ABDOMINAL NEPHRECTOMY. Abdominal nephrectomy has been practised with success, but the lumbar method is the more generally accepted operation. The former is now probably limited to some exceptional cases of floating kidney, where there are grounds for believing from the movements of the organ that there is a very complete mesonephron, and to some instances of renal tumor. The method of proceeding usually adopted is that of Laugenbuch," where the abdomen is opened along the outer border of the rectus corresponding with the kidney which is prob ably involved. This plan is adopted by Mr. Knowsley Thornton," who certainly favors the selection of this route. After the opposite kidney and ureter have been examined by passing the hand into the peritoneal cavity, a flat sterilized sponge is introduced to protect the intestines. The kidney is reached by opening the outer layer of the mesocolon, and is then enucleated. The vessels are tied either sepa rately or in a mass, and the ureter is dealt with independently. Mr. Thornton thus describes his method of dealing with the latter: "Its renal end should be secured by pressure-forceps, then a ligature tied a little way from the forceps, and a sponge placed under it before it is divided. Whenever it is possible, I enucleate it for some distance from the kidney before dividing it, so that its cut end, with the sponge under it, may be at once drawn outside the abdomen; and I afterward fix it in the lower angle, or most convenient part of the abdominal incision, with a cleansed safety-pin. I regard this fixing out of the stump of the ureter as the most important detail in the operation, and in every case in which I have been obliged to cut it off deep in the wound, I have had distinct evidence of suppuration and trouble round it." All vessels having been secured and the wound thoroughly cleansed, a Keith's glass drainage-tube may be introduced if there is any doubt as to the asepticity of the operation. Thornton does not consider there is any necessity to suture the edges of the sac from which the kidney has been withdrawn. The abdominal wound is finally closed in the usual way as after ovariotomy. Mr. Thorn
ton also describes a method of removing renal calculi by combining the abdominal and lumbar incisions, exploring the kidneys by the former and then extracting the stone by the latter. The after-treat ment of cases of nephrectomy, whichever route is selected, will be conducted with due regard to antiseptic principles, care being taken to secure the most perfect drainage of the wound. The use of opium is not to be recommended, as instances are recorded where there could be no doubt that even small closes interfered with the excretory action of the remaining organ.
I have endeavored to indicate in somewhat broad terms the condi tions which would seem to determine the selection of the lumbar or the abdominal method. In a doubtful case I have no hesitation in stating that I would prefer the former mainly on the grounds that it is the safer operation. Its technique is, as a rule, not difficult, and the fact that the operator is behind the peritoneum and not within its cavity, as it is called, is a point which in the septic varieties of the conditions demanding the removal of the kidney is of no little impor tance. Then again, as already stated, when the operation is success fully over, no form of wound heals more kindly than these, for the reason that they are so easily drained. Only a few years ago, and not without reason, considerable stress was laid on the fact that by the abdominal method such a calamity in surgery as the removing of a patient's solitary kidney could not possibly occur. The force of this objection has been met by the character of the information that is now indisputably obtalned by electric endoscopy. This instrument is no longer a chimera, and its use will relieve the surgeon of all apprehension when proceeding to perform a nephrectomy that the organ he is about to remove, though seriously and permanently crip pled, should, by reason of the absence of its fellow, be regarded somewhat in the light of an unreliable pensioner whose services he is forced to retain.