March 8. 7:30. March 9. March 11. March 15. 98.5 78 March 21. 98.6 72 Urine, 14 oz. sp. gr. 1020 acid; normal color; bowels acted last night. Urine, 8 oz.; five ounces of milk, now swallowed and relished; continued enemas. 14 oz. urine, sp. gr. 1026; more nourishment; no vomiting; removed stitches; wound healed by first intention over extent. Patient is taking more nourishment without vomiting and with relish ; urine voided in last 24 hours, 28 oz. of sp. gr. 1027; normal in color and odor. 18 oz. urine during last 24 hours; it is turbid; sp. gr. 1029; nourish- Patient better; vomiting ceased; 32 oz. urine, sp. gr. 1022; wound 32 oz. urine in last 24 hours; bowels moved by enemas; nourishment 98.5 72 Had headache during night; better to-day; 24 oz. urine; no appetite. 78 98.5 72 Urine abundant; ate egg, toast and milk for dinner, and did not vomit; sat up in bed. Sits up once a day; walks a little; complains of pain in right hypochondrium, hip and leg; inclined to vomit if she lies upon right side soon after taking nourishment, but at no other time; eats well and retains food. Nearly three months have passed since the operation, and it may be of interest to note the condition of the patient at the present time. She is up and around the house, doing a little light work. She takes liberal quantities of milk, egg and old bread, and seldom vomits if she restricts herself to these articles. She has gained several pounds in weight during the last six weeks. The remaining kidney does the work of both with apparent ease. She complains of considerable pain in the loin, through the scar, and there is some tenderness in the right hypochondrium. Except the pain, for which I am at a loss to account, her condition is greatly improved, and we may truly say that the nephrectomy was to her a decided benefit. One case, be it ever so successful, can not furnish a rule for action. It can only be suggestive. This one is reported in order to add one to the number still too small to definitely settle all im portant questions growing out of the operation. To the writer this has been an exceedingly instructive case, and in meditating upon it he has concluded that its history tends to throw some light upon a few dark points needing illumination. 1. A healthy kidney, if movable, may induce an excessive and persistent vomiting which can only be relieved by removing the offending organ. Here a carefully regulated diet, medicine, large pads, friction and counter-irritants, were all used with no avail. Nephrectomy stopped the vomiting. 2. Nephroraphy may place the patient in a worse condition than she was before the operation. Mrs. H. suffered more pain and vomited more after the operation for anchoring the kidney, than she did before it was done. The reason of this the writer thinks can be easily explained. When the kidney was exposed for its removal it was found surrounded by an envelope that had the appearance of the normal peri-renal adipose tissue, with bands running through it in all directions of a pinkish white, glistening tissue, reminding one of scar or fibrous tissue. These bands were undoubtedly cicatricial tissue, or bands of adhesion, resulting from the operation of nephroraphy. These bands reached out in all directions from the kidney to the surrounding structures and formed attachments to them. This was very apparent in respect to the liver, the colon and the structures posterior to the kidney, and it was thought with the duodenum, though not seen. Here the writer believes is an explanation of the great amount of pain present, notwithstanding the movements of the kidney were much less than they were before it was fixed. Every move ment of the kidney beyond certain circumscribed limits caused tension of the bands of adhesion and if carried far enough, pulled upon the colon and under surface of the liver and probably the duodenum. 3. In cases similar to the one the writer is here describing, it is his belief that some treatment of the peri-renal adipose tissue different than that usually employed should be adopted. In the preceding paragraph the extensive attachments of this structure and the visible evidence of former inflammation in the structure itself were both stated. In the removal of the kidney it is necessary to tear through this tissue, and if it be attached by inflammatory adhesion to the capsule proper of the kidney, which it frequently is, extensive injury to the structure must occur which must result in further inflammatory adhesions. Let us bear in mind another fact. After the removal of the kidney the cavity thereby left in its investments will be wholly or partly obliterated by the collapsing of its walls and these walls are made up of the structures under discussion, so that there would be bands of adhesion extending in various directions from a central mass. In consequence of this the movement of one organ may be felt by a distant organ, or in consequence of the contraction of the cicatricial tissue, the liver, transverse,. colon and duodenum on the right may be brought too closely together, or their movements be too much restricted to be compatible with perfect health or freedom from pain. The remedy for this possible result may, the writer thinks, be found in the removal of the whole or a part of the peri-renal adipose tissue. In the case of Mrs. H. this could easily have been done, but that there could possibly be any advantage in this did not occur to the writer. Should another opportunity present itself it will be resorted to and the result duly reported. 4. In this case the deep suture used in nephroraphy undoubtedly passed through the cortical portion of the kidney to the depth of one-eighth or one-quarter of an inch and no extensive disease of the organ resulted; a small part of the organ was, however, entirely destroyed, being replaced by cicatricial tissue. This result tends to verify the statements made by the writer in a previous article, viz. "That it is exceedingly difficult in the operation of nephroraphy to pass the sutures beneath the renal capsule without injuring the cortical portion of the kidney, since in this instance great care was used not to injure that structure." It tends to justify the procedure of Morris, who has recently reported a case of nephroraphy in which he passed a deep suture through the capsule and cortical portion of the posterior and upper surface of the kidney, and, although albumen appeared for a few days in the urine, a permanent fixation and complete recovery resulted. †Journal American Medical Association, February 21, 1885. A CASE OF HYSTERECTOMY, WITH PRACTICAL COMMENTS ON LAPAROTOMY. BY JOSEPH EASTMAN, M. D., INDIANAPOLIS. Mrs. W., married, age thirty-five, mother of two children, the youngest being five years, consulted me December 28, 1886, concerning an abdominal tumor which she had first noticed about four years previously. During the two or three months preceding her visit to my office, the tumor had given her much annoyance, becoming painful and tender, especially at her menstrual periods. These complaints were accompanied by more or less hectic symptoms, the temperature running as high as 101° and 102° F., with pulse 100. There was much nausea with deranged digestion. By the usual methods of examination in such cases, I had no difficulty in excluding all but two conditions, namely, multilocular ovarian cyst, with very short pedicle, or myoma, soft fibroid of the uterus. The uterine cavity measured three inches. I advised abdominal section and removal of the tumor, whichever kind it should prove to be. The patient could not get consent of her mind to be "cut open" during life, but was anxious to have it done post-mortem. At her next period, however, her suffering and debility became so great that she consented, for her children's and husband's sake, to "make the leap for life." She was admitted to my private hospital for women on February 1st, and at once put upon preparatory treatment to reduce temperature and control hectic symptoms, etc. In spite of treatment during three days the temperature ranged from 100°-102° F. The secretions and excretions being good as could be expected, on February 3d I opened the abdomen by an incision two inches in length, and plunged a trocar into the tumor. No fluid escaped, but a red blush spread over the surface, characterizing a tapped fibroid. The incision was enlarged, extending to the umbilicus, the tumor turned forward and out of the abdomen; the broad ligaments were clamped, ligated with cobbler's stitch, and separated with the cautery; the pedicle clamped with Eastman's large temporary clamp.1 A strong elastic ligature was then thrown around the pedicle as low as the vaginal attachment, and then it was severed between the clamp and ligature. A conical-shaped piece of tissue was cut out of the stump, the apex pointing toward the internal os, the base directed upward and outward toward the serous membrane. A cautery iron at blue heat was three times passed through the cervical canal from above downward, for the purpose of destroying mycous membrane and also to assist in drainage from interior of the stump. A dressing forceps was passed through after the cautery, by the aid of which a rubber tube, as large as my little finger, was dragged up to within a half inch of the free peritoneal surface. I expected this tube, by its expansion, to resist shrinkage of the stump. The elastic ligature was removed and over the tube the stump was stitched with No. 14 iron-dyed silk, the stitches placed in the 1The clamp, as here shown, is made in two sizes, by Shepard & Dudley, New York, and has. the following advantages: 1. It is long enough to enable the assistant holding it to be entirely out of the operator's way. 2. It is strong enough that there need be no fear of its breaking, no matter what force is exerted, purposely or otherwise. 3. It has no complicated machinery to get out of order at a critical moment. plicity of an instrument is a measure of its success." "The sim 4. No matter how large the substance grasped, or how small, the pressure is the same at either extremity of the clamping jaws, the latter being so constructed that they will not cut nor allow any substance to slip. 5. It will crush a substance as small as a shoestring, or the base of a tumor six inches in diameter. This is sometimes an advantage where the pedicle is short and more room needed for the ligature. 6. It instantly arrests all communication between the patient and tumor, so that air striking the peritoneal surface of the tumor can not chill the patient-and cold venous blood returning to the large veins is an important source of shock. 7. It instantly arrests all escape of arterial blood, which is sometimes great when we have broken up the partition walls of a cyst to reduce its size, and at the same time, where, as in this case, the pedicle includes the uterus, at the internal os, it clamps the mass so as to reduce the pedicle more than one-half. (The clamp was shown the Society.) |