[Reprinted from the Transactions of the Philadelphia County Medical Society, 1894.] 
A NEW METHOD OF EXAMINING THE KIDNEY, 
ESPECIALLY FOR STONE. 
By CHARLES P. NOBLE, M.D., 
SURGEON-IN-CHARGE OF THE KENSINGTON HOSPITAL FOR WOMEN, PHILADELPHIA. 
z 
[Read January 24, 1894.] ■ 
I desire to report a short history of the following case, together 
with an exploratory operation which I performed to enable me to 
examine her kidney, including the pelvis of the kidney and perhaps 
one inch of the ureter. 
Mrs. T. S., aged thirty-seven years, mother of three children, enjoyed good 
health until six years ago. Since that time she has been more or less an invalid, 
and for the past six months she has been absolutely an invalid, unable to attend 
to her duties. The prominent points in the history are that she has had three 
well-marked attacks of hsematuria accompanied by violent renal colic (so called), 
and that at least twice she has passed good-sized stones, the last one coming 
from the left kidney. In addition to this history of violent seizures of renal 
colic, she has suffered frequently with milder attacks of paroxysmal pain re- 
ferred to the region of the right groin, the pain being, perhaps, most acute 
just above the right trochanter major. Recently these attacks have been of 
daily occurrence, and have been brought on when she was on her feet. She is 
usually, but not always, comfortable when in bed, but shortly after any attempts 
at walking the pains come on. The sexual organs are normal, with the excep- 
tion of a trifling tear in the perineum. The urine has been examined many 
times and has a very uniform composition. Its specific gravity has varied 
between 1020, 1013, and 1018; it is acid, and contains pus, bladder epi- 
thelium, and ureteral epithelium, but none from the pelvis of the kidney. 
The urine from each kidney has been examined separately, being obtained by 
means of the ureteral catheter. Examined in this way it has been found that 
the urine from each kidney is much the same, the pathological elements it 
contains being somewhat more marked on the right side. This difference, 
however, was distinctly marked with reference to the two sides: the urine 
from the left kidney has always flowed through the ureteral catheter freely and 
regularly ; that from the right kidney has not done so. Upon two occasions 
the ureteral catheter remained in position upward of twenty minutes, and not 
more than one or two drops of urine flowed out. Upon another occasion, after 
waiting thirty minutes with the same result, suddenly one hundred and twenty 
minims poured out. 2 
NOBLE, 
Taking all the facts of the case into consideration the conclusion seemed 
fair that there was a stone in the right ureter, and that probably this was in 
the pelvis of the right kidney. Several attempts were made, both by Dr. 
Howard A. Kelly and myself, to pass a ureteral sound along the ureter toward 
the kidney. It was not possible to make the sound reach above the brim of 
the pelvis. It was therefore proposed that an incision be made in the loin 
for the purpose of examining the kidney and the upper portion of the ureter 
from above. 
My experience in performing nephrorrhaphy for movable kidney after the 
technique of Dr. Edebohls, has taught me the facility with which a movable 
kidney can be drawn out through an incision in the loin. So far as I know, 
no one has ever treated a non-movable kidney in this way. It occurred to me 
that this might be feasible, and that at all events an attempt judiciously made 
could hardly be a source of danger. 
Accordingly on December 12th, I made the usual incision in the loin down 
to and through the peri-renal fat, exposing the lower end of the kidney. With 
the index finger the kidney was then separated from its connective-tissue 
attachments and gradually drawn down into and out through the wound, so 
that it was entirely outside. It was now a very simple matter to explore the 
kidney by thumb-and-finger pressure, and to make certain that it was in a 
normal condition. It was equally easy to examine the pelvis of the kidney 
and to determine that this contained no stone. Perhaps one inch of the ureter 
also was within reach. 
As nothing abnormal could be felt, the kidney was replaced within the abdo- 
men and the incision was sutured in the usual way-buried silkworm-gut 
sutures being placed in the muscular layer, and superficial silkworm-gut 
sutures in the skin. No unfavorable reaction followed this operation, and so 
far as the operation itself was concerned the patient made an uninterrupted 
recovery. Unfortunately the operation has produced no effect whatever on the 
symptoms, which are the same now as before it was done. 
I report the case simply to bring before you this method of examin- 
ing the kidney. From my experience in this case and in cases of 
movable kidney, I believe it will be a simple and safe matter in the 
hands of a skilful surgeon, who has had some experience in kidney 
work, to remove through an incision in the loin all non-suppurating 
kidneys having approximately the normal size, for the purpose of a 
careful examination. The procedure is certainly not one of much 
gravity, and when done under the conditions laid down should have 
no mortality. Tentatively I would recommend the adoption of this 
method of exploring the kidney whenever the symptoms point to the 
presence of stone in the kidney or its pelvis, and when these symp- 
toms are of sufficient gravity to invalid the patient. I feel confident 
that as compared with the ordinary method of exploring the kidney 
through the depths of the incision in the loin, the kidney itself being 
largely or wholly above the level of the ribs, and imperfectly palpated NEW METHOD OF1 EXAMINING THE KIDNEY. 
3 
because of its movability, or examined by means of a puncture with 
an exploring needle, that there can be no question of the superiority 
of the method proposed and herewith reported. 
Upon theoretical grounds this procedure would not be applicable in 
cases of abscess of the kidney. Under these conditions, supposedly 
the kidney would be fixed and not easily separated from its connective- 
tissue bed. Moreover, it would be enlarged, and in addition to this 
there would be the risk of rupturing the pus sac, perhaps inadvertently 
into the peritoneal cavity.