—The various changes included under this head are usually bilateral. The term implies a non-pyogenic infection of the renal bloodvessels, interstitial tissues, and glomeruli or tubules, which produce changes, often spoken of in this country as constituting interstitial parenchymatous or diffuse forms of nephritis, and inducing gross changes which cause the kidney to be spoken of as contracted, large, white, waxy, etc. Discussion of the pathology of these conditions here is out of place. They have all been grouped, most loosely, in common parlance as forms of “Bright’s disease.” Apart from the significance of albuminuria and the many terms implying peculiar features, the apparent hopelessness of many of these conditions, and the disappointment following internal treatment, finally led surgeons to attempt to ascertain what they could accomplish. It was in 1886 that Péan operated on a case of chronic nephritis with nephralgia and removed the kidney. Ten years later Harrison made three nephrotomies, and, though under a wrong diagnosis in each case, it was noticed that the symptoms all cleared up and that albumin disappeared from the urine. About the same time Newman showed that albumin and casts have often appeared in movable kidney, because of torsion of the vessels, and that they disappeared after nephropexy. Then Pousson, in 1899, reported some twenty-five cases of hematuria and nephralgic nephritis, operated upon by nephrotomy and nephropexy, with great benefit. In 1899, Israel was, perhaps, the first to formulate rules for nephrotomy for these conditions. In 1899, also, Ferguson claimed that chronic nephritis should be treated as are inflammations elsewhere, by relief of tension and even drainage. Meantime, Edebohls had been doing partial decapsulation and fixation in cases of so-called unilateral nephritis (the possibility of which is disputed by the best authorities, like Kümmel), and later extended his method to complete decapsulation (capsulectomy), with replacement of the kidney in its fatty bed, claiming that by and through the new adhesions thus produced new and more complete as well as additional blood supply was furnished, and that regeneration of the slightly altered parenchymatous tissue, as well as absorption of exudates, was produced. (Guiteras.) The fact that it seems now well established that these forms of chronic nephritis are always bilateral does not of itself affect the cogency of Edebohls’ reasoning, if it be otherwise correct.
Accurate diagnosis has much to do with this problem. Israel has shown that chronic nephritis is even more difficult of recognition in the living than in the dead, not only after ordinary examination of the capsule, but also after opening into the kidney. Age is not a serious contra-indication, and enlargement of the heart is said frequently to subside after these operations. If cardiac compensation be good operation is permissible, if not otherwise contra-indicated. Edebohls’ method is to anchor the kidney to the muscles of the back, whether it was previously movable or not. Primary healing is desirable, since “nephritics” do not bear suppuration well.
Indications for Operation.
—At present a satisfactory summary is impossible. It is of the first importance that operation should be undertaken early, since to wait until anasarca or other grave conditions supervene is to invite disappointment as the result of a procedure which is by many considered capital. The coincidence of pronounced disease of any other type would be a contra-indication. Bacteriuria, pyuria, etc., would perhaps make it more desirable rather than otherwise. Cases of operative toxemia (postscarlatinal, typhoid) and of cirrhotic type, without other contra-indications, are the most favorable. When a careful examination of the patient and the urine leads the surgeon to think that preparatory treatment may be of advantage, he should find therein almost his only excuse for delay, if operation is to be done. Low hemoglobin percentage should also lead to postponement.
Operation may consist of nephrolysis, or breaking down of adhesions, by which pain is frequently relieved, of decapsulation, of nephrotomy, and, finally, of nephrectomy, in case serious lesions are disclosed. It is doubtful if benefit is due so much to formation of new vessels as to a freer circulation of blood within the kidneys, with their consequent improved opportunity for repair and elimination. Guiteras, for instance, does not believe in total decapsulation, but in partial exposure of a sufficient area on the posterior kidney surface to assist in its fixation, if movable. Otherwise he considers that simple division of the capsule over the convexity will be sufficient. In cases of unilateral nephralgia and hematuria he advises nephrotomy, not so much as an approved therapeutic measure as for exposure, perhaps for revealing the possible existence of deep lesions.
Fig. 633
Acute pyelonephritis with multiple miliary abscess formation. (Israel.)
The recent reports from various surgeons concerning the value of renal decapsulation alone are by no means unanimously favorable, although a majority of writers are in favor of exposure of the kidney, capsulotomy and fixation, either by suture or tampon. Still, it does not seem at present justifiable to maintain that decapsulation can be expected to cure diffuse or deep-seated arteriosclerosis or degenerative processes within the kidneys.
The question of the suitable anesthetic is here one of importance. For reasons set forth earlier in this work, ether should always be avoided. If the operation be one that can be speedily performed, nitrous oxide gas alone may suffice. Otherwise it should be done under chloroform, preceded perhaps with ethyl chloride, or under somnoform.