LARGE VESICAL CALCULUS.
DR. E. J. MELLISH exhibited a vesical stone which he had removed from a patient in August. It was exhibited on account of its size. It was somewhat triangular in shape and flattened. In its largest circumference it measured six and a half inches ; in its smallest four and seven-eighths inches and the intermediate circumference was six inches. Its weight was 1222 grains (about 7.88 grammes). It was composed largely of uric acid. On bi secting it, the concentric formation was well shown, and its nucleus recognized as a triangular piece left in the bladder at the time of the former operation. Patient had been subjected to lithotrity five years previously with only partial relief. He had then suffered from symptoms of calculus about three years. He removed the calculus through a suprapubic incision, having used a rectal bag and inflated the bladder moderately with air. He sutured the bladder wall, as the mucous membrane of the bladder did not seem to be seriously affected. The catheter was kept in place three or four days, then removed, After this the patient was catheterized every two hours at first ; but through an oversight of the interne, twelve ounces of urine were allowed to accumulate, and within a week after the operation extravasation occurred, an abscess formed, and was evacuated through the former drainage opening which had healed. This delayed the recovery perhaps a month. Patient was now well.
DR. CHRISTIAN FENGER considered the X-ray a valuable aid in the diagnosis of renal calculi, and he thought the position taken by the essayist was a step in advance.
As to the incision down to the kidney, he would cut the mus cles of the lumbar region transversely as little as possible. Isola tion and examination of and operating upon the kidney were comparatively easy if the kidney was movable. If it was not movable, but was located high up, the operation was not easy ; and it might become necessary to resect a rib or ribs in order to get access to the kidney and remove the calculi. He agreed with Dr.
Bevan and Dr. Harris that he would rather remove a stone or stones through the pelvis than through the kidney tissue, if he could feel the stone through the pelvis.
He did not think Dr. Harris was right in laying stress on renal inflammation as a cause of permanency of a fistula into the renal pelvis. It is the permeability of the ureter upon which the final result alone depends, as it insures closure of the wound in the pelvis. But the stone or stones will be found by resorting to bisection of the kidney, whilst they might not be found by ex ploring through an opening in the pelvis. When the lumen of the pelvis of the kidney was too small to permit the introduction of the index-finger, it was difficult or impossible to find the stone by pelveotomy. It was also in a kidney with a non-dilated pelvis difficult to make bisection of the kidney to find the way from the convex survex to the pelvis, because this incision could not be done along an aspirator needle. When the X-ray showed the existence of stones in the kidney, the surgeon might be obliged to resort to complete bisection of the kidney in order to find the stone.
He spoke of two cases in which the kidney became gan grenous following total or partial bisection of the organ.
DR. BEVAN, in closing the discussion, stated that exploration of the ureter might be omitted in an aseptic case when, from a clear X-ray picture, we feel confident all stones had been removed.
In regard to the question of Dr. Eastman, there was no doubt but that a displaced kidney would favor secondary stone forma tion, but whether it would be the cause of primary stone forma tion, he could not say.
As to the danger of necrosis of kidney tissue following a large incision, he had never before heard of such a although Dr. Fenger had mentioned two such cases.
He had been very much interested in the statement made by Dr. Fenger in regard to incision in the kidney substance. Only a week ago he made an exploration of a kidney which proved to be almost normal, tried to find the pelvis through a small incision, and expressed doubt as to whether he had accomplished it or not.