A system of practical medicine. By American authors. Vol. 4

by Unknown

²¹ Weir, New York Med. Journ., Dec. 27, 1884.

There are two distinct methods, besides, of course, all the minor differences of detail called for in the individual case. The kidney may be reached from the loin by an incision along the outer edge of the erector spinæ, as already described for nephrotomy. It is to be enucleated from its capsule of fat by the fingers, and a ligature or ligatures passed around the pedicle consisting of the veins, arteries, and ureter. The kidney is then cut off, possibly leaving a little renal substance if the pedicle be short and accessible with difficulty. The wound is left partly open for drainage. This method has the advantage of avoiding the peritoneum and the handling of other abdominal organs. Its disadvantages are, in some cases, the want of room, and when undertaken for the relief of floating kidney the difficulty of finding the organ, which is likely to be at the end of a pouch formed of peritoneum. In cases of calculous pyelitis, where it may be at the beginning of the operation uncertain whether merely an incision for the removal of a stone or a total removal of a kidney of normal size may be necessary, this line of approach presents decided advantages.

The other method is by abdominal incision or laparotomy, which is usually made through the linea alba, though in a number of cases the outer edge of the rectus abdominis on the side corresponding to the organ to be removed has been taken as the guide. The steps of the operation are similar to those of ovariotomy where the pedicle is tied and returned to the abdominal cavity. This operation may be one of choice, from the greater ease with which the pedicle can be reached and the possibility of increasing the length of the incision in case of necessity for the removal of a very large tumor. In one case a crucial incision was made. When the kidney to be removed is a wandering one, and especially when a kidney has become fixed in an anomalous position, this is by far the easiest, and sometimes the only practicable, method.

Antiseptic precautions are of course to be used.

Hydro-nephrosis.

Obstruction to the discharge of urine from the body naturally produces special disorders in the secreting and discharging organs. If the obstruction exist below the neck of the bladder, as in stricture of the urethra or enlarged prostate, then the bladder is the organ primarily affected, and it may become distended, sacculated, its muscular coat hypertrophied, its mucous membrane affected with catarrhal inflammation, and its contents changed from the normal by the addition of mucus, of pus, of bacteria, or a deposit of earthy phosphates from the ammoniacal reaction produced by decomposition of the urea.

The effects of distension of the bladder will sooner or later make themselves felt in the upper urinary passages, and will then give rise to the same dilatation of the ureters and the renal pelvis as occurs when the obstruction is higher up. As regards the rapidity with which such changes progress, much depends upon the degree of obstruction as well as upon the amount of urine secreted. It probably, however, never takes place suddenly.

In a case which came under the observation of the writer a partial paralysis of the bladder, probably existing from infancy, had in the course of three or four years, during which large quantities of light urine were passed, given rise to dilatation of the ureters, slight dilatation of the pelvis of the kidneys, atrophy of the parenchyma, and hypertrophy of the left ventricle.

Obstructions in the course of the ureters may exist at their opening into the bladder, which may be contracted by chronic cystitis; at a point immediately above this from compression by morbid growths, especially of the uterus, one of the most common causes of hydro-nephrosis, or even from retroflexion of the uterus when pregnant; at any point in its course by a twisting or sharp angle, as in movable kidney, although this is a much rarer accident than might be supposed; or at the brim of the pelvis, where it may be bound down by old peritoneal adhesions, and at its junction with the renal pelvis, which may be formed in such a manner as to constitute a valve, so that the urine escapes slowly or with great difficulty; or where it may be blocked by a calculus or other deposit in the cavity of the pelvis.

Obstructions by a twist or angle or by a valvular opening may, it is obvious, be temporary or intermittent in their action, and probably some arrangement of this kind was present in the cases which have been reported of relief of hydro-nephrosis by gentle massage of the abdomen.