Senn and others have endeavored to induce the formation of dense adhesions by packing around the kidney with gauze, left in situ for several days, whose presence should provoke the formation of granulation tissue. In theory this works well, but in practise the presence of the gauze is painful, its removal especially so, and the wound must be left more or less open for the purpose. Since I have learned of the harmlessness and the advantages of decortication I have made a practise of decapsulating almost every kidney thus exposed, and of endeavoring to utilize a portion of the capsule for the purpose of support, as by cutting it into strips, which are threaded into a needle, and then passed through the tissues, thus utilizing the capsule for suture material, or by fastening it with sutures which are not passed through the kidney substance. All in all I have had best results from a combination of some such method as this with one of suspension, for which purpose tapes or gauze are used and passed beneath the kidney—one above the hilum and one below it—after it has been delivered well into the wound, by which it is, first of all, lowered into the position in which it is intended to hold it and then maintained there, the ends being left hanging out of the wound, where they are tied over a roll of gauze or something similar. This provides the smallest amount of gauze, whose presence may provoke granulation tissue, at the same time proving an efficient means of support, and leaving trifling strips to remove when the time for their removal has come. I have usually left them in place for nine or ten days, by which time they are comfortably loosened by the presence of granulations around them, and consequent moisture, so that they are easily withdrawn, with a minimum of discomfort to the patient. Da Costa has suggested an improvement on this by sewing the ends of strips of gauze with chromic gut and letting these sewed ends be placed beneath the kidney. In the course of time, as the catgut softens, the union is separated, and the strips are easily withdrawn. If there be a tendency in these tapes to slip from their desired position, they may be attached to the capsule by a single suture of catgut, which will have softened and disappeared before the time for their withdrawal has arrived. Again in many of these instances the capsule which has been stripped off, or more or less detached, may be utilized for the purpose of fixation by suture with its own tissue.
Nearly all of these operations are without mortality, although they are not yet as satisfactory as could be desired, the trouble inhering partly in the fact that the kidney is not fastened as high up as it should be, or else not in quite the same relative position, so that there is some strain upon its vessels or upon its ureter. Every effort should be made to imitate the original position as accurately as possible. Methods theoretically more perfect, yet more complicated and but little more advantageous, include fixation of the kidney to the twelfth rib, by suture passing through the capsule and then around the rib. No matter what method be adopted, it is necessary to keep the patient in bed for several weeks after these operations, in order that adhesions may not only form but may not be stretched by too early change of posture.
TUMORS OF THE KIDNEY.
The kidney is the site of an occasionally benign and frequently of a malignant tumor of some of the known varieties. The simplest forms, like the fatty and the fibrous, are uncommon and deserve no special consideration here. There is a so-called adenoma of the kidney, which does not deserve this expression any more than does the so-called adenoma of the thyroid, in that it is not built up of the normal type of secreting gland, but represents something more or less similar to it, perhaps only undergoing multicystic degeneration, its commonest expressions being of congenital origin. The consequence is the production of the so-called congenital adenoma or cystic or multicystic or polycystic kidney, in which may be seen a conversion of original renal tissue into a mass of cysts, surrounded by degenerated kidney tissue, all semblance to the original being lost, and the whole constituting a partial or complete invasion of the organ, by which sometimes its proportions are enormously increased. The condition is essentially of congenital origin, although its serious clinical expressions may not occur for years. The result is to destroy the renal function, to produce a growing mass, and to constitute an essentially surgical condition to be relieved only by nephrectomy. (See [Fig. 637].) I recall one child of twenty-three months with a tumor of this character, of such size and extent that it could only stand erect when wearing from its neck a sort of suspensory in which the lower part of the abdomen was contained. I removed this kidney by abdominal section, the child recovering, and being at that time the youngest case that had ever survived a nephrectomy. A number of years later a similar condition developed in the other kidney, of which the child finally died, it having passed during the last thirteen days of its life not more than an ounce or two of urine.
Of the solid tumors of the kidney both carcinoma and sarcoma occur, the former usually as a secondary growth, the latter usually as primary, although any form may be met. The sarcomas are more frequent in early life and in general more common. On account of the kidney having a well-marked capsule metastasis is not so common, in the early stages, as from some other organs. These malignant tumors may attain great size; some grow regularly in shape, others constitute most irregular masses. The entire organ may be involved or only a part.
There are no indicative symptoms of renal cancer that may not be met in other conditions; the development of tumor, perhaps its displacement, pain, and hematuria, though late, and, in proportion to the rapidity of growth, enlargement of superficial veins and general cachexia. When the tumor is large enough to press upon the vena cava or upon one of the common iliacs there will be edema of one or both lower extremities. The veins of the external genitals are more likely to suffer early rather than late ([Figs. 638], [639]).
Fig. 637
Congenital cystic kidney; exterior and internal appearance; patient forty-two years of age. (Schmidt.)
Fig. 638