RENAL FISTULE are of two kinds, namely, those opening externally as in the loin, and those communicating with internal viscera such as the intestines. They are usually caused by wounds involving the kidney, such as stab-wounds or gunshot injuries, as well as by incisions in the course of surgical procedures for the opening of abscesses and the removal of renal calculi. Less frequently they have followed upon suppurations within the pelvis and cortex of the kidney. In some instances they appear to have served the purpose of providing a spontaneous means of escape for calculi and, where the ureter has been permanently obstructed, of furnishing a vent for the urine. Though externally they are most frequently found in the loin, they have occasionally opened as low down as the groin. Their urinous character is at once obvious, though the discharge, especially where their origin is of a tuberculous nature, is usually more or less mixed with pus.
Where the sinuses have opened into internal organs some remark able symptoms have been the result. Morris' refers to a well authen ticated case where a woman after an attack of renal colic and reten tion of urine vomited coffee-colored gravel and passed small stones by the mouth, rectum, and urethra. This is stated to have been an instance where a fistula connected the kidney with the stomach. Some supposed examples of internal lesions of this nature, however, have turned out to be impositions, and therefore the practitioner must be on his guard before accepting such a conclusion. Morris records a case where an autopsy showed a renal fistula communicating with the left end of the great curvature of the stomach. The same author refers to some instances of fistulae opening into the intestines as well as the lung. The former condition will probably explain some of those instances where air is voided with the urine by the urethra.
The treatment of a renal fistula is entirely dependent upon the cir cumstances surrounding it. Those following a simple incision or wound uncomplicated with any serious structural disease of the organ usually close with treatment such as is appropriate to all sinuses re sulting from the imperfect healing of a deep opening of this nature. The application of well-recognized surgical principles almost invaria bly suffices. Failures after a sufficient trial are suggestive that 'a more serious condition of the kidney than was expected may exist. An exploration and, if not more is found necessary, a curetting of the sinus may in a chronic case be required. Some cases of renal fistulae fail to heal because the corresponding ureter is either partially or completely obstructed.
I have recently seen a case of this kind in which a renal abscess followed upon an injury to the loin, and for some years the patient has passed a considerable quantity of his urine through the sinus. He
collects it by means of an apparatus which causes him but little in convenience. That he has no prospect of getting rid of his inconven ience without extirpation of the kidney I have not the least doubt, as examination of his bladder by the electric cystoscope clearly shows that the ureter is obstructed. With this instrument the pumping action of one ureter can be plainly demonstrated, while in the other it is absent. As the patient's health is excellent and the urine is normal and the question of convenience is not advanced, I should not consider the extirpation of the involved kidney justifiable.
Cases of this nature—and there are not a few of them—seem to have an important bearing upon the treatment of the most serious forms of deformity of the bladder. Reference will be found to this aspect of the subject in my article on diseases of this organ. The im portance of the electric cystoscope in enabling us to determine as to whether a patient has one or two working kidneys will now, I think, be generally acknowledged.
Passing to other instances of renal fistula illustrations will be met with where there can be no doubt, from evidence afforded partly by the local condition and partly by the state of the general health, that the kidney with which they are connected is to all intents and pur poses a foreign body. Like a joint or a limb it may have passed into a pathological condition which renders its retention eventually as a part of a healthy or a living body absolutely impossible. Under such circumstances nephrectomy after exploration must be proceeded with as in the analogous illustrations I have taken, where the removal of diseased parts becomes obvious. A similar course of action will be called for in those instances where the evidence is sufficient to show that a renal fistula is the cause of some progressive disease in an ad jacent internal organ.
An exploratory operation or nephrotomy should, as a rule, be se lected before adopting the more radical procedure, as, if found neces sary, the latter may follow upon the former without adding to the diffi culties or risks connected with it. It is under such circumstances that the great value of the lumbar method as against the abdominal becomes apparent. Many instances of fistula dependent upon .calculi, suppurations, hydatids, and the like have been completely remedied by a sufficient incision for a digital exploration of the part. Unfortu nately I cannot put my finger on the record, but I have a distinct recollection of reading a well-narrated case where a pin or needle covered with phosphates was successfully removed from a kidney through the loin and proved to be the cause of a fistula, hmnaturia, and purulent urine.