TREATMENT - RENAL CALCULUS.
The treatment of renal calculus may be considered under the three headings which the subject naturally presents : (1) Preventive; (2) Medicinal; and (3) Surgical. It is the last section that more strictly comes within the limits of this article.
It may, however, be said before proceeding to an operation for the removal of stone from a kidney the surgeon will probably satisfy him self that such expedients as massage and the shampooing of the affected side in conjunction with the flushing of the urinary apparatus from within, as, for instance, by the drinking freely of bland fluids such as pure water or barley water, or of medicinal waters as those of Contrexeville, Ems, and other spas that might be mentioned, are of no avail. If in spite of these attentions the symptoms of renal cal culus remain unrelieved, the protracted as well as the prospective suffering of the patient will demand the mechanical removal of the foreign body before the time has arrived when structural deteriora tion of the organ commences.
It will be convenient to describe in this section the two operations which a calculus within the kidney may entail. These are nephro lithotomy, or the removal of a stone from within the limits of the kid ney, and nephrectomy, or the extirpation of the organ when, by reason of the continued presence of a stone, the kidney has been so destroyed as to be not only beyond the reach of repair, but as harmful to the body generally as a disintegrated joint urgently requiring removal or amputation of the limb.
As it is not always possible to be absolutely certain of the exis tence of a calculus within the kidney, especially in those cases where for some reason or other, as for instance the fixation of a stone, the leading symptoms are in abeyance, the operation of nephro-lithotomy becomes dependent upon what exploration of the part with the finger reveals. Digital exploration of the suspected organ is a method free from risk and a necessary preliminary to, as well as part of, what will have to be done if a stone is discovered. It will be understood that my remarks now are entirely confined to the lumbar proceedings. To expose a kidney with the view of exploring it both by sight and touch, or for the purposes of nephrotomy, nephro-lithotomy, or ne phrectomy, an opening in the loin is required. Such an incision is to
be selected as is capable of adaptation for the several procedures mentioned, should exploration prove the necessity for adopting further measures.
A vertical or a transverse incision is usually selected, or a com bination of the two. The vertical incision may be made along the outer border of the erector spinet from the lowest rib to the crest of the ilium. If the transverse opening is preferred a line should be taken, to the extent of about three or four inches, corresponding in location with that for a lumbar colotomy, though somewhat closer to the rib than in the latter case. The vertical incision as described, with a transverse extension forward to the length of about three inches, will in most subjects be found convenient as giving the great est amount of room for manipulation in every direction.
The subsequent stages consist in the division of the layers of muscle and fascia until the perirenal fat is exposed, which is readily distinguishable. There is seldom much bleeding, and the steps of the operation will be greatly facilitated by the use of suitable retrac tors. As the kidney is approached, firm pressure from the front, by the hand of an assistant, assists the operator in recognizing it with the finger. The surface of the kidney should then be carefully ex plored by the finger both in front and behind as far as it is possible to do so without unnecessarily loosening its connections. In this way the operator will soon learn to recognize inequalities in surface and textural differences which indicate stone, fluid, new growth, or an undue mobility of the organ. If the finger is not sufficient for this purpose the kidney may be punctured in one or more places with a fine trocar, and thus the presence of stone, for instance, or fluid, as in the case of a cyst or a suppuration which otherwise might escape notice, may be ascertained. The information so obtained, either negative or positive, will determine what is best to be done.