In selecting a nephrectomy or extirpation of the kidney under such states of disorganization, as, for example, in pyonephrosis com plicated with a calculus, the surgeon will often find the operation one of considerable difficulty. The tissues by long-continuing inflam mation are frequently indurated and matted together. Separation has to be effected with much caution. In some instances the cavity of the peritoneum has been opened by reason of the strong adhesions that have formed between the kidney and this membrane being per forated. Hence the operator, in determining to extirpate the kidney at once, should be fully aware of the obstacles he may encounter. On the other hand, most satisfactory results are sometimes obtained by avoiding the great tax on the patient's strength that is entailed by a long and useless suppuration, however perfect the contrivances for drainage may be. Then again, in selecting between nephrotomy and nephrectomy the possibility of the drainage resulting in a lumbar fistula maintained by the vitality of a small portion of renal gland tis sue must not be overlooked. In a case of pyonephrosis which I opened and drained with a large amount of success and great comfort to the patient, I had eventually to open up the wound and scoop out what remained of renal tissue by reason of the great annoyance a small urinary fistula entailed. The operation, for reasons I have already referred to, was extremely difficult and tedious, but the result was in every way satisfactory. My only regret was that I did not do this at first, when I opened the kidney to relieve the pressing symptoms of purulent dilatation.
I have thought that some collections of matter in the kidney might with advantage be drained through an opening in the perineum, instead of being submitted to other procedures, such as incision from the loin, and even in some instances to nephrectomy. I was first impressed with this belief by observing the relief it was possible to afford to the ureters and kidneys, which were undergoing chronic suppuration as a consequence of tight stricture in the urethra. Cases
of this kind, even complicated by.ulceration of the urethra behind the obstruction and extravasation of urine, have frequently proved so satisfactory to treat, that I felt the principles of treatment which guided us here might with equal advantage be extended to some forms of kidney suppuration. Nor have I been disappointed in those instances where I had reason to think that the last-mentioned condi tion was the cause of the purulent state of the bladder for which the operation of perineal urethrotomy was undertaken. In a paper on this subject 16 I have referred to ten cases of suppurating pyelitis and ureteritis treated with advantage by this method. Had only oue organ been involved, I might perhaps have reached and drained it from the corresponding loin. In one case where I opened the per ineum and drained an extensive suppuration, I found the cause of it was a psoas abscess from caries of the vertebrae which had burst into the kidney. Though large quantities of healthy pus were in this way discharged, the reaction of the urine remained acid throughout, and the patient was spared much pain in voiding this mixture of pus and urine. Dr. Cullingworth " has reported a case of renal abscess caused by a fragment of a carious vertebra ulcerating into the kidney and forming the nucleus of a calculus.
In the after-treatment of operations involving the kidneys care must be taken that the antiseptics used are not too strong. Most of us have seen that condition known as carboluria, where the urine is darkened by the absorption of carbolic acid. Mr. Edmund Owen " relates a case where nephro-lithotoiuy was followed by severe saliva tion after mercuric chloride had been used in the proportion of 1 in 1,000.