Nephrolithiasis

NEPHROLITHIASIS GEORGER. LIVERMORE,M.D., MEMPHIS,

F.A.C.S.

TENN.

T

HE history of nephroIithiasis dates back to antiquity. Hippocrates (460 to 370 B.C.) described its symptoms and prescribed diuretics, but operations on the kidney, except for perinephritic abscess or the Iarge pyonephrotic kidney were considered certain * death. Vandenberg quotes Bernard who teIIs of a successfu1 nephrotomy and removal of severa stones by an ItaIian, Dominic0 di Marchetti, in the seventeenth century. He says this is the first authentic nephrotomy in the Iiterature. It is remarkabIe that so many centuries elapsed, from the time of Hippocrates, before an>- attempt was made to remove a kidney stone by operation. JoI?-’ dots not regard Bernard’s record authentic, as hc states the first nephroIithotomy was performed by Morris in 1880, and the first positive x-ray diagnosis of a renaI caIcuIus \vas made b)McIntyre in 1896.’ Rena1 caIcuIi may be composed of caIcium oxaIate and carbonate, phosphates of caIcium magnesium and ammonium, uric acid and urates (rare), cystine (rare), santhin (very rare), bacteria and fibrin (rare, and not true caIculi). I have IWATI seen a case of xanthin stone. JoIy says we know that uric acid stones are formed in the kidney, yet uric acid caIcuIi are rareIy found in the kidnc:-. He believes most of them are passed spontaneousIy, as he says most uric acid and urate stones are smooth and rounded, while oxaIatc and phosphate stones are covered with spicules or sharp crystaIs. It has been my observation that the rcvcrse is true. I shouId rather say that uric acid stones form chiefI> in non-infected urine (due to fauIty metaboIism) and, therefore, increase very sIowIy in size; being smal1 and remaining so for a longer time, they are more IikeIy to pass don-n the urctcr. 253

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On the other hand, phosphate and oxaIate stones form chiefly in infected urine (and are due to bacteria1 decomposition, fauIty metaboIism, and upset of the norma coIIoids of the urine), grow more rapidIy and, hence, soon become too Iarge to enter the ureter. ETIOLOGY

The etioIogy of stone in the urinary tract is stiI1 a much mooted question. The muItipIicity of theories proves concIusiveIy that no one theory is correct. As you know, stones are composed of various constituents, and it is rare to find one that is composed of a singIe materia1. It is, therefore, ridicuIous to think that the etioIogy of the different varieties couId be the same. Stones too, vary in size, shape, consistency, Iocation, and density. If one etioIogica1 theory is correct, then a11 stones shouId be more or Iess simiIar, and of the same ingredients. The author beIieves that many etioIogica1 factors enter into the formation of renaI caIcuIi; that these factors vary in different individuaIs, and that those things that are responsibIe for renaI caIcuIi in some peopIe may be whoIIy inadequate to cause them in others. Of the many theories advanced, infection stands first, and from the experiments of Rosenow and Meisser,2 as we11 as those of Keyser,3 we can no Ionger doubt the prediIection of certain strains of bacteria to the formation of caIcuIi. It is aIso a fact that true bacteria1 caIcuIi occur, either composed entireIy of dead bacteria, or a cIump of bacteria may act as a nidus for the precipitation of crystaIIine or coIIoida1 materia1. Second is the coIIoida1 theory of Spitzer and HiIIkowitz.4 This is based on the supposition that the crystaIIine matter of the urine is heId in soIution by its normaI coIIoids. An increase in either upsets this baIance and crystaIIine or coIIoida1 materia1 is thrown down and is thus ready for the other factors to utiIize in the formation of a stone. Eisendrath and RoInik state that coIon and SaImoneIIa baciIIi cause precipitation of the normaI coIIoids of the urine. This being true, then other

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bacteria may be abIe to produce the same result. Thus infection shouId be credited with a twofoId etioIog;\-: (I) the seIcctive action, and (2) the action on the coIIoids. This makes infection (as aIready stated) the foremost cause of stone formation. 3. Stasis. That stasis pIays an important rBIe in the formation of renaI caIcuIi there can be no doubt, but that other factors are necessary to produce a stone has been concIusiveIy proved by anima1 experimentation, and by the numerous cases of stasis in which infection may or ma)- not have occurred, in which no stone is found. Must the coIIoida1 theor)- come into action, or is the necessary ingredient added by (4) some metaboIic dysfunction. The author is convinced that fauIty metaboIism is often the deciding factor in the formation of many caIcuIi. Unfortunately, the cause of this fauIty metaboIism is unsoIved. Is diet responsibIe? I am sure you wiI1 agree that persons who Iead sedentary Iives, who eat imprudentI)-, cspeciaII)- of proteids, and food with a high caIcium and phosphorus content, and those who are under a nervous strain, and those who eat hurriedIy and induIge in rich foods and drink are frequent sufferers from stone. Doctors are particuIarIy suscept.ihIc; in fact, I have known more doctors who had urinary calculi than any other profession or trade. This, no doubt, is due to the inabiIity of metaboIic processes to cope with the oversuppIJ and poor eIimination of certain end-products, cnhanccd in surgeons by excessive perspiration and faiIure to provide by excessive water drinking the fIuid thus lost. Therefore, an unbalanced diet and poor jluid intake predispose to stone formation. Does the same hoId true of those sections of the country where the drinking water is heavily charged with carbonates, of caIcium and magnesium, or with suIphur and phosphorus? No satisfactory expIanation has yet been given. 3. The vitamin theory: A Iarge percentage of rats on a vitamin A and D-free diet wiI1 deveIop stones in the kidneys and bIadder in from forty to seventy days. In 1917 Osborne and MendcI” were the first to suggest avitaminosis as a cause of

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urinary caIcuIi. These experiments have been confirmed by WeIIs,‘j Fujimaki,7 McGarrison,* BIiss, Livermore and Rather9 and others. The Iast aIso confirmed the finding that in rats on a vitamin A and D-free diet inflammatory changes occur in the entire urinary tract with marked sweIIing, exudation, and epitheIia1 exfoIiation, and in view of the fact that from 38 to 43 per cent of the rats used by us9 did not deveIop stones, we suggested the possibiIity of stasis being the deciding factor, the inffammatory reaction being sufficient to produce stasis in those cases that showed caIcuIi, whiIe in those without stone, the inffammation was too miId to cause sufficient sweIIing and exfoIiation to give rise to stasis. We aIso suggest that when metaboIism of one minera is out of baIance, it may cause a disturbance in that of another. It is we11 known that irreguIarity of an uIcerating surface presents a favorabIe condition for the deposit of crystaIs, hence the swoIIen and abraded surface wouId predispose to the Iodgment of crystaIIine matter and the exfoIiated epitheIium, bIood, mucus and necrotic debris would act as a nidus for the reception of both crystaIIine and coIIoida1 materia1. Cases of stone in the kidney occur at times foIIowing injury to the spina cord, fractures and disease of the bones, where the patient is confined to bed for a Iong time. This is very rare. In a Iarge bone cIinic in Memphis they have had onIy one case in the past ten years. In cord injuries we suggest the possibiIity of some nerve derangement and in fractures and disease of bones, some disturbance of caIcium metaboIism. Is the excess of caIcium in the bIood for the repair of bone excreted in the urine, or do the inflammatory products of the fracture or disease upset the coIIoida1 baIance in the urine, with resuItant precipitation of coIIoids or crystaIIoids and consequent caIcuIi in the kidneys? The answer is yet to be found. HypercaIcemia and caIciuria may be produced by feeding parathyroid. Does a diet deficient in vitamins A and D affect the parathyroid? We beIieve that it does, because caIcuIi

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in avitaminosis are composed of caIcium and phosphates and the disturbance of caIcium metaboIism may aIso affect that of phosphorus. In rats on vitamin A and D and vitamin A deficient!diets, infection as a ruIe rapidIy supervenes. Infection is thus again brought into pIay as a factor in the etioIog,v of stone in the kidney. The organism most frequentIy found in nephroIithiasis is the StaphyIococcus aIbus, and the next is the coIon baciIIus (JoIy). It is a fact that coccus infections are much more dificuIt to eradicate than coIon infections. Most observers beIieve that many coIon infections are secondary to coccus infections and in those cases, in which coIons aIone are present, the &on has repIaced the coccus. Other organisms found in caIcuIus of the kidney are the FriedIander’s baciIIus and in pneumococcus, streptococcus, some cases urea-spIitting organisms such as the proteus baciIIus and the Micrococcus ureae. The BaciIIus aIkaIigenes faecaIis has recentIy been obtained from a renaI caIcuIus. but most renaI caIcuIi occur No age is exempt, Age. between the ages of twenty and fifty, but are much more frequent in chiIdren than is generaIIy known. In a series of 203 coIIected cases of urinary Iithiasis in chiIdren, Thomas and TannerlO reported 13.9 per cent in the kidney. Se.v. Lithiasis occurs in both sexes, though most observers report more cases in men. It occurs with aImost equa1 frequency in each kidney. except in Heredity. Th is is of no etioIogica1 significance, stones composed of cystine. Often in these cases we obtain a history of heredity, and find more than one member of the famiIy affected. I am confident that .SpeciJic Gravity and pH of Urine. concentration pIays a part in the formation of kidney stones and hydrogen-ion variation is said to be responsibIe for the precipitation of coIIoids or crystaIIoids. SureIy, the faiIure to provide sufficient fluids to keep the pH of the urine within normaI Iimits may be a potent factor in the formation of stone.

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Someone has said, if the specific gravity of the urine is kept beIow I .012 the deposition of minera matter cannot occur. Whether we agree with Ochsner or not about the vaIue of di.stiIIed water, we know that it contains no mineraIs to be metaboIized. Therefore, I advise a11 patients with renaI or uretera caIcuIi to drink distiIIed water. The chief etioIogica1 factors in the production of renaI caIcuIi, therefore, resoIve themseIves into: (I) infection; (2) fauIty metaboIism, and (3) stasis. AI1 other causes are subservient to these, and unIess one or more of this triad is present, are incapabIe of producing a renal caMus. Stones in the kidney may be singIe Number and Location. or muItipIe. They are found in the peIvis, the caIyces, the parenchyma, or in a11 three in the same kidney, or in one Iocation in one kidney and in another in the other. It is a fact, too, that a stone may be in one position at one examination and in another when the patient is examined again. Some years ago I was operating to remove a caIcuIus from the Ieft ureter, about 2 inches from the bIadder. I had freed the ureter and grasped the stone, preparatory to incising the ureter, when the stone sIipped out of my fingers and I was unabIe to Iocate it. An x-ray showed the stone in the peIvis of the Ieft kidney, from which I removed it by pyeIotomy. SYMPTOMS

These vary with the position, size and motiIity of the stone, and with the presence or absence of infection. Pain, ranging from a duII ache in the Ioin to excruciating renaI coIic is usuaIIy a predominant symptom. Pain in the opposite kidney from compensatory hypertrophy or reno-renaI reffex must not be overIooked. PaIpation may or may not eIicit pain, but fist percussion aIways does. A sick kidney pains when hit. In some cases, however, the patient has no pain and suffers no inconvenience, and the stone may be discovered onIy when an x-ray is made for possibIe fracture, or foIIowing gunshot injuries.

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Frequency and burning on urination may or may not bc present, but are more IikeIy to occur in the infected cases. BIood in the urine is a frequent symptom, but is far from a constant one, but pus ceIIs are aIways present, even though they may be so few as to be reported as a rare Ieucocyte. It is remarkabIe how much pathoIogy may be present in the genitourinary tract when urinaIysis sho\vs onIy a rare pus or bIood ceI1. In renaI caIcuIus without infection, fever is rare, but in some cases there may be a Iow-grade temperature. In infected cases, rigors, high fever and profuse sweats are not uncommon, aIthough the temperature may remain norma in many cases in which the urine is Ioaded wih pus. The cause of pain in renaI caIcuIi is increased intrarena1 pressure, due to obstruction produced by the stone or b), sweIIing and edema due to inflammation and congestion, or to spasm of a caIyx or the ureter. DIAGNOSIS

The diagnosis of a renaI caIcuIus when it can be shown on the x-ray Mm is usuaIIy easy, but, unfortunateIy, a11 stones do not cast a shadow. It has been said that uric acid and cystine stones do not cast a shadow. This is often true of uric acid stones, but aIthough I have seen onIy a few cases of cystine stones, a11 of them showed on the x-ray fiIm, and this has aIso been JoIy’s’ observation. Negative shadows, if repeatedIy found, are very suggestive of stones, but are vaIuabIe onIy in conjunction with other symptoms. The injection of a pyeIographic medium (the one that I use, and which at the Baptist HospitaI is caIIed Livermore’s soIution, is equa1 parts of 35 per cent neosiIvo1 and 20 per cent sodium iodide), and then draining it off, may coat the stone or stones and make them opaque enough to cast a shadow. Intravenous pyeIograms are especiaIIy vaIuabIe in visuaIizing stones that do not cast a shadow. CaIcareous deposits in tubercuIosis of the kidney may deceive one in the diagnosis of caIcuIus, but they are found

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onIy in the advanced cases, and tubercIe baciIIi, and other evidences of tubercuIosis of the kidney are present. Chutell is correct when he says there is no way to differentiate a smaI1 caIcified tubercuIous area on the surface of the kidney from a stone. In such cases there are no tubercIe baciIIi in the urine, hence a mistake in diagnosis may readiIy occur. He says we shouId never remove the tubercuIous area as acute miIiary tubercuIosis is Iikely to foIIow. GaII stones and caIc%ed Iymph nodes may be confusing at times, but with the Graham test and stereoscopic Mms, the differentiation is easy. LateraI pyeIograms are aIso of distinct vaIue. TREATMENT

This varies with the Iocation, size, infection, age and condition of the patient, the functiona capacity of the kidneys and whether uniIatera1 or biIatera1. It is the opinion of the author that a stone in the kidney is a potentia1 source of danger, that it usuaIIy increases in size as time passes, and if not removed wiI1 eventuaIIy destroy the kidney in every infected case, and in a Iarge percentage of noninfected ones. It may prove such an irritant to the kidney that it may be the etioIogica1 factor in the production of carcinoma or hypernephroma. Cases are reported where a stone was diagnosed some years previousIy, and when finaIIy operated on for stone a carcinoma was found (SchoI112). Some years ago I saw a patient who had been x-rayed five years before, and a smaII stone found in the Iower poIe of the Ieft kidney. He refused operation at that time. My x-ray showed the stone about three times the size it had been five years before. At operation a hypernephroma as Iarge as a walnut was found with the stone embedded in it.

I, therefore, state that as it is a foreign body, that wiI1 uItimateIy destroy the kidney or the patient, a stone in the kidney ‘shouId be removed. I wouId quaIify this statement by saying that I wouId not operate unIess the age and condition of the patient made the risk justifiabIe.

NEPHROLITHIASIS I have a patient

under

had had six operations both

kidneys.

my care at present

in the past ten years

She has a urinary

a11 her urine passes. There

fistula

in an emergency

who came to me after she for remova

from each

kidney

of caIculi through

from which

are three Iarge stones in her right, and one Iargc,

and two smaI1 ones in her Ieft kidney. Except

201

The function

no one would feel justified

of both is very poor. in operating

on such

a case.

The choice of operation, however, is not aIways easy for often it is a question of which is best: a pyeIotomy, a nephrotomy, or a nephrectomy. When possibIe a pyeIotomy shouId be done, but in many cases, especiaIIy where the peIvis is smaI1, the pedicle short, or the patient fat, it is impossibIe. Often, too, when it is thought possibIe, the difl%uIty in passing forceps through the incision in the peIvis, and searching for the stone, causes so much damage a nephrectomy may be necessar>-. I have seen this happen three times in the hands of competent uroIogists. Since GoIdstein and Iater Cumming and PhIaggemeyer in experiments on dogs have demonstrated the sIight damage resuIting from mutiIating sections of the kidney parenchyma, I feel that unIess the peIvis can be freeIy exposed, the stone Iocated and easiIy grasped with forceps, it is much safer to do a nephrotomy despite Barney’s13 doIefu1 report from the Massachusetts Genera1 HospitaI of I 5.7 per cent secondar\hemorrhage in 80 cases, in 3 of which nephrectomy was neccssary. He aIso quotes W. J. Mayo, who reported 4 ncphrectomies for secondary hemorrhage in 40 cases. The danger of hemorrhage is greatI>- exaggerated, and can he minimized by care in cIosing the nephrotomy wound, providing rubber tube drainage of the pelvis, and covering the incision in the kidney with muscIe tissue or fat. Sutures in the kidney shouId be pIain No. I catgut, of the mattress type, with a piece of fat under each Ioop, and not tied too tight. Fat or muscIe tissue shouId be sutured over the incision in the kidney and a smaI1 rubber tube shouId drain the peIvis, to be removed in twenty-four hours. A cigarette drain, with its distal end resting against the nephrotomy wound, shouId bc

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Ieft in and remain undisturbed for forty-eight hours. This shouId be shortened each day thereafter unti1 it is removed on the fifth day. When is nephrectomy indicated? This is another much mooted question. No doubt many kidneys have been sacrificed that couId have been saved. On the other hand, many kidneys have been saved, onIy to cause much suffering, and finaIIy a secondary nephrectomy. I wouId set it down as a genera1 ruIe that when a stone or stones can be removed, and the kidney Ieft so that a11portions of it wiI1 be free from stasis and the parenchyma appears heaIthy, or in such condition that a return to practicaIIy norma is assured, then the kidney shouId be saved. It has been my experience, however, when the stone is Iarge, and the caIyces diIated, stasis wiII resuIt. With the stone-forming habit aIready deveIoped, stasis wiI1 be the deciding factor in the recurrence of stone. Infection may be cIeared up if there is good drainage, but it is impossibIe when stasis is aIso present. JoIy says cocca1 infection, confined to the caIcuIous kidney, is frequentIy an indication for primary nephrectomy. It is a fact, too, that a singIe kidney (nature seeming to realize that with one kidney gone, the remaining one must do its best) often makes a better recovery than such a kidney wouId do if it had a mate to heIp it. Therefore, when, as aIready stated, the stone can be removed, stasis prevented, and a kidney Ieft that in the operator’s judgment wiI1 not be a source of troubIe, or in those cases where the other kidney is in such condition that cystoscopic treatments wiI1 aIways be necessary, the kidney shouId be saved. Two poor kidneys are better than one poor one. Of course, with infection, and a Iarge stone in one badIy damaged kidney, and the other not invoIved, nephrectomy shouId be done. Where a Iarge cavity is Ieft after the remova of a stone from the upper or Iower pole, or where the parenchyma is greatIy damaged by an abscess or hydronephrosis, heminephrectomy has proved a very satisfactory operation in my hands.

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263

In agreement with Gumming’-’ I beheve preoperative cystoscopy and peIvic Iavage to be of distinct vaIue. I disagree, however, as to the advisability of operating on the more damaged kidney first in biIatera1 caIcuIi, for the reason that if we get the better kidney in condition to carry on without the bad one, then a nephrectomy may be done with impunity, if we find the bad kidney too greatIy damaged to save. In operating on the more damaged kidney first, shouId it be found in such condition that nephrectomy is indicated, then we cannot remove it, for the reason that the better kidney may not be able to carry on aIone, damaged as it is by stones. If we arc forced to do a nephrectomy and the patient survives, then we must subject him again to a greater risk in removing the stones from the one remaining, badIy damaged, kidney. RECURRENCE

This occurs very frequentIy. Keyser,15 quoting Judd and SchoII, and Braasch and FouIds, estimated 10.3 per cent recurrences in 1413 cases. I beIieve it is higher. There were more recurrences foIIowing nephrotomy than pyeIotomy. No doubt some cases of so-caIIed recurrence are stones, and enIargements of particIes of sand or fragments that were overIooked at the time of operation. True recurrences, however, are far too frcquent and more experimenta work is necessary to Iearn the cause and give us a means of prevention. I shouId say the best we can do in our present state of knowIedge is: First, make sure that no stones, fragments, sand or bIood cIots are Ieft in the peIvis, caIyces, or parenchyma, verifying our careful paIpation, probing and irrigation of the peIvis and nephrotomy wounds with an x-ray and Uuoroscopy of the exposed kidney with McCarthy’s fI uoroscopic teIescope. Second, prevent stasis by pIacing the kidney in the best possibIe position to insure good drainage, and Ieaving no cavities where urine wiI1 be stagnant and harbor infection. Third, postoperative cystoscopy with uretera diIatation and peIvic Iavage unti1 a11 infection has been eIiminated, and

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a11 congested and thickened areas of the uretera mucosa ironed out. Fourth, the remova of a11 foci of infection. Fifth, concentration of urine and aIkaIinization prevented in the caIcium, ammonium and magnesium phosphate stones; aIkaIinization, metabolic change and Iow proteid diet in uric acid stones; a suIphur-free and Iow proteid diet and every effort to promote metaboIic change in cystine stones. Sixth. In infected cases, hexamethyIene-tetramine, ketone diet and peIvic Iavage. Seventh. Nephrostomy and peIvic Iavage unti1 a11 infection has been cIeared up as suggested by Cabot.17 Eighth. RuIe out disease, hypertrophy or tumor of the parathyroids. Ninth. In aII cases insist on fuI1 vitamin A and D diet, drinking distiIIed water in suficient amount to insure urine output of character and pH, indicated for type of caIcuIus. Exercise, bowe1 movement daiIy and diet according to chemica1 constituents of the stone. REFERENCES I. JOLY, J. S. Stone and CalcuIous Disease of the Urinary Organs. St. Louis, Mosby, 2. 3. 4. 5. 6. 7. 8. g. IO. I I. 12. 13. 14. 15. 16. 17.

1929. ROSENOW, E. C., and MEISSER, J. G. Arch. Int. Med., 3 I : 1923. KEYSER, L. D. Soutb. M. J., 25: No. IO (Oct.) 1932. SPITZERand HILLKOWITZ.J. Ural., I I: IO, 1924. OSBORNEand MENDEL. J. A. M. A., 6g: 32, Ig 17. WELLS, H. G. Cbem. Patb., p. 414, rgr4. FIJJIMAKI.Japan Med. World, 6: zg, 1926. MCGARRISON.Brit. M. J., p. 717, 1927. BLISS, PRATHERand LIVERMORE.J. Ural., 30: 6, (Dec.) 1933. THOMASand TANNER. J. Ural., 8: 2 (Aug.) 1922. CHUTE, A. L. New England J. Med., 202: No. 2 (Jan.) 1930. SCHOLL,A. E. Trans. Am. G. U. Ass’n., 1932. BARNEY, J. D. Boston M. Ed S. J. (Jan. 5) 1922. Surg. Gynec. Obst., 35: (Dec.) 1922. CUMMING,R. E. J. Ural., 12: No. 4 (Oct.) 1924. KEYSER, L. D. J. Urol., 31: No. 2 (Feb.) 1934. STEWART,THOMPSONand KRIKORIAN.Brit. J. Ural., 6: No. 3 (Sept.) 1934. CABOT, HUGH. Persona1 Communication.

NEPHROLITHIASIS

DISCUSSION

ON PAPERS OF DRS. BRENIZER, AND LIVERMORE

2hj

LOWER,

CAVE

DR. THOMAS S. CULLEN, BaItimore, Md.: As I Iistened to Dr. Cave’s interesting paper an experience of chiIdhood stood out vividIy before me. I was eight years oId and was hanging on the back of a dray at a raiIroad station. SuddenIy the dray backed up against a high freight pIatform and I was jammed in between the two. I might have had my peIvis fractured or my bIadcIer ruptured. FortunateIy my urinary reservoir was mereIy emptied instead of ruptured. Had the Iatter occurred I shouId neither have studied medicine nor had the opportunity of hearing Dr. Cave today. Abdominal operations were rareIy performed in those days. I have Iistened with much pIeasure and profit to Dr. Lower’s paper. Where a vesicovagina1 fistuIa is high up and the vagina narrow, cIosure ma? be I-ery diffIcuIt. If, however, a Schuchardt’s incision is made, then the fistula comes cIearIy into view and may be much more readiIy cIosed. Ii‘ suff?ient exposure can not be secured by one Schuchardt incision, then it may be necessary to make a similar incision on the opposite side of the vagina. In those rare cases where the greater part of the base of the bladder is missing, and where one uretera orifice opens on the margin of the fistula, then a satisfactory cIosure of the fistula may be very diffIcuIt. Free mobiIization of the hIadder is, of course, absoIuteIy essential. Remembering the fact that the ureter runs obIiqueIy in the bIadder waI1 for we11 over I cm., one can sIit up the ureter for at Ieast I cm. Its opening into the bIadder is now we11 remo\-ed from the edge of the fistuIa. It ma) now be possibIe to satisfactorily cIose the fistuIa. FistuIae foIIowing compIete hysterectomy for cancer of the cervix were, in years past, fairIy common. After the uterus has been removed, we suture the bladder peritoneum to the cut edge of the anterior vagina1 wall. After this procedure, kvhen the bIadder distends, it is only the peritoneally covered portion that dilates. The base of the bIadder, where the fistuIae are prone to deveIop, remains contracted and is we11 protected. Our postoperative fistuIae have been greatIy diminished by this simpIe method. In many of our complicated myoma cases it has been necessary to dissect out one or both ureters to see if by chance they have been injured. In one morning I have found it essential to dissect out three pairs of ureters to ruIe out injury. If fly chance a ureter has been tied or injured the damage has at once been corrected.

GEORGE

R. LIVERMORE

DR. JOHN R. CAULK, St. Louis, MO.: I wish to conhne my discussion to Dr. Lower’s paper, particuIarIy to the question of uretera IistuIae and to briehy report a simphfied technique for the repair of vesicovagina1 fistma.

FIG. I. I have seen a few cases of ureterovagina1 fistmae reIieved by diIatations from beIow by means of the cystoscope. The majority, however, need surgica1 correction. Here spina anesthesia is of tremendous help. In deaIing with a uretera IistuIa, which usuaIIy comphcates pelvic surgery, one must reIy particuIarIy on the upper ureter to secure the greatest part of the Iengthening. This part of the ureter is usuaIIy elongated and tortuous anyhow as a resuIt of the pre-existing obstruction. The Iower ureter is usuaIIy impacted in scar and offers diffrcuhy in exposure; however, such exposure may be greatIy faciIitated by the use of a catheter pIaced in the ureter by an assistant and manipuIated during the time of operation. If we are fortunate in approximating the two ends, which can usuaIIy be accompIished, we are confronted with an asymmetry between the upper and Iower segments. I have found it very advantageous to remove an inverted v wedge from the dista1 end of the upper segment tapering it down to meet the caIibre at the proxima1 end of the Iower one and then uniting these two surfaces over a catheter-spIint with very Iight suturing at the site of union. Thorough drainage of the ureter above the Iine of anastomosis by means of another catheter must be effected. If we are unabIe to approximate the two ends of the ureter, and if the space is not too wide, we can reIy on the natura1 tendency of the ureter to regenerate aIong the soft rubber catheter-spIint to aid in the pIastic process.

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I have had several cases of such defects, one over an inch and a half, which were thoroughIy united by simpIy spIinting the two ends of the ureter over a Iarge soft rubber catheter and boIstering the soft parts around it, using onIy traction or HaIIiard sutures between the two ends of the ureter. UsuaIIy in about two weeks, owing to the specialization of the uretera epitheIium, the anastomosis is compIete through the process of regeneration. I folIowed one patient for over fifteen years who has a perfect cana and a norma kidney. The experiments on uretera regeneration conducted in our Iaboratory by Dr. Wiseman showed that aImost invariabIy there wouId occur compIete regeneration and restoration of Iumen, provided massive infection couId be spared. Since it has been so defrniteIy proved that uretera peristaItic activity can function satisfactoriIy without centra1 nervous system contro1, possibIy through myogenic function, one need not hesitate in stripping the ureter a considerabIe Iength, or in aIIowing defects to exist aIong the cana1, for the reason aIso that the peristaItic wave wiI1 be resumed at the lower end of the anastomosed segment. I fee1 that such procedures are certainIy far more satisfactory, not onIy from the simpIicity in technique but from the eventua1 outcome, than uretero-intestina1 anastomosis, which in my experience is so IikeIy to result in renal disaster from stenosis of the impIanted ureter. With reference to vesicovagina1 IistuIae, Figure I (p. 266) iIIustrates a method of simphfication of the technique in cases of a hstuIa inserted high on the bIadder base, in which instances the suprapubic exposure is more satisfactory than the operation from beIow and the passage of the prostatic tractor into the vagina through the bIadder assists tremendousIy after it is opened in bringing the tistuIa within easy access to the operat.or. It allows him a firm foundation upon which to work and conduct the pIastic. In affording this dua1 purpose it makes a simpIe operation out of one that otherwise uouId be diffrcuIt. DR. JAMES M. MASON, Birmingham, AIa.: Dr. Livermore has touched upon a very important question, that of hemorrhage in nephrotomy. Its dangers may be exaggerated, but, at times, it is a rea1 hazard. I have had to remove one kidney for hemorrhage foIIowing nephrotomy, and have had serious troubIe from hemorrhage on other occasions. The mattress suture which is usuaIIy necessary for the prevention and contro1 of bleeding is often foIIowed by infarction of the invoIved sections of the kidney; therefore I consider his suggestion that the sutures be tied loosely and over a fat pad as a v-cry vaIuabIe one.

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DR. CHARLES H. WATT, Thomasvihe, Ga. : I want to mention briefly a case of interest in connection with the cases reported by Dr. Livermore. About three weeks ago a young man came to me compIaining of kidney trouble. The cystoscope and x-ray reveaIed biIatera1 nephrohthiasis, with a Iarge stone in the right kidney and smaher ones in the Ieft. He went home foIIowing cystoscopy, showing that he did not suffer any harm from it. He returned the next day and we removed the stone from the right kidney peIvis through a pyelotomy incision. The wound was closed, one drain Ieft in. Two days Iater he caIIed my attention to sweIIing of the right scrotum. There was no pain but some soreness over the testicIe. The right scrotum was two or three times its norma size, not painfu1, but there was crepitation and tympanitic note on percussion. The scrotum was IiIIed with air, as reveaIed by the x-ray. It has been a question in my mind how this air got in there. I have never seen this compIication before and cannot Iind any record of such an accident. It Iooks as if the air is between the dartos fascia and the coverings of the testicIe. The patient Ieft the hospita1 on the tweIfth day, having had a norma convaIescence aside from this unusua1, harmIess compIication. DR. FRANK H. LAHEY, Boston, Mass.: I wouId Iike to present a simpIe method of doing an extraperitonea1 operation for impIanting ureters in the sigmoid and coIon. I reaIize this is appIicabIe to onIy a Iimited number of cases, but it is so safe and simpIe it may prove usefu1 in the hands of other men, as it has in our hands. First, make a right rectus incision, wipe the parietal peritoneum back as for a ureterotomy. You then have the ureter free, can cut it off cIose to the bIadder and have the upper end ready for impIantation. You then make a smaI1 opening in the peritoneum, about 2 inches in diameter. Then reach down and puI1 the redundant sigmoid into the peritonea1 opening. You puI1 a portion of the waI1 of the sigmoid out into the peritonea1 opening so that you have onIy a portion of the waI1 of the bowe1 and the Iumen is not obstructed. You suture this with catgut sutures into the opening in the parieta1 peritoneum making it thus compIeteIy extraperitonea1. You can then do a Coffey No. 2 transpIantation and, since it is now outside the peritonea1 cavity, if a Ieak occurs you can have nothing but an extraperitonea IistuIa and you can do it again if necessary. On the other hand, you shouId not do this on a woman who may become pregnant, for this may seriousIy compIicate it. I do not present this as a method to surpIant the other methods but it is a very safe method of transpIanting ureters. DR. EDGAR L. GILCREEST, San Francisco, CaIif.: We have had no patients in San Francisco, as far as I am aware, that have gone as Iong without urinating as Dr. Cave’s. But a number have been seen which, after

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severe abdomina1 trauma, were urinating regu1arIy but on opening the abdomen a rupture of the bIadder was found. The aperture was temporariI1 seaIed by a loop of bowel. One, therefore, should not be misled just because the patient is urinating and concIude that the bIadder is not ruptured. Roentgenograms shouId be taken on a11of them. DR. C. JEFF MILLER, New OrIeans, La.: I fear the popuIarity of transpIantation of the ureters may Iead us away from some of the more conservative measures in the management of yesico-vagina1 fistulae. The secret of success depends upon wide separation and independent cIosure of both the hIadder and the vagina1 wall. It is amazing how wide a separation one can make in the dissection if one is carefur. In some cases, where the fistula was very Iarge, I have cIosed the bIadder without making any attempt to coapt the vaginal area. If you find extensive destruction, separate far enough to cIose the bIadder injury without tension, and place no sutures in the vaginal layer. Another feature is to separate the uterus from the bIadder, even to the extent of opening the peritonea1 sac, making a wide separation of the bladder from the broad Iigaments above. This faciIitates cIosure of extensive Iesions with most satisfactory resuIts. I have in mind severa cases in which transplantation has been resorted to where most probably the fistulae would more easiIy be cIosed by the above procedure. DR. .JOHN L. MCGEHEE, Memphis, Tenn.: SuppIementing Dr. Cave’s report, I wish to report a case that I saw about two weeks ago. A young woman, about twenty-four, who had been in an automobiIe accident was brought into the receiving ward of the Baptist HospitaI suffering with concussion of the brain and fracture of the seventh vertebra, and upon catheterization bIood-tinged urine to the amount of 17 ounces was withdrawn. Because of this fact no damage to the f>Iadder was suspected. A roentgenogram of the peIvis was negative for fractures. That was at I :OO .4.~. two weeks ago this morning. At I I :oo A.M. the next morning 18 ounces of urine were removed by catheterization. By that time the patient had regained consciousness and compIained of Iower abdomina1 pain. Her pulse was 80, her temperature normaI. During the afternoon the pain increased but did not require morphine. By ~:oo P.M. her temperature was 9g°F. and she complained of some abdomina1 pain. The Ieucocyte count was IO,OOO, with 73 per cent poIymorphonucIears. I saw the patient at I I :oo P.hl., when her pulse was I 20 and her temperature I OO’F. There was some discomfort in the Iower abdomen but no nausea or vomiting and the boweIs had moved naturally at IZ:OO midday. The Ieucocyte count had risen to about 17,000. There was rigidity of the entire abdomen, most marked in the Iower half, and there was a silent abdomen. A diagnosis was made of rupture of an abdomina1 viscus and operation was decided upon. About 500 C.C. of blood appeared when the abdomen was opened. The sigmoid n-as rather pendulous

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and was Iying on top of the bladder. Upon Iifting this up a rent that wouId admit three fingers was seen and there gushed from it a quantity of urine. The bIadder was closed, a split tube passed into the pouch of DougIas and the patient was treated for peritonitis. A Pezzer catheter was placed in the bIadder and remained there nine days. An interesting feature was the quantity of urine this patient secreted, on one day 5000 C.C. with a specific gravity of I .OIO. This quantity of urine never dropped to less than 4000 C.C. daiIy up to the time I Ieft Memphis. Another interesting feature was the fact that this bIadder injury was cIosed twenty-one hours after the accident and the deveIopment onIy of IocaIized peritonitis foIIowing this deIayed cIosure. DR. ROBERT S. HILL, Montgomery, AIa.: ParadoxicaI though it may seem, the frequent resort to operative procedures has both prevented and caused vesica1 fistuIae. In the earIy days before the obstetrica forceps and cesarian sections were so quickIy resorted to we had these fistuIae as the resuIt of tedious and deIayed deliveries, causing pressure necrosis of the soft tissues. Nowadays we have urinary fistuIae more frequently from unfortunate injuries during operations. Dr. Lower referred to Sims’ great work. Sims did his pioneer work in my town, Montgomery, AIabama. After exhausting efforts and repeated faiIures to cIose vesicovaginal fistulae he IinaIIy succeeded, but onIy when he struck upon the use of siIver wire as a suture materia1. It may be truIy said the duck biI1 specuIum and siIver wire suture, both of which if I mistake not were originated by Sims, made it possibIe for him to successfuIIy cIose the vesicovagina1 fistuIae. The chemist teIIs us there is a reaction between siIver wire and the tissues of the body that has antiseptic properties. This probabIy expIains the success with this materia1 as contrasted with faiIures with other before Lister bIazed the way to surgica1 cIeanIiness. It cannot detract from Sims’ great work to record that another antedated him in the successfu1 cIosure of vesicovagina1 IistuIae. I had occasion a short time ago to be reading the history of some men who contributed to the progress of surgery and in doing so I came across the name of Dr. Matteur of Virginia with whose work I was Iittle famiIiar. It seems he antedated Sims in the successfu1 cIosure of vesicovagina1 fistuIae. He used a lead wire suture, which if my recoIIection serves me right, he made himseIf. IncidentaIIy may I say if there are any of you who have not read the history of Dr. Matteur I recommend you do so. It is extremeIy interesting. It is aImost beyond beIief what this remarkable, though very eccentric, man accompIished in his preantiseptic day.

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I ha\-e two, to me very interesting, cases of injury from delayed deliveries, I wish to bring to your attention. Some years ago a IittIe negress from the country district of Georgetown, Ga., was brought to me with a history brieffy as foIIows: After being in Iabor about a week, the oId granny (some of you oIder men may know what an oId granny was) in attendance decided she needed a doctor. A doctor was secured to make the trip to the country. He did an instrumenta delivery of the dead chiId. She had a desperate time extending through many weeks but fInaIIy recovered with no urinary contro1. Two years Iater she came under my care and I found the vagina compIeteIy cIosed, the inside of the bIadder turned outside and resting between the vulvae. I was unabIe to definitely outIine the uterus. The opening through which the waI1 of the bIadder proIapsed was Iarger than a silver half doIIar. I started in with the idea of restoring the vagina but soon found this impossibIe and abandoned a11thought of doing more than closing the opening with the hope of giving this young woman a bIadder that uouIcl make Iife bearabIe. If there was a reappearance of uterine function I wouId do an abdomina1 hysterectomy. The uterus did not show any activity, and I wondered if it had not been actuaIIy destroyed, a sort of Mayo’s bloodless hysterectomy, by the sIoughing process folIowing the delivery. After three efforts I succeeded in cIosing the opening and made for her a bIadder that, though under-sized, is satisfactory. A full report of the second case was made to the Association at its meeting in St. Louis, 1908. This woman gave a history of having had a tedious Iabor, folIowed within an hour by a profuse gush of water. There had been a faiIure in emptying the hIadder during her labor. SeveraI months after her confinement she came under my care and on examination a uterovesical fistula was discovered which permitted al1 of her urine to pass out through the uterus. After this opening was cIosed I found she had no sphincter contro1 of her bIadder. A search of the Iiterature faiIing to reveal to me a satisfactory surgica1 technique for the restoration of the function of the sphincter I permitted myseIf to indulge the hope that this Ioss of function was temporary and advised her to return home and give nature a chance. She experienced no improvement, and in the course of time returned to me two or three months pregnant demanding I do something for her. I then devised an operative technique on the sphincter and neck of the bIadder that proved perfectIy successfu1. (See Transactions, St. Louis meeting, 1908.) This operation has been popuIarized by that master gynecoIogist, Dr. Howard Kirby. This patient was from an adjoining state, and I never saw her after she went home foIIowing the operation on her bladder, but my information was she passed through her pregnancy and was deIivered without troubIe and with no unhappy after-results.

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DR. ADDISON G. BRENIZER (Closing): I just wish to say that the onIy way I know of severing ureters, without removing the bIadder, that have had a IateraI anastomosis is the one I described. DR. HENRY W. CAVE (Closing): Dr. Furness after his first cystoscopic examination was under the impression that the perforation was at the site of a necrotizing thrombosed bIood vesse1. It may have been that or the rupture of a smaI1 diverticuIum of the bIadder. There has been no other way to determine the exact pathoIogy; for the diagnosis of the tissue removed was rather inconcIusive, it being statgd to be a chronic inffammation in the waI1 of the urinary bIadder.