Notes on Local Analgesia

ezror of not detecting a-calculus that is present, cases have been met with where a very evident shadow was produced, and on thorough exploration no calculus has been found. To conclude: most surgeons are agreed that it is better where the signs are evident not to allow skiagraphy to bave a casting vote; I have bad myself two cases in private, where I had no doubt about a stone being present, refuse operation simply because x rays showed nothing. Having decided to expose the kidney to remove the suspected stone, the.question arises as to the best method of doing so. This should be through a lumbar incision, and, of courme, behind the peritoneum. It has been advocated in cases where the pain present ca.nnot be definitely referred to one or other organ to do a preliminary abdominal section before removing the stone through a lumbar wound. Such instances must be rare in which the pain cannot be fixed more on one side than the other, and when this is determined it.-behoves us to explore the more painful side. Another thing to be remembered is that even when the kidneys are palpated within the abdomen, no more certain information may be gained if the stone is a very small one. Where a stone has been felt after abdominal section it has been suggested to there and then remove it, on the supposition that no more dangerous infection of the peritoneum will have to be dealt with, say, than in dealing with an appendix abscess. This risk should not be taken, and this method cannot be sanctioned except under most unusual conditions. The incision usually employed for performing nephrolithotomy is the oblique lumbar one, which begins above, just below the twelfth rib at its junction with the outer border of the erector spinae, and extends forwards for about 4 or 5 in. in a line directed towards the anterior superiorspine. To get more room this can easily be extended above and below as may be necessary to explore the ureter, or when there is considerable induration of the perineal fat preventing satisfacfactory exposure through a smaller opening. Often the loin incision is made more transverse, but this involves more muscle section, and is difficult to extend. With a view to cause as little damage as possible to the muscular wall, Abbd and Mayo Robson have exposed the kidney on MeBurney's principle-the external oblique is split in a line from the tip of the last rib to the inner side of the anterior superior spine, and the internal in a line from the ninth costal cartilage to the posterior superior spine. I have not tried this incision, but its advocates claim that it gives plenty of room to thoroughly explore both kidney and ureter. In these incisions the loin must be opened out by an air-cushion or sandbag under the opposite loin. Another incision that may be employed is that used by Edebohls for nephropexy. Here the patient is put in the prone position with an air cushion beneath the abdomen to push the kidney into the wound. The incision is along the outer border of the erector spinae ; the fibres of the latissimus are separated, the lumbar fascia cut through, and the perirenal fat and back of kidney are readily seen. I have used this method for one case-that of the lad K., from whose kidney I removed 21 calculi, one large branched, and the others small, which I here show you. Although this was on the right side there was some difficulty in bringing the kidney well up into the wound, but this was^ in the main due to considerable induration of the perirenal fat. I think it might be more difficult on the left side, and, in any case, would be so when the distance between the last rib and iliac crest was limited. In all these operations in freeing the organ after exposure care must be taken not to drag too violently on the structures composing the pedicle, for tearing through of the renal vein haq been recorded. Having got the kidney up into the wound and steadying it between the thumb and finger, the question comes where to incise it. It is an established fact that wounds through the parenchyma heal very readily, so such an incision is usually selected. This should be a vertical one about the convex border, passing well into the pelvis so that the finger can be easily introduced to make a thorough exploration,; the bleedting, which may be free at. first, very readily stops with pressure. With reference to this incision. Kelly has drawn attention to Broedel's researches on the distribution of the renal vessels in the parenchyma. There are two sets of arteries, the larger set supplying the -whole of the anterior "Peet and a part of the posterior, and a lesser set for the rest of the posterior aspect. If the incision is made-in the line between these two, there should be very slight haemorrhage ; tiii line will be situated on-the posterior surface about one-fourth of its breadth behind the outer border. This line, Kelly says, is much more defined when the renal pelvis is distended, and accordingly he has suggested artificially producing such distension by catheterizing the ureter and injecting fluid. A systematic investigation of the pelvis and calices should be made with the finger and sound, and any stone removed with forceps or scoop. The surgeon should not omit to pass the sound-down the ureter, so that no stone may remain behind lodged in this position. If the stone is felt at the start in the pelvis, should it be cut down upon ? Apart from the fact that great care must be taken in making such a cut, owing to the tendency to divide a branch of the renal vein, wounds here in the past have been frequently followed by a flstula, and as such a sequel is unusual with wounds through the parenchyma, the latter has been the approved method. Morris is, however, of opinion that, provided the wound in the pelvis is sutured, it tends to. heal readily enough. In suturing up the wound in the kidney in the ordinary way the stitches frequently, on tying them, cut through. To. avoid this, in my last two cases I have again followed Kelly, who advises the use of mattrass sutures; the stitches used have been No. I catgut. In the case we are considering to-day the operation had another termination. The extreme thinning of the cortex, and the riddling of what remained of it with calculous particles, showed us that the kidney was completely disorganized, and any attempt at saving it useless. The only course was to do. nephrectomy, which was thereupon done. The after-progress of the case has been most satisfactory, both as to the condition of the wound and as to what was of greater importance-namely, the secretion of urine. Although there was-sufficient amount of urine being passed before the operation-and from the state of the left kidney, presumably, all this came from the right side-yet there was just the element of doubt as to the effect of doing the nephrectomy. Had we considered before the operation the possibility of having to nephrectomize our patient, we might have ascertained the amount of secretion from the respective kidneys. This may be done by a Luys's separator, which divides the bladder into two halves, as some of you saw me do in another kidney case recently. That the removed kidney did not. secrete any urine is shown by the measurements and quality since the operation. The average amount passed has been 36 oz., having 6 gr. of urea per ounce, the same as before operation. The urine now has a specific gravity of ioio, is acid, without any albumen or pus.