Before the American Surgical Association in 1896, Dr. W. W.
Keen' read a paper with tables of 155 cases, not including those of
Maas. In the same year Kiister^ published a study of 306 cases.
In 1899, Tuffier* contributed an investigation into 198 cases. Del-
bet,** in 1901, went over the literature and analyzed 320 cases. In
1903, Dr. Francis S. Watson^ wrote a most admirable, exhaustive,
and analytical paper, based on 660 cases, including all published up
to June of that year, 6 being cases of his own. In February of the
present year. Dr. A. H. Barkley* published a "Tabulation of Cases
and Bibliography of Ruptured Kidney," comprising 95 cases. Of
these, however, all but 16 are included in the period covered by
Watson's paper. In addition to these 16 cases, published since
June, 1903, given in Barkley's table, the writer has been able to
find in the literature, from that time to date, reports of 14 more,
which, with the 4 here reported, make a total of 34 cases recorded
since Watson's paper. The 14 cases alluded to have been re-
ported by Mathieson,® Riddell,i^ C. A. Smith," Cahen,'^ Mauclaire,*'
Chaput" (3 cases), Edington,*^ Michel, *« Ninni,*^ Franklin," C. B.
Keetley,'' and M. B. Miller.'°
A study of these papers, tables, and case reports has been made
with the object in view of ascertaining the results of surgical treatment
of rupture of the kidney by packing, drainage, or suture of the renal
wound, as compared with those of nephrectomy, and of determining
the limitations within which conserv^ative treatment may properly
be employed. At the outset it is obvious that the comparison is
not entirely a fair one, since it has to deal with the results of injuries
which, in different cases, vary in extent, and which may or may not
be associated with other and often grave injuries, as laceration of
the peritoneum with hemorrhage into the abdominal cavity, injury
Digitized by
Google
neilson: rupture of the kidney 379
of the abdominal viscera, or injuries of other parts of the body, of
themselves threatening life.
The highest mortality in subparietal injuries of the kidney is
found in the cases not treated by surgical measures. Watson's
analysis gives 270 cases, without complication, subjected to ex-
pectant treatment, with 81 deaths — mortality 27 per cent.; and in
56 with complications, and treated expectantly, there were 51
deaths — ^mortality 91 per cent. Keen, comparing the results of
cases in which nephrectomy was done with those in which it was
not, found a death rate in the former of 36.4 per cent., and in the
latter 44.2 per cent.
As to the comparison between the results of treatment by con-
servative operation and those of nephrectomy, Watson's sta-
tistics favor the former procedures. Thus, he found that in 99
cases free from complication, treated by operations other than
nephrectomy, there were but 7 deaths — mortality 7 per cent.; and
that in 15 complicated cases so treated there were 7 deaths — a mor-
tality of 46 per cent. In 115 cases not complicated and treated by
nephrectomy, there were 25 deaths — mortality 21 per cent. ; and in 45
cases having complications, 19 deaths, or a mortality of 42 per cent.
From the 34 cases, including those of the writer now reported,
added to the literature since the publication of Watson's paper, the
following statistics are obtained:
Cases without Complications.
Treated by conservative operation: Cases. Deaths.
Lumbar incision, suture of renal wounds, with drainage . . 2 o
Lumbar incision, gauze packing, or drainage:
Primary 5 2
Secondary i o
Nephrectopiies:
Lumbar, primary 6 2
Lumbar, secondary 5 2
Abdominal, primary 5 i
Abdominal, secondary i o
Cases with Complications.
Gauze packing and drainage, primary 2 o
Gauze packing and drainage, secondary' i o
Nephrectomies:
Lumbar, primary .2 o
Abdominal, primary 4 2
Digitized by
Google
3^ neilson: rupture of the kidney
Of the II cases treated by gauze packing, suture of the kidney or
drainage, 2 died — mortality 18.1 per cent. The causes of death
were shock and collapse in i case; secondary hemorrhage in the
other.
Of the 23 cases in which the kidney was removed, 7 died — a.
mortaUty of 30.4 per cent. The causes of death were: suppres-
sion of urine, 2; septicemia, i; shock and hemorrhage, 2; peri-
tonitis, i; not stated, i.
The showing in cases not dealt with by nephrectomy is so favor-
able, as compared with those in which the organ was removed,
that it cannot fail to attract attention. It may be said that prob-
ably the difference is largely due to the fact that in the cases so
treated the kidney was less severely injured than it was in those in-
cluded in the other group. This, however, does not apply to many
of the cases, for in some of them which the writer has studied the
kidney had suffered greater traumatism than in some of those in
which nephrectomy was done.
Surgical interference in rupture of the kidney b called for in the
first place, for the control of the hemorrhage and the prevention of
extravasation of blood or of urine into the tissues, or into the ab-
dominal cavity, in case the peritoneum be torn; secondly, for the
treatment of injuries of other organs which may have occurred
in addition to that of the kidney; third, to place the injured
kidney, whenever possible, under circumstances most favorable
to repair; and, lastly, to provide means against the occurrence of
infection.
When there are sufficient grounds for belief that hemorrhage is
taking place, lumbar tumefaction, severe or persistent hema-
turia, evidence of fluid in the abdomen, with constitutional proofs
of bleeding; or if in addition to indications of lesion of the kidney
there be signs indicating the possibility of injury of the intestines
or other abdominal organs, operation should be done without
delay.
So-called expectant treatment is permissible only in cases in
which the local symptoms are insignificant, constitutional symp-
toms absent, and slight hematuria alone directs attention to the
Digitized by
Google
neilson: rupture of the kidney 3&I
probability of renal injury. Of cases of this type there are not a
few, and to their almost invariable recovery can be given the
largest .share of the credit due to non-surgical treatment.
When operation is to be done, the choice as to whether the abdo-
men should be opened, or the renal r^ion alone exposed by lum-
bar incision, must be made after consideration of the symptoms
presented in individual cases. Rigidity of the abdominal muscles,
with general or localized tenderness, or dulness in the flanks on
percussion, if present in addition to tumefaction and tenderness in
the lumbar region, should make the decision in favor of laparotomy;
while the absence of signs, except in the lumbar region, or the pre-
dominance of the latter, indicate lumbar incision as the proper
course to pursue. Should abdominal section be done, the loin also
should be opened, to provide for dependent drainage, whether the
kidney be removed or not.
Should lumbar incision be chosen, the kidney having been ex-
posed and brought out of the wound, blood and clots having been
first removed from the surrounding region, hemorrhage tempo-
rarily controlled by pressure of the organ or its pedicle, and the
extent of the injury ascertained, the question arises as to whether
or not the organ may be spared. In those instances in which the
violence has been so great as to pulpefy it completely, or for the most
part, no more doubt as to the necessity of its removal can be enter-
tained than could arise if the kidney be found entirely severed from
its pedicle. Likewise, should nephrectomy be done, if one of the
main vascular branches has been torn, fatally interfering with the
circulation in a large portion of the organ. And, again, no other
course of action should be considered, but the removal of a surgi-
cally diseased kidney, if ruptured.
But other cases will occur in which a single or even two clean
tears nearly or quite divide the kidney; and others, more in number,
having several or many more or less deep lacerations and contu-
sions at other points, in which an effort to save the organ is justifi-
able. The ease and promptness with which repair of wounds of the
kidney takes place is well recognized. It is relied upon in our
operations of nephrotomy, whether done for the removal of stone
Digitized by
Google
382 neilson: rupture of the kidney
(in which cases more than one wound through the substance of
the kidney are not seldom made), or for other causes.
It seems, therefore, to be entirely reasonable that every attempt
should be made to save the ruptured kidney, if there seem to be fair
grounds for thinking that its vitality is not threatened beyond
reasonable hope, or that enough secreting tissue is likely to sur-
vive the injury to make preservation of the organ worth the while.
Should a portion only of the kidney be badly mutilated, or even
detached, it need not necessarily cause sacrifice of the whole of it.
Partial is preferable to complete removal.
For the control of hemorrhage, the firm packing of gauze, either
plain sterile or iodoform gauze, into or against the wounds, whether
of the substance of the kidney or of its pelvis, is entirely reliable,
and, more than that, can be quickly done, which is a point of
value, and, in addition, it serves well for drainage. Loops of
gauze passed beneath each pole of the kidney before it is replaced
serve not only to hold it in position, but afford firm support to the
packs, which can be introduced through the lumbar wound be-
tween the ends of the hammock strips. For the drainage of any
dead spaces that may remain outside of the packed area, rubber
tubes should be inserted.
Another, and, when applicable, perhaps a neater way of con-
trolling hemorrhage, is approximation of the renal wound or
wounds by means of mattress sutures of chromicized catgut. This
measure does not seem to have met with general favor, however,
or else the number of cases in which it could be employed is small,
for Watson mentions but 8 instances, and the writer has found only
2 more in the cases since recorded, making in all 10 cases in 125
treated by conservative operation. Mathieson reports a case in
which there were two large wounds transversely from the hilum,
one of them almost bisecting the kidney. Catgut sutures controlled
the bleeding effectually, and in three weeks recovery was com-
plete. In a case reported by Chaput a single tear of the kidney
was sutured. This patient also recovered, but bleeding from the
wound continued for three weeks, and healing was not complete
until three months had elapsed.
Digitized by
Google
neilson: rupture of the kidney 383
In* Cheyne and Burghard's Manual of Surgical Treatment^
suture of the kidney is spoken of as "much superior" to plug-
ging, "and should be adopted whenever possible/' It is suitable,
however, in the writer's judgment only when the renal injury
consists of one or more clean tears, and when the question of
brevity of the operation does not have to be entertained; but
when the wounds are lacerated and multiple, or when haste in
operating is imperative, it is not available. If employed, drainage
should be secured by a rubber tube.
Every recorded case in which the kidney wounds were sutured
recovered, and in all but one of them the time of recovery was
decidedly shorter than in the cases treated by gauze packing.
But, while recovery from operation was prompt in all but i of
the cases (Chaput's), the ultimate result in 2 — i recorded by
Delbet and i by Watson — ^was not satisfactory. Secondary
nephrectomy became necessary in Delbet's case, and was fatal;
and in Watson's, a pseudohydronephrosis, with fistula, resulted.
In only i of the 5 cases which the writer has had could
suturing have been done. In Case II, in which death from sec-
ondary hemorrhage took place, it may be that a different result
would have been obtained if the single, clean, transverse tear had
been closed by stitches. Should I meet with a similar case, and
circumstances permit, I should suture the rent.
In spite of the advantage apparently offered by suturing, how-
ever, especially the shortening of the period of recovery, the num-
ber of cases to which it is adaptable must be small, and gauze pack-
ing, satisfactory both for hemostasis and drainage, must be relied
upon in a larger number.
It must be admitted that there are some disadvantages attend-
ing the latter method, chief among which are the length of time
required for healing of the wound, and the possible development
of a fistula. Then there is the possibility of secondary hemor-
rhage, which has occurred in a few cases, and the chance — a small
one — should infection of the damaged kidney or of the perirenal
space occur, of its being conveyed by way of the bladder to the
opposite kidney.
Digitized by
Google
384 neilson: rupture of the kidney
It is quite true that the time required for healing is much Ignger
than it is when nephrectomy is done, and this is unavoidable. As
to urinary fistula, it has, in the recorded cases, been persistent
in but a very small number, and in the cases of the writer which
recovered it healed without difficulty. Should it, however, resist
all ordinary measures to induce healing, nephrectomy may ulti-
mately be required. Secondary hemorrhage has occurred in but
a very few of the cases treated conservatively, and can usually be
controlled by packing, as in the first place, and a further attempt
made to save the kidney. The conveyance of infection to the
opposite kidney is, if proper attention be given to the bladder,
practically a remote contingency, and should not be given undue
weight.
The final question is whether the disadvantages of conservative
treatment of the injured kidney are of greater moment to the
patient than its loss would be, and whether the slight risks are not
fully compensated for by the preservation of an organ of such
vital importance.
A word as to the care of the bladder. It is of the utmost im-
portance that it should be freed of blood and clots, whether by
washing wdth boric-acid solution or normal saline solution, which
will usually suffice, or by the evacuator tube, if so filled with clot
that washing is not effectual; or, if that means fails, by supra-
pubic cystotomy, which may also be required should a tight
urethral stricture prevent the use of a catheter. For some days
after injury irrigation of the bladder should be done, and, in addi-
tion, as a further safeguard against infection of the bladder,
urinary antiseptics may advantageously be given by the mouth.
References.
1. T. R. Neilson. Annals of Surgery, 1903, xxxviii, 121.
2. H. Maas. Deutsche Zeitschr. f. Chir., 1878, 10, 126.
3. W. W. Keen. Trans. Amer. Surg. Assoc, 1896, xiv, 293.
4. Kuster. Die Chirurg. Krank. der Nieren. Deutsche Chirurgie, Lief. 52 b.,
196, Stuttgart, 1896.
5. Tufl5er. Duplay et Reel us* Traits de Chirurgie, 1899, 2d ed., vol. Wi, 164.
6. P. Delbet. Ann. des Mais- des Org. Genit.-Ur., 1901, xix, 669, 805.
7. F. S. Watson. Boston Med. and Surg. Jour., 1903, cxlix, 29.
Digitized by
Google
neilson: rupture of the kidney 385
8. A. H. Barkley. Louisville Monthly Jour. Med. and Surg., 1907, xiii, p. 307.
9. A. L. Mathieson. Quart. Med. Jour., Sheffield, 1902-3, xi, 134.
10. J. S. Riddell. Scot. Med. and Suig. Jour., Edinburgh, 1903, xiii, 54.
11. C. A. Smith. Northwest Med., Seattle, 1903, i, 385.
12. F. Cahen. Miinchen. med. Wochenschr., 1903, 1, 2205.
13. Mauclaire, Cresson and Kuss. Bull, et M6m. Soc. Anat. de Paris, 1904,
14. Chaput. Bull, et M^m. Soc. de Chir. de Paris, 1905, N. S., xxxi, 402.
15. G. H. Edington. Glasgow Med. Jour., 1905, bdii, 136.
16. G. Michel. Rev. M^. de I'Est., Nancy, 1905, xxxvii, 84.
17. G. Ninni. Gior. Intemaz. d. Sc. Med., Napoli, 1905, N. S., xxvii, 635.
18. A. L. Franklin. Amer. Jour. Surg., 1906, xx, 309.
19. C. B. Keetley. West London Med. Jour., 1906, xi, no.
20. M. B. Miller. Annals Surg., 1907, xlv, 306.
ai. Cheyne and Buighard. Manual of Surgical Treatment, 1903, Part VI,
Section II, Chap, xix, 191.
Aim tiiiift, 25
Digitized by
Google
A CASE OF OIDIOMYCOSIS (BLASTOMYCOSIS) WITH
RAPID GENERALIZATION, THE EARLY LESIONS
SIMULATING GIANT-CELLED SARCOMA;
DEATH IN SIX MONTHS.
By WILLIAM B. COLEY, M.D.,
NEW YORK,
AND
MARTHA TRACY, M.D.,
NEW YORK.
On January 21, 1907, I saw, in consultation with Dr. Geo. E.
Reed, of Brooklyn, a patient whose history is as follows:
F. N., aged twenty-seven years, policeman by occupation, of un-
usual physical development, 6 feet 3 inches in height; weight, 270
l)ounds. The man's health had always been good; the only thing
in the previous history that might possibly have some bearing upon
the etiology was the fact that while bathing in the early part of
August he cut his left foot with a clam shell. The foot swelled and
was quite painful for the next few days, without, however, detain-
ing him from his regular work. On about December ist he was
taken with a severe attack of pain in the lumbar region, which he
regarded as lumbago, and which kept him confined to the house.
Two to three days later he began to have severe pain in the dorsal
region of the left foot, which became markedly swollen, the swelling
apparently starting over the second or third metatarsal bone and
quickly involving the entire dorsum of the foot. After a few days
it showed signs of fluctuation, and at the end of ten days a small
sinus appeared between the great and second toes, from which
there exuded dirty, pus-like material; the skin, while tense and
distended, was not reddened. About a week later a similar lesion
Digitized by
Google
COLEY, TRACY: OIDIOMYCOSIS 387
developed on the dorsum of the other foot, and on the outer aspect
of the right thigh, just above the knee, two small flat papillary
tumors appeared in the skin itself. These were irregulariy circular
in shape, depressed in the centre, with indurated edges, slightly ele-
vated above the normal skin. They became quickly covered with
crusts which, on removal, showed a small collection of pus-like ma-
terial in the centre. The patient states that he often scratched and
picked around these ulcers and later scratched his face. Whether
as a result of auto-inoculation or not, about a week later similar
small papillary tumors developed in the face, the number and char-
acter of which are well shown by the accompanying figure. The
lesions upon the face were larger and more protuberant than those
just described upon the thigh, projecting about one-quarter to one-
third of an inch above the surrounding surface; they were red-
dened and indurated at the base, soft in the centre, and quickly
covered by thick scabs or crusts. These could be easily picked off,
and always showed underneath a few drops of yellowish pus.
Almost simultaneously with the skin lesions described, there de-
veloped numerous subcutaneous tumors widely distributed over
various parts of the body, but chiefly in the thighs and arms. These
tumors varied from the size of a hazelnut to that of a small egg;
they always began subcutaneously or in the deep layer of the skin,
appearing first as smooth, spherical tumors of moderately firm con-
sistence, scarcely raised above the level of the skin. As, after a
few days, they increased rapidly in size, they became much more
protuberant, the skin showed attachment in the centre; they soon
showed signs of fluctuation, and, after a few days, the entire tumor
seemed little more than an abscess cavity. If left to themselves
they usually broke after a week or ten days, discharging a dirty,
cream-colored material. Coincidently with the appearance of
the first tumors, the patient began to have a dry, hacking cough,
which is almost constant, and which has persisted steadily up to the
present time, refusing to yield to any form of treatment. The
patient's general health deteriorated very rapidly; within the first
three weeks he lost sixty pounds in weight. Two weeks after the
beginning of the symptoms one of the small subcutaneous tumors
Digitized by
Google
388 COLEY, TRACY: OIDIOMYCOSIS
was removed before it ruptured, and microscopic examination was
made by Dr. Van Cott, of Brooklyn, who pronounced it giant-
celled sarcoma.
The patient was admitted to my service at the General Me-
morial Hospital on January 23, seven weeks after the beginning of
the disease and two days after I first saw him, at which time his
condition was as I have just described. In addition to the two
superficial papillary skin lesions on the right thigh, as mentioned,
there were five or six similar lesions in the face and about twenty
of the subcutaneous tumors in different parts of the body. The
course of the disease, since his admission to the hospital, has been
briefly as follows: Photographs and drawings were made three
days after his admission, or at the end of the third week of the dis-
ease. On January 25, after carefully sterilizing the skin, and under
all possible aseptic precautions, I opened several of the subcu-
taneous tumors, and Dr. S. P. Beebe, of the Huntington Cancer
Research Fund, made cultures upon a large variety of media, and
several dogs and guinea-pigs were inoculated with the material.
As none of the culture tubes showed any growth at the end of four
days, they were thrown away. A section of the wall of one of the
tumors was examined by Dr. James Ewing, and although the gen-
eral appearance was strikingly like that of a giant-celled sarcoma,
one or two round bodies, characteristic of the blastomycosis organ-
ism, were found, and the diagnosis of blastomycosis was made.
In the opinion of Dr. Ewing, the giant cells were more like foreign
body giant cells than those seen in sarcoma. This organism is of
much slower growth than pyogenic bacteria, seldom showing
growth before the fourth day, which accounts for the fact that our
previous cultures were considered sterile. I, thereupon, opened
several other tumors, also the large swelling upon the right foot,
from which about four ounces of material of the consistence of
cream, but much darker in color than the fluid removed from the
subcutaneous tumors, was evacuated. New cultures were made by
Drs. Bcebe and Tracy, and on about the fourth day they began to
show pure cultures of the organism. The accompanying figures
show its appearance at different stages before and after budding.
Digitized by
Google
COLEY, TRACY: OIDIOMYCOSIS 389
Animal inoculations were made with the pure cultures, with the
result as shown by Dr. Tracy's report :
PATHOLOGICAL REPORT BY DR. MARTHA TRACY.
The tissue sent for examination was cut from the wall of a sub-
cutaneous abscess. It was of a rather pale-pink color and medium
firmness. Fixation was in Mliller formol and staining with hema-
toxylin and eosin.
Microscopic examination shows tissue composed of rather loose
stroma and abundant round cells. Very many of the cells are
polynuclear leukocytes. Others, less numerous, are larger, more
or less epithelioid in type, with large vesicular nuclei. Large
giant cells are also present. These are particularly abundant in a
section from the original abscess in the foot. The giant cells are
of a characteristic type, containing six or more large nuclei, cen-
trally placed. Many new-formed bloodvessels are present, and
here and there collections of free red blood cells. The whole ap-
pearance is typical of an active inflammatory reaction.
Throughout the section, and often within giant cells, are seen the
spherical forms of the oidiomyces. The bodies are granular and
their nuclei take the hematoxylin stain. They contain refractile
points, and the double refractile contour is conspicuous. Some
of the giant cells contain four or more of the organisms of various
sizes.
No endogenous cell division is observed, but occasional bud-
ding forms are seen.
Sections from lesions involving the skin show considerable dip-
ping down into the corium of cords of epithelial cells. In sections
of tissue from an experimental subcutaneous lesion in a dog the
microscopic appearance is similar, save that the giant cells are less
numerous. Rather sharply limited aggregations of leukocytes are
noted about the periphery of which the spherical organisms are
numerous. Here several budding forms are found.
Pus from the abscesses in moist show very many spherical and
budding forms of the organisms. A hanging drop of the pus in