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Related post: wholly relieved of the pain though the stone in
the ureter remained. I believe it must be excep-
tional to have a stone in the lower end of a disused
ureter give trouble. I can call to mind three cases
where there is a quiescent stone in the lower end of
such a ureter. In each of these cases the kidney,
which was destroyed as a result of the unrecognized
ureteral stone, had been removed, but the stone
itself remained and seemed to cause no symptoms.
On another patient in this group I made an at-
tempt some years ago to do a plastic operation on
a moderate sized hydronephrosis — her kidney held
seventy-five c.c. of residual urine. The cause of this
hydronephrosis was apparently a definite bandlike
narrowing of the ureter just below its junction with
the kidney pelvis. There was a mild infection in
this patient's kidney pelvis, but as it seemed very
mild, a plastic operation was carried out at the site
of the ureteral narrowing. The kidney was not
drained. This procedure was apparently success-
ful, and the patient did very well for the follow-
ing two weeks.
She then began to have a high temperature with
turbid urine and pain in her loin. A secondary
nephrectomy was done about a month after her
primary operation. The principle of adequate drain-
age through a cortical incision, that was discussed
when considering the question of pyelolithotomy,
was neglected in this case, "and I believe that it was
the neglect of this precaution that made it neces-
sary to carry out secondary nephrectomy. Another
patient in this group was operated upon only a
month or so ago; the patient, a young man, had
had his left kidney cut down upon two and one
half years before, but apparently no procedure on
the kidney itself was carried out. He had tem-
porary relief only, followed by a recurrence of the
pain, frequency, and turbid urine. The excised
kidney showed a moderate Nortriptyline Mg grade of pyelonephritis
with kidney cortex considerably atrophied. The
breaking up of the adhesions or whatever opera-
tion had been carried out had not offered the kid-
ney sufficient help to permit it to overcome its
infection ; another instance in which adequate drain-
age was neglected.
In another of these cases a man in his forties
had first shown painless hematuria a month before
an Nortriptyline 10 Mg exploration of the bleeding kidney was carried
out. An incision Generic Nortriptyline was made from the cortex to
the pelvis without recognizing any evident patho-
logical process, a tube was carried down to the
pelvis, and the kidney sewed up about this tube.
Thirty-six hours after operation this man began
to bleed so sharply that secondary nephrectomy was
done. The removed kidney showed a large infarct
which was believed to be the primary process,
though not recognized at the time of operation.
The patient made a good recovery.
The last case in this group was that of a man
with large but movable hypernephroma, on whom
an attempt had been made to remove this growth
through a loin incision, but because of hemorrhage
this had to be given up and the wound packed.
Some four months later when the patient learned
that his kidney had not been removed he was very-
insistent that an attempt be made to do it. The Nortriptyline 25 Mg
kidney was exposed by an anterior incision and
after considerable trouble was freed, all but at one
])oint, just above the hilum. A clamp was put on here,
the adhesions cut, and the kidney removed. In tying
off it was found that this clamp was upon the vena
cava. Several attempts at tying and sewing were
unsuccessful. The clamp was then adjusted so as
to control the bleeding with as little obstruction as
possible to the lumen of Buy Nortriptyline the vein and was left.
There was some oozing following the operation ;
he became worse and died some five hours later.
As I have previously mentioned, there is no
standardized technic for secondary nephrectomy.
Some modifications, however, of the technic of
jjrimary nephrectomy are required to adapt it to
this purpose ; these are made necessary because of
the anatomical changes brought about by long
standing suppuration. We find a discharging
sinus in the loin in a very large proportion of the
cases in which we are called upon to do a sec-
ondary nephrectomy. The presence of this sinus
makes it rather easier to do our various function
tests, whether they are color tests, induced polyuria,
or simply the collection of the kidney output under
normal circumstances. From a surgical point of
view, however, the disadvantages of a discharging
siiuis far outweigh its advantages.
As a general rule, a secondary nephrectomy is
harder to do the longer the time that elapses
between the primary operation and the secondary
one, since the longer the time the denser the in-
flammatory adhesions become and the greater the
distortion due to their contraction. It is this dis-
tortion Nortriptyline 25mg and the loss of the usual anatomical rela-
tions that add so much to the difficulty and dangers
of the operation. Order Nortriptyline Online
The most generally useful incision to employ in
secondary nephrectomy, cs])ecially in a ca.se in
which there is a sinus, and three fourths of the
934
CHUTE: SECONDARY NEPHRECTOMY.
[New Vork
Medical Journal.
cases have these, is an elliptical one that surrounds
the old scar. There are several ways of treating
the sinus itself, the object of which is to prevent
or minimize the contamination of the operative field
by urine or pus. A cuff of tissues may be dissected
up immediately surrounding the sinus and clamped
or tied as one would fold over or tie a bag; this
is rather the most satisfactory plan when it is pos-
sible ; it prevents effectually any spilling of pus
and urine over the operative field while Nortriptyline 10mg handling
the kidney. Another simple way is to plug the sinus
with a bit of gauze ; in a few cases where there
is very little discharge one need Nortriptyline 25 do nothing more
than swab out the sinus with a little Cheap Nortriptyline iodine. In a
considerable number of cases, especially long stand-
ing ones, the kidney will be found right under the
scar of the previous operation and very closely
adherent to it, so much so that one recognizes no
line of cleavage between the two. An unguarded
incision may open into the kidney tissue and start
a sharp oozing which obscures the field, if nothing
worse. For this reason it is well to make one's el-
liptical incision rather wide of the edges of the
scar and to carry this down cautiously that one may
avoid injury to the kidney substance should it Buy Nortriptyline Online be

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