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Studies in Fuzziness and Soft Computing

Urszula Bentkowska

Interval-Valued
Methods in
Classifications
and Decisions
Studies in Fuzziness and Soft Computing

Volume 378

Series editor
Janusz Kacprzyk, Polish Academy of Sciences, Systems Research Institute,
Warsaw, Poland
e-mail: [email protected]
The series “Studies in Fuzziness and Soft Computing” contains publications on
various topics in the area of soft computing, which include fuzzy sets, rough sets,
neural networks, evolutionary computation, probabilistic and evidential reasoning,
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significant recent developments in the field, both of a foundational and applicable
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results.
Indexed by ISI, DBLP and Ulrichs, SCOPUS, Zentralblatt Math, GeoRef,
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Urszula Bentkowska

Interval-Valued Methods
in Classifications
and Decisions

123
Urszula Bentkowska
Faculty of Mathematics and Natural
Sciences
University of Rzeszów
Rzeszów, Poland

ISSN 1434-9922 ISSN 1860-0808 (electronic)

Studies in Fuzziness and Soft Computing
ISBN 978-3-030-12926-2 ISBN 978-3-030-12927-9 (eBook)
https://doi.org/10.1007/978-3-030-12927-9

Library of Congress Control Number: 2019930980

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To my Family and Friends,
especially to my Parents
Preface

I saw the need, but I did not know how to satisfy it. I posed
the problem to my best friends, Herbert Robins and Richard
Bellman, because as mathematicians they were better qual-
ified than I was to come up with a theory which was needed.
Both were too busy with their own problems. I was left on my
own.
Lotfi A. Zadeh [1]

Since the seminal paper on fuzzy sets was published [2], plenty of books and papers
devoted to the topic of fuzzy sets theory, its extensions and applications appeared.
According to the Web of Science, there are over 198,000 works with the fuzzy as a
topic. Among them, there are also works of the best friends mentioned in the
quotation by Lotfi Zadeh (e.g., [3]). The author of this monograph also would like
to contribute to the subject of fuzzy sets, especially interval-valued fuzzy sets,
which are one of the most important and developing generalizations of the fuzzy
sets theory. However, the presented results may be also advantageous to the whole
community, not only fuzzy, but more generally involved in research under uncer-
tainty or imperfect information.
Fuzzy sets theory and its extensions are interesting not only from a theoretical
point of view, but also they have applications in many disciplines such as computer
science and technology. Fuzzy sets turned out to be effective tools for many
practical applications in all areas, where we deal with natural language and per-
ceptions. Fuzzy sets and fuzzy logic contributed to the development of the artificial
intelligence and its applications. Fuzzy sets theory and its diverse extensions are
still one of the most important approaches for dealing with uncertain, incomplete,
imprecise, or vague information. The aspect of data uncertainty is studied inten-
sively in many contexts and scientific disciplines. Many different forms of uncer-
tainty in data have been recognized. Some come from conflicting or incomplete
information, as well as from multiple interpretations of some phenomenon. Other
arise from lack of well-defined distinctions or from imprecise boundaries. It is
impossible to eliminate completely uncertainty and ignorance from everyday
experience of scientists, specialists in various fields, and also the life of an average
man. According to Lotfi A. Zadeh As complexity rises, precise statements lose

vii
viii Preface

meaning and meaningful statements lose precision. This is why there is a need to
develop effective algorithms and decision support systems that would be able to
capture the arising problems.
The main aim of this monograph is to consider interval-valued fuzzy methods
that improve the classification results and decision processes under incomplete or
imprecise information. The presented results may be useful not only for the com-
munity working on fuzzy sets and their extensions, but also for researches and
practitioners dealing with the problems of uncertain or imperfect information. The
key part of the monograph is the description of the original classification algorithms
based on interval-valued fuzzy methods. The described algorithms may be applied
in decision support systems, for example, in medicine or other disciplines where the
incomplete or imprecise information may appear (cf. Chap. 4), or for data sets with
a very large number of objects or attributes (cf. Chap. 5). The presented solutions
may cope with the challenges arising from the growth of data and information in
our society since they enter the field of large-scale computing. As a result, they may
enable efficient data processing. The presented applications are based on theoretical
results connected with the family of comparability relations defined for intervals
and other related notions. We show the origin, interpretation, and properties of the
considered concepts deriving from the epistemic interpretation of intervals.
Namely, the epistemic uncertainty represents the idea of partial or incomplete
information. It may be described by means of a set of possible values of some
quantity of interest, one of which is the right one [4]. Since the subject is wide, we
mainly concentrate on theory and applications of new concepts of aggregation
functions in interval-valued fuzzy settings. The theory of aggregation functions
became an established area of research in the past 30 years [5]. Apart from theo-
retical results, there are many applications in decision sciences, artificial intelli-
gence, fuzzy systems, or image processing. One of the challenges is to propose
implementable aggregation methods (cf. [6]) to improve the usability of the pro-
posed ideas. Such methods provide a heuristic which may be conveniently
implemented and easily understood by practitioners. Moreover, another challenge is
related to the ability of including in the proposed solutions human-specific features
like intuition, sentiment, judgment, affect, etc. These features are expressed in
natural language which is the only fully natural means of articulation and com-
munication of the human beings. This idea led to considering aggregations inspired
by the Zadeh idea computing with words [7]. Computing with words (CWW) (cf.
[8]) has a very high application potential by its remarkable ability to represent and
handle all kinds of descriptions of values, relations, handling imprecision. There are
many aggregation methods that try, with success, to resolve the challenges of
nowadays problems (cf. [9–16]). In this book, we examine the so-called possible
and necessary aggregation functions defined for interval-valued fuzzy settings. One
of the reasons to consider these types of aggregation operators is connected with the
fact that these notions of aggregation functions were recently introduced [17] and
they have not been widely examined before.
Preface ix

The book consists of two parts. In the first part, theoretical background is pre-
sented and next in the second part application results are analyzed. In theoretical
part, in Chap. 1 elements of fuzzy sets theory and its extensions are provided. There
are presented the notions of interval-valued fuzzy calculus. Diverse orders applicable
for interval-valued comparing, including interval-valued fuzzy settings, are dis-
cussed. Furthermore, in Chap. 2 aggregation functions defined on the unit interval
½0; 1 are recalled and useful notions and properties are provided. Construction
methods of interval-valued aggregation functions derive from the real-line settings
and interval-valued aggregation functions often inherit the properties of their com-
ponent functions defined on the unit interval ½0; 1. All these issues will be presented
in Chap. 2.
Part II covers two major topics: decision-making and classification problems.
Chapter 3 is devoted to decision-making problems with interval-valued fuzzy
methods involved. It is pointed out the usage of new concepts with possible and
necessary interpretation involved. Next, the classification problems are discussed.
When classifiers are used there is a problem of lowering its performance due to the
large number of objects or attributes and in the case of missing values in attribute
data. In this book, it is shown that in such situations interval-valued fuzzy methods
help to retrieve the information and to improve the quality of classification. These
issues are discussed in Chaps. 4 and 5. In Chap. 4, there are proposed methods of
optimization problem of k-NN classifiers that may be useful in diverse computer
support systems facing the problem of missing values in data sets. Missing values
appear very often in data sets of computer support systems designed for the medical
diagnosis, where the lack of data may be due to financial reasons or the lack of a
specific medical equipment in a given medical center. Chapter 5 presents methods of
dealing with large-scale problems such as large number of objects or attributes in
data sets. Specifically, there is presented a method of optimization problem of k-NN
classifiers in DNA microarray methods for identification of marker genes, where
typically there is faced the problem of huge number of attributes. Finally, in Chap. 6,
there is presented the performance of the new types of aggregation functions for
interval-valued fuzzy settings in the computer support system OvaExpert [18].
The book ends with a brief description of the future research plans in the area of
presented problems, both in the theoretical and practical aspects.
The book is aimed at practitioners working in the areas of classification and
decision-making under uncertainty, especially in medical diagnosis. It can serve as
a brief introduction into the theory of aggregation functions for interval-valued
fuzzy settings and application in decision-making and classification problems. It
can also be used as supplementary reading for the students of mathematics and
computer science. Moreover, the results on aggregation functions may be inter-
esting for computer scientists, system architects, knowledge engineers, program-
mers, who face a problem of combining various inputs into a single output. The
classification algorithms considered in this book (in Chaps. 4 and 5), along with
other supplementary materials are available at [19], where there are provided
suitable files to download and run the experiments.
x Preface

I would like to thank Prof. Józef Drewniak for introducing me to the subject of
fuzzy sets theory. Moreover, I would like to thank other Professors that helped me
in better understanding the nuances of fuzzy sets theory, its extensions, and
applications. Namely, these are the following persons (listed in the alphabetical
order): Jan G. Bazan, Humberto Bustince, Bernard De Baets, Przemysław
Grzegorzewski, Janusz Kacprzyk, Radko Mesiar, Vilém Novák, and Eulalia
Szmidt. I am also grateful to my colleagues from Poland and abroad with whom I
cooperated working on scientific problems or whom I met during scientific con-
ferences. Especially, I would like to thank my colleagues from the University of
Rzeszów with whom we spent many hours on seminars discussing scientific
problems.
Finally, I would like to express my deepest gratitude to my family and friends
for their constant encouragement and support.

Rzeszów, Poland Urszula Bentkowska

October 2018

References

1. Zadeh, L.A.: Fuzzy logic–a personal perspective. Fuzzy Sets Syst. 281, 4–20 (2015)
2. Zadeh, L.A.: Fuzzy sets. Inf. Control 8, 338–353 (1965)
3. Bellman, R., Giertz, M.: On the analytic formalism of the theory of fuzzy sets. Inf.
Sci. 5, 149–156 (1973)
4. Dubois, D., Prade, H.: Gradualness, uncertainty and bipolarity: making sense of fuzzy sets.
Fuzzy Sets Syst. 192, 3–24 (2012)
5. Beliakov, G., Bustince, H., Calvo, T.: A Practical Guide to Averaging Functions. Studies in
Fuzziness and Soft Computing. Springer International Publishing, Switzerland (2016)
6. Albers, S.: Optimizable and implementable aggregate response modeling for marketing
decision support. Int. J. Res. Mark. 29, 111–122 (2012)
7. Kacprzyk, J., Merigó, J.M., Yager, R.R.: Aggregation and linguistic data summaries: a new
perspective on inspirations from Zadeh’s fuzzy logic and computing with words. IEEE
Computational Intelligence Magazine (forthcoming) (2018)
8. Zadeh L.A.: Computing with Words—Principal Concepts and Ideas. Studies in Fuzziness and
Soft Computing, p. 277, Springer (2012)
9. Blanco-Mesa, F., Merigó, J.M., Kacprzyk, J.: Bonferroni means with distance measures and
the adequacy coefficient in entrepreneurial group theory. Knowl.-Based Syst. 111, 217–227
(2016)
10. Castro, E.L., Ochoa, E.A, Merigó, J.M., Gil Lafuente, A.M.: Heavy moving averages and
their application in econometric forecasting. Cybern. Syst. 49(1), 26–43 (2018)
11. Castro, E.L., Ochoa, E.A, Merigó, J.M.: Induced heavy moving averages. Int. J. Intell.
Syst. 33(9), 1823–1839 (2018)
12. Liu, P., Liu, J., Merigó, J.M.: Partitioned Heronian means based on linguistic intuitionistic
fuzzy numbers for dealing with multi-attribute group decision making. Appl. Soft Comput.
62, 395–422 (2018)
13. Merigó, J.M., Palacios Marqu´es, D., Soto-Acosta, P.: Distance measures, weighted averages,
OWA operators and Bonferroni means. Appl. Soft Comput. 50, 356–366 (2017)
Preface xi

14. Merigó, J.M., Gil Lafuente, A.M., Yu, D., Llopis-Albert, C.: Fuzzy decision making in
complex frameworks with generalized aggregation operators. Appl. Soft Comput. 68,
314–321 (2018)
15. Merigó, J.M., Zhou, L., Yu, D., Alrajeh, N., Alnowibet, K.: Probabilistic OWA distances
applied to asset management. Soft Comput. 22(15), 4855–4878 (2018)
16. Zeng, S., Merigó, J.M., Palacios Marqu´es, D., Jin, H., Gu, F.: Intuitionistic fuzzy induce-
dordered weighted averaging distance operator and its application to decision making.
J. Intell. Fuzzy Syst. 32(1), 11–22 (2017)
17. Bentkowska, U.: New types of aggregation functions for interval-valued fuzzy setting and
preservation of pos-B and nec-B-transitivity in decision making problems. Inf. Sci. 424,
385–399 (2018)
18. Dyczkowski, K.: Intelligent Medical Decision Support System Based on Imperfect
Information. The Case of Ovarian Tumor Diagnosis. Studies in Computational Intelligence,
Springer (2018)
19. http://diagres.ur.edu.pl/*fuzzydataminer/
Contents

Part I Foundations
1 Fuzzy Sets and Their Extensions . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
1.1 Elements of Fuzzy Sets Theory . . . . . . . . . . . . . . . . . . . . . . . . . . 3
1.1.1 Basic Notions of Fuzzy Calculus . . . . . . . . . . . . . . . . . . . 4
1.1.2 Fuzzy Connectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
1.2 Elements of Interval-Valued Fuzzy Sets Theory . . . . . . . . . . . . . . 8
1.2.1 Basic Notions of Interval-Valued Fuzzy Calculus . . . . . . . 9
1.2.2 Order Relations for Interval-Valued Fuzzy Settings . . . . . . 12
1.2.3 Linear Orders for Interval-Valued Fuzzy Settings . . . . . . . 15
1.2.4 Possible and Necessary Properties of Interval-Valued
Fuzzy Relations . . . . . . . . . . . . . . . . . . . . . . . . . . . . .... 17
1.2.5 Interval-Valued Fuzzy Connectives . . . . . . . . . . . . . . .... 19
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .... 20
2 Aggregation in Interval-Valued Settings . . . . . . . . . . . . . . . . . . . . . . 25
2.1 Aggregation Functions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
2.1.1 Development of the Concept of Aggregation Function . . . . 26
2.1.2 Classes of Aggregation Function . . . . . . . . . . . . . . . . . . . 33
2.1.3 Dominance Between Aggregation Functions . . . . . . . . . . . 36
2.2 Classes of Aggregation Functions for Interval-Valued Fuzzy
Settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... 38
2.2.1 Interval-Valued Aggregation Functions with Respect
to the Classical Order . . . . . . . . . . . . . . . . . . . . . . . . ... 39
2.2.2 Pos-Aggregation Functions and Nec-Aggregation
Functions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... 42
2.2.3 Interval-Valued Aggregation Functions with Respect
to Linear Orders . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... 45

xiii
xiv Contents

2.3 Dependencies Between Classes of Aggregation Functions

in Interval-Valued Fuzzy Settings . . . . . . . . . . . . . . . . . . . . . ... 48
2.3.1 Interval-Valued Aggregation Functions Versus
Pos-Aggregation Functions and Nec-Aggregation
Functions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... 48
2.3.2 Aggregation Functions with Respect to Linear Orders
Versus Other Classes of Aggregation Functions in
Interval-Valued Fuzzy Settings . . . . . . . . . . . . . . . . . . ... 53
2.4 Construction Methods of Aggregation Operators
in Interval-Valued Fuzzy Settings . . . . . . . . . . . . . . . . . . . . . ... 55
2.5 Properties of Aggregation Functions in Interval-Valued Fuzzy
Settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... 58
2.6 Preservation of the Width of Intervals by Aggregation
Operators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... 62
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... 65

Part II Applications
3 Decision Making Using Interval-Valued Aggregation . . . . . . ...... 71
3.1 Preservation of Interval-Valued Fuzzy Relation Properties
in Aggregation Process . . . . . . . . . . . . . . . . . . . . . . . . . . ...... 72
3.2 Multicriteria Decision Making Algorithm . . . . . . . . . . . . . ...... 74
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...... 81
4 Optimization Problem of k-NN Classifier for Missing Values
Case . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
4.1 Construction of the Classifiers . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
4.1.1 Aggregation Operators for Interval-Valued Settings . . . . . . 85
4.1.2 Missing Values in Classification . . . . . . . . . . . . . . . . . . . . 87
4.1.3 k-NN Algorithm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
4.1.4 New Version of Classifier . . . . . . . . . . . . . . . . . . . . . . . . 91
4.2 Experiments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
4.2.1 Conditions of Experiments . . . . . . . . . . . . . . . . . . . . . . . . 93
4.2.2 Discussion and Statistical Analysis of the Results . . . . . . . 97
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
5 Optimization Problem of k-NN Classifier in DNA Microarray
Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
5.1 DNA Microarray Methods from Biological Point of View . . . . . . 108
5.2 DNA Microarray Methods from Information Technology
Point of View . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
5.3 A Method of Constructing a Complex Classifier . . . . . . . . . . . . . . 113
Contents xv

5.4 Details of Experiments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115

5.5 Discussion and Statistical Analysis of the Results . . . . . . . . . . . . . 118
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
6 Interval-Valued Methods in Medical Decision Support Systems . . . . 121
6.1 OEA Module of OvaExpert Diagnosis Support System . . . . . . . . . 122
6.2 Performance of Pos- and Nec-Aggregation Functions in OEA . . . . 126
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
7 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
8 Tables with the Results of Experiments . . . . . . . . . . . . . . . . . . . . . . 135
System FuzzyDataMiner . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161
 Part I
Foundations

In this part there are presented concepts related to fuzzy sets theory and its exten-
sions. Moreover, short historical mentions regarding the development of these notions
are provided. There are recalled diverse types of comparability relations between
intervals, including orders and linear orders. Mostly, this part of book concerns
aggregation functions defined both on the real line (or the unit interval [0,1]) and
for interval-valued settings. There are presented diverse representation methods of
interval-valued aggregation operators, their properties, construction methods and
dependencies between diverse classes of these operators. The considered aggrega-
tion operators may fulfil various monotonicity conditions, namely with respect to
the classical partial order, with respect to the linear orders or with respect to the
two other distinguished comparability relations derived from the epistemic inter-
pretation of intervals. Special attention is paid to the recently introduced notions of
pos-aggregation functions and nec-aggregation functions. There is also discussed the
problem of preservation of width of intervals by aggregation operators.
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appear at the groin, or even in the left broad ligament. Abscess of
the pancreas may also burst into the stomach, when pus will be
vomited, or into the bowel, whence it will be evacuated. A sudden
relief, with disappearance of tumor, followed by diarrhea and
purulent stools, would indicate this latter termination. Under these
circumstances the abscess cavity may repeatedly refill and reëmpty
itself. Spontaneous recovery in this way is possible, but septicemia
and hectic usually persist until obviated by operation.
Diagnosis.—The history, the evidently septic type of the case, and
the distinct signs above noted will make almost certain the presence
of pus, and Mayo Robson insists that the pancreatic reaction in the
urine (Cammidge) will make clear its location and origin; but, with or
without the latter, the important feature is that there must be a deep
collection of pus somewhere in the neighborhood of the pancreas.
Treatment.—This is necessarily operative, and in such cases as
those now considered there will be plenty of time afforded for all the
precautions known to careful surgeons. The aspirator should never
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usually with caution, lest pus escape along the needle track. The
operation is made as described above for the acute form of this
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peritoneal cavity against infection. When adhesions to the anterior
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possible, only to such an extent as will permit direct approach to the
collection below. Only after the abscess cavity has been thoroughly
emptied, disinfected, and packed with gauze should the surgeon
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suitable exploration of the lower surface of the liver and the biliary
passages.
And now perhaps comes the necessity for operative attention to
these latter, as one or many stones may be recognized in the gall-
bladder or the ducts. In this case there must be followed those
general directions elsewhere given in regard to the technique of
operations upon the gall-bladder and ducts. Biliary drainage will in
these cases be nearly always indicated, for which a separate small
opening in the usual position may be made, if desirable, as it
probably will be, for one wishes usually to continue such drainage
for several weeks, whereas it is desirable to have a median incision
heal as rapidly as possible. The question of posterior drainage will
also be raised. Ordinarily it is of advantage, as the time required for
anterior drainage can be materially shortened, the abdominal wound
be encouraged to close, and because the natural effect of gravity is
thus afforded. Moreover, by it the whole period of confinement to
bed may be materially reduced. Therefore, unless the condition of
the patient absolutely contra-indicate, it will usually be a wise
measure. In a few instances it has been possible to drain a
pancreatic abscess by a tube in the common duct, after removal of
the stone which has been obstructing either it or the duct of
Wirsung.

CHRONIC AFFECTIONS OF THE PANCREAS.

Chronic affections of the pancreas which interest the surgeon are:
1. Interstitial pancreatitis:
(a) Interlobular.
(b) Interacinous, leading to—
2. Cirrhosis with accompanying diabetes.
3. Neoplasms:
(a) Cysts.
(b) Solid tumors.
4. Calculi.
Chronic Pancreatitis; Cirrhosis.—The interlobular and
interacinous forms can both be
considered under one heading so far as we are concerned, their
symptoms being similar, save that in the former the compressed
connective tissue by its presence causes atrophy of true glandular
elements, and thus by preventing their function interferes with
digestion; while in the interacinous type the proliferations of this
same sort of tissue invade the islands of Langerhans, impair their
glycolytic secretion or suppress it, and add a glycosuria to those
features common to both forms—moreover, their treatment is
essentially the same. In the advanced form of either type the
pancreas may be reduced in size and somewhat cirrhotic. This
chronic affection may be the result of an incomplete recovery from
one of the more acute conditions previously described; it may also
have its origin in the chronic irritation of the poisons of syphilis,
typhoid, alcoholism, and the like; but by far the most common
causes are obstruction of the pancreatic duct, either by biliary or
pancreatic calculi, cicatricial stenosis, the presence of tumors or the
encroachment and erosion of gastric ulcers and cancers. The morbid
condition may involve the whole gland or be localized, in the latter
case particularly about its head.
Symptoms.—These should be studied with particular attention to
the case history, for a previous record of pain, cramps, chills, fever,
jaundice, very slight digestive disturbances, soreness, or local
tenderness will be suggestive and valuable if obtainable. As
symptoms gradually arrange themselves it will be found that
tenderness over the pancreas becomes constant, and is
accompanied by at least a mild degree of muscle spasm, that pain
increases and is referred more widely, often to the left side or even
the scapula, while there may be some fulness in the epigastrium.
Dyspepsia and emaciation become more marked. By the time the
obstruction of Wirsung’s duct has become complete, perhaps
previous to it, fat and undigested muscle fibers will be found in the
stools, which are light-colored, bulky, and sometimes contain blood.
As pressure effects become more prominent evidences of biliary
obstruction, if previously lacking, present themselves; the gall-
bladder usually distends; the liver enlarges or may even become
cirrhotic from the irritation of pent-up toxic bile. Even the spleen
may become enlarged. In the urine sugar will be found in cases of
the interacinous type, though usually only at a late date; while bile
pigments are usually present and Cammidge’s test may reveal his
peculiar pancreatic reaction.
Diagnosis.—If the peculiar symptoms above rehearsed are present
diagnosis is not difficult. In many cases it is not easy to go beyond
the point of recognizing that both the pancreas and the biliary tract
are at fault, without deciding as to the exact degree of culpability of
each. The question of possible cancer arises in almost every one of
these instances. Should the ordinary pancreatic reaction in the urine
prove all that has been claimed for it, this grave problem can often
be settled previous to operation. If the operator satisfies himself by
any method short of actual operation that he has to do with cancer
of the pancreas, then operation may be considered inadvisable
unless for some special reason.
Treatment.—At least a reasonably long trial will usually be made, in
these cases, of medical, hydrotherapeutic, and other non-operative
treatment, with little or no benefit. When after appreciation of the
condition and intelligent treatment but slight relief accrues, the case
may be regarded (as it really is upon its commencement) as surgical.
Treatment, then, consists of removal of the obstructing cause by
drainage of the biliary passages. The operative procedure will
therefore take the form elsewhere described for this purpose. Should
deep exploration reveal no calculi it will be well to make sure at least
of the patulency of the ducts, by opening the gall-bladder or
common duct and exploring with the probe, or possibly even
opening the duodenum in order to do the same with the pancreatitic
duct. Whether calculi are discovered or otherwise a gentle stripping
or massage of the pancreas may be made to advantage. Biliary
drainage should then be established, and usually externally.
It has been difficult for the profession to appreciate why and how
these measures, which seem to be directed rather to the biliary
passages than to the pancreas, have given such brilliantly
satisfactory results as are everywhere reported. These are to be
accounted for by the facts that the primary cause most often lies in
the former rather than the latter, and is thus removed, and that one
source of constant irritation—namely, infected bile—is thus done
away with, while tension is removed and pancreatic juice again
permitted to flow on as it should; that a chronic toxemia (cholemia)
is relieved, and that physiological rest is afforded to the affected and
disturbed organs. When the operation is thus performed benefit may
be expected; even when done late it may be capable of great good.

NEOPLASMS OF THE PANCREAS.

 Cysts.—In addition to true cysts of the pancreas there have been
described so-called “pseudocysts” in the lesser peritoneal
cavity, and more or less surrounding the pancreas. They are rarely of
congenital origin, but are probably due rather to traumatism than to
any other cause. By many they have been likened to ranulas, or the
cysts which form in the salivary glands in consequence of
obstruction to ducts or their branches. Anything which obstructs any
portion of the pancreatic duct may lead to the formation of a
retention cyst, the true proliferation cyst—adenomas being
practically unknown. That traumatism figures so largely is due to the
fact that injury is followed by hemorrhagic extravasation, and this by
more or less liquefaction or degeneration, both of contents and of
surrounding tissue, with the secondary formation of a cyst whose
walls are made of new connective tissue.
A true pancreatic cyst is a retroperitoneal tumor, while
pseudocysts are intraperitoneal. In front of the former lie four layers
of peritoneum, which may be completely merged together, but
through which a passage must be made when opening into it from
the front. The etiology of old pancreatic cysts may be completely
concealed by the changes which have slowly occurred since their
origin. They may be single or multiple, occur in any portion of the
gland, and increase even by coalescence. Within some of them,
especially those of the duct type, papillomatous excrescences may
be found. The more distinctly traumatic cysts occur perhaps oftener
near the tail of the pancreas, while into them repeated hemorrhages
may take place, and the sac will become quite thick, even
exceptionally calcifying in places. These have been described as
apoplectic cysts.
Altogether, up to date, at least 150 of these cysts have been
subjected to operative intervention.
Pancreatic cysts contain a fluid which may be variously colored or
sometimes colorless, which is usually alkaline, and contains fat
globules, cholesterin crystals, blood crystals, albumin, and various
salts, most of these being evidences of their hemorrhagic origin. The
fluid may also contain the specific pancreatic ferments, of which the
diastatic is the more common, tryptic ferment being met
occasionally, while the fluid may also possess emulsifying properties.
In size these cysts vary from minute sacs to enormous collections of
fluid.
As such a cyst attains marked size it will displace the adjoining
viscera, pushing the diaphragm upward and impeding heart and lung
action, obstructing the pylorus and duodenum and causing gastric
dilatation, pressing upon the intestines and perhaps even
compressing the ureters, thus producing hydronephrosis. Other
peculiar pressure effects may be met in particular instances. A
sudden increase in size indicates a fresh hemorrhage, which may
lead to its rupture and to death from peritonitis. These cysts rarely
empty spontaneously into the bowel. Their contents are liable to
infection, and thus a cyst may become converted into a large
abscess.
Symptoms.—Symptoms include especially pain, which may have
been sudden, but becomes more or less constant, accompanied by a
sense of oppression, according to the size and the pressure effects
produced in each case. Digestion is always more or less disturbed;
this may be attributed to the stomach dilatation, which is itself a
sequel of the condition. The stools show little which is significant
save that they are occasionally bloody. Undigested muscle fiber
would indicate loss of pancreatic function. Other symptoms will vary
so much with individual cases that it is not necessary to consider
them here.
The physical signs, coupled with a suggestive history, especially
one which includes an account of injury, are of the greatest
importance in diagnosis. These physical signs will include usually a
yellowish tinge of the skin, marked emaciation, dry skin, and the
presence of a tumor in the upper abdomen, which is usually
centrally placed, but not necessarily so. If the patient has carefully
noted the development of his own symptoms it will be found that
the enlargement commenced above and usually a little to the left,
and developed in other directions from that location. Palpation
reveals a smooth, elastic, usually fluctuating tumor, sometimes
movable with respiration, rarely pulsating.
 It must be remembered that a pancreatic cyst may rise above the
stomach, may rest entirely behind it, or may protrude either below it
and above the colon or else quite below the colon. Distention of the
stomach will afford accurate location, in these respects, upon
percussion, while percussion without distention may mislead. A
tumor which gives dulness below the stomach and above the colon
is extremely suggestive.
Diagnosis.—Diagnosis by aspiration is inadvisable, even dangerous,
for death has followed the introduction even of a needle into such a
cyst. Aspiration, then, should be reserved for tumors already
exposed through an abdominal incision.
For the purpose of differentiation it will suffice here to remind that
tumors of the kidney, as well as hydronephrotic cysts, grow
downward and forward from the loin, and can be pushed backward
to their proper place unless too large, that they are not accompanied
by digestive disturbances, while the urine is usually more or less
indicative. A hydronephrotic cyst can scarcely be made to occupy a
position between the stomach and the colon and present in the
middle line in front. Ovarian cysts rise from the pelvis and will rarely
occur in the upper location, save those provided with extremely long
pedicles. Hydatid cysts of the liver show a continuity and fixation to
that viscus which are usually diagnostic.
Treatment.—The only treatment for pancreatic cysts is surgical, it
remaining with the surgeon to decide as between drainage and
extirpation. While it is indisputable that extirpation is the ideal
method of dealing with all cysts and tumors, most of these cases are
of such long duration that the adhesions contracted between their
exteriors and the surrounding viscera are so dense and firm that
much greater danger attaches to a radical operation than to one for
simple incision and drainage. I have been able in at least one case to
completely extirpate such a cyst, but it was one exceedingly
favorably situated and surrounded.
Incision and drainage may be effected in one operation or in two
sittings, and as between them it must be decided according to the
merits of the case. It is undesirable to permit the escape of the
contents of these cysts into the abdomen. In some instances,
therefore, it would be much better to make a small abdominal
incision and through it attach the surface of the cyst to the margins
of the parietal peritoneum, reserving the actual opening into the
tumor until a day or two later, when it may be expected that firm
adhesions will have attached the sutured surfaces. In this way any
leakage within the abdomen may be avoided. Care must be
exercised, even in such cases, as a large cyst too suddenly emptied
may cause sudden displacement of the heart or of other viscera,
which would not be to the advantage of the patient. In this case
fluid could be withdrawn in portions as desired, or, making a small
opening, one could arrange for its gradual escape. On the other
hand, there are cases where it would be of great advantage, if the
cyst could not be emptied, to so open it as to permit posterior
drainage to be made, by which the period of recovery would be
much abbreviated.
No case of this kind can be treated without drainage, the
explanation being that the cyst being emptied will collapse, its walls
coming into more or less close contact with each other, that the
presence of drainage material will provoke exudate and the
formation of granulation tissue, and that a complete obliteration will
thus in time occur—but drainage in the natural direction of gravity as
the patient lies upon the back will permit of much more speedy
fulfilment of one’s hopes; hence its advantage. Better still, perhaps,
would be through-and-through drainage, with such irrigation as
might be needed, practised daily, or oftener if necessary.
Tumors of the Pancreas.—While sarcoma and other forms of
malignant disease, as well as adenoma
of the pancreas, have been described, they require no special
consideration here, since the surgeon has so rarely to do with
anything of this character save adenocarcinoma of the pancreas.
This is a disease of middle or advanced life, more common in males
than in females, usually of scirrhous type, and localized, though it
may appear in softer forms or be disseminated. It takes its origin
from the epithelial cells lining the acini and the ducts. Metastasis is
common and direct extension by continuity most easy and frequent.
It is made known by its pressure effects rather than by any other
important signs or constant features. It has been known to lead to
chylous ascites.
It is difficult in many exploratory operations to decide as between
a chronic induration or cirrhosis of the pancreas and that due to
cancer, and, in fact, in certain cases it may be impossible to clear up
the difficulty, leaving it to be solved either by recovery or death in
consequence of extension of malignant disease. Thus when
operating for biliary obstruction, where the parts are surrounded by
adhesions and the organs are only indistinctly palpable, it may be
impossible to decide as to the nature of a hard mass felt in the head
end of the pancreas, especially when other distinct expressions of
cancer are absent.
Cancer of the pancreas is at present a primarily hopeless disease,
and is of interest to the surgeon only in that some of the most
distressing features which it causes may be temporarily relieved by
biliary drainage. The symptoms which will bring such a patient to
him will be essentially those of biliary obstruction, perhaps with the
accompaniment of glycosuria or the discovery of fat in the feces.
Neither of these, however, is an invariable symptom. Diarrhea is but
an occasional feature, and colorless stools may be discharged when
there is no jaundice. A perfectly painless progressive (bronzing)
jaundice, with distention of the gall-bladder, would perhaps more
than any other single feature indicate pancreatic cancer. When such
a growth has attained a size sufficient to make it discoverable on
palpation it might be mistaken for a biliary cancer, from which it
would have to be differentiated especially by the movability usually
noted in the latter.
The only treatment for pancreatic cancer is operative, and consists
in drainage of the gall-bladder, and after a manner elsewhere
described in the section on Diseases of the Biliary Passages.

PANCREATIC CALCULI.
From the true pancreatic secretions precipitations of mineral salts,
combined with organic elements, may occur, just as from the saliva,
the latter thus furnishing the salivary calculi elsewhere described,
the two varieties having many points of resemblance. Again, calculi,
evidently of biliary origin, may be met with in the pancreatic duct.
The former consist largely of calcium oxalate, combined with calcium
carbonate and phosphate. They may be single or multiple, and vary
greatly in size up to that of a robin’s egg. Hypothetical calculi, with
consequent duct obstruction, have been held to be responsible for
many pancreatic cysts. Thus one may explain cyst formation, even
though no calculi be found at the time of operation.
Calculi reposing within the structure of the pancreas have much to
do with the acute and subacute, as well as the more chronic types of
pancreatitis, the latter when they act alone, the former when to their
essential disturbances are added the possibilities of bacterial
infection.
When pancreatic calculi produce symptoms they resemble those of
cholelithiasis, causing paroxysmal pain, with vomiting, and perhaps
transient jaundice. Glycosuria is an occasional feature.
The condition is rarely diagnosticated previous to operation.
Should a calculus be met in this location during the progress of any
operation it should be removed by an incision made parallel to the
duct, with such closure of the wound in the pancreas as can be
subsequently effected and with ample drainage of the deep wound,
in order that pancreatic fluid may not escape into the peritoneal
cavity. If encountered during operation for pancreatic cyst the same
advice will apply.
 C H A P T E R L I V.
THE KIDNEYS.

CONGENITAL ANOMALIES AND DEFECTS OF THE KIDNEYS.

Recent embryological studies have established the fact, in regard
to the kidneys, and given rise to the inference in regard to the other
viscera, that the primary cause of congenital variations has much to
do with the earliest development of the bloodvessels. The general
inclination has been to view the vessels as following the organs. This
should be reversed, as we are now learning that organs develop
around the bloodvessels, and that so-called congenital variations
arise from departures of vascular arrangement from the ordinary
types. Without pursuing this subject further it is sufficient to say
that, aside from defects of such character that the newborn infant
can live but for a few hours or days, those which have most surgical
interest mainly comprise variations in number and in size, including
every possible combination, from absence of an entire kidney to
horseshoe forms, and various anomalies of the ureters including
defects and redundancies, double ureters, and the like. While
supernumerary renal tissue or kidneys are extremely rare, the
presence of supernumerary adrenal tissue in one or both kidneys
(even in adjoining organs) is not uncommon. Here it may lead to the
development of a distinct form of tumor, hypernephroma, which will
be discussed later. The complication of absence of an entire kidney is
sufficient to give it actual surgical importance, since it has repeatedly
happened that the remaining kidney has been removed for disease,
the inference being that its work could be carried on by its fellow,
which proved to be lacking. This accident might be prevented by a
careful cystoscopic examination. Nevertheless the rarity of this
condition permits it to be almost excluded from ordinary
consideration. After removal of one kidney the other undergoes
compensatory physiological enlargement and does double duty, if
indeed this has not already occurred.
Acquired defects may be due to intrinsic or extrinsic causes, e. g.,
disease within the renal structures or ureters, or lesions in adjoining
organs and tissues, producing mechanical or other disturbances.
Thus the functionating capacity of one or even both kidneys may be
seriously compromised by either internal or external conditions, and
it behooves the surgeon to estimate the degree of renal disability or
inadequacy before operating upon either of these organs. On the
other hand if the disease be confined to one kidney he may feel that
it is doing so little good and so much harm that the patient will be
really relieved by its removal. Nearly everything, then, depends upon
a determination of the precise existing conditions. They should be
ascertained by means of the catheter, the cystoscope, the
microscope, and by the careful chemical study of the urine. These
methods have been developed into a specialty of considerable
complexity, but of great practical importance. The surgeon should
not fail to employ them. If he is not familiar with the technique he
should seek special assistance.

INJURIES TO THE KIDNEYS.

Although the kidneys lie in a protected position they are not
infrequently injured, both by contusions and by penetrating wounds.
From the latter blood will escape externally. In the former it can only
extravasate when the cortex and capsule are torn, or escape
through the ureter into the bladder, when it will be seen in the urine,
which, however, may have to be drawn by the catheter on account
of retention. Blood in the urine after a local injury denotes serious
mischief inside the kidney or along the urinary tract. If continuing for
several hours, but especially if accompanied by local indications,
swelling or other evidences of extravasation, by muscle rigidity or by
severe pain, with general symptoms, it should be assumed that
these fluids are escaping into the perirenal tissues, perhaps into the
peritoneal cavity, and that an immediate exploratory operation
should be urged. When once this indication is clearly recognized the
 Fig. 632
condition brooks no
delay. The same is
true of penetrating
wounds. On general
principles, with a
patient in such a
condition and
showing no
improvement, or
especially if the
reverse, exploration
offers the safer
course in by far the
greater number of
cases. The surgeon
need only convince
himself that such
blood as the urine
contains does not
come from the lower
tract, but rather from
the kidney or ureter.
Exploratory
nephrotomy is by
itself so harmless that
one need never
hesitate to urge it. A
kidney found slightly
Laceration fragmentation of kidney. (Güterbock.)
lacerated may be
repaired with sutures,
while one found seriously disorganized should either be sutured and
drained or totally removed, as the case may require. There is little
room for doubt that it is better to institute such a measure early
rather than to permit the dangers and even ravages of infiltration of
blood and urine. In fact it may almost be laid down as a precept that
every patient who has received an injury in the loin or flank and who
repeatedly passes blood in the urine should be explored.

PAIN IN THE KIDNEY; NEPHRALGIA.

This is a vague term, implying pain or neuralgia in the kidney, and
can refer only to symptoms, not to any particular disease. Yet it
must be confessed that for certain cases of so-called nephralgia no
physical cause is easily discovered. Pain in the kidneys—or, as
patients will often say, in the back—may be associated with excess
of oxalic and uric acids and salts in the urine, and is then relieved by
a steady course of alkaline diuretic treatment, with plenty of fluid,
the severe pain being combated with aspirin. Nephralgia may be
expected in connection with many renal disorders, but the term
should ordinarily be confined to cases of pain without known cause.
When such pain is uncontrollable and intolerable the indication is
to make an exploratory operation, by which the kidney should be at
least exposed, perhaps delivered upon the external surface of the
body, and carefully examined. Its capsule should be split
(capsulotomy), as Harrison and others have suggested, and if on
palpation or needling (using a needle as a probe) there be any good
reason for opening it this may be done, so that with the finger its
pelvic cavity may be carefully explored, in order to find any
previously unrecognized calculus or other surgical lesion. The mere
operation of capsulotomy or capsule splitting has proved of such
great value that I always practise this measure upon any kidney
which for any reason it may seem wise to expose.

INFLAMMATIONS AND INFECTIONS OF THE KIDNEYS.

Under this head it is intended to consider (1) acute or subacute
specific infections of the upper urinary passages, due to bacteria,
with the effects of which we are familiar, i. e., septic, gonorrheal,
and tuberculous lesions, and (2) chronic nephrites of irregular or
uncertain type, for which operative treatment has been recently
proposed.
 Septic Nephritis; Pyelitis; Pyelonephritis; Surgical Kidney.
—Septic infection of the kidney is usually the result of a process
ascending from the lower urinary passages, particularly when these
are obstructed by calculus, tumor, prostatic enlargement, or ureteral
stricture. It may follow catheterism either once or prolonged,
especially when done without strict precaution; or the infection may
come from the other direction via the blood stream, as in typhoid
and various other fevers, the exanthems, and diphtheria. Gonorrhea
is a frequent cause, acting insidiously and by a creeping invasion,
with the intervention of a rather more abrupt cystitis. Nevertheless
when gonorrhea is followed by pyemia and metastatic abscess these
form early in both kidneys, and disaster quickly follows. These types
of infection spreading upward along the ureters do not spare the
pelvis of the kidney, but expend their first violence there. Beyond
this they may extend to the renal tissue proper, where they set up a
true nephritis, which may prove fatal.
Symptoms.—Clinical symptoms do not vary greatly except in detail.
They include fever, chills, and similar expressions of toxemia, with
more or less pain in the kidney, down the ureter, and even referred
to the ultimate distribution of the nerves sympathetically or
anatomically involved, e. g., to the testicle on the same side, often
with retraction of the scrotum, and down the thigh. There is a
tendency to thamuria (frequency of urination) when the bladder is
involved, as it always is sooner or later. Pus and mucus are
recognizable in the urine by the naked eye, while a microscopic
study of this fluid will reveal, from the character of the cells, the
extent and type of the invasion. The tuberculous type will be
considered separately. Suffice it to say that in this form, however
pure may have been its original type, it becomes sooner or later
converted into a mixed septic infection, with which renal abscess is
often connected. The gonorrheal type is nowise clinically distinct, so
far as the kidneys are concerned, but is to be recognized either by
the microscope or by other clinical evidence.
Treatment.—Such cases as the above may even perplex the
surgeon, since they complicate many other surgical conditions. Yet if
they go no farther than above described they are to be treated
rather by internal methods, i. e., diluents, with hot-air baths, and
especially by urotropin, the remedy of greatest value, while such
drugs as aspirin, benzosol, sodium benzoate and the like, in
moderate doses and at rather short intervals, may be administered
to great advantage.
Renal Abscess; Surgical Kidney.—The conditions above
described do not necessarily nor often terminate with resolution. Not
infrequently suppuration follows, with resultant abscesses, which
may be solitary and possibly large, but are more likely to appear in
multiple and perhaps punctate form. Should this condition occur in
one kidney alone, it determines probably its ultimate destruction; if
in both kidneys, the prognosis is very grave, since later, if not
immediately, such a case will succumb to renal failure, due to the
extra load put upon the portion still capable of secreting. It is to
kidneys thus crippled by acute or subacute infections, with punctate
abscess and similar lesions, that in the past the term “surgical
kidney” was applied, because such kidneys were seen oftener in
surgical than in so-called medical cases.
Brewer has recently called attention to a type of acute
hematogenous renal infection, to which he has given an identity of
its own. The possibility of renal infection through the blood has been
long recognized, but it has been generally supposed to produce
bilateral lesions. Of late, however, it has been shown that these may
be unilateral, on account of the diminished resistance of one kidney
as the result of previous disease or injury, among the former being
calculus, renal retention, and floating kidney. While the colon bacilli
are most frequently at fault the infection is often of the pyogenic or
mixed type. It seems to be more frequent in women than in men.
The symptoms are those of an acute infection, often ushered in by a
chill, with sudden rise of temperature, sometimes followed by such
marked remission as possibly to suggest malaria. The pulse ranges
high. Abdominal pain is an almost constant symptom, although it is
usually vague and often shifting or referred. Sometimes it will cause
such a complaint as to lead to mistaken diagnosis in favor of an
acute appendicitis. Occasionally it radiates along the course of the
ureter. Tenderness in the costovertebral angle is nearly always
present. Muscle rigidity is frequent but inconstant. There is nearly
always a leukocytosis, with a percentage of about eighty
polynuclears. Frequency of urination may accompany these cases,
but they will ordinarily be diagnosticated by physical and urinary
examination. The urine will usually contain albumin, perhaps with
pus, and occasionally a few red blood cells. Urine obtained from the
affected kidney by ureteral catheterization will contain more of these
evidences of abscess than that from the other side. Brewer has had
far better success in entirely removing the affected kidney than in
exposing and simply draining it. He has thus done a great service in
demonstrating the possibility of unilateral acute and suppurative
disease of the kidney, where diagnosis is most obscure and the
clinical picture one of acute general abscess rather than of local
affection, showing as well that the more acute cases tend rapidly to
terminate fatally unless promptly arrested by complete removal of
the affected organ.
As we consider the above infections, with others yet to be
mentioned, it becomes more necessary to appreciate those
constituents and characteristics of the urine which have for the
surgeon the greatest significance, and those methods of
investigation which furnish him the promptest and most satisfactory
results.
The following include methods in present use for determining
renal capacity and function, i. e., the matters of greatest
importance:
1. Catheterization of the ureters;
2. Cryoscopy of the blood and the urine;
3. Phloridzin test;
4. Chromocystoscopy;
5. The toxin test;
6. The test for electroconductivity (Kakells).
1. By cystoscopy, with ureteral catheterization, we determine
whether urine is secreted by both kidneys or but one, while the
secretion of each kidney may be separately collected and studied.
Even this method leaves much to be desired. Though one kidney be
actively diseased it may still contain sufficient tissue to make it partly
competent for its purpose, and undesirable to remove; or an organ
with very defective structure may, nevertheless, yield a certain
amount of nearly normal urine. These, then, are aids to determine
the character of the morbid process, and the information they
furnish is valuable, but not always sufficient.
2. Cryoscopy, based upon the physiochemical law that the freezing
point of the solution is proportionate to the number of molecules it
contains, i. e., to its molecular concentration, has revealed that the
blood of a person with severe kidney lesion freezes at a lower
temperature, while the freezing point of his urine would be much
higher than in a normal individual, because those materials which
should have been excreted in the urine are, on account of impaired
renal function, retained in the blood and do not get into the urine.
The freezing point of normal urine varies from -0.09° to -2.3° C.; the
freezing point of normal blood from -0.55° to -0.57° C. The
reasoning employed in the method is sound, but the method itself
difficult, requiring special apparatus and experience. Moreover, the
limits of the possibility of error are such that this method alone
should never be relied on. It is essentially a test of the ability of the
kidneys to act as filters, but does not test their serviceability as
secretory organs.
3. The phloridzin test is one of the most trustworthy for estimating
the secretory function of the kidneys, as it shows how much active
working epithelium remains in the organ. It consists in the
subcutaneous injection of 0.005 Cc. sterilized phloridzin with an
equal quantity of sodium benzoate, to hold the former in solution.
The bladder must be emptied just before the injection is given.
About an hour after its administration sugar should appear in the
urine, if the kidneys are acting normally. If they are to be studied
separately, catheterization of the ureters is necessary. The test is, of
course, worthless in diabetic subjects. It depends upon the amount
of sugar excreted, the time of its appearance, and the duration of its
elimination. If no sugar be present the kidneys are seriously
affected; if it be delayed, renal insufficiency is present. The average
quantity of sugar eliminated during the first half-hour, when the
kidneys are normal, is about 0.5 per cent. If the kidneys be
diseased, this quantity is reduced by a half, and there is very little
more secreted in the first than during the second half-hour. This
valuable method is unfortunately difficult of application and requires
minutely careful chemical tests.
4. Chromocystoscopy, introduced by Voelcker and Joseph, is
perhaps the simplest of all methods of estimating renal capacity. 20
Cc. of a 0.4 per cent. solution of indigo-carmine is injected into the
gluteal muscles. In fifteen or twenty minutes, if the kidneys be
normal, the cystoscope will reveal dark-blue urine flowing from the
ureteral orifices toward the median line, with a peculiar jet at regular
intervals of about twenty-five seconds, and lasting for perhaps five
seconds. There is both rhythm and force about this ejaculation. If
the color be pale, the jet weak, or the rhythm irregular, the intervals
prolonged or late, or if no flow whatever occur, there must be
hindrance in the secreting and filtering structure of the kidney, or
occlusion of the ureter. The results given by indigo-carmine in these
cases are superior to those furnished by methylene blue, since it is
not so much a solution as a mixture which is formed and ejaculated
as such. Moreover, in passing through the body the indigo-carmine
undergoes no reduction. By this method there is no necessity for
catheterization of the ureter. One needs only to use the cystoscope
with reasonable dexterity, and there is no necessity for chemical
tests of separate specimens. The method is generally useful in cases
where ureteral catheterization is made impossible by growths. It
affords an easy means of differentiation, for instance, between
ovarian cyst and hydronephrosis.
5. The toxin test is one only to be carried out by the use of
animals, since it depends upon the amount of filtered urine required
to kill an animal after injection into its veins, the number of cubic
centimeters necessary to kill, divided by the weight of the animal,
being called the urotoxic co-efficient. It has greater laboratory than
clinical interest.
6. Electroconductivity of urine is of value in determining the
capacity of the kidney for eliminating inorganic cells. It depends on
the resistance offered by the urine to the electric current. It is
complicated in method, requires special apparatus, and its results
are still of questionable value.
For ordinary purposes the most trustworthy data for the surgeon
who is not provided with ample laboratory facilities are afforded by
an estimate of the amount passed in twenty-four hours, its specific
gravity, its color and acidity, and by the presence or absence of
albumin. The test-tube and the microscope then still afford
satisfactory means of deciding those matters which the surgeon
needs to know. If applied to urine collected separately from each
kidney, they may be regarded as trustworthy. If catheterization be
impossible, then it is advisable to inspect the ureteral orifices while
elimination of indigo-carmine is taking place.
Hematuria.—The significance of blood in the urine is rather that
of a symptom than of a disease, although it should be admitted that
there are occasional patients who lose blood in this way, more or
less frequently, even periodically, without seeming to suffer in the
least. Hematuria may also be present as an expression of vicarious
menstruation. Again, blood may thus appear in scurvy and similar
conditions, especially in tropical climates; in certain of the domestic
animals its presence may be due to infection of the kidneys by
macroscopic parasites (the so-called “black-water fever” of men and
horses). Such cases as these are outside the pale of surgery.
Nevertheless general experience has shown that many cases of
hematuria, without perceptible changes in the kidney, have been
benefited or cured by exploratory nephrotomy. Among the causes
ascribed for these so-called “essential hematurias” have been
incipient tuberculosis, renal retention from prostatic enlargement,
congestion from venous obstruction (due to tight lacing or
displacement from any cause), and even the congestion of chronic
nephritis.
Treatment.—When known or recognizable causes are absent, and
the ordinary therapeutic agents, the special styptics (cotarnin), and
such measures as hypodermoclysis with a 2 per cent. gelatin
solution (see Control of Hemorrhage) have failed, an exploration
may be advised. It is of the greatest advantage to be certain that
but one kidney is involved, or it may be necessary later to operate
on the second kidney.
Operative Treatment of Chronic Nephritis.—The various changes
included under this head are usually bilateral. The term implies a
non-pyogenic infection of the renal bloodvessels, interstitial tissues,
and glomeruli or tubules, which produce changes, often spoken of in
this country as constituting interstitial parenchymatous or diffuse
forms of nephritis, and inducing gross changes which cause the
kidney to be spoken of as contracted, large, white, waxy, etc.
Discussion of the pathology of these conditions here is out of place.
They have all been grouped, most loosely, in common parlance as
forms of “Bright’s disease.” Apart from the significance of
albuminuria and the many terms implying peculiar features, the
apparent hopelessness of many of these conditions, and the
disappointment following internal treatment, finally led surgeons to
attempt to ascertain what they could accomplish. It was in 1886 that
Péan operated on a case of chronic nephritis with nephralgia and
removed the kidney. Ten years later Harrison made three
nephrotomies, and, though under a wrong diagnosis in each case, it
was noticed that the symptoms all cleared up and that albumin
disappeared from the urine. About the same time Newman showed
that albumin and casts have often appeared in movable kidney,
because of torsion of the vessels, and that they disappeared after
nephropexy. Then Pousson, in 1899, reported some twenty-five
cases of hematuria and nephralgic nephritis, operated upon by
nephrotomy and nephropexy, with great benefit. In 1899, Israel was,
perhaps, the first to formulate rules for nephrotomy for these
conditions. In 1899, also, Ferguson claimed that chronic nephritis
should be treated as are inflammations elsewhere, by relief of
tension and even drainage. Meantime, Edebohls had been doing
partial decapsulation and fixation in cases of so-called unilateral
nephritis (the possibility of which is disputed by the best authorities,
like Kümmel), and later extended his method to complete
decapsulation (capsulectomy), with replacement of the kidney in its
fatty bed, claiming that by and through the new adhesions thus
produced new and more complete as well as additional blood supply
was furnished, and that regeneration of the slightly altered
parenchymatous tissue, as well as absorption of exudates, was
produced. (Guiteras.) The fact that it seems now well established
that these forms of chronic nephritis are always bilateral does not of
itself affect the cogency of Edebohls’ reasoning, if it be otherwise
correct.
Accurate diagnosis has much to do with this problem. Israel has
shown that chronic nephritis is even more difficult of recognition in
the living than in the dead, not only after ordinary examination of
the capsule, but also after opening into the kidney. Age is not a
serious contra-indication, and enlargement of the heart is said
frequently to subside after these operations. If cardiac compensation
be good operation is permissible, if not otherwise contra-indicated.
Edebohls’ method is to anchor the kidney to the muscles of the
back, whether it was previously movable or not. Primary healing is
desirable, since “nephritics” do not bear suppuration well.
Indications for Operation.—At present a satisfactory summary is
impossible. It is of the first importance that operation should be
undertaken early, since to wait until anasarca or other grave
conditions supervene is to invite disappointment as the result of a
procedure which is by many considered capital. The coincidence of
pronounced disease of any other type would be a contra-indication.
Bacteriuria, pyuria, etc., would perhaps make it more desirable
rather than otherwise. Cases of operative toxemia (postscarlatinal,
typhoid) and of cirrhotic type, without other contra-indications, are
the most favorable. When a careful examination of the patient and
the urine leads the surgeon to think that preparatory treatment may
be of advantage, he should find therein almost his only excuse for
delay, if operation is to be done. Low hemoglobin percentage should
also lead to postponement.
Operation may consist of nephrolysis, or breaking down of
adhesions, by which pain is frequently relieved, of decapsulation, of
nephrotomy, and, finally, of nephrectomy, in case serious lesions are
disclosed. It is doubtful if benefit is due so much to formation of new
vessels as to a freer circulation of blood within the kidneys, with
their consequent improved opportunity for repair and elimination.
Guiteras, for instance, does not believe in total decapsulation, but in
partial exposure of a sufficient area on the posterior kidney surface
to assist in its fixation, if movable. Otherwise he considers that
simple division of the capsule over the convexity will be sufficient. In
cases of unilateral nephralgia and hematuria he advises nephrotomy,
not so much as an approved therapeutic measure as for exposure,
perhaps for revealing the possible existence of deep lesions.
The recent reports Fig. 633
from various
surgeons concerning
the value of renal
decapsulation alone
are by no means
unanimously
favorable, although a
majority of writers
are in favor of
exposure of the
kidney, capsulotomy
and fixation, either by
suture or tampon.
Still, it does not seem
at present justifiable
to maintain that
decapsulation can be
expected to cure
diffuse or deep-
seated arteriosclerosis
or degenerative
processes within the
kidneys.
The question of the Acute pyelonephritis with multiple miliary abscess
suitable anesthetic is formation. (Israel.)
here one of
importance. For reasons set forth earlier in this work, ether should
always be avoided. If the operation be one that can be speedily
performed, nitrous oxide gas alone may suffice. Otherwise it should
be done under chloroform, preceded perhaps with ethyl chloride, or
under somnoform.
Pyonephrosis.—As a condition this is to be distinguished from
ordinary abscess of the kidney, in that it implies the retention in the
renal cavity or pelvis of pus with eventual destruction of kidney
tissue. In other words it is an empyema rather than an abscess. It
results from septic or tuberculous invasion, plus ureteral obstruction,
regardless of the obstructing cause, e. g., calculus, plugs of mucus,
stricture, kinking of ureter, or extrinsic tumor causing pressure.
Occlusion may be so complete that no urine escapes from the
affected kidney, while that from the other is clear, or the
phenomenon may be intermittent. There results more or less
enlargement and often great dilatation of the diseased kidney. Pus
thus retained has been known to be discharged into the intestine or
even into the lung. Spontaneous recovery is rare. Aspiration from the
back in these cases is proper for diagnostic purposes.
Treatment.—Pyonephrosis, like any other collection of pus, calls for
incision (nephrotomy) and drainage, with removal of any possible
foreign body, such as calculus. If the entire kidney be found
destroyed, or so compromised as to jeopard its future, a
nephrectomy may be done at once, while it may be a secondary
measure in cases of permanent urinary fistula following drainage.
So, too, if the kidney be found tuberculous, it is better to remove it
than to temporize.
Perinephritis.—To pus formed in a perirenal phlegmon is given
the term perinephritic abscess; this is sometimes due to external or
penetrating injuries; sometimes it appears as a primary condition
difficult of explanation; but it usually follows inflammation of
adjacent structures, such as the kidney itself (tuberculous pyelitis),
the liver, the colon, and the appendix. While perinephritis usually
terminates by suppuration, spontaneous recovery, with more or less
absorption of exudate, is known to occur. These perinephritic
collections sometimes attain enormous size, and are then sure to
migrate, always along lines of least resistance, which takes them
usually downward, either toward the loin or the groin. I once tapped
below Poupart’s ligament a collection which exceeded a gallon.
These abscesses may also, more rarely, burst into any of the
adjoining cavities, and discharge either by the mouth, bowel, or
bladder, or even externally.
Symptoms.—In addition to the usual systemic indications of the
presence of pus there may be tumor in the lumbar region,
sometimes with distinct fluctuation, usually with rigidity of the
lumbar and psoas muscles, perhaps even contractions of the thigh
muscles which may simulate hip disease. These abscesses have
been mistaken for peri-appendical phlegmons. If necessary to
establish the presence of pus the exploring syringe may be used, but
this is rarely necessary.
Treatment.—While in the early stages the local application of
guaiacol may be of use, every collection of pus thus formed here, as
well as elsewhere, needs evacuation and drainage. This latter is to
be provided by opening through the loin, in order that gravitation in
the dorsal position may be of greatest assistance. A more or less
free incision, such as is made for exploring or removing the kidney,
will usually be sufficient, but may be combined with a
counteropening at any point where the latter would be of advantage.
Thus should pus present in the groin an opening should be made
both posteriorly and at the point where it appears to be coming
toward the surface.
Tuberculosis.—At no age are the kidneys exempt from
tuberculous lesions, although these are more frequent in the earlier
years of life. Here as elsewhere they may assume the disseminated
miliary type or occur as a solitary focus. The infection may proceed
upward from the bladder, or it may be a local expression of a widely
diffuse process. In the latter case it has passed beyond the control
of the surgeon as such, and calls for general therapeutic measures,
judiciously selected and actively maintained. Not a few cases of renal
abscess, of pyelonephritis, and even of perinephritic abscess, are
due to primary tuberculous lesions.
Symptoms.—About the earliest symptoms that a patient may
complain of are thamuria (frequency of urination), with blood or pus
in the urine. Even at this early stage the condition is essentially
surgical, so the diagnosis should be established. Cryoscopy alone is
hardly sufficient, although if the freezing point be studied it should
be regarded along with the amount of fluid ingested and the
quantity of carbohydrates taken with the food. Ureteral
catheterization is valuable, although until it came into vogue we
were content to study the cystoscopic appearance and to judge by
the ureteral orifices, assuming that if one appear healthy and the
other not so operation is indicated.
The question of removal of a totally diseased kidney when the
other is more or less affected is one demanding greatest judgment.
Some of the more recent operators endeavor to determine this by
the cryoscopic test of the urine from the less affected organ. If this
stand the test they do not hesitate to remove the one which is
totally diseased. Thus it would appear that the ideal method is one
of careful study of the urine from each kidney, although it is
acknowledged that when the question is still in doubt the associate
kidney may be explored before deciding to remove the one most
diseased.
Diagnosis of Renal Tuberculosis.—The most frequent and significant
symptoms of renal tuberculosis are pain, local and referred;
hematuria, polyuria, and pyuria. In young adults suffering from
bladder irritability, painless pyuria usually indicates tuberculosis of
the bladder, secondary to that of the kidney, this being particularly
true when the urine is hyperacid. This urine, if noted, will be found
at first faintly cloudy or smoky, while later the admixture of pus
becomes more evident. The frequency of micturition (thamuria,
pollakiuria), which is frequently noted early, may be due mainly to
polyuria; the final test is the discovery of bacilli in the urine. There is
another form of thamuria which is associated with tenesmus,
constituting the painful cystitis of Guyon, which depends on
complications in the bladder itself. A search for bacilli is often
disappointing, and tuberculin may be used in the endeavor to make
a diagnosis, as well as animal inoculation. Tuberculin might,
however, give rise to error were there tuberculous foci elsewhere
about the body.
 Fig. 634

Tuberculosis of kidney, nodular form. (Israel.)

Renal tuberculosis may run a painless course, or it may be

accompanied by a severe renal colic or renal crises, the latter
sometimes due to plugging of the ureter with cheesy debris. Pyuria
may be masked by hematuria, the latter trifling, apparently
spontaneous, and occurring even during repose.
 More accurate diagnosis can be rarely made without resort to the
cystoscope and catheterization of the ureters. When in the
cystoscopic image the ureteral orifice is enlarged, congested, and
even hemorrhagic or ulcerated, it may be regarded as evidence of
tuberculous disease in the corresponding kidney. Meyer has claimed
that in the descending form of tuberculosis the mouth of the ureter
is ulcerated, while in the ascending form it is apparently healthy.
When both outlets are apparently healthy, and urinalysis indicates
renal disease, the case must be one of ascending lesion. Fenwick
has described what he calls a “golf-hole ureter,” the orifice being
dilated and patulous, and the appearance being to him
pathognomonic.
Ureteral catheterization is perhaps less necessary on the
suspected side than it is to prove the healthfulness of the kidney on
the opposite side. The disease is more common in the female, and
usually occurs in early adult life. It is more often a descending than
an ascending affection.
 Fig. 635

Renal tuberculosis as seen on section. Papillary granulomata seen at T. (Israel.)

 Treatment.—Radical treatment of renal tuberculosis is possible
only when the lesion is limited to one organ. What shall be done
with the kidney involved, when exposed and the disease revealed,
may depend to some extent upon the actual degree of involvement.
More and more surgeons are agreeing that anything like partial
nephrectomy is of questionable value, and that an organ distinctly
tuberculous should be removed. In other words, partial nephrectomy
is of doubtful merit. Of course, the kidney should be opened before
its removal, unless from its exterior it is seen to be hopelessly
involved. A further question of great importance is that of
involvement of the ureter. With a few associated lesions in the
kidney the ureter may easily escape, but with a kidney thoroughly
degenerated, and with infected urine or tuberculous debris passing
constantly down through the ureter it cannot escape contamination.
It is not a difficult procedure, nor does it add to the gravity of the
operation, to extend the incision sufficiently to permit not only the
delivery of the kidney but the exposure at least of the upper portion
of its ureter. In this way the renal pelvis may be opened and the
ureter itself examined. When thus involved, and especially if it be
determined to sacrifice the kidney, as much of the ureter should be
removed with it as can be reached. While theoretical considerations
would always require these measures to be combined, many mild
tuberculous lesions of the ureter undergo spontaneous retrocession
after removal of the diseased kidney from which it has become
contaminated.
The incision intended to expose the ureter should begin about a
half-inch forward and in front of the lower costal cartilage, parallel
with the last rib, and terminate on a level with the anterior superior
spine, about one inch toward its inner side. This incision will then be
about four inches in length. The use of a pillow is of assistance in
the easy performance of this operation. The body should be rolled as
far as possible without losing negative pressure upon the abdomen.
The more abdominal fat there is present the further over the patient
should be rolled; a stout patient should have the hips raised from
the table by a cushion, in order that the abdomen may be pendent,
while the foot of the table is somewhat elevated and the operator is