NEPHRECTOMY PERFORMED FOR GUN-SHOT

WOUND.

By J. McF. GASTON, A.M., M.D., ATLANTA.

The history of this operation was considered interesting enough to detail before the nurses of the Presbyterian Hospital the day after the operation. Since the remarks I made then were taken down verbatim, they are given here as the best report of the case I can give. The operation was done March 7, 1905, only twelve hours after he was shot. He was supposed to be in a dying condition, and his testimony was taken in regard to the shot: but he has recovered entirely, the other kidney performing its function perfectly.

Nephrectomy is the removal of the kidney entirely, with ligation of the renal artery and vein. It is an operation that is not indicated except under rare circumstances -very difficult circumstances.

Nephrectomy consists of the delivery of the kidney first, such as we do in floating kidney, and then the ligation of the arteries and veins, the cutting off of the kidney and packing the wound with gauze. That, in brief, is what was done in this case.

There are two incisions, possibly three, that are used. One is the operation transperitoneally, that is the abdominal operation, going in from the front. That I will not deal with particularly, because it was not used here. There are two operations that may be done in the lumbar region. The incision in one case is immediately trans(329)

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versely as to the kidney, and the other rather diagonally across from the tip of the twelfth vertebra or the tip of the floating rib, diagonally on a line, or parallel with the tenth rib.

The kidney, anatomically, is lodged in a space between the vertebral column on the inside and the ribs around it, having also muscular tissue of portions of the diaphragm, psoas, and lumbar quadrate behind, with a space bounding it below and above, which we have to traverse in making the operation. In the ordinary operation for floating kidney, there are very few difficulties. The floating kidney, as it name implies, is already loose in its attachments and movable, dropping down, very often, with other organs, as, for instance, the stomach. But in the case of a healthy man, wounded, as this man was, that is not the case. The kidney was thoroughly embedded, and held. up above the ribs. This man is twenty-two years old. He had been shot about the ninth interspace in the midaxillary line on the evening before I saw him. He was supposed to have been shot in a diagonal direction, the bullet ranging down toward the crest of the ilium. The diagnosis was made from the bloody condition of the urine, and from pain and tenderness in the lumbar region. To ascertain positively the character of it, we removed a portion with the catheter and found it still to be full of blood. This specimen was also examined microscopically by Dr. Ephraim Smith and fresh blood found. In a man suffering from other things, of course, we would have had to exclude disease. But in a man who was healthy and who had been shot, as this man was, there was no other diagnosis that could have been made. It was gun-shot wound of the kidney. The kidney was considered to be wounded, because the bullet was in a direction so as to wound the kidney, and we did not consider

that the ureter could be wounded, or the bladder, because they were not in the line of the wound, and not tender, either, and we considered the diagnosis plain. Therefore Dr. J. H. Green, of Decatur, who was his family physician; Dr. Lucius Orr, also of Decatur now, but then of the Tabernacle Infirmary, Atlanta, who had also been called in, and myself, consulted and determined that it was a case for operation immediately, without any use in waiting to bring him to the city, or any further examination.

We cut down at the incision I have mentioned and found, by palpation with the finger, the wound through the kidney, starting at the external portion, or center, and ending at the hilus. The kidney was so thoroughly embedded and encased that it was very difficult to remove.

The finger could grasp a portion right where the exit of the bullet had been, probably, and so, using that for a start, and pulling it until it was loosened from its attachments, I succeeded, after a great deal of effort, in detaching only half of the kidney. It was so wounded that this portion pulled off, leaving other portion of the kidney still attached. The renal artery and vein were in the first portion and were tied, but the ureter was left loose. There is no danger of a regurgitation of the urine from the bladder into the kidney, and neither was there any danger of regurgitation here of the urine into the open space left where the kidney had been; therefore, we left the ureter for nature to take care of, packing the kidneyspace thoroughly with iodoform-gauze and putting in some stitches of silk in the external wound, simply to hold the iodoform-gauze there in contact with that portion of the wound, this being done when the other half of the kidney had been brought out. The man was put back to bed, in a rather uncertain condition. We did not

feel that the shock had been so very great, but the hemorrhage had been considerable and his condition was very precarious. However, I will say that you must remember that he was in health, not a sick man, and was able to stand more than a sick man could stand. By using bottles filled with hot water around him, he reacted. He spent a comparatively comfortable night, with two hypodermics of morphine, one of which had been given previous to the operation and one after. The next day he was given codeine. The patient had been visited by Dr. Green, Dr. Orr and myself. His temperature reached 100 degrees the day after the operation, and pulse about 100. I hoped for the best in this case, after he had gone over forty-eight hours since the operation, and I will say that this has been one of the few operations in the history of abdominal surgery, as mentioned by Greig Smith, so far as I can find, one of a half dozen operations done for this condition of the kidney. And two of the five I saw reported died. (Ashhurst's Surgery, page 965, extirpa

tion of the kidney-nephrectomy.)

Table of cases of nephrectomy shows that out of 532, eight operations were for injury of kidney, or ureter; two deaths, six recoveries, a percentage of mortality of twenty-five. Two hundred and ninety-nine (299) cases tabulated by John Ashhurst, Jr., had a mortality of 24.4, but he makes no division into wounds, etc.

In eighty-four cases of operations on the kidney and ureter reported by George Emerson Brewer, of New York, one of six emergency operations was a nephrectomy for traumatism, and his experience leads him to believe that all conditions of this kind require operative interference, with exploration of kidney and ureter.

The mortality from nephrectomy is very great. It is done for a great many other things. Among other condi

tions, we have very frequently suppuration going on from the kidney. Then nephrotomy or nephrectomy has been done. The danger from a kidney when wounded is that the blood may come down and clot in the bladder or ureter and cause retention of urine, with blood poison and urinary infiltration. We have therefore a condition which warrants an operation in all these cases, where the diagnosis is plain and where the other organs are not seriously involved. The organs in this case were not involved, so far as we could tell. The intestines had not been seriously injured. Forty-eight hours after the operation an action of his bowels showed an uninjured condition immediately after taking a dose of oil. The kidney on the other side was still acting well, and no blood found. It is altogether possible that some blood may be found after an operation, as the ureter is still open so as to permit it to come from the wound itself, and after the removal of packing there was blood in urine, but not afterwards.

Everything must be taken into consideration in determining upon an operation. For instance, there would be no use in cutting down and removing the kidney if, at the same time, some other organ, such as the pancreas or the stomach, had been seriously wounded, unless it was also repaired. A case of gun-shot wound is of great interest, because there is no telling when a patient may come in in just such a condition as this man was. He was a colored man, but his life was valuable to his own people and to himself; but how much more valuable would have been the life of a McKinley, a Garfield, a Lincoln, or a Stonewall Jackson, under similar circumstances. There are indications, therefore, for thorough operative measures and the most careful nursing. However, in this operation, we could not have a trained nurse. We had him there under unfavorable circumstances. He had his