_ PERINEHIEIC ABSCESS in most cases results from the extension of suppura tive processes in the kidney itself, but it may follow operative intervention or in flammatory processes in neighboring or gans. Not seldom it arises from a local infection of the perinephric tissues.
The abscess tends to burrow along the sheaths of muscles and under the fascim of the lumbar region, usually reaching the surface, but sometimes following the sheath of the psoas to the inguinal re gion, or finding its way through the dia phragm or rarely bursting through the peritoneum.
The symptoms are those of deep-seated suppuration in this region, but the con dition is apt to be of particular gravity because of the debilitated condition of the patient from the previous renal sup puration and the highly-poisonous char acter of the mixed pus and urine. The diagnosis may be confirmed by the use of an aspirating needle.
In any of the above conditions the op eration may be indicated. Small cysts are frequently found in granular kid neys, however, which never demand sur gical treatment, and in case pathological changes are far advanced in any of these conditions the operations of resection or nephrectomy may offer the patient the best chance of recovery. Puncture of the kidney and aspiration of the contained fluid is recommended by some surgeons in the treatment of cysts and hydrone phrosis, but, if successful, the procedure has to be frequently repeated in most eases and it very often fails to produce a cure or gives rise to infection.
The indications are more positive when there is suppuration in and around the kidney; incision, evacuation of the pus, and drainage are necessary. When the diseased condition has advanced so far as to call for nephrectomy, but in which the strength of the patient is much ex hausted, incision and drainage is often followed by such gain in strength and improvement of the patient's general condition as will permit of the successful performance of the more serious opera tion at a later date. In tuberculosis of
the kidney, simple nephrotomy with re moval of diseased tissue may be all that is needed; but nephrectomv is often necessary.
Operation. — Before all operations of probable gravity examination of the urine is advisable, and if possible the condition of the other kidney should be determined. In order to lessen the dan ger of infection from the micro-organ isms which are commonly found, even in healthy kidneys, Kocher ("Chirurgische Operationslehre," dritte Auflage, p. 160, '9i) recommends the administration of 3 grammes (-15 grains) of salol a day for several days before the operation.
The usual incision for exposing the kidney (described above) is generally the best. In cases of great enlargement, however, it may be more convenient to make the opening farther forward. In operating for cysts or for hydronephrosis the tissues may be found normal, with the exception of a thinning of the peri nephric fat; but in suppurative processes the skin, muscles, and fasciae are likely to be found vascular and oedematous, and the perinephric fat dense and adherent. A sufficient surface is usually denuded to permit of its being brought to or near the level of the skin, where it is sutured after being opened. Any curdy or stringy material which may be found within abscesses should be curetted away and if there are septa between abscesses they should be broken down. After thor ough disinfection of the wound a thick drainage-tube is inserted, the wound is partly closed, and a heavy absorbent dressing applied.
Simple cysts often close primarily, the cavity of an hvdatid cyst usually closes after suppuration, and there are a good proportion of cures following nephrot omy for abscess. After operations for hydronephrosis, fistulm are often left that will not close without a plastic operation or, in some cases, nephrectomy. Resec tion or neplireetomy is frequently called for after nephrotomv for tubercular kid ney.