ALTHOUGH in presenting this topic we have little new to offer, it is broached with the hope of gaining from the discus sion a clearer conception of those illy determined renal and systemic states which precede and accompany kidney failure, as well as to see formulated the best means to avert this issue when it threatens. In using the word anuria, it is not sought to exclude consideration of those cases of alarming oliguria which may happily recede before impermeability becomes abso lute. Nor is it meant to confine consideration to such sequelx after any particular operation; although the paper is written from the stand-point of renal surgery, partly, in order to admit any evidence regarding that reflex inhibition which at times is noted after a trauma to some part or single organ of the group; but just how this result could be obtained by mechanical injury, if it were sought, experimental work has not been taught us. Because the following case of fatal nephrectomy with renal suppression presents some salient features, it will be used for the framework of a very brief résumé of a subject where one retrospect suggests that sur gery makes too little of physiology and medicine. At any rate, the writer's disappointment in this individual case is coupled with the thought of what might have been the re sult had his knowledge of these subjects been more positive.
Perhaps your verdict may enable us to decide whether such experiences are to be classed as unavoidable accidents incidental to surgery, or, on the other hand, as direct results of a careless preparation of the patient, faulty technique dur ing or ill-advised management after the operation; and if, by an interchange of views on methods in dealing with these cases, we can feel that our future patients may be more safely guarded against the risks of nephrectomy, this report of a personal misfortune will have served a purpose.
A. H., an undersized, poorly developed but not flabby youth of nineteen, entered the Presbyterian Hospital in September, 1899, with a left lumbo-abdominal tumor and a temperature of 103° F. When thirteen years old he had a fall, injuring his left side ; two years afterwards symptoms of left renal disease appeared. A month before admission another fall added to his trouble, and some pain with vomiting accompanied the appearance of a lump in his side. Under chloroform anaesthesia a large pyonephrotic kidney was opened and No stone was found, and a catheter passed through the ureter showed it unobstructed. In a month he left the hospital with a renal fistula. For five months his health improved ; then the sinus began at times to close, and symptoms of absorption, with painful overdistention, returned, which he relieved by inserting a knitting-needle. In May last, 1900, he asked for another operation to obviate his pain and an noyance of the fistula. His ureters were catheterized ; there was again no obstruction in the left, and the right gave issue to normal urine from that kidney. This evidence confirmed the first requirement for nephrectomy, and otherwise he appeared a fairly suitable subject for the operation. He was directed to devote a month to out-door invigoration and given an iron and strychnine tonic.
On July io, 'goo, he again entered the hospital, and was observed for two days prior to operation. He showed an after noon temperature of me F. The urine passed from the blad der, nearly all of which was derived from the right kidney, aver aged thirty-one ounces in twenty-four hours. Its character was good and similar to that tested one month before. Now, as then, an undetermined amount of faulty left kidney excretion found its way to the bladder, but nearly all traversed the fistula. One night he had an attack of renal distention with severe pain, due to oc clusion of the sinus. He was prepared in the usual way for operation by catharsis, etc. Since chloroform was to be used, he had four minims of Magendie's solution subcutaneously an hour before and one-thirtieth grain of strychnine sulphate just before anaesthesia. The lumbo-abdominal surface was well exposed for nephrectomy by a graduated mound of underlying sand-bags.
The operation was somewhat tedious, because the old cica trix, with its central sinus, made recognition of the aponeurotic layers and peritoneum difficult, and the kidney was a large one, with much of its fatty capsule changed to cicatricial tissue. The ureter was identified at the lower pole of the kidney, doubly tied and cut.
Then the organ was turned upward and forward, giving easy access to ligate the pedicle. Extremely little blood was lost during the operation. The patient had taken the anaesthetic well, and was removed in good condition, having been one hour and a quarter under chloroform anaesthesia.
Pathologist's report showed a large typical pyonephrotic kidney having no tuberculous or calculous formations.
Pathological Report on Kidney. Pelvis and calices ex tremely dilated. Kidney is seven inches in length ; kidney tissue forming walls of cystic mass is for the most part one-eighth to one-sixteenth of an inch thick. Lining membrane is deeply congested, rough, and is covered for the most part by a thin layer of yellowish exudate. No foci found.
Microscopical Examination. Some sections show structures of kidney comparatively unchanged. Tubules a little dilated and cells flattened. Many casts, some congestion, occasionally a little focus of leucocytes. Other sections show almost no kidney struct ure; occasionally a single tubule in the midst of inflamed tissues resembling granular tissue. In some sections the capsule is much thickened, dense, and infiltrated with leucocytes.
On reaching the ward the patient was given a sedative enema (trional, sodium-bromide, whiskey, and salt solution). For the twelve hours following operation the temperature remained at we F. ; pulse averaged loo. He had been having alternating doses of strychnine, and nitroglycerin, 1/loo, by mouth, every two hours. Four hours after operation he voided three ounces of urine, with marked traces of albumen (15 per cent. volume).
Six hours after operation vomited two ounces of green fluid and passed one more ounce of urine, which was the last during the remaining forty-eight hours of life. Slept four hours during the night.
July 13. This morning he was catheterized ; no urine found, and the bladder was irrigated with hot boric solution. Vomiting again. He was given for thirst only egg albumen water by mouth. 12 M. Temperature F., pulse 8o, respiration 18. All stimulating enemata (salt solution with whiskey) had been retained. Vomiting at intervals . in afternoon. Strychnine and nitroglycerin medication was afterwards given subcutaneously. Vomiting occasionally small quantities of green fluid. No ab dominal distention or tenderness. Evening temperature me, pulse 114, poor quality.
July 14. Slept very little last night. At i A.M. pulse very weak and rapid. Improved under nitroglycerin. Again bad at 2.30 A.M. Vomiting small quantities quite frequently. 8 A.M. Temperature 99° F., pulse 122, of better quality. Stop all medi cation except strychnine, and substitute intravenous saline infu sion (2000 cubic centimetres) for enemata; vomiting continued.
A.M. Lavage ; four quarts used before fluid returned clear. Two hours later, vomiting. Given two ounces cold dry cham pagne; this is retained. 3.3o P.M. Pulse hardly perceptible ; moo cubic centimetres saline infusion. 4 P.M. Cyanosed. 5.30 P.M. Died.
rliitopsy. July is, i9oo, eighteen hours after death. Abnormal conditions, nephrectomy for pyonephrosis; cys titis and pyelitis; parenchymatous nephritis.
Frame, fair size; adipose, scant ; muscle, good.
Heart, 8% ounces. Pericardium, some petechial spots; valves normal ; muscle, very pale, especially the columnar muscles of the left ventricle. Fatty degeneration shown in a specimen teased in normal saline solution.
Left lung, 13% ounces, normal ; section, normal.
Right lung, 14% ounces, normal ; section, normal. Peritoneum, mesenteric glands slightly enlarged ; section, normal.
Gall-bladder filled with very dark and thick bile.
Liver, forty ounces. Consistence, normal ; surface smooth; parts congested ; parts pale.
Spleen, five ounces. Consistence, rather tough; surface, pale; section, pale.
230 F. TILDEN BROWN.
Kidney, left, absent. Ureter slightly distended in lower por tion.
Kidney, right, 6% ounces. Capsule free. Some congeste stars on surface, rather pale. Surface, smooth. Consistency normal. Section, cortex slightly thickened, of a pale, pinkis' yellow. Glomeruli congested. Markings somewhat indistinc Pyramidal markings somewhat exaggerated. Pelvis slightly dis tended, contains a little serous fluid. Mucous membrane som< what congested, and shows a few petechial spots.
Right ureter, lower portion congested.
Stomach contains some dark-brown fluid and a moderal amount of mucus.
Intestines. Cmcum unusually full and movable. Cmcum an lower end of ileum somewhat congested, solitary follicles et larged.
Bladder a little congested, especially at base. Contains little turbid fluid. Prostate, seminal vesicles, and urethra norma Microscopic examination of sections of Kidney. Tufts injected with red cells. Capillaries ratho congested. Tubes well preserved in most places ; some are fu of swollen granular cells with unstained nucleus.
Liver. Interstitial inflammation ; parts are congested ; few new formations of bile-ducts.
Heart. Celloidin sections show some pallor of fibres ; tl fat droplets seen in teased specimens are gone.
Before criticising the operation and after-treatment, 1,1 shall inquire into the cause of death and the cause of anuri As already noted, the two chief features before death were failing heart and renal suppression. The two chief feature of the autopsy concerned these same organs. By what pr( cesses during or following the operation was the form brought about ? Failure of a fatty heart quite surely was tt cause of death. What made it fail ? Whether general sy temic shock resulting from the operation or inhibition due I auto-infection in consequence of renal excretory failure? The kidney at necropsy and by a later microscopic e] amination showed congestion, but no nephritis.
The quantity and quality of urine excreted by this orga before operation evidenced no congestion. What happened during or after operation to cause it? We can suspect (1) Chloroform anaesthesia.
(2) Compression of the kidney and vessels of its pedicle against the spine when the superimposed body rested for a long time on sand-bags, leading to a subsequent hyperemia.
(3) Some essential vasomotor reflex started by gan glionic pressure or through the renal plexus from removing the fellow kidney, or a congestion incidental to an increased physiological demand.
Subsequent to the operation, we can suspect that a weak heart favored a condition of comparative stasis (passive con gestion). If this last is the correct explanation of the con gestion, and if the lowered heart pressure at the same time could so quickly bring about suppression, then this anuria had but the remotest, if any, influence in causing death.
Per contra, if any of the former supposed reasons gave rise to the congestion with an accompanying anuria, we could argue that this latter was a potent factor in causing death by the influence of a uremic state on the heart; but even a com plete suppression of so short duration is not apt to manifest any appreciable uremic Had the congestion of the kidney anything to do with the anuria, or had they even a common origin ? The writer is not in a position to argue it, but in leaving all this uncertain field he would express the general view that his patient with a fatty heart, after traumatism incidental to a nephrectomy, gradually developed a weaker heart, vomiting, anuria, and moderate restlessness ; in fine, symptoms associated with that lesser degree of shock known as the erethistic type, where a reflex vasomotor paralysis, involving particularly the abdomi nal vessels, so lowered the renal pressure as to both favor a passive congestion there and be the direct cause of anuria. Despite the remedies used, increasing inhibition of nerve ac tivity of all the vital organs led gradually to their functional failure, until with final complete involvement of the heart death ensued.
As to the operation. The indications for nephrectomy appear to have been unquestionable, and the condition of the organ on removal supported the presumption. The propriety of ureter catheterization as a precautionary measure was equally indicated, and, in view of the fatal result, it serves to show that a remaining healthy kidney is not the only requi site to make nephrectomy safe. Important as it is to learn the condition of the other kidney, a sound heart may more than compensate for some slight renal impairment in these operations.
While the method employed for collecting the urine was up to date, the quantity gathered and the technique of its ex amination were not in keeping with the newest European de mands. Still, the report of our patient's right kidney urine examined by Dr. Sondbern both justified the operation from a renal stand-point, and found verification at the autopsy as to its accuracy regarding the state of the organ at the time of catheterization.
Since this was here the the present review affords no reason to invoke a discussion on cryoscopy (Koranyi), or the phloridzin (Casper) and similar tests for getting at the functional capacity of each kidney.s To the preparation of our patient for operation a month was given, because his general tone so clearly needed it, and no immediate urgency was apparent.
In choosing to use chloroform, we were influenced by the fact that the patient had already taken it favorably, and by Kemp's deductions, which, as you well know, show that ether, while producing a rise of general arterial pressure, manifests simultaneously a deleterious and specific influence in a lowered renal pressure and almost immediate dimin ished excretion ; whereas chloroform, when producing a de crease in carotid pressure, exerts but an insignificant effect, if any, on the renal pressure or excretion. Although there are some whose views do not coincide with the results of Kemp's extensive laboratory experiments, Galicazi and for instance, maintain that the diminution of renal permeability is more marked when chloroform is used than when ether is administered, and they claim that this result renders any infec tious disease with which the patient so anaesthetized may be affected more severe.
While in our case we do not now impute to the chloro form any immediate influence on the kidney itself, resulting in suppression; we do infer that it had an indirect bearing in this result through adding to the pre-existing heart weak ness ; in other words, that the ensuing shock would have been less with ether anaesthesia.
We view it as a grave error in this particular case that nitrous oxide gas with ether was not employed. All of the indications would have been better met by it. The compara tively small quantity of ether required after narcosis is once induced by gas would here have served a much more valu able purpose as a heart stimulant than it could have done harm as a renal depressant; although, had pure ether alone been used throughout our operation, the congested kidney, the suppression and death, might all have been laid at the door of this agent.
In the near future another mixed anaesthetic—nitrous oxide gas and oxygen—appears to have promises of popularity ; and since no appreciable influence on the kidneys attends the use of gas, and when given with oxygen by an expert anaes thetist the feasibility and safety of prolonged anaesthesia have been demonstrated. In such cases as those we are considering, where kidney function should receive particular attention, this combination may offer special claims for recognition. The relative value in kidney operations of spinal anaesthesia by cocaine and of ethyl chloride by inhalation remains to be determined.
We have also a word about the prevailing method of posturing patients for nephrectomy. Of course, an expansion of the iliocostal space greatly facilitates the operation. This is ordinarily secured by bags of sand or air underlying the opposite anterolateral region of the abdomen. When by such arrangement the spine is sufficiently flexed to extend the opera tive field, the pelvis is nearly lifted from the table, and the pyramidal support thus bears a considerable part of the total weight of the body. This pressure impinges upon a yielding surface immediately about the sound kidney ; and that the organ may be heavily compressed against the spine with dele terious consequences appears to us quite Some experiments with bodies so postured over platform scales countersunk on the table showed that 3o per cent. of the body weight was in this way superimposed on the underlying pile.
It seems to us that this could advantageously be avoided by having the lateral pelvic surface and legs repose on an in clined plane, where the weight of the legs would tend to throw the pelvic brim upward, and with it the lower lumbar spine ; while the head and thorax resting on an opposite slope would result in giving the vertebra a faint upward curvature,— enough, at any rate, to do away with any but the slightest sup port under the mid-section of the trunk.
This experimental model of a double inclined plane is made in two sections with the idea of permitting an actual gap to underlie that part of the trunk which heretofore has sus tained all the lifting strain, and in order to be able to increase or lessen this space according to the dimensions of the patient, as well as arrange the opposing lateral planes at an angle to each other, according as the operation was rather of the lum bar or anterior sort.
While we do not know that renal disturbances can be produced by a constant heavy pressure against the sound kid ney during nephrectomy, one case 6 is found reported where a superficial abdominal trauma was followed by suppression. Autopsy showed no thrombi of the renal vessels, and no effu sions or lacerations to cause an obstructive anuria ; in the ab sence of any more plausible reason, the condition was ascribed to a ganglionic contusion with a reflex vasomotor paresis.
In answer to some questions, one pathologist, who has done much with the oncometer in studying renal pressure under dif ferent conditions, has told us that on examining the kidney shortly after each experiment it was very common to find the organ congested ; but whether this was due to pressure of the yielding diaphragm enclosing the kidney or faulty contact with its pedicle by the encircling collar of the oncometer case he did not know.
If we realize that the vascularity of the kidney is such that when in full functional activity an amount of blood equal to the weight of the organ flows through it in a minute's time, and, again, that the secretion of the kidney varies directly with the quantity of blood flowing through it, we may feel that every consideration should be accorded to the single healthy gland during the removal of its mate.
As an instance of renal susceptibility to reflex stimulation cinoma of the prostate he records. Of these only ten appeared before the fiftieth year, fifty-two between the fiftieth and ninetieth years, one at a still later period, and in four the age was not mentioned. In all but two cases the prostate was found enlarged. The growth was usually general. In nine cases reference is made to enlargement of the middle lobe only. The average size was that of an orange. The prostate was usually nodular. These nodules Guepin distinguishes from the enlargements found with hypertrophy, inasmuch as the latter. under rectal massage, disappear or can be reduced, and with their reduction in size there is an expulsion of prostatic secre tion. Occasionally you have a cystic collection with prostatic cancer. Should it be possible in this condition to force a dis charge out of the prostate, purulent streaks or an admixture of blood will be found in it. Section of a carcinomatous pros tate presents a white surface where purely carcinomatous tissue is present, and one that is grayish white where smaller car cinomatous masses are traversed by strips of prostatic tissue. Two old cases are described as presenting melanotic discolora tion. In consistence, carcinoma of the prostate is firm, may grate on section ; while in other instances we may have soft gelatinous masses in areas of firm prostatic tissue.
In sixty-four cases in which it was possible to note an extension of the disease, it was found that the bladder was involved twenty-eight times, the rectum eight, the urethra once. the seminal vesicles thirteen times, and in three the left semi nal vesicle was alone involved. Seven times a tumor projecting into the bladder was found connected with the prostate. In only ten or eleven of the sixty-four cases was there any record of ulceration. The disease infiltrated rather than destroyed the tissues. The pelvic lymphatics were involved thirty-one times, the superficial only six.
Guyon has described a form of diffuse prostatopelvic car cinoma. The very rich lymphatic vascularity which Sappey has shown the prostate to possess, with its generous pelvic anastomosis, is evidently responsible for the rapid invasion of the whole pelvis found in this form of carcinoma. It is usually soft to the touch, may be of unequal consistence in various parts, yielding at some parts the sense of fluctuation, at others being firm and nodular, and presenting a definite outline. Metastases seem to occur often in prostatic carcinoma. In 20 per cent. of the sixty-four cases metastatic disease of bones is mentioned. The pleura was involved six times, the liver six, the lungs four, the penis three, the kidneys two, the supra renal capsules once, and the spleen once.
As complicating conditions, cystitis, prostatic hypertrophy, hydro- or pyonephrosis have been frequently encountered. Death from uraemia is the usual termination. Some patients have been carried away with bronchopneumonia, and others with rectal obstruction.
Microscopically, great poverty of connective tissue is found. Alveoli in this tissue are not frequently encountered. In the glandular zones little heaps of carcinomatous cells are seen, separated from each other by strips of smooth muscular tissue mixed with connective tissue.
The clinical picture varies somewhat from that of sar coma. The course is less rapid. Of forty-six cases in which the period of disease was mentioned, in eighteen it covered less than a year, in thirteen from one to two years, in four more than two years, in eleven three years or over, and one patient had had bladder symptoms for sixteen years. Ordi narily, the disease began with the sluggish discharge of urine, especially at night, and on arising in the morning. Polyuria was usually present. Pain in the region of the bladder, pre sumably due to spasm, was a frequent complaint. At times there was retention, and in some cases the incontinence of retention. The urine was, as a rule, purulent and ammoniacal. Hannaturia is mentioned in only twenty-one cases. Half of this number had used a catheter, and frequently bleeding was associated with instrumentation. Guyon's tumor ordinarily reached a large size before the hmmaturia appeared. The bleeding was of moderate degree. It would continue for a few days and with only rare periods of repetition. In five cases rectal obstruction was more marked than the urinary.
ment are the best. Of course, certain conditions imperatively demand surgical interference. If there is a suppurating kidney, it should be removed ; if the testis is suppurating and painful and cannot be relieved by simple measures, it should be taken out, but not on account of the presence of simple foci. In cases of tuberculous cystitis where the cystoscope reveals a distinct ulcer, —not the diffuse redness often seen in these cases, the applica tion of sixty grains to the ounce solution of silver nitrate is an excellent procedure. This can be done with the aid of a local anaesthetic or under the influence of nitrous oxide gas, and can be followed by a hypodermic of morphine, if the irritation is extreme.
Dr. Tilden Brown called attention to the fact that in Dr. Murray's case the haematuria had existed for ten years before the onset of the other symptoms which so clearly coincided with the presence of tubercle bacilli, and when the bladder was opened for the first time in 1898, besides the other lesions a papillomatous tumor was found and removed. The speaker said that while the diagnosis of tuberculous cystitis was no doubt correct, he was inclined to question whether the papilloma had not antedated the tuberculosis, and if its removal had not had much to do with the benefit which accrued from the suprapubic operation and the curettage.
Dr. Brown said that no one fixed line of treatment could be laid down in tuberculosis, whether the disease involves the kid neys or bladder or any other part of the body. He had met with more disappointments in cases intrusted to climatic influences than in those surgically handled. Dr. Murray's patient had doubtlessly been decidedly benefited by the method of treatment pursued.