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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or in some methods, it is withdrawn through it and delivered upon the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).

Fig. 637

Congenital cystic kidney; exterior and internal appearance; patient forty-two years
of age. (Schmidt.)
 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.
 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).
 Fig. 640 Fig. 641

Hydronephrosis from obliteration of Hydronephrosis in first stage of

ureter by tuberculous disease. (Tuffier.) development. (Rayer.)
 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.
 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.
 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.
 Fig. 645 Fig. 646 Fig. 647

Longitudinal suture Implantation or invagination of Longitudinal incision and

of ureter. ureter with fixation and then transverse suture of ureter for
(Hartmann.) with circular sutures. stricture, similar to the
(Hartmann.) 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.
 C H A P T E R 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.