KIDNEYS TO ABDOMINAL OPERATIONS. By J. W. Bean, M. D., Ellensburg, Washington. [Read before the Washington State Medical Society, May 10th, 1898.] Not long since I lost a patient from suppression of the urine following a prolonged abdominal operation. This unfortunate occurrence caused me to give a careful study to the relation existing between renal diseases and the successful or disastrous results following abdominal operations, to ascertain as far as possible the particular form of renal disease where the giving of an anesthetic is particularly dangerous, and also to investigate the action of the anæsthetic upon the kidneys. This subject is too broad to be fully covered in a brief paper, so only the most salient features will be considered, and these more from a clinical standpoint than a pathological. It is well recognized by all abdominal surgeons that the secretion of urine is much diminished for the first few days after an abdominal section. During the first twenty-four hours the average quantity passed is about twelve or fourteen ounces, although this may vary considerably. As low as three ounces during the first twenty-four hours have been noticed with no disagreeable effects. It is often difficult to tell this normal diminution, if I may so term it, from a beginning suppression, though usually the general condition of the patient will furnish a clew to the true state of affairs. The amount of urine secreted gradually increases in quantity until the 5th or 6th day, when it reaches normal. The cause of this deficient secretion of urine is easily explained by the method usually in vogue of preparing patients by the free administration of purgatives for two or three days preceding the operation, and the withholding of liquids for a day or two casts. thereafter, together with the effect of the anaesthetic upon the kidneys. The free action of the skin during the time of the operation may also help produce this condition. This diminished quantity of urine is of a relatively high specific gravity, sometimes reaching 1040, so that practically a normal amount of the urinary solids are excreted. Before all abdominal operations the urine should be examined chemically and microscopically, the quantity passed during a twenty four hours accurately measured and the total amount of solids passed definitely ascertained. Should the operation be a severe one, or liable to be prolonged, repeated examinations should be made. It is not enough to know that the urine is free from albumin and casts. Renal insufficiency, and by renal insufficiency is meant a deficient excretion of the urinary solids, is often of far greater importance, as bearing upon the prognosis than the presence of albumin or If we know the average amount of urinary solids excreted in twenty-four hours by one in health, and physiologists place this amount at 6 or 63 grains for each pound in body wieght, the presence of renal insufficiency can be easily and quickly ascertained by following Haine's modification of Haeser's method. It is this: "Multiply the last two figures of the specific gravity of the urine by the number of ounces voided in twenty-four hours, and the product by 1 1-10." This gives the total amount in grains of all solids passed in twenty-four hours. To illustrate: Suppose our patient weighs 120 pounds and voids in twenty-four hours 36 ounces of urine of a specific gravity of 1020. By following the rule mentioned above we have 36 multiplied by 20, multiplied by 1 1-10, equal 792 grains, and 120 pounds, the weight of the patient, multiplied by 6, equals 780 grains, practically the same re sult. Urinary solids are a deadly poison when given in sufficient dosage, and all patients suffering from renal insufficiency should be regarded as poisoned patients. A diminution of 20 or 30 per cent. in the amount of urinary solids excreted is not incompatible with reasonably good health, but when we find the amount diminished 50 per cent or 60 per cent. our patient is in a far from satisfactory condition, and surgical operations of all kinds should be postponed until this condition can be rectified, otherwise the anaesthetic may so increase this disorder as to cause suppression and death. The presence of albumin does not of itself necessarily contra indicate operation. It may be transitory and due to some acute disorder, or to a faulty metabolism of the nitrogenous food products. It may be fairly constant, but due to the pressure of a large tumor on the renal veins, in this case it usually entirely disappears after operation, or it may be due to an inflammation of the urethra, bladder, ureter or pelvis of the kidney. Albuminuria, when due to any of the extraneous causes just mentioned, does not necessarily influence the prognosis. The great difficulty is in positively deciding that it is due to some of these causes, and not to an organic renal disease. The presence of tube casts always denotes an organic disease of the kidneys, and is therefore of far more serious import than the presence of albumin. Even though albumin and tube casts are present, if the kidneys are sufficiently free from disease to allow a normal amount of urine of proper specific gravity to be secreted, the prognosis is good. Where this condition exists, the strictest asepsis should be observed in order to prevent an undue amount of work being thrown on the already damaged kidneys. If, however, on the other hand, we have a renal insufficiency with a trace of albumin and tube casts, the prognosis is decidedly unfavorable. This combination of symptoms, indicating a chronic interstitial nephritis, is a positive contraindication to any abdominal operation, even though but a few minutes should be required for its performance. Ether and chloroform may, and often do, cause a marked congestion of the kidneys, but upon the normal kidney this congestion is usually transitory, and while there may be a trace of albumin it usually disappears within a few days. Should there, however, be an organic disease, this congestion may reach such a degree as to cause complete suppression and death. In well marked renal insufficiency, even though careful chemical and microscopical examination fails to reveal any organic disease, the anaesthetic is equally as injurious as it is in well marked organic disease. The kidneys in this condition are excreting a diminished amount of the urinary solids and the congestion caused by the anaesthetic still further decreases this amount and produces suppression, uræmia and death. They were already staggering under an overload and threatening to cease work, and the additional strain, slight though it might be, simply causes them to break down entirely. This I belive to be a reasonable explanation of the cause of suppression in those cases where no trace of albumin or casts. could be found prior to operation. In the case I wish to report, I can offer no other explanation of the couse of suppression. The urine was examined a number of times, but no trace of albumin or casts was ever found. There was a marked diminution in the amount of urinary solids excreted, although at that time, I am frank to confess, I failed to realize its importance. A brief history of this case will be of in terest: Mrs. W., at 36, white multipara. Menstruation normal until past few months. Was told she had lacerated cervix 6 years ago. Present history: Present trouble first noticed Sor 10 months. ago. Neuralgic pains in womb. Spotting after intercourse. Profuse leucorrhoea, which has recently become very offensive and blood tinged. During the past two months irregular and on four different occasions very free bleeding from womb. Rapidly losing strength and flesh. Examination: Vagina filled with fungating mass springing from cervix. Body of tumor hard, nodular. On right side extending three-fourths of an inch on vaginal wall. Diagnosis-Carcinoma.. Operation: Abdominal hysterectomy, by Clark's method. Uterine arteries dissected out and ligated close to internal iliac artery one inch from uterus. Ureters loosened from their bed in base of broad ligaments and lifted out of the way by traction ligatures passed under them. Entire broad ligaments removed. Cuff of vagina removed with uterus, on right side, an inch in width. Irrigation no drainage. Anæsthetic, ether. Time of operation 24 hours. Course after operation: Shock very severe when put to bed, but had recovered from it in five hours. Rapid uræmic intoxication and death in 46 hours. Urine: Repeated examinations extending over a period of three weeks preceding operation failed to show albumin or tube casts. Urine scanty, but exact amount voided in twenty-four hours not noted. Specific gravity, 1016 to 1020. After operation very little urine secreted. Bladder emptied by catheter before removal from table. Very restless and kept constantly complaining of desire to void urine Catheter again used in two hours and two ounces of urine obtained. Was again used two hours later, but only an ounce of urine obtained this time. From that time until death occurred, not more than a half once of urine altogether was secreted. No autopsy held. Dr. T. W. Cleveland, against whom a charge for manslaughter was recently brought for causing the death of an infant, has been discharged from custody on the ground that there was no evidence to warrant a trial. By Park Weed Willis, M. D., Seattle, Washington. [Read before the Washington State Medical Society, May 10th, 1898.] The treatment of tuberculosis is still so unsatisfactory that our best efforts should be put forth for its prevention. About one death in six throughout the civilized world is due to tuberculosis. With this frightful mortality we should certainly be dissatisfied and strive for better results. Physicians look back with the greatest pride on the achievements and advancements in the science of medicine during the past twenty years. But what will be the judgment of another generation, twenty years later, when tuberculosis is reported and looked after as it should be, and as far as possible sources of infection removed; when they look back on our work when every one is allowed to expectorate where he pleases. on sidewalks, in public conveyances, and in fact everywhere to sow the seed of tuberculosis? What would they think, for instance, should they happen to glance over our own Seattle records and find that such a harmless disease as rotheln must be reported, while tuberculosis, the destroyer of at least fifteen per cent. of the human race, is totally ignored? Both the medical profession and the laity look on the present conditions as a matter of course, and so the disease continues to spread. "Vice is a monster of so frightful mien, We first endure, then pity, then embrace." And so it is with the propagation of tuberculosis according to present methods. We have endured, pitied, and are now |