A CASE OF LUMBAR NEPHRECTOMY FOR PYO-NEPHROSIS. BY SCHUYLER C. GRAVES, M.D., VISITING SURGEON TO THE U. B. A. HOSPITAL, AND SURGEON TO THE CHILDREN'S HOME, GRAND RAPIDS, MICHIGAN. FROM THE MEDICAL NEWS, November 26, 1892. [Reprinted from The Medical News, November 26, 1892.] 4 CASE OF LUMBAR NEPHR ECTOMY FOR PYONEPHROSIS. By SCHUYLER C. GRAVES, M.D., VISITING SURGEON TO THE U. B. A. HOSPITAL-, AHU AimCpoN TO THE CHILDREN'S HOME, GRAND RAPIDS, MICHIGAN. The patient, Mrs. H. B. K., aged fifty-two years, married, and the mother of six children, fell, when eighteen years of age, from a porch, striking her right side just below the ribs. From that time until recently she has been conscious of trouble in that locality, experiencing dragging sensations in the abdomen, and finding it more and more impossible to lie upon her left side, because of cardiac palpitation, which seemed to be due to her injury, or its results. About three years ago she first noticed a lump in the right side of her abdomen, which was freely movable in all directions. While standing upright the tumor would sink below the level of the umbili- cus, producing painful, dragging sensations; but when the recumbent position was assumed it would slip behind the ribs, and thus lie beyond sight and touch. Whenever the patient, however, would attempt lying upon the left side the tumor would press against the stomach, invariably producing pal- pitation of the heart by reflex impressions conveyed through the fibers of the pneumogastric nerve. Shortly after the discovery of the tumor by the patient a physician in this city, after a careful ex- amination, declared it to be a pedunculated uterine 2 fibroid, adding that when the patient's "change of life" had been passed the tumor might gradually disappear. In April of the current year, the patient was taken to the Homeopathic Hospital in Chicago, where she was examined by Dr. R. Ludlam, of the hospital staff. This surgeon at once pronounced the difficulty to be a floating kidney, and recom- mended an operation for the purpose of anchoring the same. This was consented to, and, early in May, 1892, the operation was done by the said Ludlam. It seems that a man who could do a nephrorrhaphy would recognize disease, and, if necessary, do a ne- phrectomy; and, therefore, it is my opinion that at least active nephritic disease was not present at the time of Ludlam's operation ; but, be that as it may, the woman never recovered from the nephrorrhaphy. She returned to the city, and got up about the house ; but the track of the drainage-tube never healed, leaving a sinus, from which pus constantly trickled. She began to lose in flesh, and her friends suggested further surgical interference, which she always declined until I saw her, September 30th last. During the week just preceding this date her physical deterioration was so marked that she con- sented to a consultation. I met her physician, Dr. A. J. Patterson, at the bedside on the date named, and noticed the following facts : A pale, anemic, emaciated woman, of about fifty years, with a dry, hot skin ; a dry, coated tongue ; pulse 120, and weak, with a temperature of 1030 F. She had been bedridden for about a week, and had experienced a severe rigor the day before my visit. Upon inspection locally, the tumor could be easily made out, elevating, to a decided degree, the abdominal parietes. The lumbar incision, which had been made horizontally, presented several sinuses, from which thick, creamy pus was stream- ing. Bimanual manipulation showed a greatly en- larged viscus, and elicited quite decided fluctuation. The urine voided, though of febrile color and considerably deficient in normal twenty-four hours' quantity (about a quart), was clear and free from albumin, and these features, together with the fact that an operation under such circumstances would be secondary in character, thus affording our patient the unquestioned advantages connected with second- ary operations in stopping exhaustive drains upon vitality, decided me in recommending a nephrec- tomy. Consent having been given, the patient was conveyed to the U. B. A. Hospital, and prepared for the operation, which was done on the following day, October ist. I quote from my note-book as follows : " The patient being under chloroform, the lumbar cicatrix was broken up by the finger and the kidney easily located. It was, as expected, the seat of multilocular disease, some cysts containing serum, some gelatiniform fluid, and others pus; the organ was several times larger than normal. " It was tapped, and the cysts broken up as much as possible by use of the finger; adhesions were detached carefully and the viscus delivered through the wound, which had been extended somewhat beyond the limits of the original incision. A Byford's hysterectomy clamp was placed upon the pedicle and the organ liberated by the scissors. " It was found that, in spite of carefulness, a rent, inches long, had been made through the peri- toneum, showing the colon and the edge of the liver. "The abdominal cavity was thoroughly flushed with hot, boiled water; the rent in peritoneum 3 4 stitched by means of a continuous suture of aseptic catgut, and a counter-opening made in this mem- brane at its lowest point, through which a short glass drain was inserted into the peritoneal sac. The clamp was left in situ, and the greater portion of the lumbar wound closed by deep, interrupted sutures of silk. The drain was held in position by iodoform gauze packing, and antiseptic dressing was applied. "Shock was pronounced, but hypodermatics of strychnine, atropine, and digitalin, together with hot beef-tea by the mouth, brought on reaction, and the physical condition four hours after the operation was quite fair. "On October 4th the patient had rallied from the shock, was in good condition., and the prospects for recovery were excellent. The temperature had not reached 1010 since the operation, and the pulse was full, fairly strong, and remaining in the neigh- borhood of 100. The clamp was removed this after- noon, and the wound washed and repacked with iodoform-gauze. No hemorrhage took place. The patient was in good spirits and was well nourished. The bowels and bladder have moved naturally, the quantity and quality of the urine furnishing a good indication as to the excellent condition of the re- maining kidney. "On October 6th the dressings were changed again. Very little pus was present, and there was no sign of peritonitis. The glass drain, practically dry, was removed, the wound irrigated with a mild mercuric chloride solution, and fresh dressings were applied. " On October 8th the pulse was 80, the tempera- ture 98.6°, and the wound in excellent condition. The appetite was good, and the tongue moist and clean. 5 " On October 18 th quite a bit of slough came away, and on October 21st sloughing continued the entire forenoon. " On October 2 2d the urine was found to be am- moniacal, loaded with crystals of the triple phos- phates, and a slight trace of albumin was present. The patient was put upon benzoic acid, 10 grains ter in die. "The general condition was excellent on Octo- ber 28th, and the patient left the hospital for her home, feeling very well." The -urine, under the benzoic acid, gradually cleared up, and on November 10th the patient is walking about her rooms, rapidly regaining her former state of health. In conclusion, I call attention to three facts of interest in connection with this case: 1st. The presence, in great quantities, of prismatic triple phosphates in the urine about two weeks after the operation-this condition, for some reason or other, being the rule in nephrectomy cases. 2d. The use of a suitable pedicle-clamp in cases manifesting pronounced shock, by means of which sufficient time may be saved to turn the scale in favor of life. 3d. The large hopes of success that may be placed upon operations, secondary in character, when not undertaken with the patient in articulo mortis. The Medical News. Established in 1843. A WEEKL YMEDICAL NEWSPAPER. Subscription, $4.00 per Annum. The American Journal OF THE Medical Sciences. Established in 1820. A MONTHLY MEDICAL MAGAZINE. Sztbscription, $4.00 per Annum. COMMUTATION RATE, $7.50 PER ANNUM. LEA BROTHERS & CO. PHILADELPHIA.