The structures divided and their rela tions have already been described under movable kidney. It is generally pos sible to separate the peritoneum from the surface of the kidney and to push it inward. The organ is then freed from its bed and the larger vessels going to the capsule are tied. Dense adhesions are divided by scissors, but in some cases they may cause so much difficulty that it will be easier to enucleate the kidney from its capsule rather than to separate it from the circumrenal fat. After it is freed the organ is luxated from its bed, care being taken not to make much trac tion on the pedicle; the structures at the Hum are isolated, a strong silk ligature is passed about the vessels by an aneu rism-needle and tied; the ureter is sepa rately doubly ligated and tied, and the pedicle divided. If the ureter contains infectious material it may be divided with the thermocautery. After the pedicle has been carefully inspected in the wound and all bleeding points have been secured a large drainage-tube is placed in the bottom of the cavity and the wound is partly closed by deep and superficial sutures.
Abdominal Nephrectomy.—Various in cisions have been used: an oblique in cision directly over the kidney is recom mended by Kocher; an incision through the linea semilunaris is advised by Lan genbuch; that through the outer border of the reetus abdominis is preferred by Greig Smith; or the route through the linea alba may be chosen. An incision in or near the median line will facilitate the exploration of the alternate kidney in ease manual examination seems neces nary, while the removal of an adherent kidney would be easier through the lateral incision. After opening the dominal cavity the kidney is exposed by tearing through the peritoneum forming the outer layer of the mesocolon, as its inner layer contains the vessels which supply the bowel, and their division might give rise to gangrene of the tine. The freeing of the kidney from its bed and the isolation and ligation of the vessels and ureter are then carried out in much the same manner as in lumbar nephrectomy,-.
The mortality of nephrectomy varies with condition of the patient and the pathological condition for which the eration is undertaken. The prognosis in operations for malignant disease, after which nearly 70 per cent. die: The portion of deaths after operations for tuberculosis of the kidney is about 36 per cent.; recent statistics place the mor
tality at about 25 per cent. in case of traumatic lesions; the general primary mortality in all cases of nephrectomy is from 35 per cent. to 40 per cent.
Operations on malignant growths so far done 150 times with mortality of 50 to 66 per cent, before IS90, and 20 to 25 per cent. since. Seventeen cases have lived a year or more after operation. Many died of recurrence at subsequent date. Large mortality due to tardy diag nosis. When palpable tumor only symp tom, early diagnosis difficult or impos sible. When htematinuria and palpable tumor, diagnosis from renal colic diffi cult. Hmnaturia without palpable tu mor, diagnosis made by microscope; urine deposits yellowish-gray granular matter, round or spindle cells. Rovsing (Archiv f. kiln. Chir., B. 49, H. 2, '95).
Operative treatment in malignant tu mors of kidney in childhood, to be suc cessful, should be instituted as early as possible. Operation is followed by an immediate mortality of 38.25 per cent., an ultimate one somewhere between 74.32 and 49.53 per cent.; 5.47 per cent.
of cures; and a lengthening of life by S.08 months. George Walker (Annals of Surg., Nov., '97).
Resection of a Part of the Kidney.— The first partial excision was performed by Czerny in November, 1887, for an angiosarcoma. The operation has been rather rarely resorted to, although there seems to be no doubt that it is a sound surgical procedure and that it is an im portant advance in the conservative sur gery of the kidney to substitute this op eration for total nephrectomy when only a part of the kidney is diseased or has been injured.
Abscess-cavities or easeous tuberculous deposits may be scraped out and packed with iodoform gauze or diseased areas or tumors may be excised and the cut sur faces of the kidney sutured.
Bloch reported a case and gave ab stracts of ten others which he had col lected from French and German litera ture at the meeting of the British Med ical Association in 1896. Morris includes in his tables of his own operations ("The Origin and Progress of Renal Surgery," London, '98) six cases of partial resec tion. In all of the cases reported by these operators recovery followed. Sub sequent nephrectomy was necessary in three cases and renal fistula resulted in one ease.