On theoretical grounds based on the facts that glycerin is a solvent of uric acid, and that when given by the mouth it is excreted in large part with the urine, this agent was tried with success, hut it is not due to any solvent action on the uric acid, but to physical changes produced in the urine. which is rendered somewhat oily and thus causes a lubri cating effect. From I to 4 ounces are given at a dose, dissolved in an equal quantity of water, between two meals, and repeated two or three times in several days. This method was used in one hun dred and fifteen cases, and in GO per cent. it proved efficacious either by re moving concretions or by relieving the pain. Herrmann (Med. Chronicle, Jan., 1900).
Treatment, Surgical. — Nephrolithot omy—the removal of a stone located in the substance, calices or pelvis, of the kidney—is indicated when the diagnosis is reasonably certain.
Tecknique of Nephrolitholomy. — The preparation of the patient and the in cision are the same as for nephropexy. Edebohls's bag, placed under the pa tient lying on the side, is of much value in bringing the field of operation into prominence. Deep manipulation is facil itated by dividing the outer edge of the quadrates lumborum or if more room is needed in front, for inspecting or free ing the kidney or for controlling hmm orrhage. The incision may be curved downward and forward toward the ab domen. After opening the fatty capsule of the kidney the organ should be sys tematically examined by pressing on its surfaces or compressing it between the thumb and fingers. Morris recommends that the pelvis and upper end of the ure ter be palpated before the kidney is dis turbed in its position in order to detect any small calculus that might be present and prevent its falling into the ureter during manipulation. If no hard spot is detected after the entire kidney has been squeezed between the fingers, some op erators recommend that exploratory punctures be made from one end of the kidney to the other with a fine needle. This procedure is to be condemned as most unreliable for diagnostic purposes.
In case a stone is found, the kidney must be opened; and if none be found the same procedure is necessary for thorough exploration. In either case an incision should be made in the border, the in fundibulum should be opened, and the calices should be subject to digital exam ination. When a calculus is found, it may be necessary to enlarge the wound in order to extract it. Haemorrhage is controlled by temporary packing or by passing a catgut suture through the kid ney-substance. Large calculi, particu larly if branched, often have to be broken with forceps before it is possible to move them. Openings in the pelvis sometimes give rise to urinary fistula?; when, therefore, it seems proper and feasible, it is best to extract through an opening into renal tissue.
Whether a calculus is found or not, the ureter should be catheterized through the pelvis of the kidney from end to end.
to determine that it is not obstructed. Weir's long flexible probe of spiral steel is the best means of accomplishing this. When the renal cavity is suppurating, it should be irrigated with a weak anti septic solution. The wound in the kid ney is packed with iodoform gauze and a drainage-tube is carried behind the kidney passing out of the lower part of the incision. The wound is partly closed and dressed with the usual aseptic pre cautions.
Probably no major operation has a lower mortality, particularly if under taken early before any serious renal changes have resulted.
[Morris has operated in 34 cases with only one death. Newman ("Lectures on the Surgical Diseases of the Kidney," London, 'SS) collected statistics of 42 cases of nephrolithotomy in which the calculus was not associated with pyuria or suppuration within the kidney, with out finding a single death. KEEN and TINKER.] Cellulitis, renal fistula, and renal ab scess have been mentioned as possible consequences of the operation.
The aim of the surgical treatment of renal calculus should be to extend the application of nephrolithotomy and thereby restrict the necessity of nephrot omy and nephreetomy. The theory that a stone in one kidney, whether that kidney is itself painful or not, reflects or transmits pain to the opposite kidney is quite unproved. The surgical principle with regard to the exploratory operations should be that with pain, paroxysmal or continuous, on one side only, the kid ney on the painful side should be ex plored. Nephrectomy for caleulous con ditions is very rarely called for and should be done only in most exceptional eases. Nephrotomy for calculous pyo nephrosis is the proper operation, be cause of the frequency of double calcu lous disease. Nephrectomy while the opposite organ is occupied by calculus is fraught with very great danger to life; whereas nephreetomy after the op posite kidney has been freed from stone will probably be followed by recovery from the operation and possibly by very good health for years afterward. When renal calculus causes reflected or trans ferred vesical or ovarian pain, the re moval of the calculus will be followed by complete cure of the bladder or ovarian symptoms. When we have cause to suspect the presence of a cal culus we should recommend its im mediate removal regardless of the fact that it is not causing renal or trans ferred pain. Quiescent calculus is as dangerous to the possessor as unsus pected calculus, and ought to be re moved by operation. The same principle should be applied to renal calculus which has long been the rule in regard to vesical calculus, namely: when sus pected it should be searched for and, when known to exist, removed, without in the hope that it may become encysted or spontaneously expelled. The very low mortality puts this operation upon the same footing for renal cal culus as lithotrity in the most experi enced hands for vesical calculus. Henry Morris (Lancet. Apr. 23, 'OS).