infection of the kidney is usually the result of a process ascending
from the lower urinary passages, particularly when these are obstructed
by calculus, tumor, prostatic enlargement, or ureteral stricture. It
may follow catheterism either once or prolonged, especially when done
without strict precaution; or the infection may come from the other
direction _via_ the blood stream, as in typhoid and various other
fevers, the exanthems, and diphtheria. Gonorrhea is a frequent cause,
acting insidiously and by a creeping invasion, with the intervention of
a rather more abrupt cystitis. Nevertheless when gonorrhea is followed
by pyemia and metastatic abscess these form early in both kidneys, and
disaster quickly follows. These types of infection spreading upward
along the ureters do not spare the pelvis of the kidney, but expend
their first violence there. Beyond this they may extend to the renal
tissue proper, where they set up a true nephritis, which may prove
fatal.
=Symptoms.=--Clinical symptoms do not vary greatly except in detail.
They include fever, chills, and similar expressions of toxemia, with
more or less pain in the kidney, down the ureter, and even referred to
the ultimate distribution of the nerves sympathetically or anatomically
involved, _e. g._, to the testicle on the same side, often with
retraction of the scrotum, and down the thigh. There is a tendency to
_thamuria_ (frequency of urination) when the bladder is involved, as it
always is sooner or later. Pus and mucus are recognizable in the urine
by the naked eye, while a microscopic study of this fluid will reveal,
from the character of the cells, the extent and type of the invasion.
The tuberculous type will be considered separately. Suffice it to say
that in this form, however pure may have been its original type, it
becomes sooner or later converted into a mixed septic infection, with
which renal abscess is often connected. The gonorrheal type is nowise
clinically distinct, so far as the kidneys are concerned, but is to be
recognized either by the microscope or by other clinical evidence.
=Treatment.=--Such cases as the above may even perplex the surgeon,
since they complicate many other surgical conditions. Yet if they go no
farther than above described they are to be treated rather by internal
methods, _i. e._, diluents, with hot-air baths, and especially by
urotropin, the remedy of greatest value, while such drugs as aspirin,
benzosol, sodium benzoate and the like, in moderate doses and at rather
short intervals, may be administered to great advantage.
=Renal Abscess; Surgical Kidney.=--The conditions above described do
not necessarily nor often terminate with resolution. Not infrequently
suppuration follows, with resultant abscesses, which may be solitary
and possibly large, but are more likely to appear in multiple and
perhaps punctate form. Should this condition occur in one kidney alone,
it determines probably its ultimate destruction; if in both kidneys,
the prognosis is very grave, since later, if not immediately, such a
case will succumb to renal failure, due to the extra load put upon the
portion still capable of secreting. It is to kidneys thus crippled
by acute or subacute infections, with punctate abscess and similar
lesions, that in the past the term “_surgical kidney_” was applied,
because such kidneys were seen oftener in surgical than in so-called
medical cases.
Brewer has recently called attention to a type of _acute hematogenous
renal infection_, to which he has given an identity of its own.
The possibility of renal infection through the blood has been long
recognized, but it has been generally supposed to produce bilateral
lesions. Of late, however, it has been shown that these may be
unilateral, on account of the diminished resistance of one kidney
as the result of previous disease or injury, among the former being
calculus, renal retention, and floating kidney. While the colon bacilli
are most frequently at fault the infection is often of the pyogenic
or mixed type. It seems to be more frequent in women than in men.
The symptoms are those of an acute infection, often ushered in by a
chill, with sudden rise of temperature, sometimes followed by such
marked remission as possibly to suggest malaria. The pulse ranges
high. Abdominal pain is an almost constant symptom, although it is
usually vague and often shifting or referred. Sometimes it will cause
such a complaint as to lead to mistaken diagnosis in favor of an acute
appendicitis. Occasionally it radiates along the course of the ureter.
Tenderness in the costovertebral angle is nearly always present.
Muscle rigidity is frequent but inconstant. There is nearly always a
leukocytosis, with a percentage of about eighty polynuclears. Frequency
of urination may accompany these cases, but they will ordinarily be
diagnosticated by physical and urinary examination. The urine will
usually contain albumin, perhaps with pus, and occasionally a few
red blood cells. Urine obtained from the affected kidney by ureteral
catheterization will contain more of these evidences of abscess than
that from the other side. Brewer has had far better success in entirely
removing the affected kidney than in exposing and simply draining it.
He has thus done a great service in demonstrating the possibility of
unilateral acute and suppurative disease of the kidney, where diagnosis
is most obscure and the clinical picture one of acute general abscess
rather than of local affection, showing as well that the more acute
cases tend rapidly to terminate fatally unless promptly arrested by
complete removal of the affected organ.
As we consider the above infections, with others yet to be mentioned,
it becomes more necessary to appreciate those constituents and
characteristics of the urine which have for the surgeon the greatest
significance, and those methods of investigation which furnish him the
promptest and most satisfactory results.
The following include methods in present use for determining renal
_capacity and function_, _i. e._, the matters of greatest importance:
1. Catheterization of the ureters;
2. Cryoscopy of the blood and the urine;
3. Phloridzin test;
4. Chromocystoscopy;
5. The toxin test;
6. The test for electroconductivity (Kakells).
1. By _cystoscopy_, with _ureteral catheterization_, we determine
whether urine is secreted by both kidneys or but one, while the
secretion of each kidney may be separately collected and studied. Even
this method leaves much to be desired. Though one kidney be actively
diseased it may still contain sufficient tissue to make it partly
competent for its purpose, and undesirable to remove; or an organ with
very defective structure may, nevertheless, yield a certain amount of
nearly normal urine. These, then, are aids to determine the _character
of the morbid process_, and the information they furnish is valuable,
but not always sufficient.
2. _Cryoscopy_, based upon the physiochemical law that the freezing
point of the solution is proportionate to the number of molecules it
contains, _i. e._, to its molecular concentration, has revealed that
the blood of a person with severe kidney lesion freezes at a lower
temperature, while the freezing point of his urine would be much higher
than in a normal individual, because those materials which should have
been excreted in the urine are, on account of impaired renal function,
retained in the blood and do not get into the urine. The freezing point
of normal urine varies from -0.09° to -2.3° C.; the freezing point of
normal blood from -0.55° to -0.57° C. The reasoning employed in the
method is sound, but the method itself difficult, requiring special
apparatus and experience. Moreover, the limits of the possibility of
error are such that this method alone should never be relied on. It is
essentially a test of the _ability of the kidneys to act as filters,
but does not test their serviceability as secretory organs_.
3. The _phloridzin test_ is one of the most trustworthy for
estimating the secretory function of the kidneys, as it shows how
much active working epithelium remains in the organ. It consists in
the subcutaneous injection of 0.005 Cc. sterilized phloridzin with an
equal quantity of sodium benzoate, to hold the former in solution.
The bladder must be emptied just before the injection is given.
About an hour after its administration _sugar should appear in the
urine, if the kidneys are acting normally_. If they are to be studied
separately, catheterization of the ureters is necessary. The test is,
of course, worthless in diabetic subjects. It depends upon the amount
of sugar excreted, the time of its appearance, and the duration of its
elimination. If no sugar be present the kidneys are seriously affected;
if it be delayed, renal insufficiency is present. The average quantity
of sugar eliminated during the first half-hour, when the kidneys
are normal, is about 0.5 per cent. If the kidneys be diseased, this
quantity is reduced by a half, and there is very little more secreted
in the first than during the second half-hour. This valuable method is
unfortunately difficult of application and requires minutely careful
chemical tests.
4. _Chromocystoscopy_, introduced by Voelcker and Joseph, is perhaps
the simplest of all methods of estimating renal capacity. 20 Cc. of
a 0.4 per cent. solution of _indigo-carmine_ is injected into the
gluteal muscles. In fifteen or twenty minutes, if the kidneys be
normal, the cystoscope will reveal dark-blue urine flowing from the
ureteral orifices toward the median line, with a peculiar jet at
regular intervals of about twenty-five seconds, and lasting for perhaps
five seconds. There is both rhythm and force about this ejaculation.
If the color be pale, the jet weak, or the rhythm irregular, the
intervals prolonged or late, or if no flow whatever occur, there must
be hindrance in the secreting and filtering structure of the kidney, or
occlusion of the ureter. The results given by indigo-carmine in these
cases are superior to those furnished by methylene blue, since it is
not so much a solution as a mixture which is formed and ejaculated
as such. Moreover, in passing through the body the indigo-carmine
undergoes no reduction. By this method there is no necessity for
catheterization of the ureter. One needs only to use the cystoscope
with reasonable dexterity, and there is no necessity for chemical tests
of separate specimens. The method is generally useful in cases where
ureteral catheterization is made impossible by growths. It affords an
easy means of differentiation, for instance, between ovarian cyst and
hydronephrosis.
5. The _toxin test_ is one only to be carried out by the use of
animals, since it depends upon the amount of filtered urine required
to kill an animal after injection into its veins, the number of cubic
centimeters necessary to kill, divided by the weight of the animal,
being called the urotoxic co-efficient. It has greater laboratory than
clinical interest.
6. _Electroconductivity of urine_ is of value in determining the
capacity of the kidney for eliminating inorganic cells. It depends on
the resistance offered by the urine to the electric current. It is
complicated in method, requires special apparatus, and its results are
still of questionable value.
For _ordinary purposes_ the most trustworthy data for the surgeon who
is not provided with ample laboratory facilities are afforded by an
estimate of the _amount passed in twenty-four hours_, its _specific
gravity_, its _color and acidity_, and by the _presence or absence
of albumin_. The test-tube and the microscope then still afford
satisfactory means of deciding those matters which the surgeon needs to
know. If applied to urine collected separately from each kidney, they
may be regarded as trustworthy. If catheterization be impossible, then
it is advisable to inspect the ureteral orifices while elimination of
indigo-carmine is taking place.
=Hematuria.=--The significance of blood in the urine is rather that
of a _symptom_ than of a disease, although it should be admitted that
there are occasional patients who lose blood in this way, more or
less frequently, even periodically, without seeming to suffer in the
least. Hematuria may also be present as an expression of vicarious
menstruation. Again, blood may thus appear in scurvy and similar
conditions, especially in tropical climates; in certain of the
domestic animals its presence may be due to infection of the kidneys
by macroscopic parasites (the so-called “_black-water fever_” of men
and horses). Such cases as these are outside the pale of surgery.
Nevertheless general experience has shown that many cases of hematuria,
without perceptible changes in the kidney, have been benefited or
cured by exploratory nephrotomy. Among the causes ascribed for these
so-called “_essential hematurias_” have been incipient tuberculosis,
renal retention from prostatic enlargement, congestion from venous
obstruction (due to tight lacing or displacement from any cause), and
even the congestion of chronic nephritis.
=Treatment.=--When known or recognizable causes are absent, and the
ordinary therapeutic agents, the special styptics (cotarnin), and such
measures as hypodermoclysis with a 2 per cent. gelatin solution (see
Control of Hemorrhage) have failed, an exploration may be advised.
It is of the greatest advantage to be certain that but one kidney is
involved, or it may be necessary later to operate on the second kidney.
=Operative Treatment of Chronic Nephritis.=--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.
[Illustration: 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.
=Pyonephrosis.=--As a condition this is to be distinguished from
ordinary abscess of the kidney, in that it implies the retention in
the renal cavity or pelvis of pus with eventual destruction of kidney
tissue. In other words it is an _empyema_ rather than an abscess. It
results from septic or tuberculous invasion, plus ureteral obstruction,
regardless of the obstructing cause, _e. g._, calculus, plugs of mucus,
stricture, kinking of ureter, or extrinsic tumor causing pressure.
Occlusion may be so complete that no urine escapes from the affected
kidney, while that from the other is clear, or the phenomenon may be
intermittent. There results more or less enlargement and often great
dilatation of the diseased kidney. Pus thus retained has been known to
be discharged into the intestine or even into the lung. Spontaneous
recovery is rare. Aspiration from the back in these cases is proper for
diagnostic purposes.
=Treatment.=--Pyonephrosis, like any other collection of pus, calls
for _incision_ (nephrotomy) and _drainage_, with removal of any
possible foreign body, such as calculus. If the entire kidney be found
destroyed, or so compromised as to jeopard its future, a _nephrectomy_
may be done at once, while it may be a secondary measure in cases of
permanent urinary fistula following drainage. So, too, if the kidney be
found tuberculous, it is better to remove it than to temporize.
=Perinephritis.=--To pus formed in a perirenal phlegmon is given the
term _perinephritic abscess_; this is sometimes due to external or
penetrating injuries; sometimes it appears as a primary condition
difficult of explanation; but it usually follows inflammation of
adjacent structures, such as the kidney itself (tuberculous pyelitis),
the liver, the colon, and the appendix. While perinephritis usually
terminates by suppuration, spontaneous recovery, with more or less
absorption of exudate, is known to occur. These perinephritic
collections sometimes attain enormous size, and are then sure to
migrate, always along lines of least resistance, which takes them
usually downward, either toward the loin or the groin. I once tapped
below Poupart’s ligament a collection which exceeded a gallon. These
abscesses may also, more rarely, burst into any of the adjoining
cavities, and discharge either by the mouth, bowel, or bladder, or even
externally.
=Symptoms.=--In addition to the usual systemic indications of the
presence of pus there may be _tumor in the lumbar region_, sometimes
with distinct fluctuation, usually with rigidity of the lumbar and
psoas muscles, perhaps even contractions of the thigh muscles which
may simulate hip disease. These abscesses have been mistaken for
peri-appendical phlegmons. If necessary to establish the presence of
pus the exploring syringe may be used, but this is rarely necessary.
=Treatment.=--While in the early stages the local application of
guaiacol may be of use, every collection of pus thus formed here, as
well as elsewhere, needs _evacuation and drainage_. This latter is to
be provided by opening through the loin, in order that gravitation in
the dorsal position may be of greatest assistance. A more or less free
incision, such as is made for exploring or removing the kidney, will
usually be sufficient, but may be combined with a counteropening at any
point where the latter would be of advantage. Thus should pus present
in the groin an opening should be made both posteriorly and at the
point where it appears to be coming toward the surface.
=Tuberculosis.=--At no age are the kidneys exempt from tuberculous
lesions, although these are more frequent in the earlier years of life.
Here as elsewhere they may assume the disseminated miliary type or
occur as a solitary focus. The infection may proceed upward from the
bladder, or it may be a local expression of a widely diffuse process.
In the latter case it has passed beyond the control of the surgeon
as such, and calls for general therapeutic measures, judiciously
selected and actively maintained. Not a few cases of renal abscess, of
pyelonephritis, and even of perinephritic abscess, are due to primary
tuberculous lesions.
=Symptoms.=--About the earliest symptoms that a patient may complain
of are _thamuria_ (frequency of urination), with blood or pus in the
urine. Even at this early stage the condition is essentially surgical,
so the diagnosis should be established. Cryoscopy alone is hardly
sufficient, although if the freezing point be studied it should be
regarded along with the amount of fluid ingested and the quantity
of carbohydrates taken with the food. Ureteral catheterization is
valuable, although until it came into vogue we were content to study
the cystoscopic appearance and to judge by the ureteral orifices,
assuming that if one appear healthy and the other not so operation is
indicated.
The question of removal of a totally diseased kidney when the other is
more or less affected is one demanding greatest judgment. Some of the
more recent operators endeavor to determine this by the cryoscopic test
of the urine from the less affected organ. If this stand the test they
do not hesitate to remove the one which is totally diseased. Thus it
would appear that the ideal method is one of careful study of the urine
from each kidney, although it is acknowledged that when the question is
still in doubt the associate kidney may be explored before deciding to
remove the one most diseased.
=Diagnosis of Renal Tuberculosis.=--The most frequent and significant
symptoms of renal tuberculosis are _pain_, local and referred;
_hematuria_, _polyuria_, and _pyuria_. In young adults suffering
from bladder irritability, _painless pyuria_ usually indicates
tuberculosis of the bladder, secondary to that of the kidney, this
being particularly true when the urine is hyperacid. This urine, if
noted, will be found at first faintly cloudy or smoky, while later the
admixture of pus becomes more evident. The frequency of micturition
(thamuria, pollakiuria), which is frequently noted early, may be due
mainly to polyuria; the final test is the discovery of bacilli in the
urine. There is another form of thamuria which is associated with
tenesmus, constituting the painful cystitis of Guyon, which depends
on complications in the bladder itself. A search for bacilli is often
disappointing, and tuberculin may be used in the endeavor to make a
diagnosis, as well as animal inoculation. Tuberculin might, however,
give rise to error were there tuberculous foci elsewhere about the body.
[Illustration: FIG. 634
Tuberculosis of kidney, nodular form. (Israel.)]
_Renal tuberculosis_ may run a painless course, or it may be
accompanied by a severe renal colic or renal crises, the latter
sometimes due to plugging of the ureter with cheesy debris. Pyuria may
be masked by hematuria, the latter trifling, apparently spontaneous,
and occurring even during repose.
More accurate diagnosis can be rarely made without resort to the
cystoscope and catheterization of the ureters. When in the cystoscopic
image the ureteral orifice is enlarged, congested, and even hemorrhagic
or ulcerated, it may be regarded as evidence of tuberculous disease in
the corresponding kidney. Meyer has claimed that in the descending
form of tuberculosis the mouth of the ureter is ulcerated, while in
the ascending form it is apparently healthy. When both outlets are
apparently healthy, and urinalysis indicates renal disease, the case
must be one of ascending lesion. Fenwick has described what he calls
a “golf-hole ureter,” the orifice being dilated and patulous, and the
appearance being to him pathognomonic.
Ureteral catheterization is perhaps less necessary on the suspected
side than it is to prove the healthfulness of the kidney on the
opposite side. The disease is more common in the female, and usually
occurs in early adult life. It is more often a descending than an
ascending affection.
[Illustration: FIG. 635
Renal tuberculosis as seen on section. Papillary granulomata seen at
_T_. (Israel.)]
=Treatment.=--Radical treatment of renal tuberculosis is possible only
when the lesion is limited to one organ. What shall be done with the
kidney involved, when exposed and the disease revealed, may depend
to some extent upon the actual degree of involvement. More and more
surgeons are agreeing that anything like partial nephrectomy is of
questionable value, and that an organ _distinctly tuberculous should
be removed_. In other words, partial nephrectomy is of doubtful merit.
Of course, the kidney should be opened before its removal, unless from
its exterior it is seen to be hopelessly involved. A further question
of great importance is that of _involvement of the ureter_. With a
few associated lesions in the kidney the ureter may easily escape,
but with a kidney thoroughly degenerated, and with infected urine or
tuberculous debris passing constantly down through the ureter it cannot
escape contamination. It is not a difficult procedure, nor does it add
to the gravity of the operation, to extend the incision sufficiently
to permit not only the delivery of the kidney but the exposure at
least of the upper portion of its ureter. In this way the renal pelvis
may be opened and the ureter itself examined. When thus involved, and
especially if it be determined to sacrifice the kidney, as much of the
ureter should be removed with it as can be reached. While theoretical
considerations would always require these measures to be combined,
many mild tuberculous lesions of the ureter undergo spontaneous
retrocession after removal of the diseased kidney from which it has
become contaminated.
The incision intended to expose the ureter should begin about a
half-inch forward and in front of the lower costal cartilage, parallel
with the last rib, and terminate on a level with the anterior superior
spine, about one inch toward its inner side. This incision will then
be about four inches in length. The use of a pillow is of assistance
in the easy performance of this operation. The body should be rolled
as far as possible without losing negative pressure upon the abdomen.
The more abdominal fat there is present the further over the patient
should be rolled; a stout patient should have the hips raised from
the table by a cushion, in order that the abdomen may be pendent,
while the foot of the table is somewhat elevated and the operator is
facing the abdomen. After exposing the fat which is adherent to the
peritoneum, and the knife is laid aside, the peritoneum is separated
from the abdominal wall until the kidney and the perinephritic fascia
are recognized. Then with a short retractor the posterior edge of the
wound below the ribs is elevated, after which, under the influence
of gravity, the cavity opens widely, the fascia may be torn through,
and the kidney exposed and freed. The retractor is then removed,
the anterior edge of the wound pressed backward, and the kidney is
easily delivered from the abdominal cavity; or if its delivery be
impracticable, it may be at least so drawn up that the renal vessels
are easily exposed, tied, and divided. After their division care should
be given that the weight of the kidney does not drag injuriously upon
the ureter. The latter is then cleared of peritoneum, especially
to its outer side, by blunt dissection, after which a medium-width
Sims speculum, with a long bill, may be passed downward between the
peritoneum and the abdominal wall and made to draw the latter upward.
Thus an extensive view of the ureter is afforded, while its lower
portion may be still further freed toward the base of the broad
ligament. By a continuation of this process of separation and exposure
it is possible to release the ureter almost to its junction with the
bladder, where it is tied, its stump being disinfected with pure
carbolic.
=Syphilis and Actinomycosis.=--These lesions may be briefly dismissed
so far as they pertain to the kidneys. _Gummas_ are rare, renal
syphilis being usually of a disseminated type, which should be treated
by internal therapy, except when abscess results or when there arises
some peculiar surgical complication. _Actinomycosis_ is rare in the
kidneys, and is not recognized until the peculiar fungi are found in
the urine, or until some granuloma, developing toward the surface,
breaks down and discharges its characteristic products.
RENAL COLIC.
Renal colic implies severe and often agonizing pain, which follows
spasmodic contraction of the renal pelvis and ureter, in the effort to
expel an obstructing object from one or the other. It may be produced
by _calculi_, by _clots_ of blood, _clumps of pus and debris_, by
particles of _sloughing tissue_ (as in breaking-down tuberculous or
cancerous foci), by _extrinsic pressure_ of various morbid products,
or finally by _kinking_ or alternating stricture and dilatation of
the ureter. _Pain_ is the constant and significant feature, marked by
spasmodic exacerbation. It is usually well localized, and referred
along the course of the ureter and the cord to the testicle in the
male, with retraction of the scrotum, to the labium in the female, and
down the thigh in both sexes. With it there usually occur more or less
sympathetic disturbances, such as _nausea_, with most pronounced local
tenderness and sometimes abdominal rigidity.
=Treatment.=--Treatment, while palliative during the intensity of the
attack, should be later made radical. For the former hot applications,
morphine, and chloroform inhalations may be used. It may happen that
an almost complete inversion of the patient will be followed by
relief. Large does of glycerin, and sometimes of aspirin, will also
occasionally prove beneficial. Meantime the case should be carefully
studied and a skiagram be taken, in order that one may intelligently
advise and carry out whatever indications may be revealed.
RENAL CALCULUS.
_Renal and vesical calculi_ are the result of the precipitation of
material previously held in solution by the urine as it escapes from
the tubules, their nuclei or nidi being usually a clump of cells,
particles of blood clot or of tissue. They are composed mainly of _uric
acid_, _urates_ or _oxalates_, less abundantly of _phosphates_, and
rarely of _cystin_ or _xanthin_. They vary in size from the smallest
visible particle to those weighing ounces, and in number from one to
hundreds. They occur more often in males, and usually late rather than
early in life. They may be found in one or both kidneys. When the
latter it may be assumed that some systemic defect underlies their
formation. In shape they vary greatly, the small, sharp particles
often causing as much pain as do large stones, or even more. Diathetic
conditions produce them in some _de novo_, while in others they result
from previous morbid processes.
Small calculi escaping into the bladder cause intense _renal colic_
(see above), and, within the latter, unless they escape through the
ureter, as they usually do when small or are not retained behind a
large prostate, they increase in size, and become then the common
_vesical calculi_, those with uric acid nuclei. Calculi long present
in the kidney usually set up what is known as _calculous nephritis_ or
_pyelonephritis_. It is quite possible, however, for such a concretion
to first form within the tubules or at the apex of one of the pyramids,
so that it does not fall free into the renal cavity. In such locations
it may produce great pain, with hematuria and tenderness, yet not for
a long time escape into the renal pelvis. Such a stone may be shown
by a good skiagram. Calculi long retained will cause other troubles,
whose characteristics will be revealed by careful study of the urine,
especially of that drawn from the affected kidney, albuminuria and
pyuria often figuring. The symptoms include _pain and tenderness_,
which may be referred; _colic_, _hematuria_, and _pyuria_. Symptoms
of less frequency include _thamuria_ (sometimes painful), nausea, and
vomiting. The accompanying features include pyonephrosis, tuberculous
or movable kidney, or possibly various neoplasms.
=Symptoms.=--_Stone in the ureter_ may cause symptoms likely to be
mistaken for appendicitis, especially when lodged on the brim of the
pelvis, or an inflamed appendix may hang over into the pelvis and cause
bladder and rectal symptoms, while on palpation through the vagina the
tenderness and thickening may be misleading. In such cases the urine
offers the surest guide. Acute pancreatitis should hardly be mistaken
for renal trouble, as there would be a history of former attacks of
indigestion, probably associated with typical gallstone colic, while
the location of pain and the presence of pancreatic enlargement would
be significant. In pancreatitis, moreover, the urine might show sugar.
Renal or ureteral colic is sometimes followed by such reflex paralysis
of the bowel, with meteorism and tenesmus, perhaps even with nausea and
vomiting, as to suggest intestinal obstruction. Again, the crises of
Henoch’s purpura, and of angioneurotic edema, sometimes accompanied by
hematuria, may mislead.
Inspection of the entire body will probably reveal purpuric spots or
areas of edema.
Finally, _x_-rays afford very convenient means of diagnosis under many
circumstances, although mistakes have occurred from misinterpretation
of shadows. Nevertheless, when a well-taken picture shows unmistakable
evidence it may be considered as quite reliable.
=Diagnosis.=--In the matter of diagnosis few diseases, as Hunner has
shown, present such protean symptoms. Between calculous nephritis
and tuberculosis the only positive indication is the discovery of
bacilli in the urine or the reproduction of the disease in animals by
inoculation. Blood occurs in both, but is more likely to be influenced
by exercise in cases of stone. Pus occurs also in both, while pain is
unreliable. Palpation shows nothing, unless it may reveal thickening
of the ureter in the female as felt through the vagina. In pyelitis
the presence of a stone may cause any of these conditions, or it may
develop because of them. If trouble have begun soon after an acute
infection, or during pregnancy, it is more likely to be a case of
infected kidney. When tumor is suspected, urinary examination is the
best guide. The sudden occurrence of hemorrhages, with their abrupt
cessation, rather favor diagnosis of tumor, as does also the absence
of pus. Still the latter may be absent when the ureter is obstructed.
Intermittent hydronephrosis is usually due to kinking of the ureter
connected with a movable kidney. During the attacks the kidney will
be enlarged and misplaced, while blood may appear. With return to
place comes subsidence of enlargement, while increase in the amount of
urine is characteristic. Idiopathic hematuria or “renal epistaxis” is
sometimes connected with the chronic interstitial forms of nephritis.
The urine shows blood, if dealing with renal calculus, and bile if with
biliary calculus. In the former pain is more likely to radiate down
the ureter, while in the latter it is upward and backward. In biliary
trouble the gall-bladder may be enlarged and movable or even pendulous.
Kelly has suggested a method of differential diagnosis by catheterizing
the ureter, and forcibly injecting into the pelvis of the kidney a
bland, sterile solution. If the pain which it produces be identified by
the patient as the same which is usually suffered it may be regarded
as diagnostic; if somewhat different, then the actual attacks are more
likely to be biliary. A normal renal pelvis should hold about 7 to 8
Cc. before the patient begins to complain.
=Treatment.=--In the milder cases, and those where small concretions
are repeatedly passed, medicinal treatment may be given a trial. While
the alkalies, especially the lithium preparations, have repute in
certain quarters, there is probably nothing superior to piperazin in
its power of dissolving small uric calculi. Its physical properties
and its expensiveness, however, make it disadvantageous to use. It is
so sparingly soluble that part of the benefit obtained from it may be
due to the volume of fluid ingested with it, and to the consequent
dissolving and washing down of small particles. Glycerin is also an
analgesic here, as in biliary calculi, and a half-ounce, administered
every two or three hours, will often give relief. Attention to the diet
is also necessary, especially in acute and uric acid patients.
When there is reason to believe that the kidney contains a calculus
which cannot be passed, and especially when an _x_-ray picture reveals
such a condition, then _surgical treatment_ alone offers prospect of
complete relief. This includes _nephrotomy_ and what has been named
_nephrolithotomy_, _i. e._, exposure and opening of the kidney and
removal of its contained concretions. When these are easily felt
the procedure is simple. However when only a small concretion has
been shown in the skiagram, and it is not easily palpable, even with
the kidney between the fingers, it is sometimes a difficult matter
to locate. One method of doing this is with a small needle, passed
repeatedly in the direction of the supposed calculus--used, in other
words, as a probe. When such a stone is thus recognized it should be
removed.
In cases of long-standing, renal pelves are dilated into relatively
large sacs, containing numerous concretions, or sometimes a large
stone in branching form, resembling coral. If a considerable degree of
pyonephrosis or of disintegration accompany such a stone a complete
nephrectomy should be made. It remains, then, for the surgeon’s
judgment to decide as between nephrolithotomy or nephrectomy, a
question which will be settled, in large measure, by what has been
ascertained regarding the condition of the other organ. If considered
fully competent little hesitation need be felt in removing the diseased
one; if its condition be distrusted, then it were best to not carry
out the surgical indication, but to substitute for it good general
treatment.
MOVABLE AND FLOATING KIDNEY.
In most of the serious and in many of the milder degrees of unnatural
mobility of the kidney to which the adjectives “movable” and
“wandering” are applied, the surgeon has to deal with a somewhat
anomalous condition, which, while it attains serious and alarming
symptoms during life, leaves little evidence after death. Thus, Ebstein
found it in only 5 out of 36,000, and yet it is said to occur in at
least 20 per cent. of all women examined. In women and children the
kidneys lie lower and deeper in the gutter on either side of the spine,
beneath the seventh to the tenth cartilage, the upper end of the left
kidney belonging at the level of the ensiform cartilage. The kidneys
are supported by perirenal fascia, by the renal vessels, by pressure
of the surrounding viscera, their anterior peritoneal covering playing
but small part. Abnormal mobility below the twenty-fifth year of age
is rare; its etiology is still obscure, it being found in women at
least six times as often as in men; more commonly in those who have
borne several children, or who have become suddenly emaciated after
long illness, while in men it is most common on the left side. The
kidney is afforded a small, distinct peritoneal covering, the so-called
mesonephron, which, with its other supports, may be more or less lax,
permitting differing degrees of abnormal mobility, the milder being
spoken of as _movable_ kidney, the more serious as _floating_ kidney.
As Belfield has shown, in every case of functional disturbance of the
urinary organs the possibility that a floating kidney may be the cause
of the trouble should be borne in mind.
=Symptoms.=--The symptoms vary from vague discomfort to agonizing
pain. Ordinarily they include dragging sensation in the abdomen, with
indefinable discomfort, a feeling of weakness, sometimes radiating down
the legs and across the back, these symptoms frequently accompanied
by dyspnea, flatulence, constipation, and frequency of urination, all
of which may be intensified by increased activity. In the more severe
forms we find abdominal tenderness, severe pain and vomiting, with
collapse and the occurrence of peculiar crises, sometimes of intense
agony, which may occur gradually or suddenly, ceasing in the same
fashion. Not one of these symptoms is pathognomonic of movable kidney,
nor can they be with certainty attributed to it until the suspicion
is confirmed by physical examination. The severe crises are described
as coming on with intense pain, nausea, vomiting, collapse, chills,
and sometimes considerable temperature, especially in hysterical
subjects. Osler and Atlee think that too much stress has been laid
upon the condition, especially after the patient’s realization of it,
the severer symptoms often dating from the first knowledge of the
facts. Obviously, temporary hydronephrosis may be caused by temporary
obstruction in the ureter, from displacement, while temporary venous
obstruction may cause pain in a different way. Actual alimentary
disturbances are very closely simulated, and sometimes it is difficult
to distinguish between a movable kidney on the right side and a chronic
appendicitis.
A great deal of attention has of late been given to _nephroptosis_ and
to the effects of _enteroptosis_, and their production. The peculiar
crises were long ago described by Dittel, and include sometimes a
feeling of suffocation, with a desire to loosen and remove clothing,
when, after lying down, the kidney resumes its position. When after
urination relief quickly follows, there is much to suggest kinking
of the ureter and distention of the renal pelvis. Much less frequent
features are jaundice, from contraction of adjacent viscera, and
persistent nausea from the same result, or hematuria from a disturbed
circulation. The more marked forms in women are usually accompanied
by certain neurotic features, which give them a feature to which they
are not properly entitled, while the entire digestive process and the
vasomotor innervation of the viscera seem more or less disturbed, with
consequent toxemia.
The actual indication of floating kidney is its _discovery by
palpation_, the degree of displacement being in some cases quite
noticeable; thus it may cross the middle line, or may be felt even
in the pelvis. In the female the kidney should lie above the twelfth
rib, posteriorly, and above the costochondral border of the eighth rib
anteriorly, and, therefore, not be easily palpated during respiration.
This statement is somewhat at variance with some of those contained
in the text-books on anatomy, the diagrams being all made from male
cadavers. It is of importance not merely in locating the organs, but
in fastening them in place, as all methods thus far devised leave much
to be desired in complete replacement. A kidney prolapsed only to the
waist-line can scarcely be sutured to the loin without displacing it
even farther backward. On the other hand, the kidney which lies near
the brim of the pelvis rarely causes acute symptoms, because, supported
from below, it enjoys accommodation of its ureter to its abnormal
relations, so that hydronephrosis rarely occurs. The truth is that in
most aggravated cases of nephroptosis nearly all the viscera have been
displaced downward, and Ingall’s suggestion to fasten in place at one
and the same time the kidney, the liver, the spleen, the stomach, and
the transverse colon is well founded, although difficult to carry into
effect.
=Treatment.=--Fixation of an abnormally mobile kidney is indicated
in every case where its displacement causes unpleasant symptoms, yet
simple as it is in theory it is neither easy nor always successful
in practice. To completely restore the kidney to place is to fasten
it higher than the natural routes easily permit, and requires either
resection of a rib or fixation of the kidney to one of the lower ribs,
a method which has been recommended and practised by some operators.
Because of the disappointment so often resulting from these operations
conservative practitioners have felt that by pressure from below, as by
an abdominal binder with a suitably placed pad, the kidney could be so
pushed upward and held as to be made comfortable. This may at least be
tried in the milder cases. The supports should never be put in place
until the patient is on her back and completely undressed. This method
of external support failing or proving unsatisfactory, the surgeon may
choose from many different methods the peculiar plan for _nephropexy_
or kidney fixation which he will adopt.
[Illustration: FIG. 636
Nephropexy. Method by sutures passed through both kidney and capsule.
(Hartmann.)]
=Nephropexy.=--These methods all have in common the intent to produce
adhesions between the kidney and its normal environment, by which it
shall be held in or near its proper place and prevented from dropping.
The kidney more than any other organ is held in a cushion of fat, and
it becomes a question to what extent this mass of surrounding fat shall
be removed. To take it all away considerably complicates the procedure;
to leave it is to not furnish the firmest possible surroundings for the
purpose. The patient should be placed either flat upon the abdomen or
turned well over on the side opposite that to be operated, a cushion
or bolster being usually placed beneath the abdomen and loin in such a
way as to push upward and into prominence the side to be attacked. The
incision employed may be parallel to the spine, about three inches away
from it, and carried down to the tissues outside the quadratus lumborum
and other spinal muscles. Most operators prefer an oblique incision,
made between the lower rib and the upper margin of the pelvis, its
centre about four inches from the spine, extending in either direction
two inches or more, in order to afford sufficient access. It is carried
down until the abdominal aponeurosis and muscles are exposed. These
are then divided and the perirenal fat, which is sometimes excessive
in amount, is exposed. The deep opening should now be stretched to
a size to permit the introduction of a hand, and exploration made
for the identification and retraction of the kidney. Much aid may be
afforded in this effort by the use of the other hand upon the outside
of the patient’s abdomen, which should all have been protected and
sterilized to permit such free manipulation. Sometimes it is easy to
find such a kidney, at other times and in persons of certain build it
is a difficult matter. It lies behind the peritoneum, and this should
never be opened during the effort. More or less of the perirenal fat
may be cleared away. The more or less elusive kidney being identified,
it should be seized with tenaculum forceps, which should secure only
its capsule and not injure its substance. With these it is drawn up
at least to the wound, or in some methods, it is withdrawn through it
and delivered upon the surface of the body. If sutures alone are to be
depended upon they may be placed after any one of a number of different
methods. The older method was to place the kidney as nearly as possible
in its normal relations and then unite the deep margins of the wound to
the capsule, and perhaps the cortex of the kidney, by a series of two
or three sutures on either side, either of chromic gut or of silk. The
theoretical objections which prevail against passing sutures through
the renal cortex are hardly well founded, and stitches may be so
placed, if desired, but they should not be drawn too tightly (Fig. 636).
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).
[Illustration: FIG. 637
Congenital cystic kidney; exterior and internal appearance; patient
forty-two years of age. (Schmidt.)]
[Illustration: FIG. 638
Cancer of kidney, intramural, as seen after dividing the organ.
(Israel.)]
=Hypernephroma.=--There is one peculiar variety of solid tumor of the
kidney which deserves special mention, the so-called hypernephroma.
These tumors consist essentially of adrenal tissue, although when they
develop within the kidney their occurrence there is due to the presence
of aberrant rests of the original suprarenal tissue. Gravitz, in 1883,
was the first to recognize their real character. Supernumerary adrenal
rests have been met with in many parts of the body, not alone in the
kidney and perinephric tissue, but in the broad ligament, along the
spermatic vessels, in the sexual glands of both sexes, in the liver,
the mesentery, and even the solar and renal plexuses. Their occurrence
in these localities may be explained by the close relationship between
the mesonephros and the origins of these various organs. Hypernephroma
has no pathognomonic signs or symptoms. It is usually a single tumor,
although both kidneys have been affected. When the organ is not so
involved as to mask all its original features the tumor will be found
beneath the capsule, varying in size from that of a pea to that of
a child’s head, its outer surface lobulated by depressed bands of
capsule, its color lighter than that of the surrounding kidney texture,
while projecting portions will be soft and almost cystic. When met with
in other parts of the body its gross characteristics are essentially
the same. Metastasis is very common, the tumor often extending along
the walls of the veins, or even more often partially filling them than
the lymphatics. A common method of extension also is by implantation
within the peritoneal cavity; for the secondary implantation occurs
most often along some portion of the urinary tract--_e. g._, the
bladder.[66]
[66] It may assist in the recognition of hypernephromatous tissue,
after removal, to remember that adrenal tissue has the property of
decolorizing starch which has been turned blue by the addition of
iodine. Crofton has shown how there may be put into a test-tube a 1
per cent. starch solution colored with a drop of weak tincture of
iodine. If to this solution hypernephromatous tissue be added the
blue color changes gradually to a pink and then fades out.
[Illustration: FIG. 639
Infiltrating form of cancer of the kidney. (Israel.)]
Hematuria and renal colic are the most conspicuous features connected
with the growth of these tumors. The former often occurs during sleep,
and blood is passed in almost pure form, perhaps for a considerable
period of time, after which spontaneous recovery apparently takes
place, the trouble recurring at intervals.
There is but one method of treating hypernephromas, like other solid
tumors, namely, by complete extirpation, _i. e._, _nephrectomy_. Even
this may be too late, but should be undertaken, except in the most
unpromising instances. If the existence of metastatic involvement can
be determined even nephrectomy may be considered useless. (See chapter
on Cysts and Tumors.)
HYDRONEPHROSIS.
This term refers to a more or less permanent distention of the
kidney cavity by retention of urine, due to partial or intermittent
obstruction to its escape. An _intermittent_ form is common, which,
however, at almost any time may lead to some degree of enlargement,
while when the obstruction is permanent the resulting tumor becomes
practically a thin-walled cyst, which may contain an enormous amount
of fluid, more or less altered urine, which will contain, in addition
to the ordinary urinary elements, cholesterin crystals and other
adventitious products. Hydronephrosis, then, may be _congenital_ or
_acquired_ in origin, _intermittent_ or _permanent_ in character, and
_unilateral_ or _bilateral_ in location. Among the acquired causes
are strictures of any portion of the urinary tract below, either in
the ureter, the prostate, or the urethra; tumors of any kind making
pressure; movable kidney which permits of kinking; tuberculous diseases
which lead to chemosis of the mucosa and consequent obstruction; renal
calculi which plug the ureter; foreign bodies, blood clot, and the like
(Figs. 640 and 641).
[Illustration: FIG. 640
Hydronephrosis from obliteration of ureter by tuberculous disease.
(Tuffier.)]
[Illustration: FIG. 641
Hydronephrosis in first stage of development. (Rayer.)]
[Illustration: FIG. 642
Operative treatment of hydronephrosis or pyonephrosis. (Hartmann.)]
Until the infectious or suppurative element be added the urine is
in these cases but little changed. When infection is added the case
becomes one of _pyohydronephrosis_, and perhaps finally one of distinct
_pyonephrosis_. The symptoms produced at first are not very pronounced
and will vary with the exciting cause. If the result of acute
obstruction, renal colic is perhaps the most significant. When this is
accompanied by tumor in the region of the kidney the interpretation of
the phenomenon is easy. Sudden decrease in size of such tumor, with
unusually great escape of urine, is also pathognomonic of intermittent
hydronephrosis. The discovery and the history of a gradually increasing
tumor in which, when large, fluctuation can be determined, and in
which fluid is easily found with the aspirating needle, will permit a
differentiation of these pseudocysts from solid tumors of the kidney.
They are to be distinguished from _ovarian cysts_, from general
_ascitic accumulations_ within the abdomen, and from _perinephritic_
and _spinal abscesses_. Their location, which corresponds so closely
with that of the kidney, especially while they are small, their
gradual growth, the displacement of the abdominal viscera forward and
to their inner side, their enlargement downward and their fluctuating
character will usually provide features by which they may be accurately
recognized.
=Treatment.=--The _treatment_ of intermittent hydronephrosis in its
earlier stage may be accomplished by some measure less radical than
nephrectomy or nephrotomy, particularly when due simply to abnormal
movability or to pressure of some extrinsic growth. Hydronephrosis due
to obstruction by renal calculus may be relieved by removal of the
obstructing stone, but a hydronephritic cyst, which has attained large
size, in which practically all semblance to secreting kidney structure
has disappeared, should be _extirpated_, unless this should entail
too formidable an operation, in which case it should be freely opened
and drained until such time as it has contracted to a size justifying
enucleation (Fig. 642).
THE URETERS.
There are a few morbid surgical conditions of the ureters, so distinct
from those of the bladder below or the kidneys above as to require
separate consideration here. They are frequently involved in the
pyogenic and tuberculous infections, which spread along them in either
direction, but the chief surgical diseases deserving mention here are
_stricture_ and _calculus_.
STRICTURE OF THE URETER.
Stricture of the ureter may result from intrinsic or extrinsic lesions.
Thus it has been injured in operations upon the pelvic viscera, as in
parturition, and it is not infrequently pressed upon by neoplasms;
but the majority of its contractions are cicatricial, and are
consequences of ulceration or injuries done by calculi. Stricture of
the ureter is to be recognized rather by its consequences--_i. e._,
hydronephrosis--than by more direct symptoms. Its accurate location
is now possible by the use of the cystoscope and the ureteral bougie
or catheter. When by the cystoscope no urine is seen escaping from
the ureter one naturally infers its complete obstruction--in fact,
the degree of the latter is fairly estimable with this instrument.
However, with the passage of a bougie the trouble may be found. This
is particularly of value when the lesion is an impacted calculus, for
it indicates to the surgeon the level at which he should direct his
operative relief, a matter which may also be decided by a skiagram.
While in the hands of experts dilatation of the ureters may be
accomplished from below, it is usually beyond the ability of the
average surgeon. He has to decide, then, as to whether the ureter
should be exposed along its course, from the loin, extraperitoneally
along the groin, or by abdominal section. A ureter hopelessly entangled
in a mass of cancer may be turned into the other ureter or into the
bowel. A ureter fixed in a narrow, cicatricial band may be divided and
its upper end turned into the tube below the stricture by a process of
transplantation or anastomosis, which is one of the feats of modern
surgery; but a ureter hopelessly involved for a considerable portion,
or hopelessly diseased, will require nephrectomy, as the kidney above
it may be compromised and can probably be well spared.
Calculi impacted in the ureter are most commonly arrested at those
points where its caliber is normally smallest, just below its origin,
at the pelvic brim, and just above its orifice. The symptoms of
impaction are those of renal colic, already considered. It should be
sufficient that extreme pain and the escape of pus and blood in the
urine, accompanied by more or less distention of the kidney above,
are noted. If there be a history of previous attacks of this kind,
with the passage of small calculi, the diagnosis may be regarded as
positive. This may or may not be confirmed by the _x_-rays, or by the
catheterization of the ureter from below.
Gibbon has suggested _intra-abdominal exploration_ and palpation of
the ureter for the discovery and location of impacted calculi, and
recommends that when discovered they may be removed by extraperitoneal
incision, which may be lumbar, iliac, inguinal, vaginal, or even sacral
or rectal; while with the advantage of combined manipulation, the
operator having one hand in the abdominal cavity, the actual work is
more rapid and certain.
This procedure is not to be advised in every case by any means, but may
prove of advantage in doubtful cases, and especially in those where,
when the abdomen has been already opened, a stone is accidentally found
in the ureter, since when the latter is opened extraperitoneally it is
rarely necessary to suture it.
The _non-operative treatment of ureteral calculi_ has been considered
when speaking of renal calculi. The _operative treatment_, inversion
of the patient having failed, may consist of exposure of the upper
two inches of the tube, by an incision parallel to the twelfth rib,
and carried well forward and downward toward the middle of Poupart’s
ligament. Through such an incision the whole length of the ureter may
be reached. The opening is made down to the peritoneum, which is then
pushed toward the median line. On its posterior surface, adherent to
it, will be found the ureter. At the point where the stone is impacted
the ureter is to be divided and the stone removed. In theory sutures
should be inserted; in practice, they are rarely needed, as these
incisions usually heal kindly without them.
A stone impacted at the vesical orifice of the ureter may, in the
female, be removed after such dilatation of the urethra as shall permit
access, or it may be removed through the vault of the vagina. In the
male only the most expert manipulators within the bladder will attempt
its removal in this way without at least a perineal section.
OPERATIONS UPON THE KIDNEYS AND URETERS.
In addition to the operative procedures already described the principal
operation upon the kidney is _nephrectomy_. While this may be
_partial_, under rare circumstances, the procedure is so essentially
similar to the complete operation that it is only necessary to say that
if a portion of the kidney be removed, bleeding from spurting vessels
should be arrested by ligature, while the oozing, at first pronounced,
will soon subside under the application of hot water, after which
absorbable sutures may be used in sufficient number to approximate the
parts.
[Illustration: FIG. 643
Position of patient and various lines of incision for nephrectomy and
other operations upon the kidneys. _A_, the favorite method of approach
for most purposes. (Hartmann.)]
_Total nephrectomy_ is usually done by the lumbar route, the kidney
being exposed by an oblique incision extending obliquely downward from
near the spine, parallel to the lower rib, between it and the crest
of the pelvis, and as far forward as may be required for the purpose.
For removal of a large solid tumor a large opening should be made, and
the above incision may be extended in any required direction, or an
additional cut may be made wherever required. In fact, in attacking
some of the very largest growths it becomes necessary to apparently
almost bisect the patient in order to furnish sufficient space. As
the mass to be attacked lies behind the peritoneum it is rarely
necessary to open the peritoneal cavity. This is usually done only
by inadvertence or because of density of adhesions, and the effort
should then be made to at once close it temporarily or permanently.
Especially should every attempt be made to prevent contamination when
dealing with tuberculous or suppurative renal disease. Ordinarily the
abdominal opening does not extend nearer to the spine than the border
of the spinal muscles. These may, however, be divided if necessary. So
also may the deep fascia be divided in any direction, and, in fact,
the last rib may be removed _in toto_ if required. The kidney or the
tumor, having now been reached, should be isolated. If the condition be
cancerous as much of the surrounding tissue should be removed as the
case will permit; if otherwise, an enucleation of the kidney from its
more or less infiltrated bed will be sufficient. It is usually removed
with its capsule, but sometimes the latter is so adherent that it is
easier to enucleate the kidney itself from within it. Adventitious
vessels may enter the kidney, more especially from below. The surgeon
must be prepared, then, at any time to clamp and secure them if found.
Sometimes enucleation of the kidney is exceedingly easy; at other times
old adhesions or surrounding infiltration make it a matter of great
mechanical difficulty. The intent is to not only isolate it, but to
make such exposure of its pedicle that one may be securely protected
against hemorrhage. Incidentally the ureter should be examined from
above, by passage of a probe, or by injecting a colored solution, in
order to know later if it passes freely into the bladder. It is the
accurate securement of the renal vessels which is perhaps the most
necessary feature of the operation and upon which most depends. When
this is made impossible by extraordinary circumstances expedients must
be adopted, as, for instance, the use of an elastic ligature--_i.
e._, a piece of small rubber tubing, drawn tightly around the base
of the mass and secured by clamp, ligature, or suture, the intent
being to leave it for at least two or three days until it shall have
accomplished its work, and then either to remove it or to allow it to
loosen itself in time and come away.
[Illustration: FIG. 644
Nephrectomy. Complete delivery of kidney and ligation of its vessels
and ureter. (Hartmann.)]
Under some circumstances the surgeon may so complete the nephrectomy
that the external wound may be closed without drainage; but when there
has been contamination, as by escape of contents, either purulent
or urinary, or when a considerable mass of tissue has to be left
enclosed within an elastic ligature surrounding the stump, then an
opening should be left in order that slough may easily escape and
ample drainage be afforded. A reliable ligation of the renal vessels
should be made, which is best done with at least two ligatures, taking
the pedicle in parts, or else carefully isolating the vessels when
sufficiently exposed, and tying each one of them separately, after
which the whole group may also be enclosed in a single ligature. A
few operators have reported such accidents as tearing the renal vein
from the vena cava, and such a wound has been successfully sutured,
the patient recovering; this requires, however, both coolness and
resourcefulness in the presence of serious difficulty and danger.
Certain dense tumors can be removed by process of morcellation, _i.
e._, removal of a portion at a time, the separate pieces being cut away
with scissors or knife, as may be the more convenient, and hemorrhage
being controlled by clamps.
The _anterior_ or Trendelenburg route is rarely selected for
nephrectomy, but may be adopted when this procedure is made a part of
other abdominal work, or may be necessitated by the presence of a large
tumor in a small abdomen, as, for instance, in children. The abdomen
will be opened as for any abdominal tumor, either in the middle or to
one side, as may seem best. The tumor itself will so far displace the
viscera as to perhaps present at once beneath the knife. It may be
necessary to go through the peritoneum twice. After being thus exposed,
and the abdominal cavity protected, the balance of the operation is
again a process of enucleation, with securing access to the pedicle of
the tumor, where its vessels and the ureters may be found. These again
are ligated and the mass removed as though it were from the peritoneal
cavity. Posterior drainage may be added, although rarely necessary.
Other operations have been suggested to meet the needs of individual
cases. Thus _pyelectomy_, or removal of a portion of the dilated pelvis
of the kidney, has been performed by Murphy and others, the process
being essentially an excision of a portion of the sac wall and its
retrenchment by sutures. Plastic attachment of the dilated upper end
of a ureter to the floor of the renal pelvis has also been effected
in much the same way, as in a case reported by Murphy, where, after
opening the sac of the pelvis, the ureter was slit for a considerable
distance, while at the lower angle a V-shaped piece of the sac
was fastened into the ureteral opening, thus making a funnel-like
communication.
Again, as illustrative of some of the radical suggestions of recent
years, Watson has proposed that in instances of hopeless bladder
conditions, where the patient is made miserable, there should be a
turning out of both ureters on the loin, and the formation of two
_ureteral fistulas_, after which the patient may wear a drainage
receptacle, and in this way enjoy a comfort otherwise unattainable. He
has reported the case of such a patient, who has thus passed all the
urine for four years, and urine from one side for eleven years, who was
otherwise in comfortable health.
[Illustration: FIG. 645
Longitudinal suture of ureter. (Hartmann.)]
[Illustration: FIG. 646
Implantation or invagination of ureter with fixation and then with
circular sutures. (Hartmann.)]
[Illustration: FIG. 647
Longitudinal incision and transverse suture of ureter for stricture,
similar to the pyloroplastic method of dealing with pyloric stenosis.
(Hartmann.)]
=Operations upon the Ureters.=--The surgery of the ureters is also
quite modern, and has been worked out in the experimental laboratory.
That ureteral tissue will heal has been proved by Murphy, who has
remarked that “The peritoneum is the only tissue that unites as kindly
as does the ureter.” After accidental injuries during other operations
the ureter may be sutured almost as though nothing had happened. These
sutures should be made with fine round needles, and be placed closely
together. They should be made of fine silk or thread.
Not only end-to-end union but lateral anastomosis and even more
ingenious methods of transplantation and implantation are now in
vogue. Figs. 645, 646 and 647 illustrate some work in this direction,
and show what may be done by work quite similar to that done upon
the small intestines or the bloodvessels. More complete instances
of transplantation have been effected in connection with exstrophy
and carcinoma of the bladder, where, for instance, the ureters
individually, or the base of the bladder containing the ureteral
orifice, have been dissected out and implanted in the colon or the
rectum.[67]
[67] In one case I carried out the following procedure, necessitated
by cancer involving the urethra, the base of the bladder, the
rectum, and the whole floor of the pelvis, in a female patient,
the disease having attained a degree making urination or even
catheterization impossible. I opened the abdomen, dissected out the
_right ureter_ from the bladder, _implanted it into the appendix_,
and then dissecting the left ureter in the same way _implanted it
in the right_, the intent being to direct the whole urinary stream
into the colon and thus spare the bladder. The operation was not
finally successful. I afterward found that this method had been tried
experimentally by Jacobson, of Toledo, but without success.
CHAPTER LV.
THE BLADDER AND PROSTATE.
Methods of recognition of surgical diseases of the bladder have been
vastly improved, as well as complicated, within the past few years. The
bladder has now been made accessible not alone to touch, as through
the rectum or vagina, or by incisions above or below the pubis, but
to sight, through the use of the _cystoscope_. It is furthermore
possible to detect foreign bodies within it by the Röntgen rays.
_Palpation_ is chiefly of value in thin persons, or when the bladder
is greatly distended; still, infiltration of the base of the bladder
can be detected through the vagina or through the rectum, as can also
certain foreign bodies. Much of value is learned by both chemical and
microscopic examination of the urine. This may be passed by the patient
or withdrawn by the catheter. It has already been indicated how much of
value can be learned by separating the urine drawn from each kidney.
The difficulties of this procedure are greater in the male than in
the female, owing to the complications in the requisite manipulation
of the instruments. Nevertheless there is no accurate method of such
estimation save by ureteral catheterization. The method of Harris,
by the use of the so-called segregator, is of occasional assistance,
but is never accurate nor always satisfactory. If the catheter alone
be used it should be of metal, if it be desired to have it serve the
purpose of a probe, as in the search for a foreign body (calculus
and the like) or as a means of estimating the size and shape of the
bladder. For the latter purpose an ordinary sound will serve as well,
preferably one with a short beak, ordinarily known as a stone searcher.
In cases of prostatic enlargement it is of great advantage to estimate
the amount of residuary urine after the patient has apparently emptied
his bladder. This may be withdrawn by a sterile catheter under aseptic
precautions. The use of the catheter is also necessary for lavage of
the bladder, a measure of great value in many cases.
The attempt will not be made here to picture nor go into a minute
description of the various forms of the _cystoscope_. Their use, like
that of the ophthalmoscope, requires special aptitude and training.
With the latter they are of great value; without them they confuse
and complicate. The cystoscope may be used for ordinary purposes of
inspection, for aid in introducing the ureteral catheter, or even
for photographic purposes, for it is now possible with the latest
instruments to photograph the image thus obtained of the bladder
interior. To one not accustomed to viewing the field seen in such an
instrument these revelations are of little interest. To the expert,
however, they may be made of the greatest value. Without further
description, then, allusions made below to the use of the instrument
must presuppose some familiarity with it, and the advantages and even
necessity of securing special training in its use.
CONGENITAL MALFORMATIONS OF THE BLADDER.
The lesser malformations of the bladder include mainly irregularity
in shape or the formation of _diverticula_, which are not extremely
rare. These are especially likely to be met during hernia operations.
I have repeatedly in operating for inguinal, and once in operating
for femoral hernia, found a diverticulum of the bladder complicating
the situation. Its possibility, then, should be borne in mind. It may
be thin and lie in such close relation to the hernial sac as to be
mistaken for the latter. When opened urine will escape and contaminate
the wound. It would probably be best to close the bladder opening and
discontinue the operation rather than run the risk of contamination of
the peritoneal cavity, postponing further work for a few days. As the
result of allantoic defects a _double bladder_ may be met, each perhaps
having one ureter opening into it. More or less complete partitions
in the bladder are more frequently met. These conditions could not
be appreciated previous to opening the viscus or the use of the
cystoscope.
More complete forms of acquired vesical hernia may be found in such
conditions as _cystocele_, common in women after perineal lacerations,
and frequently constituting a most serious condition.
=Ectopia or Exstrophy of the Bladder.=--By far the most serious and
extensive of the congenital malformations are those constituted by more
or less complete defects of the anterior portions not alone of the
bladder, but of the abdominal wall which should cover it, and which
are known as _ectopia_, _exstrophy_, or _extroversion of the bladder_.
Of this condition there are different degrees, from a small cleft just
behind the symphysis pubis, to that which is complicated by prolapse of
the remaining posterior wall, the umbilicus being situated just above
it, while the pubic arch itself is defective or rudimentary. Thus in
the male there is usually _epispadias_ of a more or less _rudimentary
penis_, while in the female the _clitoris_ is _cleft_ and the _vulva
more or less opened_, the urethra being defective or entirely
wanting, the vagina often small, and the uterus generally infantile.
Extreme cases of this condition constitute one of the most serious
and deplorable congenital defects which are not inherently fatal.
Obviously, with these conditions, there is constant escape of urine,
usually with complete mechanical impotence, although in the female
the ovaries are usually present, and practically always the testicles
in the male. In the latter the opening of the seminal ducts may be
frequently seen on the floor of the urethra, more or less concealed by
folds of cystic mucous membrane. The condition is much more frequent
in males than in females. The prostate is usually at least rudimentary
and may be wholly wanting. Occasionally the testicles are undescended.
Double uterus has also been seen in these conditions.
Regarding its causes there is but little known. Doubtless these have
to do with allantoic defects, but the allantois is such a temporary
organ that there would seem to be some other contributing cause not yet
recognized.
Among its most distressing features are not only the lack of control
of urine, but the irritation of the exposed mucous surfaces consequent
upon friction with clothing, or decomposition of urine and consequent
uncleanliness. There is, therefore, nearly always ulceration, with
extreme irritability and more or less constant suffering. It is not
strange, then, that for its relief surgeons have taxed their ingenuity,
or that adult patients, finding the conditions unbearable, are willing
to submit to even extreme measures.
=Treatment.=--So many operative measures have been devised that it is
impossible to include them all. First of all the procedure should be
adapted to the particular case. Much will depend, for instance, upon
the extent of the defect in the abdominal wall, or in the pubic arch,
and in the male upon the rudimentary condition of the penis or the
extent of the urinary canal.
Operations for this condition may be divided into _palliative_ and
_radical_--_i. e._, those which are intended to make it more tolerable
and those which are really entitled to the latter term. Thus if only
the exposed mucous surface can be covered with a skin covering, the
condition may be mitigated since a urinal or some device may be worn by
which its worst features may be controlled. Trendelenburg has recently
called attention to the fact that a wide separation of the pubic arch
not only weakens the pelvis, but constitutes a serious difficulty in
closing the defect. He has, therefore, combined direct operation with
separation of the pelvic bones at the sacro-iliac joints, afterward
enclosing the pelvis in a comprehensive bandage, or suspending the
patient in an apparatus in such fashion that the bony defect in front
shall be narrowed, if indeed it be not completely obviated. This, of
course, is a measure to be carried out in the early years of childhood;
in connection with it the bones may even be wired at the symphysis. In
fact immediately after the birth of such an infant the attempt should
be made to narrow the pelvis, by surrounding that part of the body
with a wide rubber band, which shall influence growth without too much
interfering with nutrition. Later subcutaneous osteotomy may be done if
necessary. At all events, the growing pelvis should be surrounded with
an enclosure by which a constant influence may be maintained.
The various _plastic operations_ for this defect have the common
purpose of affording a covering, which must unfortunately be without
a sphincter to guard the outlet of the cavity. The best that can be
accomplished, then, by plastic methods is the formation of a more
perfect cavity without affording sphincteric control. A theoretically
ideal method would be one which should permit raising of skin flaps
around the margin of the defect, and so turning them in that the skin
should vicariate as mucous membrane. These flaps when united, and
the anterior wall when thus formed, could be covered by other flaps
or by skin grafts; but from these flaps hairs will grow into the
bladder. These will become encrusted with urinary salts and an amount
of irritation be produced which may become not only intolerable but
locally destructive.
In the selection of any plastic method much will depend on the size
of the defect and its completeness, the condition of the surrounding
wall, and varying complications in the surrounding structures. The
general method above suggested will answer especially for the smaller
exstrophies. Beck has suggested an excellent device, namely, the
dissection from the pubes of the recti muscles, their insertions being
severed, and the partial division of the transversalis fascia until
the muscles are so mobilized that they can be reflected and united,
thus forming an anterior bladder covering. By a second operation these
partially formed flaps may be again dissected off from the wall and
a complete osteoplastic covering afforded. Practically no operation
for extroversion can be completed in one sitting. Frequently repeated
efforts have to be made, a little being accomplished at a time. One
of the greatest difficulties met with is securing primary union along
surfaces more or less bathed or in contact with escaping urine. These
flaps, even if united, may separate in a few days as a result of
this urinary maceration. Against this there is but little possible
provision, save perhaps by catheterizing both ureters, and emptying
them into a distinct receptacle.
[Illustration: FIG. 648
Roux’s autoplastic method of raising a perineoscrotal flap with which
to cover the defect. Lines of incision. (Hartmann.)]
[Illustration: FIG. 649
Roux’s autoplastic method of raising a perineoscrotal flap and its
fixation. (Hartmann.)]
More complicated methods of furnishing a complete cavity have been
devised by Rutkowski and Mikulicz, both of whom have suggested to use
a small loop of small intestine wherewith to complete the bladder
cavity. In each of these methods the abdomen is opened, a loop of bowel
brought down, a small portion completely separated by double division,
end-to-end anastomosis of the main part being then made, while the
separated part is in one method closed at one end, while the other
end is fitted over the exposed bladder surfaces as a sort of cap. The
method is exceedingly complicated and hazardous, and depends for local
success upon a sufficient blood supply to the intestinal loop, which
should be carefully ensured by caring for its vessels and mesentery. It
has, nevertheless, been successful.
A far simpler method, perhaps the simplest of all, is that of
Sonnenburg, which consists in extirpation of the bladder proper,
with plastic closure of the opening, while the ureters are carefully
separated and sutured into the upper portion of the urethral gutter.
This removes all urinary cavity and provides only for continuous
escape; but this latter is now provided in an accessible and convenient
place, while the wearing of a urinal permits the achievement of the
main purpose of the operation. Sterson operates upon young girls by
suturing the loosened ureters to the labia minora, which are then sewed
together in the median line, after which a urinal can be worn.[68]
[68] Cantwell has suggested the following method for bladder
exstrophy, namely, to pass catheters through a perineal fistula up
into the ureters, then to dissect off the bladder wall, bringing it
over a small rubber balloon, pushing the whole into position, and
uniting the abdominal wall in front.
It has occurred to many operators to more completely divert the urinary
stream by displacing the ureters and turning them into the rectum or
the sigmoid. Operations for this purpose have been described especially
by Maydl (Fig. 650), and by Moynihan, while modifications have been
suggested by many others. In practically all of these procedures
catheters are first passed into the ureters for their identification
and control. Some would dissect out the trigone with both ureters, and,
making a sufficiently large opening in the rectum, would transplant
it in its entirety within that cavity, closing the opening. Moynihan
improved on this by making a vertical incision and entirely dissecting
away the bladder, separating it also from the prostate, thus completely
isolating it. Then the portion containing the ureters is held upward,
while at the bottom of the wound the rectum can either be seen or made
visible. The peritoneal reflection is then lifted upward from the
front of the rectum, which is opened along its anterior surface by an
incision perhaps three inches in length. Into this opening the bladder
is placed, being so reflected that its former anterior surface now
looks posteriorly. The ureters, instead of passing forward, now pass
backward and the catheters contained within them are passed into the
rectum and out of the anus. The edge of the bladder and the cut edges
of the rectum are carefully sutured, after which the abdominal wound is
closed. The sphincter is then stretched, while the catheters remain in
the ureters for four or five days.
[Illustration: FIG. 650
Maydl’s operation; diversion of ureters into rectum. (Hartmann.)]
A choice may be made, then, between some such method as that last
described or that of Peters, who dissects out the ureters, retaining
only a small circular patch of bladder wall, which is folded around the
orifice of each, the rest of the bladder being extirpated. Each ureter,
with its button of bladder wall, is then drawn through a small slip
in the rectal wall, made large enough to admit it, and the end of the
ureter is then left hanging for 1 or 2 Cm. into the rectum. It would
probably be better to hold the ureters in place by a stitch rather than
run the risk of their retraction; but care must be taken that these
stitches make no unnecessary constriction. Others have substituted the
sigmoid for the rectum, the procedure being otherwise the same, all of
these rectal implantations having for their purpose the utilization of
the rectum as a cavity, which may not only contain urine, but retain
it reasonably under control. In many respects they would be ideal were
it not for the attendant dangers. These are (1) those immediately
connected with an operation which is serious, and (2) those connected
with secondary infection of the kidneys, which seems to occur in almost
all cases, no matter how apparently successful at first.
INJURIES TO THE BLADDER.
Injuries to the bladder proper may be accompanied by those of the
parts without, or may be isolated. They divide themselves mainly into
_ruptures_ and _lacerations_, or _penetrations_ directly connecting
with the exterior. Among the causes which predispose to rupture and
other injuries may be mentioned intoxication, partly because it is
often accompanied by overdistention, and partly because of the partial
or incomplete insensibility of the patient. _Distention_, no matter how
permitted, is an important predisposing cause. The injuries usually
include blows, falls, and crushes, and gunshot or other perforations.
The location of the rent is more commonly in the upper and posterior
portion of the bladder--_i. e._, in its weakest part. Such tears
may vary from one-half to four inches in length. When _accompanying
fracture of the pelvis_ the peritoneum is more likely to be injured.
The most _significant symptoms_ are a desire to urinate and inability
to do more than perhaps expel a few drops of bloody fluid. Of course
the passage of any blood or bloody urine will suggest the occurrence of
such an injury. Patients are usually unable to stand upright, and also
show a strong tendency to flexion of the thighs. The introduction of a
catheter and the withdrawal of bloody urine do not necessarily settle
the question as to whether there has been any possible laceration.
Some surgeons have taught that normal urine is comparatively harmless
and that it is no more likely to produce infection than the catheter
used for diagnostic purposes; but this is not safe teaching today. A
clean metal instrument is of no more danger than a clean probe under
other circumstances. Weir has suggested a valuable test, consisting
of removal of all the urine possible, after which a measured quantity
of sterile fluid is injected. If on using a catheter again this be
all recovered it may be assumed that the bladder is not ruptured,
otherwise the contrary. If hours after the injury a catheter be used
and no urine secured, this fact will be most suggestive. The cystoscope
is usually disappointing, since a bladder so injured cannot often be
satisfactorily examined.
Another class of serious injury to the bladder includes the
_perforations_, such as may be effected by gunshot or stab wounds, or,
as in one case of my own, where a lad sat down upon an iron spike,
about three-quarters of an inch square and nearly six inches in length.
The point of the spike entered the anus, and the consequence of the
injury was a perforation of the anterior wall of the rectum and the
posterior wall of the bladder, with injury to its anterior wall without
complete perforation. Prompt operation saved this case, as it will most
such instances, although it was shown that a piece of his trousers had
been carried into and left in the bladder. I opened the abdomen above
the pubis, to be sure that the peritoneum was not injured, and then
drained by a tube passed into the anus and out just above the pubis,
after removing the piece of cloth. Prompt recovery followed.
The bladder may also be injured by rude manipulation of instruments,
especially the metal catheter, by one unaccustomed to using it, or when
serious difficulties are offered by prostatic enlargement.
=Treatment.=--Diagnosis or even serious suspicion of such injuries to
the bladder as above described require either perineal or abdominal
section, the choice of the procedure being based upon circumstances.
If there be reason to suspect intraperitoneal extravasation, then the
abdomen should be opened, carefully cleaned, the bladder rent sought
and sutured, the mucosa being first closed with hardened gut, while
the peritoneal aspect may be sutured with silk or thread. The bladder
should be drained, at least by retention of a catheter, passed if
necessary by perineal section, and the abdomen drained. In the female
drainage may be made through the cul-de-sac. If there be urinary
extravasation behind the perineum, then perineal section should be
made, and the bladder, thus freely opened, should be drained with
a sufficiently large tube; while in the female it will probably be
sufficient to dilate the urethra and insert a tube of sufficient size.
It is not always easy to discover an opening placed posteriorly in the
bladder wall, and after a wide exposure, with emptying and cleansing
of the pelvis, it may be of great assistance to place the patient in
the Trendelenburg position. Under rare circumstances the rent may be so
placed as to justify a suprapubic drainage of the bladder.
FOREIGN BODIES IN THE BLADDER.
Foreign bodies other than calculi occur in the bladder in consequence
of both accident and of design. The former are, _e. g._, represented by
pieces of broken catheter, while the latter are materials introduced
from without in consequence of sexual perversion, during intoxication,
or from some other vicious tendency. The latter occur more often in
girls and women, the former more often in men. In such a collection
of cases as was made by Poulet (_Foreign Bodies in Surgery_) almost
every imaginable object that could be introduced into the bladder is
mentioned. Some of these have slipped in accidentally after external
manipulation, as in masturbation, and some have been deliberately
introduced. Perhaps as common an object as any is the ordinary hairpin.
It is the short urethra of women which is made the much more frequent
resort for such practices than the long urethra of men, in which latter
foreign bodies are often entangled or arrested before they reach the
bladder.
Any object allowed to remain in the bladder will serve as a nidus for
the formation of a calculus, which will form in time, and it may result
that not until the removal of the calculus and examination of its
interior structure will the original foreign body be found.
All objects of this kind should be removed as early as possible
after their introduction. Such removal may be easy and accomplished
by dilatation of the female urethra, with or without the use of the
cystoscope; or the bladder may require to be opened, either above the
pubis, through the perineum, or through the vagina, in order that the
object in question may be extracted.
INCONTINENCE, RETENTION, AND SUPPRESSION OF URINE.
Students often confuse not only terms but conditions, and it is
necessary to be accurate in teaching regarding these subjects.
_Suppression of urine_ is purely a matter of cessation of renal
function, and _has nothing to do with the bladder_. _Retention of
urine_, on the other hand, has nothing to do with the kidneys, but is
purely a bladder affair. It may be due to spasm of the bladder outlet,
or to its obstruction by calculi, other foreign body, or by prostatic
enlargement, or it may be a consequence of paralysis of bladder muscle.
Such retention is the inevitable consequence of fracture of the spine,
since paraplegia is to be expected in such cases, and the condition is
to be atoned for by careful and _regular catheterization_. Retention,
again, is occasionally seen in hysterical patients. It furnishes the
distressing and sometimes permanent or even fatal consequences of
prostatic enlargement in old men. _No matter how produced, it must be
relieved_, for urine tends to accumulate and to distend the bladder,
which will finally burst unless the difficulty be sufficiently overcome
so that urine may in some way escape. Distention of the bladder under
these circumstances is recognized by the formation of a rapidly
increasing tumor, which finally rises to the level of the umbilicus,
fluctuates, and is accompanied or not by pain according to the nature
of the cause of retention. In paralytic cases there will be little or
no pain. In obstructive cases it will be agonizing.
By natural efforts final rupture of the bladder is usually prevented,
as after a certain degree of distention has been attained urine begins
to escape drop by drop. This is simply an _expression of an overflow_,
and is not to be confused with incontinence in the proper sense of
the term. It may be spoken of as _stillicidium_, due to retention.
The young and indifferent practitioner may mistake this escape of
urine for incontinence, which would be a most serious error. Under any
circumstances, when such a condition may possibly occur, the lower
abdomen should be palpated, when the presence of a distended bladder
should be instantly recognized. The first indication is for its prompt
relief by the use of the catheter, while the necessary catheterization
should be done with the usual precautions. When the passage of an
ordinary instrument is made difficult or impossible the cause of the
retention is usually thereby revealed, and may be shown to be so
serious as to necessitate further operative procedures.
When the bladder is distended and no catheter can be introduced it
is advisable to _aspirate_, the aspirating needle being introduced
through the sterilized skin just above the pubis, its point directed
toward the centre of the mass formed by the distended bladder. Repeated
aspiration may be necessary, and it has been suggested to make more
or less permanent use of such a tube or hollow needle. At present no
surgeon would continue this as a permanent measure, but simply as a
temporary relief, even if repetition be necessary, until more radical
procedure can be carried out. Whether this be the removal of a foreign
body or calculus, or of an enlarged prostate, it is indicated just the
same, the only exception to this statement being those cases already
too seriously involved to justify more than perineal section (cystotomy
for drainage). _Retention of urine, then, is always a preventable
condition, and its continuance is inexcusable._
_Incontinence_ implies a paralytic condition, usually of the expulsive
muscles, but sometimes of the sphincter apparatus in either sex, by
which urinary control is lost and urine escapes involuntarily. It
may be a temporary and occasional phenomenon, occurring under the
influence of strong excitement or during sleep, especially in children,
or it may be due to spinal disease or traumatisms, with paralysis of
the lower segments of the cord and nerves given off from them. When
originating in the latter way it is usually a hopeless condition,
but _nocturnal incontinence_ of children, or even of adults, or
that due to hysterical or other neurotic conditions, may usually
be benefited. For this purpose the surgeon should search for the
cause from which the reflex proceeds. This may be extreme acidity of
urine, the irritation of a tight prepuce in either sex, the presence
of worms, intestinal disturbances, or any one of a great number of
possible causes of disturbance of nerve control. Some of them permit
of surgical relief; others require simpler measures. Children thus
suffering should be given no fluid late in the evening, but should
be made to empty the bladder before retiring, and perhaps be aroused
once or twice through the night for the same purpose. In all cases
the urine should be examined and hyperacidity overcome. All forms of
genital excitement should be obviated. In the adolescent and in adults
thus annoyed, and in the insane, it has been shown to be of great
benefit to make a few intraspinal injections of sterile salt solution,
as for local anesthetic purposes, a little cerebrospinal fluid being
first withdrawn, and then from 2 to 10 or 15 Cc. of the solution being
introduced. This seems to have been empirically suggested by a French
surgeon, but has been found of value by Valentine and others, including
the writer.
The above forms of incontinence are to be distinguished from intense
irritability of the bladder, with frequent calls to empty it, which
accompany many such conditions as cystitis, tuberculosis, tumors,
calculi, and the like. This is the extreme irritability of local
disease rather than true incontinence. But there is also a form,
in women, characterized by falling away of the urethra and neck of
the bladder from the pubis, due usually to injuries received during
parturition, with consequent sacculation or dilatation of the urethra
and formation of a cystocele. (Dudley.) This may also be associated
with other results of perineal laceration. Here loss of urine is not
constant, but occasional or frequent. For its treatment the following
methods have been suggested: the injection of paraffin; partial torsion
of the urethra (Gersuny), _i. e._, a partial dissection of the urethra
and revolution upon its own axis, with subsequent suture, by which
incontinence may be overcome, but at the possible risk of sloughing.
Finally, Dudley has proposed the method of advancement of the urethra.
He makes a horseshoe denudation, between the meatus and the clitoris,
down on either side of the urethra, and nearly its entire length.
Its anterior end is then loosened sufficiently so that the meatus
can be drawn forward and secured below the clitoris by two sutures.
The balance of the wound is then closed, the effect of the operation
being to replace and retain the urethra and prevent its sagging. Other
surgical treatment, as for cystocele, laceration, etc., may be added as
needed.
CYSTITIS.
The condition of true _cystitis_ arises invariably either from the
_irritation of a foreign body_ or the _presence of bacteria_; the
former need not necessarily be large, and minute and irritating
crystals are often sufficient to produce at least some of its features.
Sooner or later, however, the germ element enters, and from that time
on cystitis is a bacterial infection. Furthermore this infection is
usually secondary, rarely if ever primary, and may come from without or
within. Thus it may be the consequence of the introduction of unclean
instruments; is a very frequent consequence of gonorrhea, including
all forms of urethritis; or may be the result of local tuberculous
processes or those travelling downward from the kidneys; or, again,
of more general toxic or septic conditions, such as typhoid and other
infectious fevers. Certain conditions predispose, such as the presence
of calculi or the occurrence of traumatism. Again, a bladder weakened
by overdistention or paralysis, as in cases of spinal injury, loses its
natural resisting power and succumbs to infection abnormally easily.
It should be emphasized that the absolutely healthy bladder wall is
resistant to all germ activity, but this resistance is easily lost or
modified in the presence of disease, either close by or distant. A
bladder whose normal shape has been greatly changed by enlargement of
the prostate is again rendered not only unhealthy, but incapable of
acting normally. It becomes, therefore, easily infected, and _cystitis
is a frequent accompaniment of prostatic hypertrophy_.
[Illustration: FIG. 651
Internal appearance of bladder in some cases of inveterate cystitis;
mucosa sacculated by columns of hypertrophied tissue. (Launois.)]
=Symptoms.=--The _cardinal symptoms of cystitis_ are three in number,
_i. e._, _pain_, _frequency of micturition_, and _pyuria_, the latter
being the consequence of changes in the urine, as well as in the
bladder wall, while the pain and the thamuria are expressions of
irritation, especially of the base of the bladder and the posterior
urethra. In fact, all the more violent expressions of cystitis are
found at the lower part of the bladder rather than in its upper
portion. Obviously, then, irritation of adjoining organs is more easily
accounted for, _e. g._, of the urethra, the seminal vesicles, the
prostate, and the lower ends of the ureters.
The _pain_ may be severe, and is especially complained of with each
act of urination. It is referred not only to the region of the bladder
proper, but along the urethra to the end of the penis in the male, and
down the thighs in both sexes. With frequency of urination there is
also distressing urgency, so that once the necessity be felt nothing
can restrain the promptness of the act. In fact so powerful is the
expulsive tendency that the tenesmus affects not only the bladder but
often the rectum, while the feeling or desire to urinate continues
after the bladder has been emptied of its last drop, even for several
minutes, and may cause the patient to sit in agony for some time.
The distress produced in acute cases of cystitis is excessive, and
sedatives and anodynes constitute no small part of the treatment.
The amount of _pus_ contained in the urine will vary with the degree
of acuteness and the stage of the disease. At first it is but slight,
but rapidly increases, until the urine may contain thick mucus and pus
up to one-third or more of its volume. Finally _blood_ may appear, by
whose appearance a serious degree of inflammation is betokened.
Later, at a variable date, the putrefactive element is introduced; and
when the urine begins to smell of ammonia--_i. e._, when _ammoniacal
decomposition_ has once begun--the bladder is thereby the more
irritated and the case made still worse.
No vesical mucosa left suffering from such acute inflammation will
remain unaffected in its tissue elements, but will rapidly become
more or less thickened. In fact the entire bladder wall undergoes a
process of thickening, from hypertrophy of its inner and its muscular
or middle coats, the latter due to extra activity in consequence of
the constant tenesmus. There results in time a marked _eccentric
hypertrophy_, whose result is really a contraction of the bladder
cavity and a distortion of its lining. Under these circumstances, also,
the mucosa becomes _sacculated_, and numerous little pockets, which may
contain decomposing urine, serve to complicate the situation; while,
finally, more or less _incrustation_ or _calculous degeneration_ and
implantation modify the character of the mucous coat. For all these
changes to occur requires time, but their combined effect is such
thickening and contraction of the bladder as to permanently alter it
and lead to a final _concentric_ hypertrophy.
=Tuberculous Cystitis.=--The picture presented by tuberculous disease
of the vesical mucosa is, in the beginning, one of miliary or
disseminated involvement; but later, when ulcerative changes have taken
place, the end results are scarcely different from those rehearsed
above, save that the ulcerative element is more predominant, and
there is great probability of involvement of the ureters or of any of
the adjoining organs. As conditions do not essentially vary, neither
do symptoms, and a diagnosis of tuberculous cystitis often must, in
the early stages, be reached by a process of exclusion, corroborated
perhaps by the cystoscope.
=Postoperative Cystitis.=--A different clinical type of irritation,
or mildly infective cystitis, is known to be a sequel of certain
operations, not alone those upon the pelvis. In the majority of cases
it occurs when catheterization has been required, the first event being
urinary retention, by which the bladder mucosa must be more or less
disturbed. It may be perhaps accounted for by the fact that the urethra
is practically never free from germs, which, in that canal, seem to
be innocent, but which, carried upward into an irritated bladder may
excite serious inflammation. These cases are perhaps more frequent
after pelvic operations for cancer. There seems, however, no doubt
but that repeated catheterization for several days lowers bladder
resistance.
=Treatment.=--When the occurrence of cystitis is imminent prophylactic
or preventive treatment is recommended. This should consist in
administration of large quantities of fluid, with urinary antiseptics,
in lavage of the bladder itself, and in reliable antiseptic precautions
in catheterization. Thus to operate upon a bladder which has long held
seriously infected or decomposed urine, without previously cleansing it
as much as possible, is simply to invite further trouble.
The medicinal treatment of cystitis, on which we mainly rely, consists
in dilution of the urine by large amounts of fluid ingested, in
overcoming hyperacidity by the administration of alkalies, and in
combating putrefactive conditions, so far as possible, by antiseptics
which are eliminated through the kidneys. Balsams have been long held
in great repute; but remedies like urotropin and other synthetic
compounds have taken their place. Of them all, and especially in the
presence of ammoniacal urine, urotropin and the alkaline salts of
benzoic acid seem most reliable. Excessive irritability may be overcome
by local measures, such as frequent hot rectal douches, hot sitz baths;
by quieting irritation of the genitospinal centres by administration,
_e. g._, of cannabis indica, in doses pushed to the physiological
limit; by local anodynes, as by opium suppositories, or in extreme
cases by general anodynes like morphine.
Theoretically a seriously infected bladder should be washed out and
cleansed as any other pus cavity, but when so inflamed the bladder
becomes so intolerant and exquisitely irritable that the mere act of
washing can only with difficulty be borne by the patient. Retention of
a catheter, which might be advisable under most circumstances, may also
be impossible for the same reason. The condition of a patient under
extremes of this kind is pitiable, and resort to general anodynes
unavoidable. Still it is possible with patience and the use of selected
drugs to gradually allay even a most acute cystitis. Confinement in bed
and an almost fluid diet are also necessary features of treatment.
If the introduction of an instrument can be borne it may be possible to
leave in the bladder some soothing solution after it has been washed,
such as a mild cocaine solution containing a little morphine, or olive
oil containing orthoform, or a mild preparation of ichthyol. Even if
these be retained but for a short time they will usually afford relief.
Finally in severe forms of cystitis the _bladder may be opened_ for
the purpose of giving it physiological rest, selecting either the
suprapubic or the median perineal route. The relief thus afforded is
usually gratifying, while drainage may be maintained until the local
treatment has been sufficiently effective to permit either spontaneous
closure of the drainage opening or its repair by suture. This measure
is known as _cystostomy for the relief of cystitis_.
Obviously if cystitis be due to the presence of any foreign body its
treatment becomes necessarily surgical, the same being true of those
forms due to or connected with hypertrophy of the prostate. It is
impossible to accomplish a cure here until the mechanical difficulty is
first overcome.
VESICAL CALCULUS.
In the urinary bladder as well as in the gall-bladder mineral
elements held in solution by the contained fluids are precipitated,
the consequence being the formation of _calculi_ or _stones in the
bladder_, which vary in size from the smallest concretions to those
weighing many ounces, and in number from one to scores, a large
proportion of these representing original concretions passed down
from the kidneys, _i. e._, minute renal calculi. Every calculus has a
nucleus, and in many instances this may be a clot, or clump of cells
encrusted with salts, which have formed within the bladder and not
come down from above. Such foreign bodies will become the nidus for
a calculus, while in vesical calculi are frequently found pieces of
catheter, of straw, chewing-gum, hairpins, and the like, which have
been introduced from without. These stones are constituted mainly
of the ordinary urinary salts, _i. e._, _phosphates_, _urates_, or
_oxalates_, deposited as described above. Much more rarely _cystin_ and
_xanthin_ are found. Instead of urates crystallized _uric acid_ will be
occasionally seen. The oxalates are mostly those of calcium, while the
phosphates are those of calcium, magnesium, or ammonium, more or less
combined. The first requisite for a calculus is a nidus, the second
the deposition of one or more of these salts. Calculi are sometimes
_composite_ in structure, some having a uric or urate nucleus becoming
later encrusted with phosphates. The oxalic calculi are exceedingly
hard and usually rough, being often spoken of as _mulberry_. They
rarely attain large size. The rapidly forming phosphatic calculi are
often so small as to disintegrate or break in the process of removal.
Thus there may be great differences in density of these stones. Their
formation is particularly favored by retention of alkaline urine, as in
many cases of prostatic enlargement.
=Symptoms.=--Discomforts and symptoms produced by bladder stone depend
upon their size, number, roughness, movability, and location. The
larger and rougher stones, which are more or less easily moved inside a
tender and irritable bladder, will cause a large amount of discomfort
and actual pain, while a small calculus, which may be formed within a
pocket or become encysted at some distance from the urethral opening
may remain unnoticed. The indications of calculi are essentially those
of cystitis, _pain_, _frequency of urination_, and _pyuria_, sometimes
with hematuria. The pain is local and referred, especially along the
urethra, to the glans in the male, and is often aggravated by the final
expulsive movements of the bladder at the termination of urination.
Local discomfort is aggravated by active exercise. Reflex pains have
been known in distant parts of the body. The frequency of urination is
increased by exposure to cold or by activity. Pyuria and hematuria do
not differ from those of non-calculous cystitis. A most significant
feature is sudden _stoppage of the urinary stream_, with more or less
pain. Statements to this effect, especially if accompanied by a history
of renal calculi in time past, are most suggestive.
Unless, however, particles of calcareous material have been passed the
positive diagnosis of calculus rests upon its detection by examination,
either with a _stone searcher_ or with the _cystoscope_. The former
is essentially a short-beaked, light sound, which may be more easily
manipulated after introduction within the bladder. In using it the
same precautions are taken as for catheterization or sounding, while
the deep urethra may be made less sensitive by a cocaine solution. The
instrument is introduced exactly as is a sound, and its beak is carried
completely into the bladder. Sometimes even before this has been
accomplished will be noted the rough, grating sensation which indicates
contact with a stone. At other times it is only after considerable
search that a small stone is “touched.” A stone easily found is within
the possibilities of unskilled manipulation, but to accurately examine
a bladder, especially behind a large prostate, is a fine art. For this
purpose the bladder should be partially distended with fluid, the
patient should be in the horizontal position, and the stone searcher so
manipulated that its beak may be made to traverse every portion of the
lower part of the bladder and to come into contact with its wall, for
only in this way can an encysted calculus be discovered. The beak must,
moreover, be rotated so as to be carried down into the pocket behind an
enlarged prostate, as in such pockets many calculi nestle. Some stones
are felt even in introducing a soft catheter; others are discovered
only after such manipulation as the above. Nothing but necrosed bone or
a foreign body can convey to the metal instrument, and through it to
the finger, the peculiar sensation produced by contact with a stone. By
attaching an auscultatory tube to the instrument a characteristic sound
may also be heard.
With the cystoscope in the hands of an expert it is possible to orient
one’s self definitely concerning the size and location of a calculus,
but much information can also be obtained by the use of the ordinary
searcher.
It has occasionally happened that calculi have been discovered by
accident, either during a suprapubic or some other pelvic operation.
=Treatment.=--The presence of vesical calculus being established,
there is but one rational treatment, _i. e._, its _removal_. It
remains, then, only to select the method of operation and to perform
it. Vesical calculi are removed by two general kinds of operations: by
_crushing and evacuation of fragments through the natural passages_,
or by a _cutting operation and extraction entire_. The former is known
as _lithotrity_, or, as now performed in one sitting, _litholapaxy_,
and the other as _lithotomy_, which may be performed either above the
pubis, through the perineum, through the vagina, or through the rectum.
Each method has certain obvious advantages. Thus _in favor of crushing_
there is freedom from an open wound, with its dangers of infection and
of hemorrhage, while it appeals to the sentiment of those patients who
“dread the knife.” One objection to it is that even when performed with
skill assurance cannot be given that the bladder shall be freed from
all calcareous particles, one of which may, by remaining, serve as a
nidus for another calculus. In _favor of the cutting operations_ are
their brevity, _i. e._, the celerity with which they may be performed,
the relief afforded by drainage, which can be carried out through the
lithotomy wound, and which is often indicated in bladders that have
been long tortured by the presence of calculi; while, finally, their
simplicity, at least in most instances, makes lithotomy attractive
to the operator of limited ability. It may be added that certain
calculi, especially of the oxalic type, are so dense and resistant that
even when secured in the grasp of an instrument they can scarcely be
crushed. It may be urged also that septic urine is just as harmful in a
bladder whose mucous membrane has been slightly injured here and there
in the process of crushing as in one which has been more or less opened
by a lithotomy.
Between cutting methods choice varies also according to the taste and
views of various operators, as well as the nature of the case. When the
prostate is large a suprapubic operation was held the simpler for the
removal of calculus, and this earlier teaching is not abandoned. In the
young the urethra is small and the bladder lies high in the pelvis,
and both these conditions favor the suprapubic method. Again it enjoys
repute because there is no danger of injury to the prostatic urethra
or the seminal ducts or vesicles, and because it leaves the genital
apparatus absolutely untouched. It is also free of possibility of harm
to the rectum, which was by no means unknown in the hands of the older
operators who resorted to the perineal route. But the removal of a
large stone by the suprapubic route entails an opening of considerable
size, and it is not unlikely that a large calculus may need to be
fragmented and removed in pieces rather than leave a large opening at a
point where urinary fistulas would likely ensue. It will be seen, then,
that even lithotomy is not always to be performed without crushing of
the calculus.
Of the perineal routes only two are in vogue today, the _median_ and
the _lateral_. The _median_ is resorted to for stones of moderate
dimensions, while the lateral will be required for large calculi. The
vaginal route is often selected in women, although, rather than make an
extensive opening between the bladder and the vagina, it will probably
be easier and better to dilate the urethra, and, through it, crush
a calculus which, in the female, could thus be made more accessible
than in the male. Therefore in the female the suprapubic route or a
litholapaxy is usually adopted. The operation through the rectum has
been long since abandoned.
After a calculus has been removed by crushing a self-retaining catheter
should be inserted, for at least a day or two, and the bladder
washed, while at the same time treatment for the cystitis, which is
still present, should not be discontinued. After opening the bladder
the wound is drained for at least a day or two. Drainage has this
disadvantage, that if long continued it leaves a urinary fistula, often
slow to close, but a metal, glass, or hard or soft rubber tube may be
placed in a median perineal opening, around which should be packed
gauze to check oozing, and left in this condition for two or three
days. Usually within a week after its removal the deep sphincters have
recovered their retentive power, and the patient can retain urine for
some time, while generally within two weeks the entire wound is closed.
In all these cases a sound or bougie should be passed at suitable
intervals for the purpose of preventing stricture formation in the deep
urethra at the site of the operation.
_Litholapaxy_ is performed by first crushing the stone between the
beaks of an instrument known as the _lithotrite_, which is constructed
in various forms, yet all conforming to one type, which is introduced
into the bladder through the urethra, after which its blades are
separated and manipulated until the stone is felt to be entangled
or secured between them. By a device at the handle the blades are
then locked, and screw power exerted, also from the handle, by which
the blades are forced together and the stone between them more or
less broken (Figs. 652 and 653). By repetition of this process each
fragment is seized separately and crushed until the bladder contains
more or less debris resulting from the manipulation. The lithotrite
is then removed and a _washing tube_ or catheter of large dimension
inserted, and connected with a so-called _washing bottle_, which is
compressible and permits a stream of water to be violently thrown into
the bladder, thus stirring up the fragments and particles, and which is
an instant later withdrawn by suction in such a way as to carry them
with it. Escaping into the washing bottle they drop by gravity into a
glass receptacle at its base, where they become at once visible. This
process is repeated until everything has been washed out of the bladder
which will come. The lithotrite is then substituted and the maneuver
repeated, and as many times as may seem desirable. In this way calculi,
especially soft ones of large size, may be disintegrated and removed
in small fragments. The final test of success is failure to aspirate
any more particles or to discover them with the cystoscope (Fig. 654).
The time consumed in the operation will depend on the operator’s skill
and the size or hardness of the stone. It is frequently performed
under local anesthesia, the bladder being injected with a weak cocaine
solution, or under spinal anesthesia.
_Lithotomy_, by either of the above methods, is performed by utilizing
a grooved sound known as a _staff_, which is first inserted into the
bladder, and serves not merely the purpose of a grooved director, but
to indicate the course of the urethra.
For the _suprapubic operation_ the staff is passed deeply, and its
handle depressed between the thighs, so that the end of the instrument
rises behind the pubis and carries the bladder up toward the surface.
A median incision above the pubis permits access between the recti
muscles to the prevesical space (space of Retzius), which is more
or less filled with fatty and connective tissue. If the bladder has
been previously distended with fluid and elevated on the point of
the staff, there is but little danger of wounding the peritoneum,
although its reflection may be sought and carried out of harm’s way.
It is a convenience to pass a silk suture with a stout, full-curved
needle through the bladder wall after it has been exposed, on either
side of the point of the staff which elevates it, and to pass this
through in such a way as to have thus a double loop, or two retractors,
by which it may be more conveniently manipulated after it has been
opened and would otherwise collapse. The bladder should be opened upon
the point of the staff, whose groove may then serve as a guide in
still further nicking or incising it, the silk sutures on each side
preventing it from collapsing as it otherwise would after the gush of
escaping fluid. The surgeon should now endeavor so far as possible
to dilate rather than to merely cut this opening, and thus give it a
size sufficient to permit the introduction of the finger, by which
intravesical exploration and orientation are effected. Calculi having
been identified and located, suitable forceps are then introduced, and
with them the stone or stones seized and withdrawn through the opening,
which may be stretched still farther for the purpose unless their size
make it advisable to crush them and remove them in fragments.
[Illustration: FIG. 652
Method of seizing the stone behind the prostate.]
[Illustration: FIG. 653
Ordinary position in seizing the stone.]
[Illustration: FIG. 654
Bigelow’s lithotrites, catheters, and evacuator.]
This is suprapubic cystotomy or epicystostomy, according to the purpose
for which it is intended. It serves not only for removal of calculi
but for extirpation of tumors, or enlarged prostates, and perhaps for
permanent drainage. By the silk loops at first introduced the bladder
wall may be attached to the abdominal wound, while other stitches may
be added to any desired extent. In most instances it is desirable to
reduce the opening, for which purpose buried and superficial sutures
may be used. As leakage, however, may produce infection it is customary
either to provide for drainage by insertion of a catheter through the
urethra, or by the implacement of a small tube, whose lower extremity
shall reach the base of the bladder and serve for drainage, which
latter may be made more effective by siphonage.
PERINEAL LITHOTOMY.