1910 Journal of the American Medical Association (JAMA)  
this method is obvious. Not everyone is able to operate through an operating cystoscope, as Dr. Young does. The extraperitoneal method alone requires a formidable incision-5 or 6 inches in length-so that one can see the entire anatomy of the parts-iliac vessels, ureter, etc.-but by my method one is able to extract the stone through a two-inch extraperitoneal incision, being assisted by the assistant's hand in a suprapubic incision through the bladder. Dr. Stephen A. Maiioney, Holyoke, Mass.: A
more » ... ase re¬ cently came under my observation that covered some of the points brought up by Dr. Young relative to the extraperito¬ neal method of removing stone from the ureter, and In which 1 had a great deal of trouble in carrying out the method in its entirety. The patient came under my care about 3 years ago, suffer¬ ing from what appeared to be a nephritic colic. I had confidence in the <r-ray and sent him to an expert radio¬ grapher. The plate was returned to me, showing a stone the size of a large olive down in the lower part of the left ureter. I operated and easily removed the stone. About 2 months after that the man had a severe attack of colic and the next day 2 small stones were evacuated from the bladder. A year ago he again came under my observation, this time for a mere discomfort in the back. He went to the radiographer and had both his kidneys examined. The left kidney was found to be practically normal, but in the right kidney, much to our surprise, was a stone occupying the entire pelvis. The entire tracts on both sides were oe-rayed. We removed the stone from the right kidney. That was in June, 1909. In April, 1910, he had another attack of nephritic colic on the right side. A radiograph Was again taken and a stone the size of an almond discovered down in the lower part of the right ureter. The first stone had been removed from the left ureter. Comparing the 2 skiagrams, the one from the first operation 3 years ago and the last skiagram made before the final operation, it appeared that, owing to the fact that the latter stone was so much nearer the brim of the pelvis than the former, we would have an easy time removing it. At operation we discovered the ureter easily enough, but in running the finger upward and downward we failed to discover any stone, but having sullicient confidence in the tu-ray I opened the ureter, inserted a large-sized probe, passed it downward and upward along the course of the ureter, but still failed to discover the stone. Then I had the assistant pass a sound into the bladder to see whether we could meet the sound in' the ureter from below, but failed. Still thinking that there must be some cause for the shadow in the skiagram, I did a laparotomy and, thinking that possibly the shadow might have been caused by a concretion in the appendix, we examined the appendix and found it practically normal. I ran the finger down behind the bladder in the cul-de-sac and palpated a small movable lump, which could easily be brought upward along the ureter, and therefore was easily delivered in the incision. I had used all the methods I could think of to discover that stone by the extraperitoneal method, but had failed entirely in doing so. When I got the stone out it was about the size of an almond. I could easily see on the stone lines of demarcation where it had projected into the bladder. The stone was half in half out of the bladder, and I would have failed entirely to discover it, had I not opened the abdomen. Du. A. D. Bevan, Chicago: In a considerable experience, covering about 70 stone operations, I have formed, as the result of rather sad experiences at times, some convictions in regard to the technic of the operation itself. I believe that whenever possible pyelotomy is preferable to a nephrot-°B ay. In three cases, I have been compelled to remove the kidney for hemorrhage after a nephrolithotomy. In nephrohthotomy the great danger is subsequent hemorrhage, and this íb almost entirely avoided if the operation of pyelotomy is done, and that should be done whenever it is possible. Of course, when it is not possible, on account of multiple stones or of the position of stones in the calices, a nephrolithotomy 's indicated. When this is done, however, the incision in the kidney should be made as small as possible. I have not tried the silver wire division recommended by the Hopkins school, but the division, so far as the knife is concerned, should be a small one, a division of the connective tissue by blunt artery forceps, stretching the kidney and removing the stone in that way. Of course, when the kid¬ ney is extensively involved and it is evident that it will remain an organ of little use to the individual, and when the other kidney is sound, it is better to do a primary nephrectomy and clean up the case at one sitting. When the stone is in the upper end of the ureter, the case can be handled with the same incision and technic as in pyelotomy. If the stone is located in the central portion of the ureter, it is better to do a muscle-splitting operation, such as is done in appendectomy, with the exception that tho peritoneum is not divided, but is lifted up and the ureter sought for. If possible, the catheter should be put into the ureter im¬ mediately before the operation, because it would serve as a guide of much value. Then with blunt hooks the ureler can be lifted well up into the wound, incised, the stone removed, the incision closed, the ureter dropped back, and the catheter removed. In the lowest part of the ureter in 2 cases I have resorted to an interesting as well as an unusual technic, and that is attacking the ureter through a perineal incision, very much like the old left lateral lithotomy oper¬ ation. The incision is carried down to the prostate, but not into it. Then by blunt dissection first with one finger, then with two fingers, the incision is carried around the prostate to the base of the bladder, and the stone found. This operation is, of course, limited to cases in which the stone is in the lower part of the ureter. The stone having been located, a pair of closed, sharp-pointed scissors is car¬ ried down to the ureter by a blind dissection, and the ureter is then divided, tho stone being removed in this way. The procedure is applicable only to cases of stones of fair size located in the far lower end of the ureter. Dr. Miles F. Porter, Fort Wayne, Ind.: How many pictures did Flam take in the case in which both kidneys contained stones and in which the radiograph showed stones in only one kidney? Dr. Elam : Two exposures were made of each kidney. Dr. Porier: This demonstrates again that we often find fault with instruments of precision when the fault lies with the individual who uses them. Separate radiographs should be made of each kidney, in order to study the organs thor¬ oughly. I do not believe that a satisfactory picture of both kidneys can be taken at one time, but when a number of plates are made of each kidney separately we may expect that one at least will show the stones, if present. I do not believe in the infallibility of anything human, but I do believe that the (U-ray is the best single diagnostic element in this work that I know anything about. The clinical use of digitalis has proved one of the greatest problems of medicine and, despite the advances made in our knowledge of the pharmacology of this group, the problem has been advanced only, not solved, and there are few practitioners who can invariably distinguish the toxic action of digitalis from the symptoms of cardiac disease. The difficulties in the way of the therapeutic use of the digitalis bodies depend on several factors. In the first place, we have no definite knowledge of the rate of
doi:10.1001/jama.1910.04330200007002 fatcat:2fvehmqb6fchfebzrec3juzu5a