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RENAL SURGERY IN KASHMIR.

By JOSHUA DUKE, LIEUTENANT-COLONEL, I.M.S.,

Residency Surgeon in Kashmir.

Considering the enormous preponderance of cases of stone in the bladder prevalent in

India, and its extensive removal by litholapaxy, it is curious that stone in the kidney is

comparatively rarely met with; and Surgeons in this country do not appear to have the same opportunities of exploring the kidney that are enjoyed by their confreres at home. When Mr. Henry Morris, the great pioneer and

exponent of kidney surgery in England, was House-Surgeon at Guy's Hospital, 1867. I had the honour of being dresser at that institution ; but during my period of studentship I cannot recall seeing a kidney cut down on, nor, unfor- tunately have I ever seen this operation performed by a skilled Surgeon. In Indian civil and hospital practice, however, one has to take every case that comes to hand. A* bearing on this subject since my case of nephrotomy performed for neuralgia of kidney, and published in your journal in 1895, though I have per- formed litholapaxy many times, the two cases

quoted below are the only ones that have occurred in my practice.

Case I.?Nephrolithotomy.?The patient, a sepoy in the Imperial Service Troops, Kashmir, came before me at an annual Invaliding Board in December 1898. He

then complained of severe pain in the right hypo- chondriac and lumbar regions. This pain he said rendered his life a burden to him, and he could serve no longer as a soldier. Enquiry proved that he had previously undergone an operation at Gilgit for the relief of this pain, and he showed a scar in the right loin. He was, therefore, admitted to hospital for further examination and operative treatment. I then wired to the Agency Surgeon, Gilgit (400 miles distant), enquiring whether the man's statement was correct He

replied by wire, that an operation had been performed ; the kidney manipulated ; but no stone was found.

Owing to the kindness of Major J. 11. Roberts, I.M.S., f.r c s., I am able to give the patient's previous history and a note on the primary operation.

Previous history and operation.?Sepoy Earn Dhun, cet. 28, was admitted to the Military Hospital, Gilgit, on 23rd January 1899. He complained of pain in the right loin. Sometimes

this pain was situated in the loin, at other times over

the sacro-iliac joint, radiating to the other side. The urine contained albumen. As the case progressed,

the amount of albumen varied from one-eighth to one- sixth, sometimes almost disappearing. There was no blood.

About the middle of April he began to have pain radiating from the loin into the right groin and testicle. As the case did not improve under treatment it was decided to explore the kidney, in the supposition of stone, although the amount of albumen in the urine was not in favour of this.

No. 1 Operation, 8th May 1899.?The usual oblique incision was made in the right loin, and the peri-renal fat exposed. This was stripped off, and the anterior surface and the hilum exposed to the touch of the finger. The kidney was judged to be small, and no prominence could be made out on any part The pos- terior surface and ureter were also explored. It was not judged necessary to try the needle. Deep catgut sutures were placed in the muscles and a drainage tube in the wound, which healed without any complica- tion.

Subsequent progress.?After the operation there was an interval without pain in the loin, but this symptom returned.

The patient was sent back to Kashmir and Jammu, leaving Gilgit 16th June 1899. On August 24th, at Jammu, the condition of the urine

is noted as follows

Sp. Gr. 1026 Albumen ... \ Litliates in abundance.

392 THE INDIAN MEDICAL GAZETTE. [Oct. 1900.

He was re-admitted to Jammu State Hispital 011

December 26th, 1899.

Symptoms then severe and almost constant pain in the right hypochondriac region and in the right loin. The pain was aggravated by pressure before and behind. Urine normal in every respect.

No. 2 Operation, January lsZ, 1900.?The right loin was opened for the second time. The incision was now made parallel with, but fully half an inch posterior to the primary scar. The renal fat was exposed, some torn out, and the kidney brought well into view. Care- ful palpation revealed nothing. Needling was then commenced, and six punctures

were deeply made in various positions. Nothing could be felt, and I began to despair of finding anything. At

the seventh puncture, however, made from below up- wards, a stone was felt and then struck on audibly. A

deep incision was then made and a Thompson sound pass- ed. This at first entered the ureter, running easily ; it was then withdrawn, turned up and struck the

stone in the upper calyx of the kidney with a

metallic noise. The opening was then enlarged free

bleeding ensuing. The finger was now passed into the hilum on to the stone. The calculus, however, was firmly adherent, and its pointed apex imbedded, so

that it had to be slowly peeled off and loosened. It was then removed with forceps. After the haemorrhage, controlled by sponge pressure,

had ceased, a drainage tube was inserted, and the wound firmly closed. The stone weighed, on removal, 36 grains, and was of

the size and shape as depicted.

Subsequent progress.?The patient did well, though a good deal of blood was passed with urine, a symptom which continued until the ninth day. January 15th.?The drainage tuba which had been

frequently shortened was taken out and the sutures re-

moved?slight sweet discharge. Urine contains mucus and lithates, but no blood or pus. February lsi.?Wound soundly healed, patient up

and about.

The points of interest in this case are (a) the presence of a large, though transient, quantity of albumen ; (6) that simple manipulation failed to discover the presence of a calculus.

Case II.?Nephrotomy.?Nikab, Hindu male, cet. 35'

admitted 16tli March 1900.

Previous history.?Ten years ago had an acute attack of pain in the left lumbar region which lasted for twelve hours, and was relieved by taking a warm drink prescribed by a native physician. The pain was asso- ciated with a sensation of something rough passing down from kidney, and patient thinks his left testicle was drawn up. Three years later he passed some sand and gravel with his urine. Four years subsequently he had another attack cf lumbar pain similar to the first. No history of lnematuria, or deflnite pain, and drawing up of testicle. Has never had retention of urine. His

general health had failed since these attacks.

Present symptoms.?Marked tenderness on pressure over the lower border of right kidney below the rib, the patient wincing when the thumb is pressed in. The

pain is increased when the hand is placed over the

abdomen and pressure made from behind. He com-

plains of a sensation of something rough moving in kidney region. The above are the only symptoms. Urine Sp. gr.

1029, healthy in every way. Operation, 20th March 1900.?The kidney was exposed

in the left lumbar region by an incisio n four inches in length; about two inches of peri-renal fatwas removed and the kidney brought into view, but not, outside the loin. On drawing the lower end of the kidney into the wound a small cyst size of a pea was seen. This was needled and a little yellow serum let out. On passing the needle in deeper, some more of the same serum, almost pus, oozed up The needle was then passed in deeply at the lower fourth, and struck on what felt exactly like a stone or concretion. A cataract knife was

passed down over needle which was withdrawn, but no stone was felt, although the needle had given the actual sensation of hitting a stone. A free incision was then made in the lower part of the organ, and the finger passed in, but nothing could be felt. A sound was then inserted which, however, did not pass down the ureter owing, probably, to the incision being in the lower third of the organ. The finger was then thrust into the hilum ; all the calyces were explored, but no stone could be felt, with the finger inside and careful palpa- tion outside. Several small nodules or lumps were felt. All these were needled. They were probably small cysts of the same nature as that seen on the surface. The operation had, therefore, unwillingly to be aban- doned, although the operator could have sworn that a

stone or coucretion had been originally struck on. One mightn ote that while exploring with the finger

inside, the respiration thrice stopped. The haemorrhage in this case was very trilling. A drainage tuba having been inserted, the deeper

structures were drawn together by catgut sutures, and the wound firmly closed by six silk sutures. Morphia gr.-J was injected after the operation as the kidney had been severely handled.

Subsequent ?progress. ?The patient passed a restless

night. 22nd March.?Patient uneasy andVestless. The dress-

ing, soaked with bloody serum, were changed. Tempera- ture 102?, cough and viscid white expectoration, pointing to pneumonia. March 23rd.?Temperature normal, pain much easier

general condition satisfactory. Murch 24th?Doing well. March 27th.?Urine still smoky. Sanguineous dis-

charge from wound with uriniferous smell. Cough still present with frothy expectoration. Respiratory sounds clear over both lungs.

April 3ro?and 4th.?Rise of temperature at evening.

April 5th.?Dressing still soaked with uriniferous

discharge. Lower two-thirds of wound have healed, but there is no attempt at union in upper third, "which is a fistulous track, four inches deep. Urine now quite clear. Erysipelatous blush around wound and inter-

scapular region. Patient removed to a separate room, the ward in which he had been treated being rather

over-crowded and occupied by some very foul cases?

famine-stricken, sloughing ulcers and such cases.

To continue briefly the patient was brought to death's door by this and subsequent erysipelatous attacks, from which recovery was slow, and he was not discharged from hospital until June 3rd with the following note :?- The wound has completely healed, the process of union

being retarded by consecutive attacks of erysipelas. There has been no recurrence of pain in the loin ever since the operation, and the deep seated-tenderness over the kidney is no longer complained of.

Jk m

Oct. 1900.1 JOINT SURGERY IN KASHMIR. 393

Remarks.?The operation only revealed cystic disease of the kidney. No stone was found,

although the kidney was most freely handled and examined. It is just possible that a small stone was pushed on or slipped into the ureter, which was not carefully catheterised.