Statistics of 2100 kidney operations. Of this number 1118 were nephreetomies which have been reported since the first deliberate excision of a kidney in 1869; 399 of the patients were males, and 676 females, while in the remaining 34 the sex was not specified; S17 patients re covered and 301 died, giving an average mortality of 26.9 per cent. During the first ten years after the operation was introduced nephrectomy was performed on 81 patients, with a mortality of 50.6 per cent.: during the following decade on 4S3 patients, with a mortality of 34 per cent.; but during the past decade 554 operations gave a mortality of only 17.4 per cent. The mortality of nephree tomy has been reduced from 55 per cent. during the first decade to 19.4 per cent. during the past decade by the abdominal route: and from 43.9 to 17 per cent. by the lumbar route. The mortality statis tics of nephrectomy at the present time, therefore, compare very favorably with those of other major operations. A still further reduction in the mortality rate may be expected by earlier operation, more exact methods of diagnosis, and by a proper appreciation of the factors which may cause death.
The death of 91 patients from shock and collapse after operation suggests that every effort should be made to shorten the period of narcosis, to pre vent unnecessary hemorrhage, and to support the patient by artificial stimu lation. A second source of great danger is disease of the opposite kidney, which caused death in 50 of the above cases, and which may Ilriscl in either one of ways: The opposite kidney may be I lie seat of disease before the operation. This can generally be determined by the usual methods of diagnosis, but if any doubt arise the kidney should lie ex amined by a lumbar incision before its fellow is extirpated. The danger of nephritis developing after nephrectomy can be diminished by abstaining from the use of poisonous disinfectants dur ing the operation and by protecting the patient from the conditions which are known to NIIItie. nephritis. Peritonitis was the cause of death in 30 eases ; 27 of these occurred after operation by 1 abdominal route, and were probably due not to an infection at the time of opera tion, but to the development of an ab scess behind the reunited layer of the posterior parietal peritoneum. This cause of death could have been avoided by making a counter-incision for drain age in the loin of all the cases operated upon by the abdominal route. In 28 cases intercurrent diseases, chiefly pul monary complications, were the cause of death. Sepsis caused death in 15 cases; primary or secondary hemor rhage in S; absence or congenital atrophy of the opposite kidney, 7; acute miliary tuberculosis, 13; and exhaus tion, long-continued suppuration, or amyloid disease in 13 cases. Two pa
tients died during operation, and in the remaining 33 the cause of death was not known.
The extremes of life do not afford a contra - indication to nephrectomy, if good reasons for the operation are pres ent. During the past thirty years 175 children ender fifteen years of age have been operated upon chiefly by the ab dominal route, with a mortality of only 28.6 per cent., being only 1.7 per cent. higher than for adults during the seine period. The mortality for 2S operations on patients over sixty years of age was 39.3 per cent. Selimieden (Deutsche Zeits. fiir Chin, Jan., 1902).
Nephrectomy.
Removal of the kidney may be indi cated in cases of renal tumor; severe in juries accompanied by serious Immor rhage, suppuration, or infiltration of urine; renal or ureteral fistulae; diseased movable kidney; tuberculosis of the kid ney, hydronephrosis, calculus, cysts, and suppurative processes in which resection seems unlikely to relieve or cure.
—But few well authen ticated cases are on record in which this operation was undertaken for injuries of the kidney. Nasse (Berl. klin. Woch., Aug. 22, 'PG) was only able to find nine cases with seven recoveries. While a suc cessful result may follow without inter vention, operation has no doubt often been delayed until too late. Severe hTm orrhage—as evidenced by bloody urine, acute antenna, and the physical signs of fluid in the abdominal cavity—is an in dication for immediate exploratory op eration. The same is true in the event of severe secondary hTmorrhage, which sometimes occurs as the result of the rupture of a traumatic aneurism. It is often difficult to decide what to do if the bleeding is less copious, but in any case operation should not be deferred until the patient is too weak and anaemic. In the less severe cases the lumbar in cision will answer; in graver injuries the extraperitoneal incision from the tip of the twelfth rib to the junction of the middle and outer thirds of Poupart's ligament will give more room and seems more generally applicable; ceeliotomy is called for in case there are signs of haem orrhage into the abdominal cavity. The ligation of vessels and suturing or the use of the tampon followed by suture may be sufficient in less severe injuries, but nephrectomy is indicated in case a main branch of the renal artery is injured or if there is very extensive laceration and contusion of the renal substance.