In this way nephrotomy or the free opening of the kidney may be practised, for the introduction of a drainage-tube in suppurative conditions involving the interior of the organ as previously men tioned. Where the kidney is opened along its free border for drain age as is usually the case, the sides of the wound may be anchored by silk or catgut sutures to corresponding positions in the superficial incision, so that there may be no obstacle to the escape of matter, though the mere insertion of the end of the drainage-tube within the kidney opening generally suffices. Any hemorrhage may be arrested by packing antiseptic gauze round the tube.
Assuming, for instance, that these methods of exploration fail in determining the presence of a stone, it is not to be concluded that no good will come out of the proceeding. In several cases where I have explored for pain no stone was found, but complete recovery fol lowed. I am disposed to think in some instances tension has been relieved and pain permanently alleviated by the opening of the cap sule of the kidney for the purposes of puncture or further explora tion, as sometimes happens in the case of the testes when inflamed. I have never seen any harm arise from direct lumbar examination of the kidney, and I can hardly recall an instance where permanent benefit did not follow. Some of these cases of recovery were explain able by a more absolute fixation of the organ following upon the pro cedure. Where the kidney has not been opened or is only punctured the wound in the skin may, if desired, be immediately closed by sutures.
I will now take the case where either by the finger or the exploring trocar direct and unmistakable evidence is afforded of the presence of a, stone. Our course of action will be influenced to a large extent by the position the calculus occupies in the kidney, and its size.
The last two cases of renal calculus I operated upon presented varieties which will conveniently serve to illustrate this point. The first case was that of a man who for many years had a fixed pain in his kidney without, I may say, any other symptom. I hardly expected to find a stone, yet on reaching the kidney my finger felt one about the size of a filbert situated in that part of the cortex which naturally would first come within my reach. With a few scratches of my nail I was able to expose the calculus and then to remove it with a pair of forceps. A drainage-tube was introduced and the wound was closed around it with superficial sutures. Recovery was complete in ten days. In the second case the symptoms of renal calculus were much more pronounced, the patient frequently suffering from acute attacks of lumbar colic but with no hmmaturia. In a similar way I
explored the kidney, and in front of the organ, just at the junction of the pelvis and hardly within reach of my finger, I felt a stone, but without drawing the kidney out of the wound for the purpose of ex amination, a step which I do not prefer, it was impossible for me to expose the foreign body in this position. Even if I had been able I should not have removed it in this way, as by scratching through the anterior surface of the organ so near to the pelvis I should have left an opening which would certainly have resulted in a renal fistula. Under these circumstances I entered the organ by an incision along the convexity, which was easily within reach, and passed my finger into the dilated calyces from which two stones were speedily removed by forceps. A drainage-tube was introduced down to the surface of the opening in the kidney, and then the superficial incision was drawn together by sutures around it. The patient rapidly recovered without, as far as I could ascertain, any urine escaping except by the urethra.
By thus reaching the stone, after its position had first been defined by examination of the surface of the organ with the finger, its removal was rapidly effected without any unnecessary laceration, and by means of such an opening for the withdrawal of the calculus as would not be likely to fail in healing rapidly and completely. These two different proceedings thus illustrated represent, I believe, important principles in the operative treatment of renal calculus.
Where exploration shows that the stone is very large and branched, as is often the case, it is desirable to extend somewhat, by means of a probe-pointed bistoury, the incisions referred to. In some instances it has, I believe, been found necessary to divide the lowest rib where the lumbar space is preternaturally small. This, however, is not to be recommended if it is possible to avoid it, as it adds considerably to the risk of the operation and endangers the pleura. It is occasion ally necessary to break up a stone with a pair of forceps before at tempting its removal. This may be the case in some of those stones which appear to be moulded within the expanded calyces. When there is evidence from exploration that the kidney has been so destroyed by the presence of the foreign body as to be beyond reasonable chance of speedy repair, it is best to proceed at once with the extirpa tion of the organ. To leave the mere remnants of a suppurating gland with its fibrous investment more or less thickened by a long process of inflammation, is sure to result in the formation of a troublesome sinus and the prospect of another operation.