A series of tucks or reefs may be made in the anterior wall of the stomach by a row of interrupted sutures, the operation being known as " gastrorrhaphy " or " gastroplication." NEPnRovrosis.—This is often a part of the so-called Glenard's disease, but though caused by the same factors it often exists alone or prepon derates over the other displacements. The organ may only be found to slightly descend with the diaphragm on deep inspiration. Its entire bulk may be palpated below the costal arch on the patient taking a full breath, or it may be freely movable or even floating at all times. The symptoms, however, bear no proportion to the degree of motility.
An attempt should be made to keep the organ in its normal position by a properly adjusted binder or corset applied when the patient is in the lying position with the pelvis raised, a movable diamond-shaped pad or small air-cushion being inserted inside the support with the acute apices of the pad lying across the abdomen. Garland maintains that not more than i per cent. of the eases of displaced kidney require operation, and he has devised a rational corset which seems to meet the requirements of the condition better than any hitherto employed.
Surgical methods if possible should be avoided in marked neurasthenic patients where the renal functions are not really interfered with, as the operation of fastening the kidney has been abundantly proved to fail in relieving the profound neurotic symptoms present before the operation. It appears almost equally clear that when operation is undertaken for the relief of kidney symptoms where the condition is part of a general ptosis of the organs in the upper zone of the abdomen, mere fixation of the kidney will prove a failure if the other organs are not at the same time stitched in their normal positions.
Operation is, on the other hand, clearly indicated after the failure of the abdominal support when the ureter or pedicle becomes twisted or kinked, causing Dietl's crisis and hydronephrosis or producing dragging upon the bile-ducts or duodenum.
Nephropexy, nephrorrhaphy, or fixation of the kidney may be effected by the posterior or extraperitoneal route through an oblique lumbar in cision. The kidney being exposed, its fat is stripped off and the organ care fully examined for evidence of gross disease or calculi. Some surgeons, in order to he certain of its integrity, advise that it be slit open (nephrotomy), and sutured afterwards if found to be sound. capsule is to be split by a crucial incision, and the segments reflected backwards to the hilum. These are then sutured to the posterior abdominal wall, the upper ones being stitched to the muscle attached to the last rib and the lower ones sutured to the aponeurosis of the posterior wall, so as to form a shelf upon which the organ may rest by utilising the parietal peritoneum and both layers of the perirenal fascia.
The operation has been modified in various ways. MeLaurin produces the shelf by simply suturing Zuckerkandl's fascia and the peritoneum to the fascia on the front of the quadratus lumborum muscle, and closes the wound up without gauze packing or drainage.
Fullerton has ingeniously devised the simple operation of suspending the kidney by a piece of its capsule attached to the ligarnentum arcuatum externum, and reports excellent results, and A. B. Mitchell also uses the posterior capsule, but in a slightly different way.
An anterior operation has been devised by ITarlan and Bishop, and carried out by Cheyne in the following manner: The organ being reached from the front by an incision made below the edge of the ribs, the peri toneum on being pushed to the middle line exposes the posterior surface of the kidney with its surrounding tissue. This latter structure is divided and the fat removed, and the capsule is incised on its posterior surface and reflected backwards from the outer and lower areas. These flaps are finally attached to the muscles behind the organ, one wing supporting the lower end and the other the outer convex portion of the kidney. The anterior operation permits of greater freedom in fixing the displaced kidney in its normal position. The kidney, if found diseased, must be removed (nephreetomy) should previous examination by the cystoscope have demonstrated the integrity of its fellow.
The attacks known as Dietl's crises caused by twisting of the renal pellicle may be often relieved by inverting the patient or raising the lower extremities and pelvis by elevating the foot of the bed to a considerable height. In a similar manner the gastric crises may often be temporarily relieved when the duodenum has become kinked.
ENTEROPTOSIS.--limploying this term for the moment only to those cases where the main and most obvious trouble is due to prolapse of the transverse colon, the V-shaped loop extending into the pelvis, much may be done by rest and the application of a corset and systematic purgation. The writer has observed that in such cases lavage of the stomach is some times followed by the emptying of an enormously distended colon which has resisted enemata, the lavage having excited a very pronounced con traction of the walls of the displaced colon.
For the chronic constipation in this type of ptosis, which may amount to intestinal obstruction, little may be expected from any attempt to keep the displaced colon in the normal position by suturing or stitching. Ar buthnot Lane has carried out successfully the heroic procedure of excising the entire colon. The first step in the' operation is to perform ileosigmoid ostomy by dividing the small intestine above the ileocmcal valve and making a lateral anastomosis by joining the proximal end of the small intestine to the lower part of the sigmoid, and leaving the colon in the abdomen with the distal end obliterated by sutures. Sometimes this preliminary is sufficient, but there is always the danger of some aces finding their way upwards into the useless colon, in which case after several weeks a second operation is carried out which consists in the removal of the whole of the large intestine above the juncture at the sigmoid.