as well as into 
 that beneath the pelvic epithelium, pushing the pelvic epithelium 
 before it, and so acquiring a surface layer of transitional epi- 
 thelium of the same kind as that of the pelvis. 
 
 The ureter was dilated and thickened, and into it projected 
 a remarkable prolongation of the tumour, six inches long, ter- 
 minating in a smooth blunt end. This prolongation had no 
 attachment whatever to the ureteral walls, though it filled the 
 lumen. The tumour which resembled exactly a large tabulated 
 lipoma as well as the prolongation of it into the ureter, was 
 composed of fibro-adipose tissue. The two elements fibrous tissue 
 and simple lipomatous tissue were not equally distributed through- 
 out the tumour ; the sections of some parts were like those of 
 a hard fibroma, with but few fat cells ; in other sections, the 
 fat cells greatly predominated over the fibrous tissue, and the 
 typical appearances of adipose tissue perfectly resembling an 
 ordinary simple lipoma were presented. There was nowhere any 
 resemblance to sarcoma. The mucous membrane of the ureter 
 was thickened and uneven, presenting to the eye small cyst-like 
 papillae yellowish or brownish in colour. These little cyst-like 
 bodies were formed of exudation material and blood collected 
 beneath the epithelium, and were not simple retention cysts 
 due to the closure of mucous glands in the mucosa of the 
 ureter. 
 
 Alsberg,* some years ago, also operated upon a case of 
 renal lipoma by removing the right kidney, enlarged to the 
 size of a child's head, supposing it to be malignant, from a 
 woman aged forty. The kidney was found to contain a large 
 number of the lipomata and fibro-lipomata, varying in size from 
 a millet seed to a walnut. P. Weber, who has investigated 
 the subject, believes Alsberg's and Warthin's cases to be the 
 only instances in which a surgical operation has been required 
 on account of renal lipomata. 
 
 * Archiv f. klin. Chirurgie, Berlin, 1892, vol. xliv., p. 458.
 
 630 SURGERY OF THE KIDNEY AND URETER. 
 
 ANGEIOMA. 
 
 It has been questioned whether angeioma ought to be in- 
 cluded amongst . tumours of the kidney ; whether it is anything 
 more than a " vascular ecstasis." It is customary, however, 
 and there are good reasons for so doing, to regard it as a dis- 
 tinct formation, or new growth, of reticulated cavernous tissue. 
 
 True angeioma, or simple naevus, is very rare. In structure 
 it is practically the same as the cavernous angeioma or erectile 
 tumours of the liver and parotid. It may or may not be en- 
 capsulated ; it is usually of a bright red colour ; it varies in 
 size from a cherry-stone to a walnut, and is situated either in 
 the medullary substance or immediately beneath the capsule. 
 Though called a tumour, the surface of the kidney over the 
 angeioma and the parts around it may be shrunken rather than 
 prominent or enlarged. 
 
 A simple angeioma may have a clinical importance as well as 
 an anatomico-pathological interest. In a case in which I was 
 consulted in 1897 severe intermittent haematuria as well as 
 slight pyuria was present. A young woman, aged twenty-three, 
 was taken ill with swelling of the cellular tissue about the trachea, 
 superficial ulceration over each vocal chord, and suppurative 
 cellulitis of the right leg. She had at this time profuse haema- 
 turia and slight pyuria, with left lumbar pain ; and she gave 
 the history of having had previously, over a period of some years, 
 several attacks of haematuria, with pain in the left loin. Each 
 attack lasted on an average for from three to four days. She 
 died with symptoms of septicaemia eleven days after the onset 
 of the cellulitis. On the day of her death she was comatose, 
 and passed very little urine. Her temperature at death was 
 107'4. At the post-mortem examination the cause of the haema- 
 turia turned out to be multiple aiigeiomata in the left kidney, 
 one of which had ulcerated into the upper calyces. This kidney 
 weighed eight ounces ; its pelvis contained some blood ; there 
 was no calculus, though one had been suspected ; the ureter 
 was normal. The renal tissue in the neighbourhood of the 
 ulcerated calyces showed a peculiar plexiform arrangement of 
 vessels like an angeioma. There were areas of red spongy tissue 
 in the renal substance, all in the medullary rather than in the 
 cortical structure of the organ. Thev had extended into the
 
 RENAL ANGEIOMA OF CLINICAL IMPORTANCE. 631 
 
 kidney between the papillae, thus following the course of the 
 vessels. To the naked eye the angeiomata had no distinct cap- 
 sule, and their cut surfaces showed the open mouths of two or 
 three large vessels, with a wide zone of cavernous tissue sur- 
 rounding them. Microscopically, these areas were composed of 
 a collection of vascular spaces, as in an angeioma. The walls 
 of the spaces were composed of muscle tissue, without elastic 
 laminse, and resembled venous channels. Some of them, 
 however, seemed to be mere spaces in fibrous tissue. They 
 were mostly filled with red and white cells ; very little fibrin 
 was discoverable. In one part there was some extra vasated blood, 
 and much granular matter, probably old clot. There were no 
 signs whatever of malignant disease. The cortex of the kidney 
 showed some interstitial thickening, but the glandular tissue was 
 normal except for post-mortem change. The right kidney 
 weighed eight and a half ounces ; it was in a state of interstitial 
 nephritis ; its pelvis and ureter were normal. 
 
 Angeioma must not be confused with simple haemorrhage, 
 nor with the hsemorrhagic forms of cystic adenoma or sarco- 
 matous teleangeiectasis. 
 
 Allen and Cherry,* in their exhaustive account of the histology 
 of twenty-nine cases of primary neoplasms in the kidney con- 
 tained in the Pathological Museum of the University of Melbourne, 
 remark : " True angeioma of the kidney may show all grades of 
 capillary dilatation until networks of inter-communicating vascular 
 spaces are formed. In the neighbourhood of a simple angeioma 
 the epithelial cells of the renal tubes may be active, with deeply 
 staining nuclei." 
 
 Rolleston and Kanthackf have described a peculiar form of 
 vascular growth which they met with in the left kidney of a man 
 (sixty-two) who died of epithelioma of the lower part of the pharynx. 
 Projecting from its convex border, and embedded in the kidney, 
 was an irregular lobulated tumour about the size of a walnut. 
 On section, it was very vascular to the naked eye, and from the 
 large quantity of blood in it it was thought to be a cavernous 
 angeioma. It was marked off from the renal parenchyma by a 
 capsule, which was not adherent to the renal capsule. The 
 structure of the tumour suggested convoluted and straight tubules 
 
 * International Medical Congress of Australasia, Fourth Session, 1897. 
 t Journal of Path, and Bacterial., 1894, vol. ii., p. 80.
 
 632 SURGERY OF THE KIDNEY AND URETER. 
 
 of the kidney, which had been distended by circulatory blood 
 derived from the capillaries of the Malpighian tufts, and not a new 
 growth. 
 
 In parts of the tumour the remains of a few Malpighian 
 bodies were made out. The epithelium lining the inner surface 
 of Bowman's capsule contained large fat globules, while the epi- 
 thelium covering the capillary tufts was unchanged. Fat globules 
 were universally present in the epithelium lining the spaces and 
 tubes throughout the tumour, whether collapsed or distended with 
 blood, while the remainder of the kidney showed no marked 
 degeneration. 
 
 LYMPHANGEIOMA, 
 
 which is very rare, consists of small, soft nodes of connective 
 tissue limiting small cavities filled with pigmentary and fatty 
 granules ; such growths have been described by Heschl,* but have 
 been placed by Klebsf among the adenomata. 
 
 MYXOMA. 
 
 A case of pure myxoma of the kidney has been described 
 and illustrated by Bezold. He found several small, opalescent, 
 bluish-white nodules of mucous-like tissue in the cortical 
 substance of the kidney. Hollen, in an inaugural address 
 (Greifswald, 1890), mentions a case in which a pure myxoma 
 was situated on the level of the hilum of the kidney. Turner 
 speaks of having seen a case in which the tumour followed a 
 calculous pyelo-nephritis : the patient died without metastases. 
 In a man, aged thirty-nine, who was a patient in the Middlesex 
 Hospital, simple myxoma rapidly developed into a large tumour, 
 causing death within a year from the first discovery of the swell- 
 ing. The symptoms were merely those due to pressure, wasting, 
 and pain ; there was no haematuria, nor was there any metastasis. 
 Myxomatous changes occur in tumours of other kinds, and 
 myxo-sarcoma sometimes occurs in the kidney. 
 
 * Arch. General de Med., 1366, F. ii., p. 617. 
 t Handbch. der Path. Anat.
 
 033 
 
 CHAPTER XXI. 
 TUMOURS OF THE RENAL PARENCHYMA. 
 
 (Continued.} 
 (C) CYSTS OF THE KIDNEY. 
 
 THERE are several forms of cysts in the parenchyma of the kidney : 
 
 1. The small and numerous cysts which occur in granular 
 kidneys, and which are of pathological rather than clinical im- 
 portance. They never give rise to tumour, and are not amenable 
 to surgical treatment. They present in the form of small vesicles, 
 from the size of a pin's head to a small cherry or larger. They 
 may be few or numerous. They are seen upon the surface of 
 the organ, projecting slightly, as minute cysts with clear contents 
 and very thin transparent walls; or, upon section of the organ 
 they may be seen deeply within the cortex in the zone between 
 the cortex and the pyramids, or even in the medullary part itself. 
 The cysts within the organ are smaller than many of those near 
 the surface. The fluid within these cysts is yellow, clear, limpid 
 and serous, not urinous. They result from the compression and 
 constriction of urinary tubules due to the sclerosis which follows 
 interstitial nephritis. They are, in fact, obstruction or retention 
 cysts. 
 
 2. Dermoid cysts. Such cases occur in animals. There is .a 
 specimen in the Hunteriaii Museum containing wool rolled up 
 with oil and fatty matter. It was removed from the body of a 
 sheep, and was occupying the natural position of one of the 
 kidneys, which was deficient. I personally have not met with any 
 instance of such a cyst in the human body. Though included in 
 the classification of the Liverpool committee,* no specimen came 
 under the direct or indirect notice of the gentlemen who formed 
 that committee. Cases have, however, been recorded by Paget, 
 Madelung, Walker, and Biggs.f In Walker's case there were three 
 dermoid and several serous cysts present. In Biggs's case the 
 
 * See Mr. Paul's paper, Brit. Med. Journ., Jan. 12th, 1884. 
 t New York Path. Soc. Trans., Ixxxviii.
 
 634 SURGERY OF THE KIDNEY AND URETER. 
 
 kidney was small, with six or seven cysts varying in size from a 
 pea to a filbert, containing fatty pasty matter composed of choles- 
 terine crystals, fat globules, epithelium and granular corpuscles. A 
 doubtful case was recorded by Jackson,* which however may have 
 been a dead hydatid cyst or a changed tuberculous kidney. The 
 cyst was removed from a woman aged seventy-seven who died 
 of cancer of the uterus. It measured six by three and a half 
 inches, was entirely cretaceous, and contained a material like 
 plaster-of-Paris mixed with water and about to set. This material 
 consisted of carbonate and phosphate and oxalate of lime in about 
 equal proportions, with a little carbonate of magnesium and triple 
 phosphate. 
 
 3. Simple cysts. 
 
 4. Conglomerate cysts, polycystic disease or cystic metamorphosis 
 of the kidney. This form of disease is sometimes congenital ; 
 sometimes found in adults. The kidneys thus affected are occa- 
 sionally of great size, and present themselves as abdominal swellings. 
 
 5. Hydatid cysts. 
 
 6. Paranephric cysts, or cysts which are external to the 
 capsule, and formed in the circumrenal fatty tissue, but which 
 are intimately adherent to the kidney, and sometimes communicate 
 with the renal cavity. They are indistinguishable in their clinical 
 aspects from some of the cystic formations of the kidney itself. 
 
 SIMPLE OR SEROUS CYSTS. 
 
 Distinct from that form of cystic distension of the whole 
 organ which results from obstruction in the ureter, and which is 
 commonly known as hydro-nephrosis ; distinct also from that 
 rather rare form of disease in which the whole kidney is con- 
 verted into a mass of conglomerate cysts ; and distinct, too, from 
 the cysts of small or microscopic size met with in great numbers 
 in the " granular kidney," there are simple cysts frequently seen 
 in the kidneys of elderly people, one or more of which may attain 
 considerable size, and so constitute a disease of great importance 
 (Figs. 98, 99, 100). 
 
 In the Museum of the Middlesex Hospital are some beautiful 
 
 specimens of this form of cyst, though none of them is, perhaps, 
 
 of a size to have formed a very noticeable tumour during life. 
 
 In the Hunterian Museum there are three specimens of this sort, 
 
 * The Boston Medical Journal, April, 1874, p. 408.
 
 SIMPLE CYSTS USUALLY WITHOUT SYMPTOMS. 
 
 635 
 
 and the Transactions of the Pathological Society of London con- 
 tain scattered through the volumes the records of some cases. 
 
 Simple cysts cause no symptoms except those due to their 
 size ; probably not one-fourth of them reach a size large enough 
 
 Fig. 98. Two views of a Kidney containing Blind Serous Cysts. 
 (Middlesex Hospital Museum.) 
 
 to attract attention during life ; and not one-third could be 
 detected if deliberately sought for by palpation. 
 
 Pathological anatomy. These large cysts are frequently 
 single, but one or two small cysts, or sometimes even many (as in Fig. 
 98), may be present by the side of the large one. They are met 
 with in any part of the organ and upon either surface, but their
 
 636 SURGERY OF THE KlDNEY AND URETER. 
 
 ordinary situation is at one or other end of the kidney. Their 
 form is round. The cyst wall, composed of connective tissue, 
 is smooth, thin, and transparent, and adheres so closely to 
 the renal tissue that it cannot be enucleated but has to be dis- 
 sected away. Its external surface is quite smooth, and its internal 
 surface is lined with tesselated epithelium. Occasionally the cyst 
 wall is of great thickness, semi-cartilaginous in places, or here and 
 there impregnated with salts ; or fibrous bands may project on its 
 inner aspect, and veins of varying size course beneath the mucous 
 lining. The cyst capsule, which bulges the renal capsule, is really 
 not formed by it, though it may seem to be so. 
 
 These cysts vary in size from that of a walnut or orange to 
 that of a large ovarian cyst. Newman states that there is in the 
 Museum of the Koyal Infirmary at Glasgow a very large thin- 
 walled cyst which projects from the middle of the convex border 
 of the kidney ; the cortical substance is entirely and the 
 pyramidal portion in great part destroyed, and the cyst 
 almost extends to the renal pelvis but does not open into it, 
 the cyst cavity and the pelvic cavity being separated from one 
 another by a thin wall of renal tissue. Microscopically the rest 
 of the kidney proved to be healthy, except where more or less 
 altered by direct pressure of the cyst. In a case in his own 
 practice Newman found a large simple peripheral cyst, which 
 projected from the posterior aspect of the kidney, deeply indenting 
 the renal substance, so that its deepest part extended to the renal 
 pelvis, but did not open into it. 
 
 In a case which I saw in 1869-70 * the greater part 
 of the abdominal cavity was occupied by a large fluctuating 
 cyst, involving the lower part of the left kidney, which was 
 spread out in a thin layer over the attached part of the 
 cyst. The upper half of the kidney was normal, except for 
 a small nodule of medullary cancer. The ureter, with the 
 spermatic artery and vein, took a very curved course to the 
 bony pelvis along the back of the cyst. The fibrous capsule 
 of the kidney was continued over the cyst. In the ex- 
 panded portion of the renal parenchyma was a second small trans- 
 parent cyst the size of a currant. Some of the calyces were seen 
 to extend into that part of the kidney which was spread out 
 over the cyst, but did not communicate with it. The ureter in 
 * Path. Soc. Trans., vol. xxii., p. 171.
 
 LARGE CYSTS CAUSING FLUCTUATING TUMOURS. 637 
 
 the greater portion of its length was of normal size and closely 
 adherent to the back of the tumour. The cyst with its contents 
 weighed sixteen pounds, and measured twenty-nine inches in one 
 diameter and twenty-six inches in another. It was filled with a 
 dirty brown fluid, and discoloured blood-clot, looking like coffee- 
 grounds ; much of the clot was deposited in layers on its inner sur- 
 face, but there was also evidence of recent blood extravasation into 
 the cyst cavity, The cyst wall averaged about one-eighth of an 
 inch in thickness, but was not uniform throughout, being in some 
 
 3/5 
 
 Fig. 99. Large simple Cyst communicating with a Calyx of the Kidney; the 
 Eenal Pelvis dilated. (Middlesex Hospital Museum.) 
 
 places thinner, in others thicker. Its outer surface was smooth, 
 except where uncovered by peritoneum, and was marked by 
 large veins meandering in it. Branches of the renal artery and 
 vein were traced into its walls. The presence of the cancer 
 was a coincidence, and had nothing to do with the etiology of 
 the cyst. 
 
 The sizes of the cysts in the Hunteriaii Museum are respec- 
 tively six, four, and three inches in diameter ; two of them occur 
 in granular kidneys ; one has associated with it a few others, 
 of the same kind, but only a line or two in diameter. The largest 
 cyst is situated on the outer aspect of, but deeply embedded in, 
 the kidney; the others are on the anterior surface close beneath
 
 638 
 
 SURGERY OF THE KIDNEY AND URETER. 
 
 the capsule, and more or less coalesced with it. Of eight cases 
 of cystic formations in the kidney met with in 2,610 post-mortem 
 examinations at the Middlesex Hospital, five were single cysts> 
 and three were specimens of large cystic degeneration in the adult. 
 In one of the five cases of single cyst the tumour was as large 
 as a Tangierine orange, had very thin walls, and sprang from 
 the lower end of the kidney ; in another the cyst, filled with 
 serous fluid, grew from the upper end of the organ, and was 
 
 Fig. 100. View of the same Kidney and Cyst in section. (Middlesex 
 Hospital Museum.) 
 
 the size of a medlar ; in the third it was situated at the upper 
 end of the right kidney, and the left kidney was granular and 
 had small cysts in it ; in the fourth the cyst grew from the lower 
 part of the left kidney, had calcined walls and gelatinous contents, 
 and was of the size of a horse-chestnut ; in the fifth case each 
 of the kidneys had a single cyst, each the size of an olive, and filled 
 with clear brown fluid. The ages of these patients were forty-nine, 
 fifty -five, fifty-nine, nineteen, and sixty-one. All died of causes 
 independent of the kidneys. In another case in which the pelvis 
 of the kidney of a woman aged seventy-five was dilated owing to 
 a block in the ureter from new growth secondary to carcinoma
 
 CONTENTS OF CYST NOT URINOUS. 639 
 
 of the bowel, there was behind the kidney a paranephric cyst 
 the anterior wall of which was formed by the kidney capsule and 
 the outer and posterior walls by the condensed connective tissue. 
 There was a small communication between the cyst and the 
 dilated renal pelvis. 
 
 These simple cysts arise in the cortex of the organ, and 
 project in relief from its surface. As they grow they tend to 
 spread out the renal substance, so that a large part of the kidney 
 may be stretched in a thin layer over the base of the cyst wall. 
 The rest of the kidney will be healthy and functionally active, 
 or it may be granular, or more or less atrophied from the pres- 
 sure of the cyst itself. Sometimes a communication is established 
 between the cysts and one of the calyces of the kidney (Figs. 
 99 and 100). 
 
 The contents of the cysts are generally a clear, colourless, 
 or straw-coloured fluid, containing a small quantity of albumen 
 and a little saline matter, but rarely, if ever, anything more 
 than the merest trace of urea or other special urinary in- 
 gredients. Ilokitaiisky \vas never able to discover in them even a 
 trace of urinous precipitates or concretions. Dr. William Walter* 
 records a case of cystic tumour in a floating kidney, for which 
 iiephrectomy was performed. The cyst contained ten ounces of a 
 pale, straw-coloured fluid, of specific gravity 1,013, holding two- 
 fifths albumen ; it was not urine. The' walls of the cyst were 
 very thin and tense, and of transparent bluish hue. In Mr. 
 Caesar Hawkins' case of " aqueous encysted tumour " of the kidney 
 the transparent fluid of the cysts contained no albumen, w r hich 
 suggested its possible hydatid nature; but Dr. Prout wrote of it, 
 " The fluid is serous ; I have not detected anything urinary in it." f 
 
 Haemorrhage may take place into the cyst cavity either as the 
 result of injury or of extravasation from one or other of the 
 veins, often quite large, which ramify in the cyst walls. 
 
 If haemorrhage has taken place the fluid will, of course, 
 have a sanguineous colour and character. Very often some of 
 these cysts contain a thick jelly-like matter, like thin glue, and 
 others a nearly solid substance which resembles the colloid material 
 found in other parts of the body. Cholesterine is sometimes 
 present, especially in cysts which contain blood-stained fluid. 
 
 * Brit. Med. Journ., Sept. 29th, 1883. 
 t Med.-Chir. Trans., vol. xviii., p. 186.
 
 640 SURGERY OF THE KIDNEY AND URETER. 
 
 Rokitansky once found such a cyst of considerable size, seated 
 at the circumference of a kidney, inflamed and ruptured, its con- 
 tents having escaped into the surrounding adipose tissue. 
 
 Pathogenesis. The origin of these cysts is uncertain ; 
 possibly they arise from the conversion of the cellular layer in 
 the Malpighian corpuscles into serous cysts, or from the dilatation 
 of tubes or Malpighian capsules, or perhaps from vacuolation of 
 epithelium. The following questions arise concerning them : 
 (1) Are they retention cysts consecutive to sclerosis of the inter- 
 tubular tissue following chronic interstitial nephritis, or are they 
 truly new formations ? (2) Do they arise from the convoluted 
 tubules or from the Malpighian capsules ? 
 
 But however these questions may be answered, we know 
 that the fluid contents of cysts of different origin, and even of 
 varying microscopical structure, may be physically and chemically 
 alike. 
 
 Etiology. It is stated by some writers that the large simple 
 cysts are much more frequent in women than in men. Turner 
 gives the proportion as twenty to three. In the only two cases 
 recorded by Newman the patients were males, aged respectively 
 sixty-one and forty-nine. In the remarkable case which I pub- 
 lished many years ago in the Transactions of the Pathological 
 Society the patient was a male aged sixty-nine. In the five 
 cases referred to above collected from the Middlesex Hospital 
 post-mortem records three were in men and two in women. 
 
 These cysts occur in either kidney alike, but are rarely bilateral. 
 The}' affect persons in middle and advanced life. They are 
 probably in every instance due to localised obstruction special to 
 the tubule or tubules in which the cyst originates. Whatever 
 may be the cause, intra-tubular or peri-tubular, congenital or ac- 
 quired, traumatic or inflammatory, and whether it be blood-clot, 
 tube-cast or calculus which obstructs the tubuli uriniferi, the secre- 
 tion accumulates behind the obstruction and distends the Malpighian 
 capsule or tubule, as the case may be, until a thin-walled cyst is 
 developed. It is probable that in some of the cases several 
 tubules are obstructed, and that the resulting cysts break into 
 each other and then expand as a single cavity. 
 
 Symptoms. Simple renal cysts commence insidiously, grow 
 slowly, and, as a rule, do not attain to a size sufficiently great 
 to give rise to a tumour which can be discovered by palpation.
 
 CYSTIC TUMOUR MOVING WITH KIDNEY. 
 
 641 
 
 When of such a size as to be detected clinically they present 
 themselves first in the loin or in the lumbar area of the 
 front of the belly, and may be so hard at first as to be mis- 
 taken for solid growths; or they may fluctuate, give a dull note 
 on percussion in the loin, and if the cyst be situated on the 
 posterior aspect of the organ the kidne} 7 may be felt to be well- 
 defined and movable on the front aspect of the swelling. In 
 
 Fig. 101. Kidney with a Double Ureter and Double Pelvis. A cyst the size of 
 an orange projects from the outer border of the kidney and a few small 
 cysts are scattered through the renal substance. A pyramidal calculus 
 occupies the lower renal pelvis. (St. Thomas's Hospital Museum, No. 2110.) 
 
 some cases the tumour moves with the kidney, and if at the 
 same time fluctuation is detected the diagnosis will probably be 
 " hydro-nephrosis in a movable kidney." As the cyst increases 
 it may gradually monopolise the greater part of the abdominal 
 cavity ; if it does so, its point of attachment ceases to be even 
 approximately ascertainable ; in the female it may give rise to 
 the idea of ovarian tumour. Pain may follow the formation 
 of a tumour, and may even, though much more rarely, precede it ; 
 it is of a dull aching character and gives rise to a sensation of 
 VOL. I. 2 P
 
 642 SURGERY OF THE KIDNEY AND URETER. 
 
 weight limited to the loin and hypochondrium ; at times, espe- 
 cially after much exertion, the pain may be more severe. 
 
 The general symptoms which may be met with are sickness 
 after food, weakness and inability to work ; cardiac weakness 
 has been noticed. The urine usually remains regular in quan- 
 tity and normal in amount. Emaciation, increasing debility, and 
 at last utter prostration may mark the growth of a cyst to a 
 great size. 
 
 Diagnosis. The difficulty in the diagnosis of these cysts 
 will be apparent from the reports of such cases as those recorded 
 by the author * and Dr. Bristowe.t The symptoms excited are 
 merely those of pressure, and are therefore not unlike the symptoms 
 of other abdominal swellings. The locality of the tumour in its 
 earlier stages will somewhat aid the surgeon in correctly judging of 
 the organ affected ; but not even then in estimating precisely the 
 character of the swelling. In Bristowe's case, in its symptoms, 
 position, and cure by repeated tappings, the tumour resembled 
 some of those false cysts which are formed by adhesions after 
 rupture of the kidney (or liver ) and which have been described 
 in previous sections. My own case in its early days was most 
 like one of solid tumour in the abdominal walls, and afterwards, 
 like Bristowe's, might have been mistaken for ovarian disease had 
 the patient been a woman. The relative position of bowel to 
 ovarian cyst, as compared with that of bowel to renal tumour, 
 would not have assisted a differential diagnosis in either instance. 
 Nor did the character of the urine. Bristowe, in the same 
 number of the Lancet, recorded another case which simulated 
 his first case, but which on post-mortem examination turned 
 out to be a round-celled sarcoma growing from among the pelvic 
 viscera and containing a large haemorrhagic cyst. The cyst was 
 tapped five times, fluid of a reddish-brown colour, alkaline reaction, 
 and specific gravity 1024, being drawn off in quantities varying 
 from 74 to 167 ounces. 
 
 Adenomata and other new growths of the kidney have a 
 tendency to become cystic, the cysts in some instances attaining 
 
 * Trans. Path. Soc., vol. xxii., p. 171. 
 
 t Lancet, May 5th, 1883 ; and previously published in St. Thomas's 
 Hospital Reports. 
 
 I See article by author in Ashhurst's " International Encyclopaedia of 
 Surgery."
 
 DIFFICULTY IN DIAGNOSING SIMPLE CYST. C43 
 
 a great size, whilst the proportion of solid new growth is very 
 small indeed. It is thus impossible without a careful microscopical 
 examination of the cyst wall to be absolutely certain of the true 
 nature of the cyst. The histological characters of the tissue spread 
 out upon the attached part of the wall of a simple cyst are 
 those of normal renal tissue, or renal tissue but slightly sclerosecl 
 as well as compressed. 
 
 Thus the difficulties which surround the diagnosis of these very 
 rare cysts are extremely great ; for not only may they be mistaken 
 for hydatids of the kidney, for hydro-nephrosis, and other renal 
 tumours and perinephric fluid collections, but it is moreover 
 almost impossible, after using every care in examination, to dis- 
 tinguish them sometimes from solid tumours in the parietes ; 
 sometimes from hepatic or splenic cysts, or cysts of the omentum, 
 mesentery, or pancreas ; sometimes from malignant cystic tu- 
 mours springing from the pelvis or elsewhere within the belly, 
 and sometimes (indeed generally, in their later stages) in the 
 female from ovarian cysts. 
 
 Prognosis. The growth of these cysts is always slow, and 
 it is only by their size and the compression effects which they cause 
 when of great dimensions that they are injurious. They compress, 
 and tend to produce sclerosis of the renal parenchyma, and for 
 that reason their removal is a matter of importance. If removed 
 when small or of but moderate size, the kidneys from which 
 they arise will probably be left unaffected. 
 
 Treatment. The treatment by puncture, recommended in 
 the earlier days of renal surgery, should no longer be employed. 
 As a means of diagnosis between simple serous cysts and simple 
 chronic hydro-nephrosis puncture is useless, although it would 
 probably enable a hydatid cyst to be diagnosed from the other 
 two forms of enlargement just mentioned. As a method of treat- 
 ment it is uncertain, and not free from risks ; and if the cyst 
 refills again and again, puncture, though ultimately successful, is 
 unnecessarily tedious. It has been employed with success for 
 simple serous cysts as for hydro-nephrosis ; but it is not to be 
 compared with incision and drainage, or with excision being so 
 often followed by reaccumulation of the contents of the cyst. 
 Partial and total nephrectomy have been employed, but ought 
 to be reserved for cases in which the cyst is of voluminous 
 size and has in great part destroyed the renal tissue.
 
 644 SURGERY OF THE KIDNEY AND URETER. 
 
 For cysts of moderate size, especially when situated at one 
 of the extremities or in the posterior surface of the kidney, the* 
 most perfect and satisfactory plan is that which Turner and 
 Bardenheuer have practised in one case each, namely, the excision 
 of the cyst from its renal couch through a lumbar incision. 
 These cysts will not readily shell out, as does an adenoma from 
 the thyroid for instance, but require to be dissected away. This 
 
 Fig. 102. Cyst of the Eight Kidney, from a man jt. 76. There was cirrhosis of the 
 liver, with jaundice. The cyst, which was not connected with the renal 
 pelvis, contained two ounces of dark green turbid fluid. (Middlesex Hospital 
 Museum.) 
 
 can be done without removing any, or at most but the smallest 
 quantity of renal tissue. It leaves, however, fresh-cut surfaces 
 in the kidney tissue of greater or less depth dependent on the 
 degree of penetration of the cyst ; these surfaces should be 
 brought into apposition by means of fine silk or catgut sutures 
 as after removal of a wedge of renal tissue for tubercle or new 
 growth. Turner's case was quite successful, but Bardenheuer 
 had to perform nephrectomy upon his patient five days later 
 because of septic infection of the kidney. This plan is, I consider, 
 preferable to primary nephrectomy for cases in which there are 
 one or perhaps two cysts of moderate size, even if several others
 
 OPERATIVE TREATMENT OF SIMPLE CYST. 645 
 
 of minute size are studded about within the renal cortex, as is 
 seen to be the case in Fig. 102. 
 
 Another plan is to expose the cyst through a lumbar incision, 
 and, after emptying it and cutting away all the projecting part 
 of the cyst wall, to stitch the shortened edges of the part still 
 connected with the renal parenchyma to the deep layer of the 
 lumbar fascia after destroying its secreting surface with pure 
 carbolic acid or nitric acid. A small drain tube should be 
 retained for a few days, and the rest of the wound in the lumbar 
 parietes should be closed by sutures. 
 
 A third plan for cysts of large size is to cut down through 
 the linea semilunaris upon the front or side of the tumour, 
 and, after drawing off the fluid contents, to incise the wall of 
 the cyst and stitch its cut edges to the cut edge of the abdominal 
 parietes, and then drain the cyst cavity. This treatment leads to 
 subsequent contraction and in some cases to complete oblitera- 
 tion of the cyst either by adhesion of the collapsed surfaces 
 or by granulation after suppuration. It, however, cannot be 
 recommended. Five cases at least have been so dealt with under 
 the impression, formed before the operation was commenced, 
 that the tumour was ovarian. All the patients recovered, but 
 a fistula followed in three of them. If a fistula should remain 
 and prove troublesome, the question of nephrectomy may be con- 
 sidered ; but it must be borne in mind that the kidney structure 
 in these cases is functionally useful, and therefore the organ 
 ought not to be sacrificed without specially strong reasons. 
 
 Primary nephrectomy for removal of the cyst may be neces- 
 sitated by the great size and pressure effects of the tumour and 
 the relations of the cyst to the renal parenchyma and renal 
 vessels, large branches of which sometimes run into and spread 
 over its walls. Tuffier has collected thirty-one cases in which 
 ablation of the kidney with the tumour has been performed, 
 seven times by the lumbar method with a mortality of 11 per 
 cent., and twenty-four times by the trans-peritoneal method with 
 a mortality of 40 per cent. Nephrectomy must be avoided 
 when possible. 
 
 Partial nephrectomy should be performed when the cyst 
 is situated at one pole of the kidney and a considerable part of 
 the renal parenchyma is spread out over the cyst wall, and if 
 the large renal vessels can be left intact.
 
 646 SURGERY OF THE KIDNEY AND URETER. 
 
 THE LARGE POLYCYSTIC KIDNEY. 
 
 " The large polycystic kidney " has been described under a 
 variety of names, such as " cystic disease," " conglomerated cysts," 
 " congeries of renal cysts," " cystic degeneration of the kidneys " 
 (Bayer), and " cystic metamorphosis or transformation of the 
 kidney " (Cruveilhier). I shall use the term " the large polycystic 
 kidney," rather than that of " cystic disease," which is more 
 generally employed b}^ English authors, because the latter seems 
 to me in a way to prejudge the nature of a lesion which is 
 still but very imperfectly understood. Moreover, the term "cystic 
 disease " is often used indifferently for a number of cystic states 
 of the kidney, and if employed at all had best be kept as a 
 general title to embrace the entire group. The cases of multiple 
 small cysts which occur in ordinary chronic interstitial nephritis, 
 and the large simple serous cysts previously described, as well as 
 the cysts of parasitic origin, are excluded from this class of 
 " large polycystic kidneys." 
 
 Pathological anatomy. In the lesion now to be con- 
 sidered the whole kidney is converted into a vast number of 
 conglomerated cysts of varying size, which leave unchanged 
 scarcely any (if any) portions of the glandular structure, and 
 give a greatly increased bulk to the metamorphosed organ. Some- 
 times the cystic organ is ten times as large as the normal 
 kidney. 
 
 The shape of the kidney is fairly well retained by the enlarged 
 mass, which often weighs a pound or two, sometimes five or 
 six pounds ; and in Dr. Hare's case (probably the largest on 
 record) the left kidney measured fifteen and a quarter inches 
 in length and weighed sixteen pounds, the right kidney being 
 double its normal weight. 
 
 The medullary and cortical portions are alike replaced by 
 the cysts which bulge the capsule and protrude on the surface 
 as oval or circular translucent sacs (Figs. 103 and 104). The cysts vary 
 in size from microscopic minuteness to the dimensions of grapes 
 or walnuts, the largest being often in the centre of the organ. 
 In Dr. Hare's case one of the cysts held half a pint of fluid. 
 
 Content* of tlir cyxta. The cysts contain different coloured 
 fluids clear, pale straw coloured, deep yellowish, purplish, or 
 deeply blood stained. These variously coloured contents are either
 
 PATHOLOGY OF POLYCYSTIC KIDNEY. 647 
 
 serous, limpid, and transparent ; or viscid, turbid, treacly, colloid, 
 or pea-soup like; or caseous, and sometimes even almost solid. 
 Occasionally they are purulent, as in the case reported by William 
 F. Farr* which occurred in a woman aged fifty-three, who for seven 
 years had suffered from rigors and fever. The contents of the cysts 
 are acid or neutral in reaction, and consist of a large quantity 
 of albumen, some urea, a variable amount of triple phosphates, 
 molecules of fat, epithelium, crystals of cholesterin and of uric 
 acid, blood corpuscles, and occasionally leucin. The colloid 
 material in the smaller cysts is homogeneous, in some of the larger 
 cysts it is disposed in concentric layers. In certain of the medium 
 sized cysts may be found little connective tissue vegetations 
 covered with several layers of epithelium resembling the papillary 
 proliferations in ovarian cysts. Eitchie states that there are 
 diverticula containing renal elements tubules and blood vessels 
 projecting into cyst cavities. The cysts do not communicate 
 with the pelvis or calyces, but often with each other. They 
 are closed cavities whose walls are excessively thin, composed 
 of connective tissue and lined by a delicate layer of cubical or 
 pavement epithelium. The original renal substance is atrophied 
 and in some places wholly removed, in other places portions 
 remain unchanged between the cysts ; and in other places, again, 
 .around, between, and even at a distance from the cyst wall, the 
 renal tissue is sclerosed, and the arteries show signs of endarteritis 
 and periarteritis. 
 
 The connective tissue varies in amount in different cases, 
 and may be either very fibrous or hyaline. In most there 
 is an increase, and in very advanced cases the increase may be 
 considerable. Leucocytes and increased numbers of connective 
 tissue corpuscles are seen even at a distance from the cysts, 
 giving evidence of local irritation. All stages of changes are 
 to be seen in the tubules and Halpighian capsules, from slight 
 dilatation to actual cyst formation. In some of the capsules 
 the remains of the glomerulus may be detected. The epithelium is 
 undergoing degenerative changes, the nuclei are shrivelled or absent 
 and stain badly, and large epithelial shreds become detached from 
 the walls of the cysts during the process of preparing the specimens. 
 
 The perinephric tissue has in a small number of recorded 
 cases been the seat of abscess, -but when this is the case there 
 * Amer. Journ. Med. Sciences, vol. ciii., p. 277 (1892).
 
 648 
 
 SURGERY OF THE KIDNEY AND URETER. 
 
 has been usually suppuration in some of the cysts also, one or 
 more of which have broken on the surface of the organ. 
 The kidney by its weight sometimes becomes displaced, and in 
 many cases is very mobile. 
 
 Sometimes the renal pelvis, but not the ureter, is much dilated. 
 
 Fig. 103. Polycystic Kidney ; the left half seen in section, and the right half on its 
 outer surface. (Middlesex Hospital Museum.) 
 
 The dilatation is due to dragging, not to obstruction. In one 
 of my cases the pelvis was enormously dilated. 
 
 One of the most important features of the disease is that both 
 kidneys are commonly affected. Dickinson found only one case out 
 of twenty-six in which the disease was confined to one kidney. 
 Lejars, out of sixty -two cases in the adult, found only one 
 case which was unilateral, and in that case there was a round 
 cystic space the size of a penny piece in the cortical substance 
 of the other kidney.* Four out of the seven cases in which 
 * See Hogg, Trans. Path Soc., I860, and Lejars' case, 21.
 
 ASSOCIATED CYSTS IN LIVER AND SPLEEN. 649 
 
 I have operated were unilateral. It is rare for the lesion to 
 be equally advanced in the two organs. 
 
 Bristowe,* Wilks, Pye-Smith, and I have described cases in 
 which the " large polycystic kidney " has been associated in the 
 same person with cysts of a similar nature in the liver or spleen. 
 Pye-Smith's f case was one of cystic disease of the liver and of 
 both kidneys in a man, aged fifty-three, who died of pulmonary 
 gangrene, and to his description of the case he added a summary 
 account of the other published cases, commencing with Bristowe's. 
 Lejars has collected fifteen other cases in the adult in which the 
 liver as well as the kidneys of the same individual was the seat of 
 cystic degeneration. He includes Bristowe's and Pye-Smith's cases 
 in his observations, and thus found seventeen out of sixty-two hi 
 which the liver was involved. Ritchie states that on post-mortem 
 examination of eighty-eight cases, both kidneys were found polycystic 
 in all but two. In twenty-one cases the liver was cystic, and of 
 these it is noted that in one case the thyroid, in one the uterus, 
 and in one the ovary was also cystic. In other cases the ureters 
 and bladder were also affected with cystic disease Cystic disease 
 of the liver is but seldom found associated with " congenital cystic 
 kidney." In thirty-five cases of cystic disease of the liver associated 
 with cystic kidney collected by Still,! only three occurred in infancy. 
 Still's statistics show that this associated condition is more common 
 in women than men, for out of twenty-eight cases in which the 
 sex was recorded, twenty-one were females and seven males, thus 
 making the proportion of females to males three to one. 
 
 According to Wilks and Moxon, the cysts are an excessive 
 production of that minuter cystic condition of the kidney which 
 we have already referred to as occurring in granular kidneys ; 
 and as with granular kidneys, so with the large cystic kidney, 
 hypertrophy of the heart is not unfrequently associated. In one 
 of my cases the left ventricle of the heart was much hypertrophied, 
 the right kidney alone being converted into a congeries of cysts, 
 the secreting structure almost gone, and the pelvis enormously 
 dilated ; the left kidney was large and granular, had a wasted 
 cortex, and was puckered in places on the surface. Newman 
 found hypertrophied heart recorded in 60 per cent, out of 105 
 
 * Path. Soc. Trans., vol. vii. 
 t Ibid., vol. xxxii., p. 114. 
 I Ibid., 1898.
 
 650 SURGERY OF THE KIDNEY AND URETER. 
 
 cases which he collected, and the arteries atheromatous in 15 
 per cent. Newman has also observed cystic kidney coincident with 
 malformations of the aortic valves and of the septum ventriculorum. 
 He considers the congenital theory of the origin of this affection 
 in the adult is supported by the co-existence of such deformities. 
 
 " Congeries of renal cysts " sometimes lead to enormous ab- 
 dominal distension of the foetus in utero. Parturition is thus 
 occasionally rendered difficult, or even impossible, and the child, 
 when born, presents the appearance of one having an ovarian 
 cystic tumour. Cystic degeneration with abdominal distension is 
 even a cause of death of the fcetus in utero, or during parturition. 
 It is sometimes found associated with various malformations 
 such as talipes, cleft palate, and imperforate anus.* I have 
 the notes of a dissection made by an old pupil (Mr. John Palmer) 
 of a child born at the eighth month, and which lived five hours. 
 Both its kidneys were wholly composed of cysts ; and the anus, 
 rectum, urethra, and external genital organs were absent. The 
 bladder was misplaced and malformed, the sigmoid flexure was 
 malformed, the uterus was arrested in its development, and the 
 outlet of the pelvis was smaller than natural. Drs. Lever and Duffey 
 and Prof. VirchoAv have described cases of the sort. The absence 
 or malformation of the renal pelvis and of the ureter has also 
 been found with fostal cystic kidney. 
 
 These cases are also considered to support Kiister's view, which 
 is that the lesion is caused by abnormal development, such as 
 the absence of renal calyces and pelvis, and in many cases of 
 the ureters also. Commandeur has cited a case of congenital 
 cystic kidneys associated with bilateral hydro-nephrosis due to (con- 
 genital) valvular stricture of the urethra : the bladder was hyper- 
 trophied and but slightly dilated, but the ureters and kidneys were 
 enormously distended. No other malformation was present. 
 
 Pathogenesis. Numerous theories have been evoked to ex- 
 plain the development of this disease, and the greatest diversity 
 of opinion exists amongst pathologists. For a very excellent 
 historical sketch of the literature of the subject, together with an 
 epitome of the several theories which have been held, the reader 
 is referred to a report by Dr. James Ritchie in the fourth volume 
 of the Laboratory Report*, issued by the Edinburgh Royal College 
 
 * Transactions of London Obstetrical Society ; also Proceedings of 
 Medico-Chirurgical Society for 1S7G (Load.).
 
 PATHOGEXES1S OF POLYCYSTIC KIDNEY. 651 
 
 of Physicians. From that report the following account is in 
 large part drawn : 
 
 1. One of the theories of the cause of this affection is that 
 which ascribes it to the included remains of embryonic life, 
 i.e. to persistent germinal rudiments. In this country Shattock 
 is the most definite in his statements that there are retained 
 remains of the Wolffian body that there is a combination 
 of mesonephros with metanephros, and that the cysts in the 
 kidney are due to a late development of these rudimentary 
 cells of the mesonephros. Newman, whilst admitting the origin 
 from Wolffian remnants of cysts in the ovary and testis, states 
 that such remnants have not been demonstrated in the kidney, 
 though if the}- had been found it would be strongly in support 
 of the embryonic origin of the large polycystic kidney. 
 
 Other theories of a congenital origin are (1) a malformation 
 resulting from a failure of union of the excretory canals with 
 the convoluted tubules, and (2) an excessive feebleness of the 
 tubules which renders them incapable of bearing the normal 
 infra-renal pressure : thus, Bard (of Lyons) compares the poly- 
 cystic kidney with cavernous angeioma. In connection with 
 the theory of congenital origin of the large polycystic 
 kidney of the adult, there arises the question, " Is this affection 
 related to ' congenital cystic kidney ' of the fo?tus and new-born 
 infant ? " I think it may be said without fear of contradiction 
 that whatever may be the difference as to origin, there is at 
 least no other essential difference between the polycystic kidney of 
 the adult and the " congenital cystic disease." 
 
 2. Another theory is that there is a peri-tubular sclerosis 
 with constriction of the tubules and backward dilatation of the 
 tubules and Malpighian capsules : that the disease is an 
 essential part of cirrhosis. Virchow holds that there has 
 been a foetal inflammation of the papillae causing atresia of the 
 papillae, so that there is no communication between the urini- 
 ferous tubules and the calyces of the kidney, and that the poly- 
 cystic kidneys of the adult are only the consequences of the 
 fretal cystic state. Goodhart, Fagge, Bristowe, Wilks and Moxon 
 consider it is consequent on cirrhosis ; Kennedy thinks it due 
 to interstitial nephritis occurring first and chiefly in the medulla. 
 Beckmann, Rindfleisch, Juhel-Renoy, Paterson, Harley, and 
 others believe it occurs in cirrhosis in consequence of strangula-
 
 652 SURGERY OF THE KIDNEY AND URETER. 
 
 tion of the tubes by fibrous tissue. Others, connecting it with 
 cirrhosis, state that it is induced by exudation into the tubules. 
 Roberts held that it is due to strangulation of the tubes along 
 with epithelial change ; and Sabourin adds to this that it is 
 related to adenomata. Many others also account for it by oc- 
 clusion and isolation of portions of tubes which have not lost 
 their secreting power. 
 
 Harley, Klein, and others regard the cysts as dilated Malpighian 
 capsules. Others are of opinion that they are developed at the 
 expense of the tubuli uriniferi. Simon and Bouillaud, whilst 
 blaming obstruction of the tubules, think there is a rupture of 
 the limiting membrane of the tubules, and the former regards 
 the cysts as arising from extravasated epithelium and its paren- 
 chytic development, whilst the latter thinks there is a filtering 
 of the retained fluid into the surrounding tissue ; there is 
 nothing, however, to support this theory. 
 
 3. A third theory, held by Dickinson, Cornil, Brault, Kiener, 
 Kelsch, and Green, is that there is a local destruction of tissue, 
 and that the cysts are centres of softening, or of degeneration 
 related pathologically to fatty or colloid fatty change. 
 
 4. A fourth theory, which possesses great attraction for many 
 is that the cysts are of the nature of a new growth. Hommey, 
 Gombault, Lancereaux, Lejars, Brault, Malassez, Nauwerck, Sirleo, 
 Weichselbaum, Greenish, Kahlden, Hufschmid, Brigidi, Severi, 
 Goodhart, Saundby, and Bateman regard the epithelium of 
 the tubules as the starting point and the disease as being of a 
 true neoplastic nature. Some of these observers class the disease 
 with the adenomata, some think it a fatty or colloid degeneration 
 of adenomata, others hold that it is a gelatinous degeneration of 
 the epithelium, and call it mucoid epithelioma. 
 
 Ritchie's view is that there is an irritative lesion leading 
 to proliferation of epithelium and to connective tissue changes ; 
 that the irritation is propagated through the nervous system ; 
 that the cysts are formed from the pre-existing tubules and 
 Malpighian todies of the kidney ; and that the disease is related to 
 and should be studied along with the adenomata ; that the cystic 
 kidney is similar in character and origin to cystic liver; and that 
 the large polycystic disease of the adult has no direct relation to 
 congenital cystic kidney, which is due to an error in development. 
 
 The theories alxive referred to are not all inconsistent with
 
 POLYCYSTIC KIDNEY DUE TO OBSTRUCTION. 653 
 
 one another. Thus, the theory that cirrhosis is an essential 
 part of the disease is quite consistent with that of local " destruc- 
 tion of tissue," or " centres of degeneration," the one leading 
 to the other. Again, the epithelial changes which result in ade- 
 noma or mucoid epithelioma, may be caused by the strangulation 
 of the tubes owing to sclerosis of the inter-tubular structures. 
 We have also seen in previous sections how congenital malfor- 
 mations, as, for example, the inclusion of embryonic rests, and 
 the failure of union of certain areas of the secreting with the 
 carrying portions of the kidney, resulting in the functional 
 isolation of these areas, may lead to adenomatous or epithelioma- 
 tous neoplasms which are prone to take on a cystic character. 
 
 But interesting from the pathological point of view as these 
 various theories are, the practical outcome of a careful study of 
 them, and of the differences and similarities in the histological 
 characters of a large number of the recorded cases, leads me to 
 the conclusion that the cysts in the congenital cystic kidney, as 
 well as in the large polycystic kidney of the adult, are in all 
 cases alike of the nature of retention cysts. Whatever may be 
 the originating cause, whether congenital, such as intra-uterine 
 papillary nephritis, congenital malformation, or included remains 
 of embryonic life ; or acquired, such as sclerosis or interstitial 
 nephritis, injury or impacted calculus ; whether there is a neo- 
 plastic formation of adenoma or epithelioma or not ; whether 
 such new formations undergo fatty or colloid degeneration or not 
 in all cases the essential condition which determines the develop- 
 ment of the cysts is obstruction. In some cases the obstruction 
 may be due to strangulation of the tubules by fibrous proliferation 
 around them ; in others to the exudation into the tubes of some 
 material w r hich blocks them call it " solid albuminates " (Virchow) 
 or " colloid " (Paget and Lancereaux), " epithelial and fibrinous " 
 (Johnson), or what you will ; in others, again, the tubules may 
 become functionally isolated as the result of cicatrisation after 
 nephritis, or of a congenital defect due to the failure of union of 
 the secreting with the carrying-off parts of the kidney; but 
 in all cases there is obstruction, resulting in cystic dilatation. 
 
 In Guy's Hospital Museum is a beautiful specimen of a large 
 polycystic kidney with a renal calculus impacted in the upper end 
 of the ureter (Fig. 104). Soller * recorded two cases of polycystic 
 * Lyon Medical e, vol. xxxv., p. 333 (1880).
 
 054 
 
 SURGERY OF THE KIDNEY AND URETER. 
 
 kidney associated with traumatic obstruction ; Littre,* a case' in 
 which the ureter was coiigenitally obstructed. 
 
 Obstruction (such as an impacted calculus) in the ureter or 
 renal pelvis may cause either (1) hydro-nephrosis with polycystic kid- 
 neys, as in the case of Commandeur above mentioned ; and in the 
 
 Fit 
 
 104. Cystic Kidney, with Calculus obstructing the Renal Pelvis. 
 (Guy's Hospital Museum, Xo. 1667.) 
 
 case reported by Farr of a suppurating conglomerate cystic kidney 
 with liydro-nephrosis and obliteration of the ureter, in a woman 
 in whose kidney was also a dumb-bell shaped calculus ; or (2), 
 as shown in Fig. 104, a polycystic kidney Avithout hydro-nephrosis ; 
 or (3), as in Fig. 04 (p. 447) and Figs. 08 and 09 (p. 450), a saccu- 
 lated pyo-iiephrosis, with atrophy of the secreting substance, but no 
 polycystic change. In other cases a more localised obstruction will 
 lead to dilatation of one or two calyces with atrophy or cystic 
 dilatation of the corresponding parts of the parenchyma. 
 * ''Mom. do 1'Acad. des Sciences," aim. 1705, p. 111.
 
 WHEN POLYCYSTIC KIDNEY COMMENCES. 655 
 
 The character of the distension from the same kind of cause 
 will depend upon the situation of the earliest or the most intense 
 obstruction. Take, for instance, a calculus in a calyx, or in 
 the ureter : if the distension effects of the calculus are produced 
 before secondary interstitial nephritis leads to obstraction in the 
 minute tubules, then partial or , general nephrectasis will result ; 
 this is the common condition. If, on the other hand, cirrhosis 
 from interstitial nephritis has led to strangulation of the tubules 
 before the obstruction effects of the calculus came into force, 
 then poly cystic dilatation without nephrectasis may be expected. 
 If obstruction in the tubules from cirrhosis is increasing at the 
 same time as the obstruction in the renal pelvis or ureter is 
 causing iiephrectasis, then both polycystic disease and hydro- 
 nephrosis may be found together. 
 
 M. Bar, on the other hand,* considers the sclerosis as only a 
 secondary condition in the polycystic kidney. The pericystic sclerosis 
 is for him only the evolution of the disease tending to a cure. He 
 observed the polycystic lesion in the kidneys of three successive 
 children born of the same mother, each of whom presented the cystic 
 degeneration in a different degree. In the first child there was 
 no sclerosis ; in the third, on the contrary, the sclerosis was ex- 
 tremely marked. The kidneys of the second child showed the 
 changes to an intermediate degree. In the third child the 
 abdominal walls were wrinkled as if the kidneys, primarily large, 
 had become reduced in size under the influence of the sclerosis. 
 
 Etiology. Regarding as I do the congenital cystic kidney 
 of the foetus and new-born, and the large polycystic kidney of 
 the adult, as essentially the same disease, both being due to 
 dilatation the result of obstruction, one must yet recognise 
 different causes of obstruction in different cases some congenital, 
 some inflammatory, some malformation, some traumatic, some 
 in the kidney, some in the ureter, and some in the urethra. 
 The affection may commence in utero, or during the first few 
 months of extra-uterine life, or in early childhood, or not until 
 middle life or* advanced or quite old age. 
 
 Out of eighty -eight cases collected by Ritchie the ages are 
 
 given in seventy-five. The average for the seventy-five casea is 
 
 45' 3 years, the youngest being twenty-three, the oldest eighty-eight. 
 
 The youngest case in eight of my own was a man, twenty-one. 
 
 * Ann. des Maladies des Organ. Genito-uritiaires, Juillet, 1899, p. 723.
 
 656 SURGERY OF THE KIDNEY AND URETER. 
 
 In a case recorded by Talamon, the age is given as five and 
 a half years, and a tumour had been noticed since the child 
 had been six months old. Cruveilhier reports a case in a child 
 of three years. In both these cases only one kidney was affected. 
 Though alluded to by Ritchie, neither Talamon's nor Cruveilhier s 
 case is included by him in his list of seventy-five cases. Lejars 
 gives forty to fifty years as the mean age of the sixty-two cases 
 collected by him, most of which are included in Ritchie's list. 
 
 Males seem to be somewhat more frequently affected than 
 females, in the proportion of forty-five to thirty-seven according 
 to Ritchie ; of thirty-five to twenty-eight, according to Lejars ; of 
 sixty to forty, according to Newman who collected 105 cases. 
 Michalowicz considers that malaria contributes in a distinct manner 
 to cystic degeneration both of the liver and kidneys. In the 
 case described by him, as well as one by Strubing, the patients 
 had had several attacks of intermittent fever. Gout, rheumatism, 
 the gravel, arthritic affections, tuberculosis, atheroma, and alco- 
 holism have each been found associated with the disease, but 
 are probably only indirectly related hi a causal manner. 
 
 Polycystic kidney has been known to follow a natural labour 
 in a mother of five children ; it affected only one of her kidneys. 
 There cannot be said to be more than a slight hereditary tendency 
 to polycystic kidney. The three cases in the same family reported 
 by Bar have been just referred to. A case is recorded in which 
 it affected one kidney of a woman two members of whose family 
 died of post-scarlatinal nephritis, and another child, a daughter, had 
 a polycystic kidney. Dr. Savory of Bedford has recently given 
 me notes of two children of a family of six, aged six and a half months 
 and three and a half months respectively, in whom cystic kidneys 
 (bilateral) were found after death, while of the four other children 
 three showed other congenital defects and one was born dead. 
 The father of these children was the only survivor of thirteen 
 children born to his father and mother ; of the other twelve one 
 only lived five months, the remainder being born prematurely or 
 dying at birth. 
 
 Symptoms. The commencement of the disease is usually 
 insidious : there may be no symptoms pointing to the kidney, 
 or the}' may be masked, if any such exist, by others referred to 
 some other organ. Ritchie states that seven cases out of 
 seventy-eight were reported to have had no kidney trouble and
 
 SYMPTOMS OF POLYCYSTIC KIDNEY. 657 
 
 no evidence of illness, the kidney condition being discovered only 
 after death. In exceptional cases the first indication has been 
 uraemia, quickly followed by coma and death, the discovery of 
 the condition of the kidneys having been a post-mortem surprise. 
 As a rule the symptoms are somewhat the same as those of chronic 
 Bright's disease, although there is seldom any tendency to dropsical 
 effusions, and not rarely painful crises, not met with in chronic 
 Bright's disease, occur simulating colic caused by calculus. 
 
 The symptoms may be divided into local and general. The 
 local symptoms are pain and tumour. Pain, or a dull aching in 
 the lumbar region, is commonly and early complained of, at first 
 in one side, and later, if the disease becomes bilateral, in both 
 sides. There may be pain referred to the abdomen as well 
 as to the loins. It is of a sickening character but not severe 
 except during the movements of the patient or the wandering 
 of the kidney. Whilst resting in bed the pain is either absent 
 or very slight. If the polycystic kidney is also movable, suffering 
 is increased. The pain may be persistent or intermittent, or 
 being persistent it may be exacerbated by attacks of great severity. 
 The exacerbations may resemble renal colic, and while they last 
 the swelling may increase and the general and urinary symptoms 
 become worse. There may be tenderness on pressure, and in 
 some cases even when only very slight pressure is used. In 
 other cases there is only the sense of general discomfort due to 
 the size and weight of the kidney, without any actual pain. 
 Twenty patients out of seventy-eight complained of pain in the 
 loins or in the abdomen. 
 
 Tumour. Besides the two classes of cases above mentioned, 
 
 (1) where there are no symptoms referring to the kidney, and 
 
 (2) where uraemia comes on suddenly and is quickly followed 
 by coma and death, there are two other classes of cases of the 
 large polycystic kidney, (3) one in which the symptoms are 
 simply those of chronic nephritis, and (4) the other in which, in 
 addition to these symptoms, there is a more or less marked aug- 
 mentation in the size of the kidney. Sometimes when the liver 
 also is cystic there will be an increase in the size of that organ. 
 In thin subjects the bossy surface of the kidney presented by the 
 cysts may be felt. 
 
 A renal tumour on each side together with the symptoms 
 of chronic nephritis may be looked upon as fairly pathognomonic 
 VOL. I. 2 Q
 
 658 SURGERY OF THE KIDNEY AND URETER, 
 
 of polycystic kidney. A tumour, however, has been found in 
 less than one half of the cases recorded (Newman), and a tumour 
 in each flank, but very rarely. This is probably due to the fact 
 that no attentive examination of the abdomen or loins was ever 
 made in many of the cases, they being regarded throughout 
 as cases of chronic Bright's disease. 
 
 In Lejars' list of sixty-two cases a tumour was present in 
 only eighteen, and in only three of these was there a tumour 
 in both flanks. In Ritchie's list of eighty-eight cases, a tumour 
 was discovered in twenty-one cases, in eight of which there was 
 a tumour in both flanks : in one the swelling presented in the 
 epigastrium also, and in two other cases in the epigastrium only. 
 In four out of eight cases which have come under my own 
 notice large tumours were present. In one case there was a 
 tumour on each side. 
 
 When a tumour is present, percussion gives a dull note 
 between the ribs and iliac crest, and from side to side to within 
 three inches of the median line, or even less. The size of the 
 tumour as detected by palpation may not correspond exactly with 
 the dull area on percussion because the anterior margin or surface 
 of the swelling may give a clear resonant note, and the percussion 
 note may pass gradually from dulness into tympanitic resonance. 
 The liver may obscure the percussion of the upper limit of the 
 swelling, especially as it may be dragged down by adhesions, 
 pushed down by tight lacing, misshapen, or enlarged by cystic 
 degeneration or other cause. On the left side the spleen may 
 interfere with the renal percussion above, and the crest of the 
 ilium may interfere with the lower limit on either side. 
 
 Thus it is that the size of the swelling as detected by palpation 
 may be either smaller or larger than the dull area elicited by 
 percussion. 
 
 A feeling of undue resistance is given by the swelling even where 
 the percussion note is resonant. By palpation sometimes the 
 upper limit of the swelling can be made out when the liver 
 or the spleen masks the percussion of the kidney, if the fingers 
 are dipped beneath the lower edge of the organ and run upwards 
 between it and the surface of the kidney. When the polycystic 
 kidney is also movable it can be pushed out of its position, and 
 when pressed towards the middle line, or when by change of 
 the posture of the patient it falls in that direction, severe
 
 ABDOMINAL TUMOUR FROM POLVCYSTIC KIDNEY. 
 
 659 
 
 sickening pain or actual nausea may be caused. In emaciated persons 
 and also in those with very flaccid abdominal walls the limits of 
 the tumour can be better defined by palpation than by percussion. 
 The tumour may extend upwards beneath the anterior edge 
 of the liver or lower edge of the spleen ; downwards below the 
 crest of the ilium ; inwards to within a few inches of the median 
 line, and outwards so as to bulge the lateral outline of the 
 
 Fig. lOo. Polycystic Kidney, from a woman aged 51, causing much irregularity of 
 the surface, but leaving the pyramidal portions comparatively intact. (St. 
 Thomas's Hospital, No. 2088.) 
 
 abdomen. In a few instances it has nearly filled the abdominal 
 cavity ; whilst in many cases the kidney is not sufficiently en- 
 larged to be easily detected during life unless specially searched 
 for; on the other hand it may weigh five or six or even sixteen 
 pounds (Hare's case). 
 
 In some of the recorded cases the increase in size has taken 
 place chiefly in the direction of the median line, and the tumour, 
 or the bulk of it, has presented in the epigastrium. The char- 
 acter of the tumour varies : it may be more or less soft or yielding, 
 but more often it is hard and feels solid to the touch. It does
 
 660 SURGERY OF THE KIDNEY AND URETER. 
 
 not fluctuate, may be more or less rounded, but often preserves 
 quite the kidney outline. It is more or less tender on pressure ; 
 frequently its surface is irregular and bossy, or botryoidal, owing 
 to the projection of the cysts beneath the capsule (Fig. 105). On 
 the other hand, it is often quite smooth and even ; but 
 whether smooth or irregular, it is, as a rule, equally non- 
 fluctuant. In only very exceptional cases has obscure fluctuation 
 been noticed. The kidney is very likely to be movable, and 
 to be easily pressed towards the middle line. 
 
 The general symptoms. Under this head must be considered 
 the urine, the gastro-intestinal, the nerve, the pulmonary and 
 cardiac disorders, and osclema. 
 
 1. The urine is in most cases normal in amount, and there 
 is no undue frequency in micturition. Exceptions to this rule 
 have been observed, and more frequently in respect to the amount 
 of the urine excreted ; but in one or two cases there has been great 
 frequency in micturition throughout (Bond). Anuria (not very 
 rarely) and polyuria have been recorded. Intermittent polyuria 
 of moderate intensity has been noticed in many cases. 
 
 Intermittent albuminuria and hsematuria are amongst the 
 frequent symptoms. Haematuria is a fairly common but by no 
 means constant symptom ; it was found in nineteen out of 
 seventy-eight cases. It may be recurring and profuse ; it may 
 come on with attacks of pain ; and it may be quite an early 
 symptom ; or, on the other hand, only appear a very short time 
 a few weeks or a day or two before death. In a typical case 
 recorded by Whipham* a large quantity of blood appeared in the 
 urine three days before the man's death, which occurred sud- 
 denly from urgent dyspnoea. There had never been any renal 
 or urinary symptoms previously. 
 
 Albuminuria is more frequent than hsematuria. It was found 
 in thirty-three out of seventy-eight cases ; but it is inconstant, 
 in some cases being slight and intermittent, in others moderate, 
 and in others again considerable. In this respect it is like the 
 albuminuria of interstitial nephritis. It has in several cases been 
 absent throughout. The urea is frequently diminished in amount. 
 The occasional presence of hyaline or granular casts in abundance 
 shows a degree of inflammation of the portions of parenchyma 
 persisting between the cysts. After the disease has existed some 
 * Path. Soc. Trans., vol. xxi., p. 244.
 
 GENERAL SYMPTOMS OF POLYCYSTIC KIDNEY. 661 
 
 time pyuria may appear, the pus being derived from the pelvis 
 of the kidney. On rare occasions one or more of the cysts 
 which may have suppurated burst into the renal pelvis and give 
 rise to a distinct discharge of pus with the urine, which previously 
 may have been and subsequently may again become free from pus- 
 
 The characters of the urine are often like those of the urine 
 formed by granular kidneys pale in colour, of low specific 
 gravity, abundant in quantity, and albuminous when not admixed 
 with blood. Coagula, as well as granular casts, are occasionally 
 present. The reaction may be either neutral or acid. The specific 
 gravity in the same patient may vary from 1008 to 1020 at 
 different times. In some of the cases, especially of " movable " 
 polycystic kidney, sudden distension of the bladder has occurred 
 with immediate relief of pain in the renal region, though without 
 entire disappearance or marked diminution of the loin tumour. 
 In cases where hydro-nephrosis does not co-exist the distension of 
 the bladder and diminution in the size of the tumour are prob- 
 ably explained by the bursting of one large or several smaller 
 cysts into the renal pelvis. 
 
 (Edema, anasarca, and ascites are all rare occurrences, and 
 when present are often the mechanical effects of the pressure of 
 the tumour. In these respects polycystic kidney seldom simulates 
 chronic nephritis (Bright's disease). (Edema, according to Eitchie's 
 analysis, was recorded to have existed for a time in eleven cases 
 out of seventy-eight. In ten cases it is stated definitely that 
 there was no oedema. 
 
 2. Gastrointestinal disorders were noted in nineteen out of 
 seventy-eight cases, but it is certain that they occur much 
 more frequently than this. Nausea, vomiting, flatulence, loss of 
 appetite, furred tongue, diarrhoea or constipation and consequent 
 increasing weakness and emaciation, are common symptoms. 
 
 3. Nerve disorders. Headache, giddiness, delirium, convulsions, 
 and finally coma have each been observed repeatedly. The 
 delirium may be continuous, loquacious, or violent. M. Jaccoud 
 has recorded a case in which the uraemia took the form of 
 tetanic spasms. On the other hand, in a large number of in- 
 stances, the intellectual faculties remained quite undisturbed. 
 
 4. The pulmonary and circulatory organs. Dyspnoea, due to 
 asthma, pleuro-pneumonia, pleurisy, broncho-pneumonia, or gen- 
 eralised bronchitis, is not unfrequent. Croupous pneumonia, with
 
 662 SURGERY OF THE KIDNEY AND URETER. 
 
 acute oedema of the lung, has been mentioned by Strubing. 
 Dyspnoea, or some pulmonary affection, was present in thirteen 
 out of seventy-eight cases. Pericarditis, hypertrophy of the 
 left ventricle, dilatation of the right ventricle, with hypertrophy of 
 the left, have been found during life, but more frequently dis- 
 covered after death. With cardiac hypertrophy very generalised 
 atheroma of the arteries has been observed, and this no doubt 
 has in some cases accounted for the haemorrhages in various forms 
 which have occurred in certain cases of polycystic kidneys, such as 
 cerebral haemorrhage, epistaxis, haemorrhage of the bowel, haemor- 
 rhage at the back of the pharynx, petechiae, and bleeding gums. In 
 one case in which there was haemorrhage from the gums there 
 were also haematuria, epistaxis and haemorrhage from the rectum, 
 so that the case appeared like one of haemorrhagic purpura or 
 scurvy. 
 
 The general aspect of the patient. This varies between 
 the extremes of apparently robust health and the so-called 
 cancerous cachexia. Twenty out of seventy-eight cases are 
 described as anaemic, cachectic, or emaciated. When the other 
 symptoms have been sometimes prolonged or are very pronounced, 
 the patient becomes thin, his face drawn and pinched, and his 
 skin pallid sallow, or of a bronze tint such as is seen in Addi- 
 son's disease. In one or two cases the suprarenal capsules have 
 been diseased, but the bronze tint has been seen in cases in 
 which these organs have been quite healthy. 
 
 Diagnosis. When it is remembered that in nearly 9 per 
 cent, of the patients there are no symptoms whatever referable 
 to the kidneys ; that in many instances uraemia has been followed 
 rapidly by coma and death in persons who have shown no pre- 
 vious evidence of illness ; that a tumour was discovered during 
 life in only 25 - 5 per cent., and that about 50 per cent, of the 
 patients complain of symptoms more or less closely resembling 
 those of simple chronic nephritis, we cannot be surprised to learn 
 from Lejars' analysis of sixty-two cases that a correct diagnosis 
 was made during life in only live of them. 
 
 When with a sallow complexion, hypertrophy of the heart, 
 and increased arterial tension, the above characters of urine and 
 a tumour in each of the renal regions, or a tumour in one and 
 an increased fulness in the other, are found, the diagnosis of 
 " large cystic kidney " is pretty clearly indicated.
 
 DIAGNOSIS FROM CHARACTERS OF TUMOUR. 663 
 
 When the symptoms of small contracted kidney, anaemia, 
 oedema, hypertrophy of the left ventricle, increased arterial tension, 
 diminution in the quantity of urea in the urine, polyuria, slight 
 albuminuria, uraemia, or retinitis, co-exist with a tumour in one 
 flank, or with increased volume of both kidneys, the diagnosis 
 of polycystic disease is possible. In less than 5 per cent, of the 
 cases only, is a tumour present on both sides. 
 
 It is to the characters of the tumour, when one is present, 
 that the chief attention must be given. When there is no tumour 
 the history, the general symptoms, the haematuria and lumbar 
 pains may lead us to suspect polycystic kidney ; but we cannot 
 positively affirm its presence. 
 
 A tumour of long duration, steady increase, and bossy surface, 
 possessing the usual topographical characters of renal tumours, 
 should lead us directly to the diagnosis ; more especially if there 
 is a fulness in both flanks. Except for these characters of the 
 tumour, the case might be one of renal new growth. Bilateral 
 enlargement, whilst all in favour of polycystic kidney, is strongly 
 against neoplasms. 
 
 Polycystic kidney is slow in growth, consistent with good 
 health, does not fluctuate unless one of the cysts has acquired 
 a predominant size, and is unattended by rigors or fever except in 
 rare cases in which, probably at a late stage of the disease, one 
 or other of the cysts suppurates. In Farr's case there was a 
 history of attacks of rigors and fever for seven years before 
 the kidney was removed. It had formed an enormous tumour 
 made up of numerous sacs, the largest of which was 20 cm. in 
 diameter, and contained about a gallon of puriform fluid of the 
 consistence of cream. The smaller cysts contained fluid of varying 
 characters. 
 
 The absence of any marked elevation of temperature and of 
 pyuria, even though there be rigors and painful micturition 
 (as in one of jSTewman's cases), would tend to discountenance 
 abscess and tuberculous pyo-nephrosis. 
 
 Abscess of the renal parenchyma does not form a large tumour, 
 though it may cause some increase in the size of the kidney, 
 and it is commonly confined to one kidney. 
 
 The tumour in hydro-nephrosis and pyo-nephrosis may in- 
 termit and disappear entirely, and is certainly more likely to 
 alternate in size than polycystic kidney, which usually steadily
 
 664 SURGERY OF THE KIDNEY AND URETER. 
 
 increases. Hydro- and pyo-nephrosis may be absolutely non-fluc- 
 tuant, and parts of a polycystic kidney may be elastic if not 
 actually fluctuant. But a uniformly smooth-surfaced renal tumour 
 which fluctuates throughout is characteristic of nephrectasis ; 
 whilst an irregular surfaced renal tumour which is hard and 
 solid to the touch or which is only elastic, soft or fluctuant in 
 places, is characteristic of large polycystic kidney. It must be 
 admitted there are exceptions in each class. 
 
 The presence of considerable quantities of pus in the urine 
 in a polycystic case would seriously complicate the diagnosis, but 
 would not altogether contra-indicate it. 
 
 From hydatid cyst of the kidney, as well as from simple serous 
 cyst, polycystic kidney is to be diagnosed by the character of the 
 tumour where there is one, by the bilaterality and by the symptoms 
 indicative of chronic interstitial nephritis such as are shown by the 
 urine, the cardiac hypertrophy and the arterial changes. In hydatid 
 disease, when the liver as well as the kidney is the seat of a 
 tumour, the swelling of the liver is rounded, uniform, and often 
 fluctuating ; not nodular or bossy on its surface like a poly- 
 cystic kidney. Hooklets or scolices will most probably be found 
 in the fluid of hydatid cyst. In the presence of metrorrhagia 
 polycystic kidneys have been mistaken for double ovarian cystomata, 
 as in the case reported by Jean Ferrand.* 
 
 Prognosis. The evolution of polycystic kidney is slow, 
 its duration is indefinite. There may be a long latent period 
 during which 110 indication is given that the patient is not in 
 full health, and then an unexpected attack of uraemia, or 
 pneumonia, pulmonary oedema, cerebral haemorrhage, rupture of 
 the left ventricle, convulsions, coma, or anuria may cause sudden 
 or rapid death. In the last stages of the disease when the 
 approach of death is gradual, obstinate vomiting, convulsions, 
 suppression of urine, and coma supervene, and immediately precede 
 the fatal termination. Death sometimes occurs from exhaustion 
 brought on by hoematuria, sometimes from bronchitis or pneu- 
 monia, sometimes from oedema of the lungs, and sometimes from 
 some quite independent cause. 
 
 If one kidney only is affected life may last for years and be termi- 
 nated finally by exhaustion from pain in the loins and the abdomen, 
 hsematuria or other haemorrhages, or gastro-intestinal disturbances. 
 * Societe Anat., Mai -20, 1893.
 
 URAEMIA A FREQUENT CAUSE OF DEATH. 665 
 
 Life has certainly been prolonged in two cases under my care 
 by nephrectomy. 
 
 If both kidneys are affected the duration of life depends on 
 the rate of progress of the cystic change, and will probably be 
 terminated in from one to ten years. In twenty-eight cases 
 collected by Ritchie, the time during which the symptoms had 
 existed is recorded : fifteen died between the first and tenth year, 
 the others lived periods varying widely from three weeks up to 
 one year, and from ten years up to twenty-two years. In one 
 of my own cases symptoms like those of renal calculus extended 
 over fourteen years before death from double renal and hepatic 
 polycystic formations occurred. 
 
 The causes of death were coma, convulsions, or uraemia in 
 thirty-eight out of seventy-two cases ; pulmonary oedema or some 
 other form of chest affection in thirteen ; cerebral haemorrhage 
 in eight ; exhaustion in six ; heart and aortic disease, haemorrhage, 
 and pyaemia after injury, are given as the causes of death in 
 the other cases. One succumbed after an operation. 
 
 Treatment. The surgeon's aid will not often avail, owing 
 to the frequency of the bilateral character of the disease. When 
 the disease is unilateral the elimination of urine is carried on 
 sufficiently well by the sound kidney, and no treatment is requisite 
 unless the size of the tumour is very inconvenient and the 
 pain caused by pressure is considerable, or unless some condition 
 such as haemorrhage or infection from suppuration is threatening 
 the life of the patient. 
 
 The prevalent teaching at the present time is opposed to any 
 surgical procedure in the treatment of large polycystic kidney. 
 The reasons given for this attitude are in the great majority 
 of cases only too valid : they are (1) that polycystic disease 
 affects both kidneys, and if the disease is much advanced in the 
 other kidney nephrectomy exposes the patient to rapid death from 
 anuria within a few hours, or at longest within two or three 
 days ; (2 s ) that as the cystic changes do not affect both kidneys 
 to the same extent or in quite the same manner, nephrectomy 
 of a large tumour-sized kidney is more than hazardous, because 
 the other kidney may be too much affected to be able to maintain 
 life, though it does not give any clinical sign of enlargement; 
 (3) after recovery from nephrectomy for a large polycystic kidney 
 the remaining kidney may rapidly develop cystic changes, and
 
 666 SURGERY OF THE KIDNEY AND URETER. 
 
 so after a few months, or longer, may present all the clinical 
 and pathological characters of the one removed. 
 
 Whilst agreeing with these objections in the main, I am unable 
 to give unqualified adhesion to them. In the first place, I would 
 say that no surgical operation should be entertained if there is 
 good ground for suspecting polycystic disease of both kidneys, either 
 from the characters of the tumour, or the presence of the ordinary 
 symptoms of chronic interstitial nephritis. 
 
 If, on the other hand, the tumour though typical in 
 character is unilateral, if the suffering caused by it is great, 
 or if the tumour is rapidly increasing or causing distressing 
 gastro-intestinal symptoms, the question of nephrectomy ought 
 to be entertained. A trans-peritoneal incision should be made, 
 the opposite kidney palpated, and if found normal, nephrectomy 
 of the polycystic kidney should be performed. These are cases 
 in which the incision of Langenbuch is of great value, permitting 
 as it does a manual examination of the kidney for a pathological 
 condition which is readily detected by touch, and in which the 
 changes are frequently (some writers state constantly) most 
 marked on the anterior surface, the only aspect of the organ 
 which can be palpated across the abdomen. Moreover, through 
 the incision much of the tumour can be enucleated from its 
 areolar tissue couch, and can be ultimately delivered. 
 
 In cases where there is no tumour detectable either because 
 of the thickness of the abdominal wall, the very moderate dimen- 
 sions of the kidney, or some other cause there are often urgent 
 symptoms, such as profound or continuing hsematuria and severe 
 renal pain, which will naturally lead to an exploratory lumbar 
 incision and thus to the discovery for the first time of the polycystic 
 state of the organ. Under these circumstances the opposite kidney 
 should first be explored, either by the trans-peritoneal route or 
 by an incision in the opposite loin, and if the second kidney is 
 not affected or but very slightly so, nephrectomy of the kidney 
 causing the pain and haemorrhage should be performed. 
 
 These have been the principles which have guided me in 
 five cases upon which I have operated. Two of the cases operated 
 upon on May 3rd, 1804, and February 21st, 1898, respectively, are 
 now alive and well. In a third case, a large rapidly growing 
 tumour was removed by the lumbar and trans-peritoneal method, 
 but the patient on the second day after the operation got acute
 
 EXCISION OF POLYCYSTIC KIDNEY DISEASED. 667 
 
 dilatation of the stomach and was suffocated whilst vomiting 
 a large quantity of fluid. In a fourth case the kidney was large, 
 rapidly growing, and the cause of very great pain; nephrectomy 
 was performed in July, 1893 ; the patient recovered and was 
 very well for a time, but within four months after the operation 
 the second kidney had become like the first, and hi November, 
 1893, I exposed the kidney through the loin and relieved the 
 pain and tension by tapping two large cysts. The patient died 
 several weeks later from slowly increasing uraemia. 
 
 In the fifth case a well-made, muscular, though stout man, a 
 teacher of languages, aged fifty, had suffered from right renal pain 
 and symptoms like those of renal calculus over a period of fourteen 
 years. He had passed gravel on several occasions, and a small 
 stone four years before. In March, 1898, he had an attack 
 resembling renal colic on the left side as well as on the right, 
 and the quantity of urine passed became very small. No tumour 
 could be detected on careful palpation. This case, which I had 
 on several previous occasions seen, came with these symptoms 
 again under my notice and was diagnosed as one of double 
 renal calculus with partial anuria from the sudden stoppage of 
 the left the previously unaffected kidney. The left kidney 
 was exposed through the loin, and found to be polycystic, but 
 contained no stone. Several of the cysts were punctured, with 
 such marked relief that two days later the right kidney was 
 similarly treated with a similar beneficial result as regards 
 pain ; it was in a similar condition to the left. The patient 
 died on the ninth day after the attack, after five days' complete 
 anuria. A post-mortem examination showed the liver as well 
 as the kidneys to be in a most advanced stage of polycystic 
 degeneration. There was no stone or other gross obstruction 
 present throughout the urinary organs. 
 
 Unsatisfactory as these results are, yet two out of the five 
 patients have had their lives prolonged and in complete comfort 
 by nephrectomy, in one case for nearly seven years, in the other 
 for three years. In the third case of unilateral disease the 
 patient might have recovered and survived for years, like the 
 other two, had he not, so to speak, died an accidental death by 
 suffocation whilst vomiting. Kelly, of Johns Hopkins Hospital, 
 in 1890, successfully removed the suppurating cystic kidney reported 
 bv William F. Farr and referred to above.
 
 668 SURGERY OF THE KIDNEY AND URETER. 
 
 Vitrac,* quoted by Tuffier and by Albarran, collected seventeen 
 cases of nephrectomy for large polycystic kidney, with only five 
 deaths, two only of the deaths being due to uraemia. From a col- 
 lection of cases published between 1867 and 1886 by various 
 authors, Brodeur tabulated fifteen cases of operation for different 
 forms of cystic kidney, of which two were polycystic kidneys ; 
 and of these two cases one died and one recovered. 
 
 Turner and Albarran discountenance the operation. Tuffier, 
 however, practised partial nephrectomy upon a woman who had 
 a number of small cysts in the inferior third of her kidney ; 
 he removed the inferior half of the organ, and the patient 
 remained well two years afterwards. 
 
 The argument against nephrectomy, because of the liability 
 of the second organ to subsequently take on the same change 
 as the first, applies equally to partial nephrectomy ; one would 
 expect the cystic degeneration to take place even more rapidly 
 in the other half of the same organ than in the second kidney. 
 But I do not think the argument altogether a good one : it 
 would apply equally to nephrectomy for calculous pyo-nephrosis, 
 if the second kidney has been, or because it may become, the 
 seat of stone : it is the argument popularly employed against 
 operations for cancer generally. 
 
 When the opposite kidney has been ascertained, either by 
 inspection or palpation, to be unaffected, we are not justified, 
 in my opinion, in refusing a patient the relief from severe pain 
 or haemorrhage or from the dangers of infection from suppuration 
 of the cysts which nephrectomy affords. 
 
 In any case in which the life of the patient is threatened, 
 as, for example, by profuse and persisting haemorrhage, as in 
 Depage's case, the operation would be imperative. 
 
 When a kidney is cut down upon for an exploratory 
 purpose, or because of the mobility of the organ, and the poly- 
 cystic condition is revealed, nephrectomy ought certainly not to 
 be performed, until the state of the opposite organ is ascer- 
 tained to be good. A movable polycystic kidney may be fixed by 
 one of the methods of nephropexy : if hydro-nephrosis complicates 
 the cystic state of the organ, as in a few recorded cases it has 
 done, the hydro-nephrotic sac should be tapped or incised, and its 
 edges stitched to the skin and drained if the obstruction in the 
 * Journal de Medecine de Bordeaux, Decembre, 1895.
 
 CASES UNFIT FOR NEPHRECTOMY. 669 
 
 renal pelvis or ureter cannot be removed. Relief may follow fixa- 
 tion, as Newman points out, by remedying " transitory hydro- 
 nephrosis" if existent in a movable polycystic organ. Newman 
 in one case practised the removal of a large part of the fibro- 
 fatty capsule, and advises this procedure if this tissue is redun- 
 dant. Contrary to the opinions expressed above, but in accord 
 with the majority of authors, he thinks that it is not advisable 
 to cut into a polycystic kidney or to remove it even when 
 there is no evidence of disease of the second organ. 
 
 When the disease is suspected to be bilateral ; or when one 
 organ is discovered to be polycystic on exposure, but is neither 
 hydro-nephrotic, nor movable, nor suppurating, nor painful, the 
 wound should be closed without further interference. If, how- 
 ever, great pain is caused by the size of the cysts, temporary 
 relief, as I found in the case above referred to, may be given 
 by puncturing or incising some of the larger cysts. 
 
 HYDATID CYST OF THE KIDNEY. 
 
 Before the thesis of Beraud,* published in 18C1, there is 
 little accurate information to be found bearing upon hydatids 
 of the kidney. Prior to this date simple serous cysts, cystic 
 degeneration of the kidney, and even hydro-nephrosis, were indis- 
 criminately described by writers and catalogued in museums 
 under he title of " Hydatids of the Kidney." Even Chopart, 
 who in his work "Diseases of the Urinary Organs" (1855), de- 
 votes a chapter to the subject, makes this confusion. 
 
 After Beraud's classical monograph, there appeared Finsen's 
 work on "Hydatid Disease in Iceland" (1869), and in this country 
 the instructive chapters in the standard works of Roberts and 
 Dickinson, and the articles by Davies Thomas. f On the Con- 
 tinent the admirable study of the subject by J. Bosckel was 
 preceded and followed by various contributions by Neisser, Simon, 
 Madelung, Fisk, Vogt, and others. In the Australian Colonies 
 the subject of hydatid disease generally received great attention, 
 especially in regard to operative treatment, after Gardner brought 
 it before the Intercolonial Medical Congress of Melbourne in 
 January, 1889. 
 
 Hydatid cysts sometimes form large tumours in connection 
 
 * " Hydatides du Rein," Paris. 
 t Lancet, 1S79, vol. i., p. 297.
 
 670 SURGERY OF THE KIDNEY AND URETER. 
 
 with the kidney. They are comparatively rare, occurring very 
 seldom in comparison with the frequency with which they are met 
 in the liver, and being somewhat less common than hydatids 
 in the lungs ; but they are more frequent than hydatids in. 
 any other organ of the body except the liver and lungs. 
 
 Davaine, among 566 echinococcus cysts, found only thirty, 
 or 5 - 3 per cent, affecting the kidneys. Xeisser, in a later re- 
 search, found eighty cases amongst a total of 983. Finsen found 
 only three cases of renal hydatids amongst 255 of hydatid disease 
 observed in Iceland ; Davies Thomas says " the kidney is affected 
 in 4' 74 per cent, of all collected cases," but records only two cases 
 in 307 hydatid cysts of all organs occurring in Australia. In his 
 own practice, according to Gardner, Thomas only met with a single 
 case of hydatid of the kidney. Gardner's own statistics show r 
 that less than 1 per cent, of all his own cases were situated 
 in the kidney, and he is of opinion that the kidney is not even 
 nearly so frequently affected as the statistics of published cases 
 would lead one to suppose. If we add together the figures of 
 Davaine, Xeissen, Finsen, and Thomas, we have 2,111 cases of 
 hydatid disease of all parts and organs, in 115 of which the kidney 
 was the seat of the disease, giving a percentage of 5'44. The 
 figures of Thomas and Finsen, taken alone, support Gardner's 
 view that the relative frequency is much nearer 1 than 5 per 
 cent. Mossier also, who practised in Mecklenburg where the 
 disease is very common, only met with hydatid of the kidney 
 in one case in twenty years. 
 
 There is no difference, judging by the aggregate of recorded 
 cases, in the frequency with which hydatid of the kidney occurs 
 in the two sexes, although in the experience of Gardner of, 
 Melbourne, which was very considerable, men were twice as often 
 attacked as women. Houzel, on the other hand, states that 
 women are more commonly affected than men ; and Bosckel 
 seeks to explain the same by attributing the cause to pregnancy, 
 though the causation effect is not clear. As regards age, the 
 disease appears more frequent between eighteen and forty years,* 
 instances, however, are cited in a child of four years (Desault and 
 Chopart and Raver), and in a woman of seventy-five. 
 
 Pathology. The left kidney seems to be nearly twice as 
 frequently affected as the right, but for this the explanations 
 * Beraud, " These de Paris," 1SG1.
 
 HYDATID OF KIDNEY SOMETIMES BILATERAL. 671 
 
 which have been offered are not satisfactory ; neither that sug- 
 gested by Beraud, namely, the greater attraction of the liver 
 for the eggs of the taenia, which travel to the right side, than 
 of the spleen for those which go to the left side ; nor that offered 
 by Houzel, namely, that the eggs which have travelled through 
 the lymphatics, systemic veins, pulmonary circulation, and left 
 side of the heart, as, according to Boeckel, they must do before 
 they can arrive at the kidneys, go to the left organ rather than 
 to the right, because of the shorter distance to the left kidney 
 along the left renal artery than to the right kidney along the 
 right renal artery from the aorta. The cysts may occupy one or 
 both kidneys. Richardson and Hogg have each recorded instances 
 of bilateral renal hydatid. A cyst, or several small cysts, may 
 occupy one end of the organ only, while the remainder may be 
 healthy any part of the kidney may be invaded. A cyst may be 
 situated immediately beneath the capsule or be lodged deeply in the 
 substance of the kidney ; in either case, as it grows, it forms 
 an elastic rounded and sometimes fluctuating tumour projecting 
 from the surface of the organ. The whole kidney may ulti- 
 mately be destroyed and the cyst may come to fill a large part 
 of the abdominal cavity ; in other cases it remains quite small 
 and does not exceed the size of an egg or an orange. The 
 renal substance, as a consequence of pressure, tends to atrophy 
 and to degenerate ; and as the result of the irritation there is not 
 unfrequently an increase in the amount of fibrous tissue ; in other 
 words, the parenchyma may be either entirely destroyed by pres- 
 sure or greatly altered by sclerosis. Surrounding the "endocyst" 
 of Huxley, there is the usual tough fibrous ectocyst of variable 
 thickness, such as is common to hydatid tumours of all other 
 organs. The eudocyst may undergo calcareous or cartilaginous 
 transformation. The inner surface may be either smooth or mam- 
 millated like an hypertrophied bladder, or irregular and shrivelled 
 upon itself, " m the surface of the ovary of an old woman." 
 The contents of the cysts vary : generally there are brood capsules, 
 scolices, daughter cysts few or abundant, small or large ; some- 
 times there is nothing but fluid, the cysts being " sterile " or 
 " barren " the so-called " acephalocysts." Of the daughter cysts, 
 some move freely within the parent cyst, others are adherent to 
 its walls. The hydatid fluid is clear, limpid, colourless, or slightly 
 opalescent, and of low specific gravity (1004 to 1015). It usually
 
 672 
 
 SURGERY OF THE KIDNEY AND URETER. 
 
 contains uric acid crystals, crystals of phosphates, and ammonio- 
 magnesian phosphates, phosphates of soda, and oxalate of lime ; 
 chloride of sodium, little if any albumen, and scolices or booklets 
 are usually present. Sometimes small calculi the size of peas or 
 horse-beans composed of these salts are formed in the cysts. 
 When the cysts are of large volume they are apt to contract 
 adhesions with surrounding organs. In many cases a hydatid 
 
 Fig. 106. Hydatid Cyst of Kidney, about three inches in diameter, with partly 
 calcined walls. It does not communicate with the renal cavity. (St. 
 Thomas's Hospital Museum, No. 2134.) 
 
 cyst of the kidney has co-existed in the same person with hydatid 
 cyst of some organ tissue or organ, but especially of the liver. 
 An echinococcus cyst may bring about an abnormal degree of 
 mobility of the kidney. 
 
 A renal hydatid cyst may burst into the pelvis of the kidney, 
 or into the intestine or lung. Out of sixty-eight cases collected 
 by Beraud forty-eight opened into the pelvis of the kidney, with 
 the development in some cases of pyelitis. Ebstein states that 
 " cysts open into the renal pelvis most quickly when they are 
 developed in the medullary cones. The tumour in these cases 
 does not attain a large size. AY hen developed in the cortex, or
 
 ETIOLOGY OF RENAL HYDATIDS. <>73 
 
 l)etween the renal capsule and the kidney, the c^ysts attain the 
 largest dimensions of which they are capable." Roberts tells us 
 that they have a natural tendency to discharge their contents by 
 the ureter, and that out of sixty-three cases collected by him hydatids 
 were disharged by the urethra in fifty- two cases. In forty-seven 
 the cysts opened into the pelvis of the kidney only, in one into 
 the pelvis of the kidney and the lung, in three into the intestine, 
 and in one into the stomach as well as into the renal pelvis. 
 In one case the opening was into the lung only, in two the cyst 
 was opened artificially, and in eight cases it did not open at all. 
 Roberts also states that there is no authenticated case of a hydatid 
 cyst of the kidney opening upon the loin, and that Raver's two 
 cases which so opened were hydatids in the muscular tissue 
 of the lumbar region. In a third case there was post-mortem 
 proof that the cyst was unconnected with the kidney. 
 
 Hydatid cysts of the kidney as of the liver may inflame and 
 suppurate ; or may wither, contract, and dry up into a putty-like 
 mass consisting of phosphates, cholesterine, and fatty granules, 
 together with echinococci booklets and shreds of laminated mem- 
 brane. Perinephritis or an abscess near the kidney may be 
 excited by the presence of the tumour. Hydro-iiephrosis has 
 resulted from impaction of a vesicle in the ureter. 
 
 Etiology. The formation of hydatid cysts in man is the 
 result of the entrance into his body of the ova of the tsenia 
 echinococcus of the dog. They are met with in most countries 
 where men and dogs are brought into intimate association, but 
 they are especially common in parts where the poorer classes use 
 the flesh of the domestic dog as food, or eat off the same plates 
 as their dogs, e.g. Iceland, Mecklenburg, and Silesia. The disease 
 is very common also in Australia. 
 
 In order to reach the kidney the eggs of the tenia, which 
 are taken into the stomach and intestines with any form of 
 ingesta except those which have been cooked, must enter the 
 general circulation either by the venules of the portal circulation or 
 through the lymphatics of the mesentery. By either route they 
 must pass through the right side of the heart and the lungs 
 before they can reach the left side of the heart and the general 
 systemic arterial system. When travelling by the lymphatics, 
 they must enter the thoracic duct, and thence gain the jugular vein. 
 We thus see why the liver and the lungs are so much more com- 
 VOL. i. 2 n
 
 674 SURGERY OF THE KIDNEY AND URETER. 
 
 monly the seats of the disease than any other organ. Once through 
 the lungs these eggs may obtain a habitat in the heart itself, in 
 the brain, spinal cord, the muscles, spleen, kidney, or other structures. 
 
 Kirmissoii attributes to injury an important causation in local- 
 ising the disease. Contusion ruptures the small vessels, and the 
 escape of the blood, if it contains the eggs of the tsenia, into the 
 tissues tends to the development of the hydatid at the site of 
 the injury. This possibly may explain the occurrence of hydatid 
 cysts in the muscles of the limbs, in the brain and spinal cord, 
 but can hardly do so in the case of the heart, and probably only 
 very rarely does so in the case of the kidney. 
 
 Wherever arrested, the embryo sets up a slight inflammation 
 whereby it becomes encysted, whether it remains sterile or pro- 
 liferates. Developing very slowly, it causes but little interference 
 with the surrounding tissues, until it becomes troublesome by its 
 excessive volume. Thus is explained the very slight effect these 
 cysts produce, and the length of time they take to become harm- 
 ful to the individual they infest. 
 
 Symptoms. A hydatid cyst develops insidiously and pain- 
 lessly and often without awakening any suspicion of its presence 
 until it has attained a size when, it begins to cause symptoms 
 of compression on surrounding organs. A sense of weight or 
 dragging, not pain, is the first or only symptom complained of, 
 though the tumour may be discovered on palpation before even 
 this degree of local sensation has been aroused. In some in- 
 stances there are no symptoms, and the cyst is met with as a 
 post-mortem surprise. In others there are 110 symptoms until 
 the cyst bursts, in the common manner of the disease, into the 
 renal pelvis, when attacks of renal colic begin and recur owing to 
 the passage of the daughter cysts and portions of the hydatid 
 membrane along the ureter. In a third class of cases there is an 
 abdominal tumour, with or without the symptoms excited by the 
 escape of the contents of the cyst along the urinary passages. 
 There are no urinary symptoms before rupture. If the secreting 
 capacity of the kidney involved is much impaired, the opposite 
 organ is correspondingly hypertrophied. Even the affected kidney 
 does not cease to properly perform its functions ; and Houzel 
 records a case of a patient on whom he operated who had but 
 a single kidney, and that was occupied by an enormous cyst, yet 
 the organ secreted a litre of urine a dav.
 
 PATHOLOGY OF HYDATID CYSTS. 675 
 
 In eighteen out of sixty-three cases, according to Sir W. Roberts, 
 a tumour in the side was discernible during life, and varied in 
 size from an orange to an adult head. Fluctuation is not always 
 to be detected, owing either to the extreme tension of the cyst 
 walls, or to the small proportion of fluid to daughter cysts 
 of many succeeding generations. The hydatid thrill or fremitus 
 has been but seldom observed. Out of thirty cases it was present 
 only in two. It is a symptom of great value if it exists, but its 
 absence goes for nothing. Several conditions may 'prevent fre- 
 mitus as well as fluctuation from being felt ; such as the deep 
 situation of the cyst, the thickness of the abdominal parietes, the 
 degree of tension of the cyst, the thickness or cretification of the 
 cyst walls, and the close packing of daughter cysts, with a scanty 
 quantity or no free fluid in the cyst. For hydatid fremitus to 
 be present, certain conditions are required : the cyst must be 
 superficially placed, not too tense, and the daughter cysts must be 
 able to glide against one another. Sterile cysts are possibly 
 capable of giving the fremitus ; for, as Gardner pointed out, 
 it can be felt by taking an unruptured daughter cyst in the 
 palm of the hand and tossing it up. It is doubtful whether true 
 fremitus is ever felt except in echinococcus cysts. Davies Thomas 
 states that it has been noticed in other conditions ; but it is 
 generally regarded as pathognomonic of hydatid cyst. I have 
 never observed it in any other class of cases. 
 
 By palpation the cyst can often be made out to be insepar- 
 able from the kidney, which is usually at the back of the cyst. 
 
 The hydatids discharged per urethram, are in various states, 
 broken or entire, as fragments, or vesicles simplyc ollapsed. There 
 may be one or two only, or scores of vesicles : some contain 
 only water ; others enclose minute cysts ; crystals of uric acid 
 have been found adhering to them ; crystals of triple phos- 
 phates, uric acid, and oxalate of lime have been found within. 
 When the parent cyst has suppurated before bursting, pus is 
 discharged as well as hydatids. Haematuria sometimes occurs. 
 In a case of which I have notes the cysts were discharged with 
 large quantities of pus, but some of the smaller and unruptured 
 cysts which were passed contained the ordinary clear saline and 
 non-albuminous fluid characteristic of hydatids. In some cases 
 booklets, shreds of hydatid membrane, and oil particles, but no 
 vesicles, are found in the urine.
 
 676 SURGERY OF THE KIDXEY AND URETER. 
 
 Iii relation to the escape of hydatids by the urethra it 
 must not be forgotten that hydatid cysts of the liver have some- 
 times discharged into the renal pelvis, and hydatids in the cellular 
 tissue of the hilum or in the track of the ureter have broken 
 into the ureter or bladder, and thus escaped by the urethra. 
 Such cases are infinitely rare. Birkett* knew of one case in 
 which hydaticls were withdrawn by a catheter from the bladder, 
 the cysts having escaped into the bladder from a hydatid tumour 
 between it and the rectum. Other similar cases of hydatid 
 tumours in this situation opening into the bladder are oil record ; 
 but they are to be distinguished from hydatids in the kidney 
 by the formation of a pelvic tumour, and by the prolonged and 
 increasing pressure effects upon the bladder and rectum. 
 
 The escape of the vesicles may or may not excite nephritic 
 colic ; there may be one or several discharges at shorter or longer 
 intervals of a few months or several years. Sometimes at the 
 first escape the cyst empties itself and dries up ; in other cases 
 there have been numerous discharges extending over many years, 
 and occurring at uncertain and very variable intervals. 
 
 Pain in the lumbar region and along the course of the ureter 
 of the affected organ, with a sensation of something giving way, 
 usually precedes the discharge. Eigors, vomiting, spasmodic 
 colicky pains, and sometimes suppression of urine and retraction 
 of the testicle, accompany the passage of the vesicles along the 
 ureter ; then comes a period of relief during their stay in the 
 bladder, and this is followed by the distress caused by retention 
 of urine and painful efforts to micturate which indicate their 
 journey through the urethra. 
 
 An accident, such as a blow, kick, or fall, or the jolting of 
 horseback or carriage exercise, may lead to the rupture of the 
 tumour and to the subsequent escape of the vesicles by the urethra. 
 
 When a tumour exists it fills the loin, and to a greater or 
 less degree the corresponding side of the abdomen ; it may be 
 quite round and regular in outline, or present a somewhat nodu- 
 lated surface. Its relations to the l>owel and to the ribs and 
 surface are the same, and are subjected to the same exceptions 
 as renal tumours generally (see p. .">.'} 1 et zeq.}. 
 
 In a case shown by Dr. Fotheringham f to the Glasgow 
 
 * Med. Times and Gaz., vol. i., p. 101 (1855). 
 t Brit. Mcd. Journ., Dec. nth, 1884.
 
 COMPLICATIONS OF HYDATID CYSTS. 677 
 
 Pathological Society, the patient had a nodulated tumour which 
 filled the right lumbar region and caused pain and tenderness ; 
 there were, too, the ordinary symptoms of Bright's disease. 
 Within a fortnight after it had suppurated and discharged pus and 
 cysts by the urethra, the symptoms of Bright's disease disappeared. 
 
 Suppuration may occur as the result of violence, or of puncture 
 whether for the purpose of diagnosis or of treatment ; or indepen- 
 dently of either. If it occurs, then rigors, fever, and increased 
 pain and tension about the tumour set in. 
 
 The complications of hydatid cysts of the kidney are (1) 
 their excessive volume, (2) the consequences of rupture, (3) 
 the dangers of suppuration. (1) The size attained by a 
 hydatid cyst of the kidney may be such that it nearly fills the 
 whole abdomen. In such cases, the digestive organs and the 
 diaphragm and the respiratory and circulatory organs are inter- 
 fered with, and death may be brought about by syncope or 
 marasmus. (2) Before attaining such a size, however, it is more 
 frequent for the cyst wall to rupture. Injury may also cause rupture 
 of the cyst. It may open into the general peritoneal or pleural 
 cavity, or into a hollow or tubular organ, e.g. the stomach, bowel, 
 bronchus, or renal pelvis or ureter. Spontaneous or traumatic 
 evacuation may be followed by cure, but it is very likely indeed 
 not to be. Beraud and Breckel quote twenty -nine cases in which 
 the opening was into the renal pelvis : six were completely cured, 
 six remained stationary, in seven the results were unknown, 
 and ten died. The causes of death were : seven from marasmus, 
 one from cancer, one from phthisis, and one from secondary 
 perforation of the lung. Of four cases which burst- into the 
 intestine one died. Rupture into the lung or into the peritoneal 
 cavity is very fatal. The danger of rupture is increased by the 
 greater tendency there is for the cyst to suppurate after rupture 
 has taken place than before, and thus the patient is exposed 
 to death from septicaemia or exhaustion. Rupture into the 
 peritoneal cavity gives rise to peritonitis if the cyst is suppura- 
 ting; if there is 110 suppuration it may cause the development 
 of multiple iiew r cysts, or iirticaria, or death. (3) Suppuration 
 does not frequently attack a hydatid cyst so long as it is intact 
 and is not in communication with the organs around it or with 
 the exterior of the body. But if, from rupture or puncture, 
 infective micro-organisms gain entrance, the cyst soon becomes
 
 SURGERY OF THE KIDNEY AND URETER. 
 
 converted into a large abscess. Cure may follow the suppuration 
 if the contents of the cyst freely escape into the intestine or 
 renal pelvis, or still more probably if the cyst is thoroughly 
 drained after a free incision has been made through the loin. 
 Otherwise death is caused by septicaemia or exhaustion. 
 
 Diagnosis is made certain when, with a tumour in the 
 renal region, there is a discharge of hydatid vesicles by the 
 urethra, or of the other products of hydatid tumour, as shown by 
 microscopical examination of the urine. If the cyst does not 
 rupture into the renal pelvis, the urine presents no evidence 
 of the nature of the disease ; and if a tumour exists without 
 discharging its contents by the ureter, there is nothing to point 
 out the precise nature of the enlargement except the general 
 characters of the tumour, and the use of the aspiratory trocar, 
 a means of diagnosis which, however, ought not to be resorted to 
 without preparation for proceeding at once to further surgical 
 measures. The renal origin of the swelling must be diagnosed 
 by the same means as other renal tumours. When vesicles are 
 voided, but 110 tumour exists, nephritic colic generally indicates 
 the locality of the hydatids. 
 
 A correct diagnosis is important because the treatment which 
 should lie adopted depends upon it. There is 110 use, and there 
 may be danger, in delaying surgical treatment when once the 
 diagnosis of renal hydatid is made clear. But strikingly clear 
 and characteristic as the diagnosis may be in some cases, 
 errors have nevertheless been committed by the most distinguished 
 surgeons in past times ; and in more recent years, from 
 amongst twenty -eight cases related by Boeckel and Houzel in 
 which renal hydatids have been submitted to operation, there 
 were thirteen in which errors in diagnosis were made, four in 
 which the operator was undecided, and eleven only in which 
 a correct opinion had been formed. The points of importance 
 in forming a diagnosis are the following : (1) The residence, 
 habits and callings of the individual in reference to association 
 with dogs. (2) The slow, silent, insidious growth of a tumour. 
 (3) The absence of pain, of fever, of general constitutional dis- 
 turbances and of any change in the composition or any variation 
 in the quantity of the urine. (4) The uniformly smooth, globular 
 outline of the tumour, with possibly distinct fluctuation and 
 hydatid fremitus. (5) The independence of the tumour of the
 
 DISEASES MISTAKEN FOR RENAL HYDAT1DS. 670 
 
 movements of ordinary respiration, although possibly it may be easily 
 ancl extensively moved by palpation or deep inspiration. (6) The 
 inseparable connection of the kidney, which may possibly be 
 felt on one aspect of the tumour, in front> or behind, or at its 
 lower end ; if the cyst springs from the lower end of the kidney 
 the kidney itself will probably be out of reach under cover of 
 the ribs. (7) The renal situation of the tumour, and possibly 
 the discharge of hydatids per urethram, by the mouth or by the 
 anus. (8) If there be a discharge of hydatids or scolices with the 
 urine there will probably be attacks of renal colic, and there may 
 be associated with these symptoms another and most important 
 one, namely, the diminution or subsidence of the flank tumour. 
 
 Apart from hydatid fremitus, the escape of the cyst contents 
 by the urethra, or the result of aspiration or exploratory in- 
 cision, a positive diagnosis can scarcely be made. Renal hydatids 
 have been mistaken for ovarian, mesenteric and splenic cysts, 
 and for the following tumours of the kidney : (1) Hydro-nephrosis, 
 (2) large simple serous cyst of the kidney, (3) polycystic disease 
 of the kidney, and (4) cystic sarcoma of the kidney. 
 
 A suppurating echinococcus renal cyst may be wrongly 
 diagnosed as (1) pyelitis, (2) pyo-nephrosis, (3) tuberculous or 
 other abscess of the kidney, (4) perinephric abscess. 
 
 The points mentioned above, and the account of the diagnosis 
 of each of these affections as given under their separate headings, 
 render it unnecessary for me to repeat here the features of the 
 differential diagnosis of these several affections. 
 
 Prognosis. Although it is impossible to reckon upon a 
 spontaneous cure, still there are cases in which the hydatids 
 have withered up into a soft pultaceous mass, and others in 
 which recovery has followed spontaneous rupture. The perils of 
 suppuration and rupture, however, are so great that it is much 
 better to prevent their occurrence by surgical treatment. 
 
 Roberta's list of sixty -three cases yields twenty in which recovery 
 was believed to have been permanent ; nineteen which were 
 fatal ; in the remainder (twenty-four) the results were not known. 
 In ten of the fatal cases the cause of death was directly due 
 to the hydatids bursting into bronchi, to pleurisy, the effects 
 of pressure of the tumour, or of suppuration of the contents. 
 In one case a large renal calculus was found with the hydatids 
 in a solitary kidney, and the hydatid tumour opened into the
 
 680 SURGERY OF THE KIDNEY AND URETER 
 
 renal pelvis and obstructed the .outflow of urine. In nine 
 cases the causes of death were unconnected with the hydatids. 
 
 The duration of the disease is uncertain, but often very pro- 
 longed. Patients have gone on passing vesicles at intervals for 
 twenty and even thirty years. There are no means, except by 
 waiting, of telling whether more remain behind after some have 
 escaped by the passages. If, when the cases are left untreated, 
 the prognosis of hydatid tumours of the kidney is more favourable 
 than that of similar tumours in the liver or other internal organs, 
 it is because of the tendency to rupture into the renal pelvis, 
 although, as seen from what has been stated above, this is far 
 from being a safe or satisfactory accident. When the tumour 
 is small and situated in the central parts of the kidney, however, 
 the evacuation is comparatively easy and safe. There is no fatal 
 case 011 record in which the vesicles have escaped per urethram 
 from a renal hydatid cyst where the cyst had not given rise to 
 an abdominal tumour. The discharge of pus with the vesicles is 
 not necessarily unfavourable ; cases have recovered where the 
 quantities of pus discharged have been very great. When the 
 cyst breaks into the pleura or a bronchus the probability of recovery 
 is very slight ; when into the bowel or stomach it is much more 
 favourable. AVhen the cyst grows continually, and does not 
 burst in any direction, the clangers of a large tumour and of 
 its pressure effects have to be met. The evolution of hydatid 
 cysts is very tardy, many years often elapsing before any serious 
 complication arises. But however slow the development of the 
 cyst, it commonly leads, if left to take its course, to a fatal ter- 
 mination, either by rupture, suppuration, or pressure effects on 
 the organs of digestion and nutrition, respiration or circulation. 
 
 Treatment. Writing 011 this subject in 1884, I stated: "The 
 only proper treatment is to cut down upon the tumour. 
 and having tapped and emptied it of its fluid contents, to incise 
 it and stitch the edges of the cyst to the margins of the parietal 
 wound. The cysts should be opened from the loin if possible ; 
 if not, then at its most prominent or projecting point. Aspiration 
 may be tried before incision, but is less surely successful." There 
 is nothing to add to or to alter in this description except to 
 exclude aspiration or puncture as a method of treatment, and 
 to counsel excision of the cyst itself in certain cases. 
 
 In 1884, electrolysis, simple puncture, puncture followed by
 
 XEPHRECTOMY RARELY JUSTIFIABLE FOR HYDATIDS. (581 
 
 injection of iodine, perchloricle of mercury or other drugs, puncture, 
 followed by immediate drainage, and the employment of caustics 
 or other means for exciting adhesions between the cyst wall and 
 the parietes before puncturing or incising, were becoming matters 
 simply of historical interest. To-day they have quite passed into 
 the limbo of discarded procedures. 
 
 Nephrectomy has been resorted to in a few cases with 
 very bad results. Houzel quotes six cases with five deaths ; 
 a mortality which is only excusable or explicable on the assump- 
 tion that the kidney affected in the fatal cases was a solitary 
 kidney, which he states was the fact in the patient he himself 
 operated on, and in an unpublished case operated upon by Billroth. 
 
 It has been argued that such a mistake would be avoided 
 if the cystoscope and ureteral catheter were employed, but to 
 this Bazy replied that he had seen a case of single kidney 
 with a ureter that passed round the bladder and opened upon 
 the opposite side, which would have led to the inference that 
 there was a kidney on the side where none existed. 
 
 In Houzel's case there were two independent ureters, but only 
 one kidney, which contained a large hydatid cyst : the patient 
 passed, however, a great quantity of urine, and a cystoscopic 
 examination could not have led to the diagnosis of a single kidney. 
 
 If it is borne in mind that the function of whatever remains 
 of the secreting tissue of the affected kidney is little or not at 
 all destroyed by the presence of the hydatid cyst, and that as soon 
 as the pressure is relieved the secreting function will be increased, 
 there is no justification for removing the kidney in an ordinary 
 case. If an intractable fistula should follow nephrotomy it 
 will be time enough to consider the question of nephrectomy ; 
 but such a fistula is most unlikely to occur. The only con- 
 ditions under which primary nephrectomy should be performed 
 for hydatid disease are suppuration of the kidney or rupture of the 
 hydatid cyst into the lung or peritoneum. 
 
 Nephrotomy, on the other hand, should be the immediate 
 operation, and has given 100 per cent, of successes. Houzel * 
 gives fourteen cases, with fourteen recoveries. Brodeur collected 
 four cases of hydatid cysts of the kidney which were submitted 
 
 * "Contribution a 1'Etude des Kystes Hydatiques du Rein," par M. le 
 Dr. G. Houzel de Boulogne-sur-Mer : Annales des Maladies des Organes 
 Gc'nito-urinaires, Juin, 1899, p. 595; which see for bibliography.
 
 682 SURGERY OF THE KIDNEY AND URETER 
 
 to operation; in two nephrotomy was performed by Pean, and 
 both, recovered : in one a partial and in the other a complete 
 nephrectomy by the abdomen was performed, and both of these 
 patients died. The best route is the lumbar because by it 
 (1) there is no risk run of any of the contents escaping into 
 the peritoneal cavity ; (2) if the kidney is movable, as it often 
 is when affected by hydatid, it can be fixed or anchored in its 
 proper place ; and (3) cysts which are expanding, even from the 
 front aspect of the kidney, can be reached, incised, emptied, 
 fixed, and drained through the loin ; whereas those which are 
 expanding from the posterior surface or from either pole can 
 much more satisfactorily be treated from behind. 
 
 After exposing the cyst it should be punctured and as 
 much of its fluid contents as possible should be drawn off. Then 
 the cyst wall should l)e pulled as far as possible outwards, 
 opened freely, and the contents removed. The cavity should next 
 1)6 irrigated with some hot aseptic solution and the cut edges 
 of the cyst wall should be sutured to the cut margins of the 
 parietal incision. A drain tube should be introduced and re- 
 tained. The after treatment consists in careful daily changes 
 of dressing, and if requisite, daily irrigation with weak alcoholic 
 or iodine solution. By degrees, and in time van-ing from two 
 or three weeks to a few months according to the size and the 
 amount of cyst wall to be cast off, the cavity Avill contract and 
 l>e filled up entirely with granulations. 
 
 Excision of the Entire Cyst. In certain cases, when, the cyst 
 is situated on or near the surface of the kidney, or when it pro- 
 jects greatly from the surface of the kidney, even though at 
 the same time it has encroached much towards the renal cavity, 
 the whole cyst may be dissected away, and the raw surfaces of 
 the kidney, if feasible, should be brought together by one or 
 more sutures. This treatment expedites recovery, and is very 
 practicable in such cases as are illustrated in Fig. 100 (p. 072) 
 and Fig. 110 (Vol. IT., p. 41). 
 
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 Morris, Sir Henry. 
 
 Surgical diseases of the kidney and 
 ureter. 
 
 MEDICAL SCIENCES LIBRARY 
 
 UNIVERSITY OF CALIFORNIA, IRVINE 
 
 IRVINE, CALIFORNIA 92664