Four Successful Nephrectomies. 
With Remarks. 
BY /' 
maurice h. richardson; m.d., 
Visiting Surgeon to the Massachusetts General Hospital, Boston; 
Assistant Professor of Anatomy, Harvard Medical School. 
Reprinted from, the Boston Medical and Surgical Journal 
of April cj, i8gj. 
BOSTON: 
DAMRELL & UPHAM, Publishers, 
283 Washington Street. 
1893. FOUR SUCCESSFUL NEPHRECTOMIES: WITH 
REMARKS.1 
BY MAURICE H. RICHARDSON, M.D., 
Visiting Surgeon to the Massachusetts General Hospital; Assistant 
Professor of Anatomy, Harvard Medical School. 
Case I. Tuberculosis of right kidney; excision; recovery. 
Case II. Tuberculosis of left kidney; extensive infiltration in 
perinephritic tissues; sinus into pelvis; excision and drain- 
age; recovery. 
Case III. Tumor of right kidney; probably adenoma; exci- 
sion ; recovery. 
Case IV. Hydronephrosis, calculus, and double ureter of left 
kidney; excision; recovery. 
Previous to 1892 I had made but one attempt2 to 
remove the kidney. The operation was abandoned on 
account of extensive adhesions caused by a perinephri- 
tic inflammation of many years’ duration. The patient, 
J. R., at the age of sixteen, in 1874, had been oper- 
ated upon by Dr. Porter at the Massachusetts Geueral 
Hospital, and a small stone had been removed from 
the bladder bv crushing. In 1880 he began to have 
pain in the left lumbar region, which in the course 
of a year was attended by a swelling occupying the 
whole space between the last rib and the crest of 
the ilium. July 5, 1881, at the Carney Hospital, I 
laid open the tumor, which contained a large amount 
of pus, and removed a phosphatic stone weighiug 
thirty grains. The wound never ceased discharging, 
but the general health became so much improved that 
life was useful and enjoyable. 
On August 9, 1886, this patieut applied at the Massa- 
1 Read before the Surgical Section of the Suffolk District Medical 
Society, January 4, 1893. 
2 Boston Medical and Surgical Journal, May 26, 1882, vol. cvi, No. 21. 2 
chusetts General Hospital for further treatment, there 
being still a free offensive discharge. 
August 25, 1886, I made an incision in the left loin 
extending from the last rib to the crest of the ilium. 
There was no kidney-tissue to be found : in its place 
there was the thin-walled cavity of an extensive pyo- 
nephrosis. The wall of the abscess was more than ad- 
herent to the surrounding parts : it had become so inti- 
mately connected with adjacent structures by extension 
of the inflammatory process in all directions that it 
was impossible safely to attempt dissection. The de- 
scending colon was practically a part of the renal wall, 
and the pancreas, stomach and spleen were involved. 
Attempts to remove the kidney were given up; the 
abscess cavity was thoroughly explored, curetted and 
drained. A good recovery followed, but the sinus has 
existed ever siuce.8 
This patient has been a baker at the Tewksbury 
Almshouse till very recently. A letter from Dr. 
Howard states that he has enjoyed good health except 
for the persistence of the fistula. 
During my connection with the Massachusetts Gen- 
eral and Carney Hospitals I have made several explor- 
ations in cases of renal tumor where the kidney and 
surrounding tissues were found to be so extensively 
involved that enucleation was impossible. 
Case I. August 4, 1892, Mary B., aged twenty- 
five, from Nova Scotia, was admitted to the Massachu- 
setts General Hospital. Eleven years before she had 
had a sinus over the olecranon, leading down to the 
bone, which healed after two years with a stiff elbow. 
The family history is decidedly phthisical. Last March 
she was taken with violent pain in the right side, which 
continued until the abdomen became distended and 
very sensitive. The pain was localized in the right 
renal region and a swelling appeared there. Since 
April of the present year she has been in bed more or 
* Mass. Gen. Hosp. Surg. Records, vol. 226, p. 106. 3 
less, and has had sharp pain in the right hypochondrium 
on any exertion; has had to pass water every hour, or 
oftener, both night and day. 
This woman was pale, poorly nourished, and some- 
what emaciated. Examination of the lungs and heart 
was negative. The urine was normal in color, specific 
gravity 1,016, and contained one-eighth of one per 
cent, of albumen. The sediment contained pus, free 
and in clumps, with masses of epithelium. The right 
elbow was anchylosed at a right angle. The abdomen 
was not distended. In the right hypochondrium there 
was a solid tumor the size of the closed fist, which 
could be grasped between the fingers, was movable, 
and could be displaced downward and inward half the 
distance to the median line. There was no evidence 
found of tuberculosis. The amount of urine ranged 
between twenty and forty ounces. 
On August 17th, I made an incision five inches 
long on the outer side of the right rectus muscle through 
the linea semiluuaris. An enlarged, irregular, and 
movable kidney was found in the usual positiou, cov- 
ered with peritoneum, over which lay the collapsed 
ascending colon. An incisiou was made through the 
peritoneum on the outer side of the margin of the as- 
ceudiug colon, and the kidney was uncovered and deliv- 
ered with the greatest ease. The ureter was cut about 
an inch from the kidney between two ligatures. A 
further separation was then easily accomplished until 
the organ remained attached only by its main vessels. 
These were tied separately with the greatest care, and 
the organ was then cut away with scissors. There was 
no bleeding whatever from the pedicle. The abdomen 
in the neighborhood of the kidney was then carefully 
irrigated, and dried with dry sterilized gauze. The 
distal end of the ureter was sewed into the lower angle 
of the wound, and a small gauze drain left at the bot~ 
tom of the renal space. The abdominal walls were 
united by interrupted silver-wire and silk sutures. 4 
During tlie operation, before removal of the right 
kidney, the hand was passed to the other kidney. 
This was apparently normal in shape and size, and 
there was no evidence of tubercular infiltration. T he 
upper part of the excised kidney was occupied by an 
abscess connected directly with the ureter. Consider- 
ably more than half of the organ was involved. Be- 
fore cutting the kidney open, however, it was impossi- 
ble to say that there was very much disease. The 
time of this operation was twenty minutes. 
On the following day she passed twenty ounces of 
urine. The temperature rose the next night to 100.4°, 
but after that came down to normal. Four days 
after the operation the bowels were moving well, 
the temperature was normal, and the gauze drain had 
been removed. The amount of urine was about twenty 
ounces. The stitches were taken out at the end of 
one week; the appetite was good, the urine had risen 
to fifty ounces, and the temperature was normal. 
On the 30th of August, thirteen days after the oper- 
ation, the wound was entirely healed. On the 10th 
of September she insisted on going home, an<( was dis- 
charged. The urine at that time was normal in color, 
acid, specific gravity 1,014, and contained a slight 
trace of albumen. There was a small amount of pus 
in clumps, with fatty degenerated epithelial cells and 
mucus; no casts. 
Cask II. Sarah D., a patient of Dr. Burst of 
Malden, thirty-one years of age, was horn in England. 
There was no tubercular history. The present trouble 
came on after the birth of her second child, five years 
ago. Then every six weeks she would have spasms 
of very severe pain in the left renal region running 
down to the groin and thighs. These would last for 
about a day and then pass away, leaving her very 
weak for a day or two. Three years ago she fainted 
in one of these spasms and went to a hospital in Liver- 
pool, England, where a lump was found in the left 5 
side. For a month or two before this she had noticed 
that her urine was thick and cloudy and deposited 
much white sediment and that micturition was more 
frequent. She was told that she had an abscess of the 
kidney, which was opened. Ever since there has existed 
a sinus in the left lumbar region. For the first year 
the discharge of pus was very great, and for the last 
six months about half a cupful a day. Urine has 
come through the sinus. Since the operation she has been 
able to work and has felt pretty well. Sometimes her 
legs would swell. The urine has been quite clear. 
During the last three mouths she has felt poorly, has 
lost flesh and had chills. 
Physical examination shows a poorly nourished and 
anaemic woman; temperature 100°; pulse 82; no 
oedema. In the left lumbar region there was a tender 
tumor the size of a child’s head, well defined below, in- 
definite above and flat on percussion, which extended 
down into the left groin. In the left lumbar region 
were scars of old incisions and a sinus from which a 
small amount of puriform discharge was oozing. The 
urine was normal in color, acid, 1,028, with a trace of 
albumen, much pus, some blood, squamous epithelium, 
excess of urates and mucus. Examination of heart 
and lungs was negative. 
This case seemed very much like the one referred 
to of operation for renal stone, but the woman was in 
such condition that it seemed to me wise to provide 
better drainage, if it was found impossible to remove 
the cause of the suppuration. A long incision was 
made in the left linea semilunaris directly over the 
tumor and extending as high as the margin of the last 
rib. When the peritoneum was opened a mass of ad- 
hesions was found filling the whole left hypochoudrium. 
The intestines lay on the inner side of the tumor, some- 
what adherent; these were separated and pushed 
towards the median line and kept there. The tumor 
contained numerous pockets which extended in all di- 6 
rections, the most distant through the mesentery of 
the descending colon to the right side of the bodies of 
the vertebras. These were all thoroughly curetted 
and packed. The kidney was found at the centre of 
the inflammatory mass, directly through the middle of 
which extended the sinus which had been discharging 
for so many years through the hack. This evidently 
was a pyo-nephrosis which had resulted in perforation 
of the kidney and an abscess requiring external drain- 
age. The kidney tissue was shelled out without 
much difficulty, and there was no hemorrhage from 
the pedicle. The whole left side of this woman’s 
abdomen at the close of the operation was packed with 
gauze which extended in all directions through the 
sinuses. The few renal vessels were secured with Bilk. 
The ureter was tied, cauterized, and dropped back. 
The whole cavity was thoroughly flushed before pack- 
ing. An incision an inch and a half in length was 
made across the old sinus in the left flank and a 
long rubber tube was carried through the cavity down- 
ward and to the right into the opening in the mesen- 
tery of the descending colon. 
The patient stood the operation, which did not last 
more than half an hour, very well indeed. There was 
no nausea. There was a good deal of serous ooze 
during the evening and night. August 28th, the fol- 
lowing day, she was very comfortable. Passed twelve 
ounces of urine from the bladder. 
On the third day there was some nausea and the 
abdomen was slightly distended. On the fourth the 
gauze was removed from the abdomen. The wound 
was very clean and beginning to granulate; it was 
loosely packed with iodoform gauze. The bowels 
moved this day. 
On the 6th of September the urine was found to be 
normal, acid, 1,012, with a slight trace of albumen, 
very little pus, squamous epithelium, mucus, and no 
casts. After the 13th of September the wound was 7 
dressed daily for a while, and then every second day. 
The cavity became closed almost entirely by granula- 
tions and the drainage through the flank was free. 
On the 14th of September she was feeling perfectly 
well. The temperature was normal on the 25th, and 
there was no pain ; she had gained in weight; the 
cavity was filling up rapidly — now the size of an 
orange — and the sinus was very small. She was 
then up and about in a wheel chair, and passing fifty 
ounces of urine. 
On October 6th she was discharged to Waverley, 
having gained about ten pounds. 
This woman made a complete recovery. 
Case III. Lucinda W., age fifty-nine, born in 
Maine, entered the medical side of the hospital on 
August 9, 1892.4 
One sister died of consumption. She has had more 
or less dyspepsia since 1882 ; she has had five children ; 
one miscarriage. 
During the last ten years she has had frequent 
attacks of dyspepsia with intense pain, and occasional 
spitting of blood. Vomiting has been infrequent. Blood 
came up without cough, bright red. At each attack 
noticed increase in size of a lump in the right side which 
she first observed eight years ago. Her attention was 
first called to the tumor by its slipping under the ribs 
when she stooped over. Its size then was about that 
of a teacup. She had clay-colored stools after attacks 
of pain and at times had chills with them. Of late has 
had pain more frequently, the last ten days ago, when 
she vomited half a cupful of bile. Ten years ago 
weighed 146, now 101 pounds. 
A tumor of the abdomen was found occupying the 
right lumbar region extending as far as the navel. 
It descended with respiration, and was globular in 
shape, slightly tender and elastic. Nothing suggestive 
of the right kidney could be felt in the loin. The 
4 East Med. Records, Vol. 443, p. 61. 8 
mass could not be dissociated from the liver, except 
in the knee-elbow posture. On inflating the rectum 
with air and water, the tumor was crowded upward and 
backward. The urine contained pus, bladder cells, 
and a little blood without casts.” 
During the next few days the case was seen bv all 
the staff in consultation, and the tumor was thought to 
be a kidney, it was tapped with a hypodermic needle 
several times, the needle apparently entering a solid 
body. The first time a clear fluid was withdrawn, 
highly albuminous, that did not give mucine reaction. 
Under the microscope this fluid was found to contain 
blood corpuscles and some square crystalline bodies, 
probably not cholesterine. At the second and third 
tapping the fluid was bloody and contained similar 
bodies. 
On August 23d I saw the patient for the first time, 
and advised operation.6 
On August 26th an incision four inches long was 
made in the right linea semilunaris. The edge of the 
omentum presented through the healthy peritoneum, 
and was pushed toward the median line. The left 
kidney was felt and found to be normal. The right 
kidney was much enlarged and covered by a thin layer 
of adhesions and by a net-work of large veins. The 
peritoneum was cut through and the tumor carefully 
dissected out with the fingers. Gauze strips were 
packed into the cavity left by the kidney. A large 
silk ligature was passed through the pedicle with an 
aneurism needle and tied in two parts ; then the renal 
vessels were separated and severally tied with pedicle 
silk. The kidney was removed together with the 
supra-renal capsule. The wound was thoroughly dried 
with dry sterilized gauze. There was no irrigation. 
The peritoneum was stitched to the edges of the wound 
with continuous silk sutures. A small iodoform gauze 
drain was putin the upper part, running to the bottom 
* See East Surg. Records, Vol. 272, p. 153. 9 
of the cavity. The edges of the wound were brought 
together with silk sutures, and the whole protected 
with gauze dressing and swathe. A large flax-seed 
poultice was placed over the left kidney. In the after- 
noon there was a slight chill, pulse became feeble, 
irregular, and intermittent, and the breathing rapid 
and superficial. Enemas of brandy, black coffee, hot 
water, digitalis, etc., were given. In the evening the 
general condition was much improved ; no nausea. 
August 27th passed a fair night. Complains of 
very little pain. Passed ten ounces of urine in twenty- 
four hours; pulse irregular but stronger. The chief 
difficulty was respiratory. On the following day she 
was stronger; the gauze drain was partly removed. 
On August 29th the improvement continued. The 
amount of urine this day was twenty-one ounces, dark, 
acid, specific gravity 1,024, with granular casts, renal 
cells, pus, and squamous epithelium. The pulse at 
times was intermittent. 
On September 6th all the stitches were taken out 
and the union found to be firm. On the 11th the 
gauze drain was entirely removed. 
On the 29th of September she was discharged. She 
had gained very much in strength, and felt well in 
every way. An abdominal supporter was applied pre- 
vious to her discharge. 
The tumor which I show was pronounced by I)r. 
Whitney to be an adenoma, though there was some 
doubt a3 to the exact histological character. The 
greater part of the kidney was involved. 
Case IV. Miss Mary M., South Boston, aged 
thirty-three, was kindly referred to me on October 15, 
1892, by Drs. Devine and Cutler. This young wo- 
man, of sedentary occupation, always had been well 
until a year ago. At first she complained of indiges- 
tion and was treated by Dr. Devine for dyspepsia. 
She suffered from a good deal of pain immediately after 
eating and had occasional attacks of vomiting. At 10 
times there was a little blood in the voraitus. She was 
naturally inclined to constipation, and at one time no- 
ticed a small amount of blood in the stools. For the 
last two weeks has been troubled with faiutiug-spells, 
though not subject to them. These were probably 
due to the general weakness from which she was suf- 
fering. The vomiting stopped under liquid diet, al- 
though the nausea remained. Her only occupation 
was housework. Her temperature has been a little 
elevated, generally about 100°. Three days ago she 
had a chill, after which the temperature went up 
to 101°. The pain of late has been in the left lumbar 
region. Examination of the urine was negative, and 
the heart and lungs were normal. For the past year 
has been gradually running down. There was a well- 
marked cachexia; the pulse was rapid, but of fair 
quality. In the left half of the abdomen there was a 
large, smooth tumor, tense and fluctuating, extending 
from the umbilicus into the left lumbar region. In 
front of the tumor the outlines of the ascending colon 
could be made out. A well-marked depression existed 
directly under the umbilicus, evidently corresponding 
to the pelvis of the kidney. The diagnosis was tumor 
of the kidney containing fluid, of doubtful origin, prob- 
ably malignant. The effect of this upon her general 
health was so marked that there was little doubt in 
our minds as to the advisability of an attempt at re- 
moval. 
On Saturday, October 15, 1892, with the assistance 
of Drs. Mumford and llrooks and in the presence of 
Drs. Cutler and Devine, I made the same incision as 
in the previous cases, — a long vertical cut in the linea 
semilunaris. I came down immediately upon the as- 
cending colon, the mesentery of which formed the 
covering of the anterior right half of the tumor. The 
peritoneum and the attachments to the kidney were 
separated by an incision external to the descending 
colon. The tumor was then tapped with a trocar and 11 
a large amount of clear, light-colored fluid was with- 
drawn. Another cyst was found, which was also tap- 
ped. This collapsed the mass so much that it was easily 
delivered through the wound and the pedicle isolated 
and tied. The operation was very rapid and success- 
ful, without any complications or any apparent dangers. 
The ureter was tied and the wound was united by in- 
terrupted silver-wire sutures. There were no unfavor- 
able symptoms whatever following the operation. The 
amount of urine continued about the same as before. 
Dr. Whitney’s report on this specimen is as follows: 
Harvard Medical School, October 21, 1892. 
Dear Doctor: The,kidney removed by you on October 
15, 1892, case of Mary M., measured twenty-five centimetres 
by ten centimetres, was partly sacculated and partly solid. 
The latter portion, which was about a quarter of the 
whole, was normal in appearance and microscopic structure, 
and opened into a small ureter, distinct and separate from 
that into which the sacculated portion emptied. This latter 
part was separated into three large primary sacs with sec- 
ondary partial divisions, all which opened into a common 
pelvis communicating with a small perfectly normal piece 
of ureter. The kidney substance covering these sacs was 
firm, very fibrous, and with but little active renal substance 
in it. The walls of the sacs were smooth and fibrous look- 
ing. Blocking up the pelvis was a large, dark, firm, single 
calculus, which prevented fluid escaping by the ureter, and 
also from passing from one sac to the other freely. 
The case is one of a kidney with a double ureter with 
calculus-formation in one pelvis and subsequent hydro- 
nephrosis of the corresponding part of the kidney. 
Yours very truly, W. F. Whitney. 
There was a double ureter, one branch of which was 
plugged by a large stone, as was seen in the specimen. 
The result of the plugging was an enormous dilatation 
of the pelvis drained by this ureter, and a very extensive 
hydronephrosis. The rest of the kidney drained bv 
the other ureter was normal in appearance. The 
whole specimen was a most unique and beautiful one. 12 
The indications for removal of the kidney are not 
always clear. Benign and locally malignant tumors 
of this organ are most favorable for interference, or 
cases of cancer in the early stages, before the sur- 
rounding parts become infiltrated. For temporary 
benefit a local tuberculosis makes the operation justifi- 
able. Like tuberculosis elsewhere, however, the ulti- 
mate result must be greatly in doubt. 
The removal of a kidney for extensive disease of a 
benign character, like the fourth nephrectomy, witli 
the impaction of a stone, or cases of simple pyelitis, 
non-tubercular, or of pyelitis of a calculous origin — 
for such conditions it seems to me that the indications 
are usually quite clear. At times nephrectomy is 
indicated even in cases of movable kidney. Many 
such cases have been reported, where the operation 
of nephrorrhaphy was not possible. 
The results in the four nephrectomies which 1 have 
reported would seem to indicate that in the absence of 
serious constitutional or local complications the immedi- 
ate mortality is quite small. I am aware, of course, 
that it is impossible to make any general statements 
based upon so small a number of cases, or to draw 
any conclusions as to the prognosis from four cases, 
but I feel very much encouraged in considering the 
indications for nephrectomy by the favorable results 
which have followed the methods which I have used 
in these operations, some of wjiich were certainly very 
hazardous and formidable. 
In the absence of malignant or tubercular disease 
the prognosis is certainly much more favorable, both 
as to immediate and permanent results. 
The method which I have taken to remove the kid- 
ney is one which it seems to me would appeal to an 
anatomist. The most deplorable accidents which have 
occurred in this operation have been caused by haem- 
orrhage. I therefore selected this method of anterior 
incision in the linea semilunaris in order to be where 13 
I could tie without delay the renal branches of the 
abdominal aorta and vena cava. This incision permits 
also the easy exposure of the alfected kidney and a 
clear understanding of its relations; it moreover en- 
ables the operator, by going directly into the peritoneal 
cavity, to ascertain the state of the other kidney or 
other organs where it is important to know their con- 
dition. 
If my experience has been small — and the experi- 
ence of every surgeon thus far certainly must be small 
— in this operation on the living, my experience in 
the removal of kidneys in the dead has been very great. 
I should never seriously think of attempting the re- 
moval of a kidney through the loin. What I have 
seen of this operation in the hands of others convinces 
me that it is a very difficult and a very dangerous pro- 
cedure. In the lumbar operation I believe that the 
hazard from hmmorrhage alone would exceed the im- 
mediate and the remote dangers of the whole operation 
by the anterior route ; it is impossible to deliver a 
kidney satisfactorily without the greatest danger of 
tearing the renal vein ; and again it is very difficult 
indeed to tie the pedicle. It should be borne in mind 
that in quite numerous cases there are several branches 
of the abdominal aorta going to the kidney, instead of 
one. This makes a broad, flat pedicle, which, when 
tied by the lumbar incision, must necessarily be very 
tense. The moment the tumor is cut away from such 
a pedicle the ligatures may become loosened. The 
haunorrhage in such a calamity is fearful, while to find 
and secure the bleeding-vessels is practically impossi- 
ble. I therefore should not consider seriously the 
lumbar operation upon the kidney where any ques- 
tion of its removal is involved. For the operation of 
nephrectomy, the lumbar is the better method. 
By the anterior incision we open at once the perito- 
neal cavity. On the right side we find the ascending 
colon, which may be easily turned one side, and come 14 
down directly upon the kidney. On the left side the 
descending colon passes in front, and at times its 
mesentery is spread over the anterior surface of the 
tumor. Separation is very easy, however, and may be 
accomplished without danger to the large vessels of 
the meso-colon, especially if the kidney is not much 
enlarged. By first separating the attachments of the 
colon ou either side at the outer edge, and pushing 
the whole toward the median line, we avoid all danger 
of injury both to the bowel and its vessels. By this 
route the kidney may easily be isolated and its attach- 
ments secured, the important structures meantime being 
easily accessible in a well-lighted field. 
On separating the kidney, the pedicle should be tied in 
sections, with the greatest care, not using too large silk. 
One disadvantage in the use of silk ligatures sterilized 
with corrosive sublimate is the difficulty of completing 
the knot— of pulling it “ home ’• —on account of fric- 
tion. Having tied the pedicle in sections with small 
silk, and being sure that each knot is firm, it is a 
go.od plan to apply a ligature of larger silk around the 
whole, fastening it with the greatest care. In this 
manner the danger of hsemorrhage is very slight. In 
the tubercular cases I have used gauze packing, and 
where there has been much oozing, the gauze drain. 
Provided the other kidney is healthy, it seems to 
me that this method offers, in the absence of a septic 
element, the very best prognosis. In one case I sewed 
the ureter into the wound ; in all the others, I tied, 
cauterized, and left it. All the cases did equally well, 
and there seems to have been no difference in the re- 
sult by any of these methods; one would, however, 
feel safer having the ureter sewed into the lower 
angle of the wound. In tuberculous and inflam- 
matory cases I believe in packing the whole cavity 
with dry sterile or iodoform gauze. The danger from 
iodoform absorption, however, has made me very cau- 
tious iu the use of this drug, and I generally use dry 15 
sterilized gauze. I prefer, in closing the wound, to 
use silver-wire sutures in this, as in all parts of the 
body. In almost all cases there is no suppuration 
whatever. Sterilization is much more easy and perfect 
than in the use of silk. 
In the preparation of patients for operations on the 
kidney I have not varied from the usual methods 
pursued in private practice, as described in the article 
by Dr. Mumford and myself. In this operation as in 
all others, time is a very important element. None 
of the operations here reported have occupied more 
than thirty minutes. In considering, however, the 
question of time, none of the steps of the operation 
should be taken in haste. In the natural sequence 
of events in the removal of the kidney it seems to me 
that, by allowing plenty of time for them all, not more 
than thirty minutes should be taken. 
In most cases the diagnosis can be made with suffi- 
cient accuracy to decide the question of operative inter- 
ference. A movable tumor of the kidney usually 
presents enough physical evidence in addition to that 
from the history and the urinary examination to base 
a reasonably certain diagnosis upon. The distinction, 
however, between a movable tumor of the kidney and 
a dilated gall bladder is not always easy. The same 
is true of a tumor of the pancreas or spleen. In one 
case I found a dilated gall-bladder containing gall- 
stones where I fully expected to find a diseased kid- 
ney. This being the only case in my experience 
where I have been wrong in placing the disease, I 
think I may safely maintain that it is very seldom 
that there can be a serious doubt as to the location of 
the lesion. 
It is not so easy to make an accurate diagnosis of the 
nature of the lesion itself, nor is it essential generally, 
from the very fact that in many instances an accurate 
idea of the condition is beyond human skill. We need 
to consider only those points which may or may not 16 
justify the risks of an exploration. I venture to repeat 
my views upon this subject in connection with the kid- 
ney, already expressed in remarks upon the gall bladder 
and the vermiform appendix : — that in cases of disease 
of doubtful nature, affecting but one kidney, the pa- 
tient is entitled to the benefit of the doubt, and should 
have, at leasf, the advantage of an exploration. These 
remarks apply to doubtful cases, and not to those often 
seen where the nature of the disease is plain and its 
hopelessness conspicuous. 
Explorations by needles and other devices, notably 
Dr. Mixte'r’s punch, at times give the lacking inform- 
ation, but the method should only be used in cases of 
doubt, and never in such a way as to pass through the 
peritoneum, on account of the occasional presence of 
enormous venous trunks and the danger of hemor- 
rhage into the abdominal cavity, together with the 
liability to peritonitis. A sufficient contraindication 
to exploration lies in the detection of metastases, remote 
or near, or a well-marked cancerous cachexia. A 
wasting of tuberculous origin, however, does not justify 
non-interference. 
At times it is very evident that one kidney only is 
the seat of disease requiring radical relief, but which 
kidney it is cannot be made out. In such cases a 
median incision may be made large enough for digital 
exploration of both kidneys, followed by a second cut 
in the right or left, as the case may be. The best 
plan is to make an incision over one kidney for the 
removal of that one, if diseased, followed by a similar 
cut on the other side if the lesiou is there. By this 
method there is an even chance that the first will be 
the only cut necessary.