Technique of Nephropexy. — The pa tient is placed on the side, resting on a hard pillow or pad, so as to increase the costo-iliac space. The incision for ne phropexy answers also for nephrotomy, nephrolithotomy, and nephrectomy. The twelfth rib is carefully located by both palpation and counting, to avoid the pos sibility of opening the pleura. Begin ning half an inch below the last rib and close to the outer border of the erector spina:, the incision is carried obliquely downward and forward for about 7 to 8 centimetres (3 inches). It divides the skin and subcutaneous tissues, the su perficial fascia, the latissimus dorsi, the external oblique, the internal oblique, the transversalis with its aponeurosis, and the deep layer of the lumbar fascia. The anterior border of the quadratus lumborum may require division if im possible to retract it sufficiently. Broad retractors are now made to gather up all the divided tissues, and the perinephric fat will bulge in the wound. The fat is separated by the fingers or by two pairs of dissecting forceps and the fibrous cap sole is exposed. The kidney is pushed well upward and into the loin by the hand of an assistant pressing on the ab dominal wall. Special care should be taken that the kidney be in its normal position. The kidney is secured by pass ing four to six sutures through the cap sule and about 2 centimetres (1 inch) of kidney-substance and then through the adjacent fascia and muscles of the wound, tying subcutaneously. Fine silk, kan garoo-tendon, and chromicized catgut are used as suture-material; but, if cat gut is used, it should be made certain that it is not too readily absorbable.
After the kidney is firmly fastened in place the external wound is closed and the usual aseptic dressing applied.
modifications of this operation have been suggested, having, as their main object, the securing of firmer or more general adhesions about the kidney.
Leaving a drainage-tube along the con vex border of the kidney for some time, packing the wound with gauze, incising and stripping back the capsule so as to get a raw surface in contact with the surrounding parts may be mentioned as prominent among these procedures, but simply stitching the kidney in place, as described, has given perfectly satisfactory and permanent results in the experience of several prominent surgeons. While the oblique incision is generally recom mended, a vertical incision along the sacro-lumbalis muscle permits of more ready access for the purpose of sewing the kidney in its normal axis.
Vulliet's method performed ten times with satisfactory results. It consists in the fixation of the kidney by means of a detached strip of the tendon of the erector spina: passed through the paren chyma of the kidney. A small swivel fixed to a long delicate handle facilitates the separation of the fascieulus of the tendon. Two longitudinal incisions are
made in the fibrous capsule of the kid ney, one near the outer border of the or gan and one near the hilum; the capsule is then freed from the parenchyma by blunt dissection, and the split tendon of the erector spine is passed beneath the separated capsule from without inward, the ends being secured in a wound near the spine. A few sutures are passed through the capsule and the fascia lum borum. J. L. Thomas (Brit. Med. Jour., Nov. S, 1002).
Renal Calculus.
Symptoms.—Pain and haemorrhage are the most important symptoms, in case the stone is small and the kidney healthy; indeed, these may be the only symptoms present. The pain is usually felt in the loin over the affected organ; it is of a dull, heavy, dragging character. Hmma turia is generally remittent, the amount of blood passed is not great, it is thor oughly mixed with the urine, and the blood-cells are altered. A larger cal culus, producing suppuration, is sug gested by pus in the urine with pain on pressure and perhaps increased resistance in the loin. A calculus blocking the ure ter and producing hydronephrosis is sug gested by feeling a soft, elastic tumor of variable size through the abdominal walls or in the lumbar region; but this is apt to disappear simultaneously with the passage of a large amount of urine. The attacks usually recur and the urine becomes alkaline or putrid. Vesieal irri tation, pain, retraction of the totes, and gastric disturbances are other symptoms frequently met with in all forms of renal calculus. In case of renal colic there is acute suffering, the pain shooting down the ureter to the testicle or labium majus and often radiating to the thigh. There may be nausea and ineffectual vomiting, vesical tcnesmus, faintness, cold sweat ing, and even collapse. Oftentimes the pain ceases as suddenly as it began; but relief is not permanent unless the stone has receded into the pelvis of the kidney or has passed into the bladder. The paroxysms of pain recur at intervals of from a few minutes to several hours or days.
Diagnosis. — In the differential diag nosis from stone and malignant or villous growths of the bladder the imperfect mixing of the blood with urine, the larger amount of blood, less altered blood-cells, the presence of clots, and more severe pain would be of aid. In the case of malignant growths of the kidney the cachexia and the palpation of a tumor, possibly irregular in outline, are of use in establishing a diagnosis.
The Röntgen rays have been used by a considerable number of surgeons, and with quite satisfactory results in most cases. Calculi of calcium oxalate give the most distinct pictures, those formed of urates are less easily recognized, and phosphatic calculi are most difficult to photograph.