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Large Solitary Abscess of the Kidney1
LARGE SOLITARY ABSCESS OF THE KIDNEY1 HOWARD S. JECK From the Urological Service of Bellevue Hospital, New York City
By solitary abscess of the kidney is meant an abscess which lies wholly within the renal parenchyma and communicates neither with the renal pelvis nor the perinephric space. According to the literature of the past 20 years, large solitary abscess of the renal parenchyma is not often seen and less often recognized preoperatively. However, there have been reported a comparatively large number of multiple cortical abscesses of the kidney, perinephric abscesses and kidney carbuncles2-similar lesions having in all probability etiological factors identical with those of the solitary abscess. It was thought worth while to report the following 2 cases of solitary kidney abscess not only because very few have apparently been recognized preoperatively but also because the second case presents a rather interesting pyelographic demonstration of the seeming rapidity with which a diseased kidney may resolve following operation. Case 1. A man, 22 years of age, entered the Bellevue Urological Service, on January 15, 1938. He complained chiefly of pain in the left loin, chills, fever and loss of strength. Three months before admission, the patient had had some type of infection of his left hand. Three weeks before admission he noticed a discomfort in his left side. Physical examination disclosed fairly marked tenderness in the left costovertebral region and slight tenderness anterior to the left kidney. Palpation in the right loin disclosed no abnormalities. The urine was grossly clear and was negative for albumin, sugar and pus cells. His temperature on admission was 100.3F. degrees and this gradually increased to 101.2 degrees the day of his operation. Intravenous urograms made on the day of admission indicated an incomplete filling of the left kidney pelvis and fixation of the left kidney. one of the radiographs the edge of the psoas muscle was fairly distinct for a distance of about 8 cm. in its upper portion. The right urogram indicated a normal kidney on that side. Two days after admission a white blood count showed 15,800 cells with 83 per cent polymorphonuclear cells.
In
1 Read before annual meeting, American Association of Genito-Urinary Surgeons, Absecon, N. J., May 2, 1938. 2 Graves and Parkins, in their excellent article entitled "Carbuncle of the Kidney," brought the number of reported kidney carbuncles up to 67, including 1 of their own. They also cite 15 additional cases which were reported between the writing of their article and its publication in the latter part of 1935, tlms making the total number 82 at that time. 28
LARGE SOLITARY ABSCESS OF KIDNEY
29
A tentative diagnosis of perinephric abscess was made, and, because the patient appeared to be quite sick and his temperature was increasing, it was thought best to explore the left renal region without further delay. This was done by means of the usual oblique kidney incision below and parallel to the last rib. The operator found the perirenal tissues (retrorenal fascia and perinephric fat) to be thickened and pale. No free pus was found anywhere. However, in exposing the kidney proper, and it was not until the fatty capsule of the kidney had been completely removed that an area of fluctuation was detected about the mid-portion of the posterior curvature of the kidney (fig.1). This fluctuating area was opened and about 2 ounces of heavy pus was evacuated. Material was taken for a culture. Drains were inserted and the wound was closed in layers. The patient's temperature became normal the ninth postoperative day and remained so until his discharge from the hospital about one month after the operation. Before leaving the hospital both ureters were catheterized and, according to the urea and indigo-carmine tests, the functioning capacities of the two kidneys were about equal. Both ureteral specimens were grossly clear. The patient made an uneventful recovery and 3 weeks after the operation both kidneys functioned well and about equally. Case 2. A young woman, 27 years old, was admitted to one of the medical services of Bellevue Hospital on November 25, 1937, with the chief complaints of pain in the left side, chills and fever. She had had chills and fever 1 week before entering the hospital. At one time her temperature had reached 104, but on admission to the hospital it was only 101.2. She also complained of pain in the left lower quadrant which alternated with similar but less marked pain in the right quadrant. There were no noteworthy urinary symptoms. No history of a recent pre-existing skin lesion was obtained. A diagnosis of subsiding grippe was made, but 2 weeks after admission it was noted that she had exquisite tenderness in the left costo-vertebral angle and a urologic consultation was requested. Repeated urinalyses of the non-catheterized bladder specimen showed only a few white blood cells; some showed the urine to be normal. When seen by members of the Urological Staff on December 13, 1937, the patient was exceedingly pale and very thin. She had lost agood deal of weight. She had marked tenderness in the left costovertebral angle and, while no mass could be felt, there was a definite sense of fullness in the left loin. There was no tenderness in the right loin, but the lower pole of the right kidney could be felt. An intravenous urogram suggested marked compression of the left kidney pelvis, and catheterization of the left ureter and retrograde urograms were advised. It was felt that the patient was too sick to prolong the cystoscopy by a similar examination of the right kidney, which had given rise to no symptoms.
30
HOWARD S. JECK
On cystoscopy the bladder and ureteral orifices appeared to be normal. Indigo-carmine, injected intravenously, appeared promptly and in quite deep concentration from both ureters. The left ureter was readily catheterized, a specimen of urine was collected and a retrograde urogram made. The urine specimen, thus obtained, showed only 2 to 4 white blood cells per,high power field. The retrograde pyelogram was similar to the intravenous pyelogram in the chief essentials and definitely suggested marked compression of the renal pelvis (fig. 2) . Blood studies : red blood cells, 2,690,000; hemoglobin, 53 per cent; white blood cells, 17,600; polymorphonuclear cells, 84 per cent. The temperature was 104 and was of the spiking type. Because of the septic type of temperature, the kidney tenderness, the pyelogram indicating compression, the blood count and the absence of an appreciable amount of pus
S 01,.1TARY ABSC"'-SS
FIG. 1. Case 1. Approximate position and comparative size of abscess
in the urine, a diagnosis of carbuncle of the kidney was made and immediate operation advised. On December 14, through an oblique loin incision, the kidney was exposed. The perinephric fat was very pale. The kidney itself was also very pale and appeared to be somewhat enlarged and quite firm. In the upper half of the kidney on the posterior surface, well up under the ribs, was felt a fluctuating area about the size of a half dollar, and while attempting to separate the upper pole, a finger was accidentally passed into this area, immediately releasing quite a large quantity of yellowish, fairly liquid pus. The cavity, whence the pus came, was then explored digitally and apparently did not communicate at all with the kidney pelvis. As far as could be estimated, the cavity had contained 3 to 4 ounces of pus and its walls were smooth. A large rubber tube drain was led to the opening in the upper pole, a couple of large cigarette drains were placed about the kidney and the wound was closed in layers. With the assistance of a blood transfusion, the patient began to improve rapidly and made an uneventful recovery.
L\RCE SOLITARY ABSCF~SS OF KIDNEY
31
A blood culture u( the pus obtained at !he time of operation showed
lococcus aureus. nme postoperative was 30. An intravenous urogram made 3 weeks after the operation indicated a. normal left renal (fig. 3). The non-protein
Notable among the cases of solitary abscess reported arc those of Hunt (1 Judd and Brown (1 Beer (1936) and Flanclrin (1936).
Frc. 2 FrG 3 FIG. 2. Case 2. Left pyelogram sho1Ying marked compression of renal pelvis Frc. 3. Case 2. Left pyelogram (3 weeks after operation) showing apparently norm,tl renal pelvis.
Beer points out the fact that in the pyelogram, 2 of the calices may be more widely separated than usual. In Judd and Brown's case, the pyelogram appeared to be normal, but on close inspection the curve made by the upper ureter and lower border of the pelvis was unusually rounded due to pressure from the large abscess in the lower pole of the kidney. The abscess contained 75 cc of thick, yellow, odorless pus, a culture of which revealed Streptococcus hcrnolyticus and staphylococci. The pyelogram in Flandrin's case was also normal except that the upper
32
HOWARD S. JECK
calyx was pushed somewhat outwards by the large abscess in the upper pole of the kidney. The author did not approximate the size of the abscess but merely referred to the pus released as large in amount, odorless and of greenish color. An examination of the pus showed a pure culture of Staphylococcus aureus. Etiology and pathology. In most of the reported cases where cultures were made from the pus evacuated from the abscess cavity, Staphylococcus aureus was found in pure culture. In a few instances, however, other organisms were found along with the staphylococcus. In many of the cases reported the patients gave a history of some preexisting lesion such as a boil or other type of staphylococcic skin infection. As one would expect, the incidence of such pre-existing infections is seemingly about the same as it is in multiple cortical abscesses, perinephric abscesses and carbuncles of the kidney. Hunt believes that the large solitary abscess may be the result of extensive coalescence of small embolic abscesses. This may be the same view, expressed differently, of other authors who claim that the large solitary abscess is due to the breaking down of the renal carbuncle. Smirnow, however, opposes this theory by stating that kidney carbuncles have no tendency towards suppurative fusion. But whether the large solitary abscess is the result of coalescence of smaller abscesses or breaking down of a carbuncle, or perhaps merely the gradual enlargement of a solitary abscess which begins as a very small one, there can be little doubt that the kidney infection is secondary to another focus of infection, usually a skin infection, wherein coccic emboli or masses of bacteria (cocci) are borne to the kidney by the blood stream and are deposited in the small terminal renal arteries. The diagnosis of any suppurative parenchymal lesion (not communicating with the kidney pelvis) or any perinephric suppurative lesion is frequently difficult. The large solitary kidney abscess is no exception to this rule. A history of boils, carbuncles, paronychia, acute osteomyelitis, infected teeth, tonsils or other similar foci of infection, is of the utmost importance in establishing a diagnosis when other signs point to the kidney. In all types of such infections one usually finds chills followed by the spiking type of increased temperature, pain in the loin of the affected side, more or less tenderness about the infected kidney, a moderately high leukocyte count, a low red cell count with a low hemoglobin percentage and finally rather marked loss in weight.
LARGE SOLITARY ABSCESS OF KIDNEY
33
The urinary findings are often negative and therefore frequently misleading. The urine may contain a few white blood cells or staphylococci or both, but at times does not contain either. However, it should be remembered that the suppurative lesions under consideration do not communicate with the kidney pelvis. Thus, a negative ureteral specimen of urine, considered in connection with the history of a pre-existing skin lesion together with the signs and symptoms indicating renal involvement, should at least arouse one's suspicion as to the true state of affairs rather than confuse the picture. Frequently, in a fresh specimen of urine, staphylococci may be satisfactorily demonstrated by the centrifugal and smear method. In many instances, kidney functional tests show little or no difference between the functioning capacity of the 2 kidneys. Hence, diagnostic help from this source cannot always be obtained. Of considerable aid, however, is the pyelogram. This is especially true in large solitary abscess where the kidney pelvis may be encroached upon by the inflammatory lesion. As mentioned in the foregoing, one looks chiefly for pressure signs such as compression of the pelvis, unusual separation of the calices or displacement of a single calix. The same pyelographic changes may be present in a carbuncle of the kidney, especially if the carbuncle is a large one. But in carbuncle, filling defects of the pelvis seem to be more common, and in many carbuncles there are no significant changes in the pyelogram at all. Also in the differential diagnosis, one must frequently consider perinephric abscess. In this condition the symptoms are likely to be less pronounced and there may be no tenderness in the loin whatsoever. The fl.at radiograph usually shows a curvature of the spinal column (concavity towards the affected side), absence of the psoas muscle shadow on the affected side and fixation of the kidney. The pyelogram nearly always indicates a normal condition. Treatment. The treatment of large solitary kidney abscess is incision and drainage. On exposure of the kidney in suspected abscess, if the abscess is not at once apparent, decapsulation of the kidneys should be performed, for, as Beer has pointed out, a solitary abscess or multiple abscesses may not be discovered until the true capsule of the kidney is removed. SUMMARY
Large solitary abscess of the kidney is comparatively rare and is not often diagnosed pre-operatively.
34
HOWARD S. JECK
Attention is called to a few of the outstanding cases which have been reported. Two cases of the writer are reported in detail. In one of these the pre- and postoperative pyelograms are interesting and significant. The similarity, clinically, of this condition to multiple cortical abscesses, perinephric absc,ess and carbuncle of the kidney is pointed out. The treatment of solitary abscess of the kidney is incision and drainage. 745 Fifth Ave., New York City. REFERENCES AsCHNER, P. W. : Staphylococcus infection of renal parenchyma. Am. Jour. Med. Sci. 172: 63, 1926. BEER, EDWIN: Coccic infections of renal cortex. J. A. M. A. 106: 1063, 1936. BRADY, L . J.: Carbuncle of the kidney (metastatic staphylococcus abscess of the kidney cortex). J. Urol. 27: 295, 1932. DrcK, B. M.: Staphylococcal suppurative nephritis (carbuncle of kidney). Brit. Jour. Surg., 16: 106, 1928. FLANDRIN, M . P.: Un cas de volumineux abces du rein a staphyloccoques gueri par incision et drainage. Bull. de la soc. Fran~aise d'urol., pp. 175- 184 (April) 1936. GRAVES, R . C., AND PARKINS, L.: Carbuncle of the kidney. Trans. Am. Assn. Genito-Urinary Surgeons, 28: 41, 1935. HUNT, V. C.: Cortical abscess of kidney. Southwestern Med. 13: 166, 1929. JUDD, E. S., AND BROWN, C. B.: Cortical abscess of kidney. Surg. Clinics of North America 9: 801, 1929. KRETSCHMER, H. L .: Carbuncle of the kidney. J. Urol. 8: 137, 1922. NEFF, J. H.: Enucleable multilocular abscess (carbuncle) of the kidney. Trans. Am. Assn. Genito-Urinary Surgeons, 23: 27, 1930. O'CoNOR, V. J.: Carbuncle of the kidney. Trans. Am. Assn. Genito-Urinary Surgeons, 26: 17, 1932. RESCHKE, K.: Ueber Paranephritis Und Nierenkarbunkel. Arch. f. klin, Chir. 129: 303, 1924. SMIRNow, A. W.; Ueber Nierenkarbunkel. Ztschr. f. urol. Chir. 20: 243, 1926.
By solitary abscess of the kidney is meant an abscess which lies wholly within the renal parenchyma and communicates neither with the renal pelvis nor the perinephric space. According to the literature of the past 20 years, large solitary abscess of the renal parenchyma is not often seen and less often recognized preoperatively. However, there have been reported a comparatively large number of multiple cortical abscesses of the kidney, perinephric abscesses and kidney carbuncles2-similar lesions having in all probability etiological factors identical with those of the solitary abscess. It was thought worth while to report the following 2 cases of solitary kidney abscess not only because very few have apparently been recognized preoperatively but also because the second case presents a rather interesting pyelographic demonstration of the seeming rapidity with which a diseased kidney may resolve following operation. Case 1. A man, 22 years of age, entered the Bellevue Urological Service, on January 15, 1938. He complained chiefly of pain in the left loin, chills, fever and loss of strength. Three months before admission, the patient had had some type of infection of his left hand. Three weeks before admission he noticed a discomfort in his left side. Physical examination disclosed fairly marked tenderness in the left costovertebral region and slight tenderness anterior to the left kidney. Palpation in the right loin disclosed no abnormalities. The urine was grossly clear and was negative for albumin, sugar and pus cells. His temperature on admission was 100.3F. degrees and this gradually increased to 101.2 degrees the day of his operation. Intravenous urograms made on the day of admission indicated an incomplete filling of the left kidney pelvis and fixation of the left kidney. one of the radiographs the edge of the psoas muscle was fairly distinct for a distance of about 8 cm. in its upper portion. The right urogram indicated a normal kidney on that side. Two days after admission a white blood count showed 15,800 cells with 83 per cent polymorphonuclear cells.
In
1 Read before annual meeting, American Association of Genito-Urinary Surgeons, Absecon, N. J., May 2, 1938. 2 Graves and Parkins, in their excellent article entitled "Carbuncle of the Kidney," brought the number of reported kidney carbuncles up to 67, including 1 of their own. They also cite 15 additional cases which were reported between the writing of their article and its publication in the latter part of 1935, tlms making the total number 82 at that time. 28
LARGE SOLITARY ABSCESS OF KIDNEY
29
A tentative diagnosis of perinephric abscess was made, and, because the patient appeared to be quite sick and his temperature was increasing, it was thought best to explore the left renal region without further delay. This was done by means of the usual oblique kidney incision below and parallel to the last rib. The operator found the perirenal tissues (retrorenal fascia and perinephric fat) to be thickened and pale. No free pus was found anywhere. However, in exposing the kidney proper, and it was not until the fatty capsule of the kidney had been completely removed that an area of fluctuation was detected about the mid-portion of the posterior curvature of the kidney (fig.1). This fluctuating area was opened and about 2 ounces of heavy pus was evacuated. Material was taken for a culture. Drains were inserted and the wound was closed in layers. The patient's temperature became normal the ninth postoperative day and remained so until his discharge from the hospital about one month after the operation. Before leaving the hospital both ureters were catheterized and, according to the urea and indigo-carmine tests, the functioning capacities of the two kidneys were about equal. Both ureteral specimens were grossly clear. The patient made an uneventful recovery and 3 weeks after the operation both kidneys functioned well and about equally. Case 2. A young woman, 27 years old, was admitted to one of the medical services of Bellevue Hospital on November 25, 1937, with the chief complaints of pain in the left side, chills and fever. She had had chills and fever 1 week before entering the hospital. At one time her temperature had reached 104, but on admission to the hospital it was only 101.2. She also complained of pain in the left lower quadrant which alternated with similar but less marked pain in the right quadrant. There were no noteworthy urinary symptoms. No history of a recent pre-existing skin lesion was obtained. A diagnosis of subsiding grippe was made, but 2 weeks after admission it was noted that she had exquisite tenderness in the left costo-vertebral angle and a urologic consultation was requested. Repeated urinalyses of the non-catheterized bladder specimen showed only a few white blood cells; some showed the urine to be normal. When seen by members of the Urological Staff on December 13, 1937, the patient was exceedingly pale and very thin. She had lost agood deal of weight. She had marked tenderness in the left costovertebral angle and, while no mass could be felt, there was a definite sense of fullness in the left loin. There was no tenderness in the right loin, but the lower pole of the right kidney could be felt. An intravenous urogram suggested marked compression of the left kidney pelvis, and catheterization of the left ureter and retrograde urograms were advised. It was felt that the patient was too sick to prolong the cystoscopy by a similar examination of the right kidney, which had given rise to no symptoms.
30
HOWARD S. JECK
On cystoscopy the bladder and ureteral orifices appeared to be normal. Indigo-carmine, injected intravenously, appeared promptly and in quite deep concentration from both ureters. The left ureter was readily catheterized, a specimen of urine was collected and a retrograde urogram made. The urine specimen, thus obtained, showed only 2 to 4 white blood cells per,high power field. The retrograde pyelogram was similar to the intravenous pyelogram in the chief essentials and definitely suggested marked compression of the renal pelvis (fig. 2) . Blood studies : red blood cells, 2,690,000; hemoglobin, 53 per cent; white blood cells, 17,600; polymorphonuclear cells, 84 per cent. The temperature was 104 and was of the spiking type. Because of the septic type of temperature, the kidney tenderness, the pyelogram indicating compression, the blood count and the absence of an appreciable amount of pus
S 01,.1TARY ABSC"'-SS
FIG. 1. Case 1. Approximate position and comparative size of abscess
in the urine, a diagnosis of carbuncle of the kidney was made and immediate operation advised. On December 14, through an oblique loin incision, the kidney was exposed. The perinephric fat was very pale. The kidney itself was also very pale and appeared to be somewhat enlarged and quite firm. In the upper half of the kidney on the posterior surface, well up under the ribs, was felt a fluctuating area about the size of a half dollar, and while attempting to separate the upper pole, a finger was accidentally passed into this area, immediately releasing quite a large quantity of yellowish, fairly liquid pus. The cavity, whence the pus came, was then explored digitally and apparently did not communicate at all with the kidney pelvis. As far as could be estimated, the cavity had contained 3 to 4 ounces of pus and its walls were smooth. A large rubber tube drain was led to the opening in the upper pole, a couple of large cigarette drains were placed about the kidney and the wound was closed in layers. With the assistance of a blood transfusion, the patient began to improve rapidly and made an uneventful recovery.
L\RCE SOLITARY ABSCF~SS OF KIDNEY
31
A blood culture u( the pus obtained at !he time of operation showed
lococcus aureus. nme postoperative was 30. An intravenous urogram made 3 weeks after the operation indicated a. normal left renal (fig. 3). The non-protein
Notable among the cases of solitary abscess reported arc those of Hunt (1 Judd and Brown (1 Beer (1936) and Flanclrin (1936).
Frc. 2 FrG 3 FIG. 2. Case 2. Left pyelogram sho1Ying marked compression of renal pelvis Frc. 3. Case 2. Left pyelogram (3 weeks after operation) showing apparently norm,tl renal pelvis.
Beer points out the fact that in the pyelogram, 2 of the calices may be more widely separated than usual. In Judd and Brown's case, the pyelogram appeared to be normal, but on close inspection the curve made by the upper ureter and lower border of the pelvis was unusually rounded due to pressure from the large abscess in the lower pole of the kidney. The abscess contained 75 cc of thick, yellow, odorless pus, a culture of which revealed Streptococcus hcrnolyticus and staphylococci. The pyelogram in Flandrin's case was also normal except that the upper
32
HOWARD S. JECK
calyx was pushed somewhat outwards by the large abscess in the upper pole of the kidney. The author did not approximate the size of the abscess but merely referred to the pus released as large in amount, odorless and of greenish color. An examination of the pus showed a pure culture of Staphylococcus aureus. Etiology and pathology. In most of the reported cases where cultures were made from the pus evacuated from the abscess cavity, Staphylococcus aureus was found in pure culture. In a few instances, however, other organisms were found along with the staphylococcus. In many of the cases reported the patients gave a history of some preexisting lesion such as a boil or other type of staphylococcic skin infection. As one would expect, the incidence of such pre-existing infections is seemingly about the same as it is in multiple cortical abscesses, perinephric abscesses and carbuncles of the kidney. Hunt believes that the large solitary abscess may be the result of extensive coalescence of small embolic abscesses. This may be the same view, expressed differently, of other authors who claim that the large solitary abscess is due to the breaking down of the renal carbuncle. Smirnow, however, opposes this theory by stating that kidney carbuncles have no tendency towards suppurative fusion. But whether the large solitary abscess is the result of coalescence of smaller abscesses or breaking down of a carbuncle, or perhaps merely the gradual enlargement of a solitary abscess which begins as a very small one, there can be little doubt that the kidney infection is secondary to another focus of infection, usually a skin infection, wherein coccic emboli or masses of bacteria (cocci) are borne to the kidney by the blood stream and are deposited in the small terminal renal arteries. The diagnosis of any suppurative parenchymal lesion (not communicating with the kidney pelvis) or any perinephric suppurative lesion is frequently difficult. The large solitary kidney abscess is no exception to this rule. A history of boils, carbuncles, paronychia, acute osteomyelitis, infected teeth, tonsils or other similar foci of infection, is of the utmost importance in establishing a diagnosis when other signs point to the kidney. In all types of such infections one usually finds chills followed by the spiking type of increased temperature, pain in the loin of the affected side, more or less tenderness about the infected kidney, a moderately high leukocyte count, a low red cell count with a low hemoglobin percentage and finally rather marked loss in weight.
LARGE SOLITARY ABSCESS OF KIDNEY
33
The urinary findings are often negative and therefore frequently misleading. The urine may contain a few white blood cells or staphylococci or both, but at times does not contain either. However, it should be remembered that the suppurative lesions under consideration do not communicate with the kidney pelvis. Thus, a negative ureteral specimen of urine, considered in connection with the history of a pre-existing skin lesion together with the signs and symptoms indicating renal involvement, should at least arouse one's suspicion as to the true state of affairs rather than confuse the picture. Frequently, in a fresh specimen of urine, staphylococci may be satisfactorily demonstrated by the centrifugal and smear method. In many instances, kidney functional tests show little or no difference between the functioning capacity of the 2 kidneys. Hence, diagnostic help from this source cannot always be obtained. Of considerable aid, however, is the pyelogram. This is especially true in large solitary abscess where the kidney pelvis may be encroached upon by the inflammatory lesion. As mentioned in the foregoing, one looks chiefly for pressure signs such as compression of the pelvis, unusual separation of the calices or displacement of a single calix. The same pyelographic changes may be present in a carbuncle of the kidney, especially if the carbuncle is a large one. But in carbuncle, filling defects of the pelvis seem to be more common, and in many carbuncles there are no significant changes in the pyelogram at all. Also in the differential diagnosis, one must frequently consider perinephric abscess. In this condition the symptoms are likely to be less pronounced and there may be no tenderness in the loin whatsoever. The fl.at radiograph usually shows a curvature of the spinal column (concavity towards the affected side), absence of the psoas muscle shadow on the affected side and fixation of the kidney. The pyelogram nearly always indicates a normal condition. Treatment. The treatment of large solitary kidney abscess is incision and drainage. On exposure of the kidney in suspected abscess, if the abscess is not at once apparent, decapsulation of the kidneys should be performed, for, as Beer has pointed out, a solitary abscess or multiple abscesses may not be discovered until the true capsule of the kidney is removed. SUMMARY
Large solitary abscess of the kidney is comparatively rare and is not often diagnosed pre-operatively.
34
HOWARD S. JECK
Attention is called to a few of the outstanding cases which have been reported. Two cases of the writer are reported in detail. In one of these the pre- and postoperative pyelograms are interesting and significant. The similarity, clinically, of this condition to multiple cortical abscesses, perinephric absc,ess and carbuncle of the kidney is pointed out. The treatment of solitary abscess of the kidney is incision and drainage. 745 Fifth Ave., New York City. REFERENCES AsCHNER, P. W. : Staphylococcus infection of renal parenchyma. Am. Jour. Med. Sci. 172: 63, 1926. BEER, EDWIN: Coccic infections of renal cortex. J. A. M. A. 106: 1063, 1936. BRADY, L . J.: Carbuncle of the kidney (metastatic staphylococcus abscess of the kidney cortex). J. Urol. 27: 295, 1932. DrcK, B. M.: Staphylococcal suppurative nephritis (carbuncle of kidney). Brit. Jour. Surg., 16: 106, 1928. FLANDRIN, M . P.: Un cas de volumineux abces du rein a staphyloccoques gueri par incision et drainage. Bull. de la soc. Fran~aise d'urol., pp. 175- 184 (April) 1936. GRAVES, R . C., AND PARKINS, L.: Carbuncle of the kidney. Trans. Am. Assn. Genito-Urinary Surgeons, 28: 41, 1935. HUNT, V. C.: Cortical abscess of kidney. Southwestern Med. 13: 166, 1929. JUDD, E. S., AND BROWN, C. B.: Cortical abscess of kidney. Surg. Clinics of North America 9: 801, 1929. KRETSCHMER, H. L .: Carbuncle of the kidney. J. Urol. 8: 137, 1922. NEFF, J. H.: Enucleable multilocular abscess (carbuncle) of the kidney. Trans. Am. Assn. Genito-Urinary Surgeons, 23: 27, 1930. O'CoNOR, V. J.: Carbuncle of the kidney. Trans. Am. Assn. Genito-Urinary Surgeons, 26: 17, 1932. RESCHKE, K.: Ueber Paranephritis Und Nierenkarbunkel. Arch. f. klin, Chir. 129: 303, 1924. SMIRNow, A. W.; Ueber Nierenkarbunkel. Ztschr. f. urol. Chir. 20: 243, 1926.