Abdominal 
Nephrectomy, with case. 
By REUBEN PETERSON, M. D. 
REPRINTED FROM 
VHE MEDICAL AGE, JULY 10, I&JS. [reprinted from THE MEDICAL AGE, JULY 10, 1895.] 
ABDOMINAL NEPHRECTOHY, WITH CASE 
REUBEN PETERSON, M.D. 
Operations for the removal of a kidney are 
not of such frequent occurrence as to inhibit 
reports of single cases; for this reason I have 
thought the following might be of interest: 
Miss A. C , American, aged 22 years; 
single; house-maid. Family history nega- 
tive, except that she thinks her father died 
of some kidney trouble. When eight years 
of age she fell and sustained an injury to the 
right side which kept her in bed for two 
weeks; since then she has always had more 
or less pain in that side, usually dull (but oc- 
casionally so severe as to confine her to bed). 
As she grew older the pain became more 
severe and more disabling. She first noticed 
blood in her urine at the age of nine, and this 
appearance was of almost daily occurrence 
thereafter until her eighteenth year, since 
which time it has been observed only during 
attacks of pain. About two years ago she 
had quite a severe seizure in the right side, 
accompanied by a cessation of menstruation; 
Doctor Murphy, of Chicago, diagnosed the 
trouble as cystic disease of the kidney, from 
a lump situated just at the border of the 
right ribs. (The patient had noticed this 
tumor for six years.) Some fluid was drawn 
off, and an operation advised. After this she 
was laid up for some time with severe pain 
and fever. Next she went to St. Joseph’s 2 
Hospital, where she was under the care of 
Doctor Senn, but he could find no evidences 
of cystic kidney. Then Doctor Henrotin 
was consulted, who made a vaginal examina- 
tion and found a cyst of the right ovary, 
which he removed by coeliotomy; she made 
a good recovery from the operation, but the 
pain in the right side still continued, and 
was so severe in character as to prevent her 
from working. At times the urine contained 
considerable blood. 
Examination, made September 26th, 1894, 
gave no evidences of cystic kidney, but there 
was some tenderness in the right vaginal 
fornix which was considered to be due to the 
stump of the excised right tube and ovary; 
accordingly she was sent to the Butterworth 
Hospital, and there treated locally with 
ichthyol tampons for over two months, dur- 
ing which period the urine showed no evi- 
dences of any kidney trouble, the amount 
passed being about normal. She gained in 
flesh and strength, color and appetite im- 
proved, but the pain in the right side still 
persisted. After consultation with Doctor 
Eugene Boise it was decided to make an 
exploratory coeliotomy for the purpose of 
ascertaining the cause of the suffering—the 
question of possible chronic appendicitis was 
considered, as the pain was located in the 
region of the appendix. It was suspected 
there was either trouble with the kidney or 
the appendix, or adhesions from the previous 
coeliotomy. 
Assisted by Doctor Boise, I operated De- 
cember 3d. An incision was made three 
inches in length in the right linear semi- 
lunaris over the region of the appendix, 3 
which was found to be perfectly normal. 
The stump of the excised right tube and 
ovary was next examined, and nothing ab- 
normal was found in connection therewith; 
no ligature was present. A systematic ex- 
aminat on of the entire abdominal contents 
was then made, which resulted in the dis- 
covery, beneath the peritoneum and in the 
region of the right kidney, of a fluctuating 
tumor. The left kidney was palpated and 
found to be apparently normal. The peri- 
toneum was cut through over the centre of 
the tumor until a blue, glistening cyst-wall 
was disclosed. The tumor was then care- 
fully dissected from its bed, which proved to 
be a most difficult and delicate task because 
of the thin wall and the density of adhesions. 
The kidney was finally cleared in all direc- 
tions, except the pedicle made up of the ureter 
and renal vessels. The ureter was isolated 
and cut midway between the silk ligatures 
which were applied. One large silk ligature 
was placed around both artery and vein. 
Forceps were then placed close to the kid- 
ney, and the mass removed. The stump was 
dropped and the peritoneum allowed to settle 
over it, no stitches being used. The abdomen 
was not irrigated, but little haemorrhage hav- 
ing taken place. No drainage was used. 
The parietal peritoneum was sutured with 
catgut, the fascia with interrupted silkworm- 
gut sutures, and the muscles with catgut. 
Catgut was also used for the skin. The pa- 
tient suffered very little from shock, the 
operation lasting a little over an hour. She 
made an uninterrupted recovery. The stitches 
were removed on the ninth day, and the wound 
was found to have healed by first intention. 4 
The patient is now free from pain and able 
to do light work. The urine was examined 
carefully after the operation. About the 
normal amount was passed in the twenty- 
four hours, showing that one kidney was able 
to do all the work.* 
Regarding the diagnosis of cystic disease 
* Pathological Report by Doctor J. B. Whinery.— 
The kidney, at the time of removal had become 
changed into a fluctuating, lobulated kidney-shaped 
tumor. The length was six inches, breadth four 
inches, weight one pound; surface smooth, and no 
evidences of inflammatory action. On palpation, 
calculi ranging in size from a grain of sand to a 
pea or a little larger could be detected scattered 
through different parts of the tumor. On making 
an incision into the mass, twelve ounces of brown- 
ish-colored liquid escaped, which, however, was not 
subjected to chemical or microscopical examination 
because the tumor had been in preserving fluid for 
some time and more or less osmosis had taken 
place. Most of the kidney structure had disap- 
peared, and there remained only pouches separated 
from each other by septa of fibrous tissue, in which 
free calculi were found, about two dozen in all, some 
of a dark clay-colored appearance, others dark 
brown; a thin crust of crystals covered a few of 
the calculi. Firmly imbedded in the mouth of the 
ureter was a dark-brown calculus the size of a 
hazelnut, completely occluding the lumen and pre- 
venting the passage of urine. Of the kidney struc- 
ture, only a small portion, varying in thickness 
from a mere shell to three-quarters of an inch, was 
left. Microscopical examination of this remaining 
kidney structure revealed atrophy and a function- 
less condition of the secretory elements. 5 
of the kidney by means of the cystoscope 
and the use of ureteral catheters: Only 
since Howard Kelly’s work on the bladder 
and accessories has it been practicable to 
make use of catheterization of the ureters 
as a means of diagnosis of disease of the 
kidney. By means of Kelly’s instruments 
both ureters may easily be catheterized and 
the excretion from each kidney carefully ex- 
amined; great additional aid to diagnosis is 
thus obtained. In the case just considered, 
there is no question but that passage of a 
catheter into the right ureter would have 
shown that no fluid was coming from the 
corresponding kidney. The amount of fluid 
excreted from each kidney can be deter- 
mined, and thus the surgeon can decide as 
to the advisability of the removal of one 
when the other is slightly diseased; in short, 
the diagnosis of surgical disease of the kid- 
ney has been placed on a scientific basis, and 
much more accurate and successful work 
may be confidently looked for in the future. 
The advantages of abdominal over lumbar 
nephrectomy for such cases as the one re- 
ported, are evident. Had the incision been 
made in the loin, it is doubtful if the dense 
adhesions could have been separated—cer- 
tainly not without rupture of the cyst wall, 
thus materially complicating the operation. 
With the abdominal incision the field of oper- 
ation is brought plainly into view and the 
work of enucleation may be carried on both 6 
by sight and touch; and the shock attendant 
upon opening is offset by the greater rapidity 
with which the kidney can be removed. 
Lumbar nephrectomy, even though the peri- 
toneal cavity be not opened, is attended 
usually by great shock, because of the neces- 
sary strain to which the renal vessels are 
subjected in bringing them into position for 
ligation—the operator is almost invariably at 
a disadvantage, no matter how extensive the 
incision may be. Mynter relates of a recent 
case that his arm was buried nearly to the 
elbow in attempts at enucleation. One can 
thus readily understand the dangers attend- 
ing the ligation of the renal vessels. One of 
the chief causes of secondary haemorrhage is 
ligation of vessels while on the stretch, and 
the slipping of the ligature usually proves 
rapidly fatal — a difficulty that is avoided 
when ligation is through the abdomen. Again, 
dissecting-room experience teaches that anom- 
alies in the way of blood-supply to the kid- 
ney are by no means uncommon, and these 
can be seen and provided for better by the 
abdominal route; the latter method also en- 
ables one to carefully palpate the sound kid- 
ney before removing the diseased one: for it 
has happened that a kidney has been removed 
and the post-mortem revealed the fact that, 
although diseased, it was the only renal organ 
present. The possibility of such accidents 
should be continually borne in mind and care- 
fully guarded against. 7 
Shall the cut edges of the posterior perito- 
neum covering the tumor be sutured ? If the 
kidney be in its proper position, removal will 
leave a large hollow into which the edges of 
the peritoneum drop in such a way that union 
readily takes place; the raw surfaces left after 
peeling out the kidney (which is usually ad- 
herent) are covered by the peritoneum, and 
thus the abdominal cavity is shut off from the 
retroperitoneal space. And yet, while sutures 
can be dispensed with in some instances and 
no unfavorable symptoms supervene, in other 
cases if there is no great amount of shock and 
the peritoneum not too redundant I would 
certainly unite the peritoneal edges by a run- 
ning catgut stitch, feeling that by so doing I 
had left the peritoneum in a more favorable 
position for speedy union than by any other 
method. 
Drainage, as a rule, should be employed 
only when absolutely necessary. As applied 
to nephrectomy it differs from other abdomi- 
nal cases in the fact that the retroperitoneal 
space may be drained through the loin, while 
the abdominal cavity can at the same time 
be closed without drainage; and this would 
seem to be the most satisfactory method to 
employ. Gauze is in the main preferable to 
rubber tubing, owing to the tendency of the 
latter to collapse and thus prove worthless. 
In disposing of the ureter, two ligatures 
should be applied and severance made be- 
tween them; stitching the end of the ureter 8 
into the abdominal wound, as is the custom 
of some, is totally unnecessary. If the con- 
tents of the ureter are believed to be septic, 
the end should be cauterized; otherwise it is 
simply dropped after ligation and excision. 
I have wondered whether the history of 
the injury to' the right side in the case just 
reported could have had any influence in the 
production of the calculi and the subsequent 
development of the hydronephrosis; certainly 
a blow may produce a blood clot within the 
kidney, from which a calculus can subse- 
quently develop. 
The history of paroxysms of pain, and of 
haemorrhages from the bladder, would lead 
to the conclusion that these were induced by 
frequent passages of calculi along the ureter, 
and that finally one larger than the rest 
lodged in the mouth of the ureter, when 
hydronephrosis resulted. 
In conclusion let me say that this case has 
taught me a valuable lesson: it is, to place 
more credence in the patient’s statement in 
regard to pain, and if it be located in the 
abdomen, and the position be constant, to 
make an exploratory incision to clear up the 
diagnosis. 
Grand Rapids, Mich.