The removal of most impacted calculi, however, is usually plished through the extra-peritoneal loin incision made for nephro lithotomy. By prolonging the lumbar incision downwards and forwards the entire ureter can he exposed without dividing the peritoneum. A cal, ulus in the pelvic portion of the ureter tray then be removed by opening the tube ov er the stone or by squeezing this backwards into the abdominal Imrt upon] ig the ureter there.
A calculus impacted at any spot between the renal pelvis and the bony pelvis should be reached and removed through the lumbar incision by dividing the ureter in its lung axis, and lifter extraction of the stone closing the ureteral incision by tine catgut sutures.
Cah 'don, .1iiuria occurs with the bladder empty when a calculus blocks the renal pelvis or ureter, the opposite kidney having been formerly blocked in a similar manner, and long rendered functionless, or from suppressiun in one kidney, the other ureter being blocked by a calculus. The condition is always an exceedingly grave one demanding immediate treatment.
Expectant treatment such as is indicated fur acute uremia as hot packs, saline purgatives and Pilocarpine hypodermically with Normal Saline by the ieims has in some instances proved effectual, but obviously these measures ran only delay the certainly fatal issue unless, during the time in which they are being employed, the recently impacted calculus chances to travel onwards into the bladder. The diagnosis once established, no time should tie lost. in carrying, out an operation for the removal of the stone; this should be dune even in the ahsence of all un.emic symptoms within IS hours, and when this rule has been lulluwed the mortality has been lound to fall to well under 5u per a cut. I f time has been lost by e\peetant treatment the clitince of saving life fades with each day of delay. advocated the necessity of not merely removing the most recent block in the ureter, but also of performing at the same time a nephrotoiny or nephru-lithotomy operation on the opposite kidney with the view of saving every vestige of secreting structure. In this case the kidney is exposed, the pelvis is opened, either directly or through the cortex, and a tube inserted and brought out through the wound in the loin.
The ;nutria which somet Imes supervenes as the result of shock following a severe operation upon one kidney when the opposite organ is already diseased or contains calculi must be treated upon the expectant method when the condition of the patient does not warrant exploratory or operative measures being undertaken upon the kidney which has not been exposed.
Stone lodged in the kidney or its pelvis and causing pain, albuminuria or Immaturia calls for prompt treatment. and the question at once arises, Should this be medical or surgical ? As regards medicinal agents the 7eat difficulty presents itself of determining the nature of the calculus, since the reaction of the urine cannot always be depended upon to supply reliable evidence of its chemical composition. Should there, however, he good reason for believing that the stone is a uric acid one, Robert's alkaline treatment may have a trial, and the Bicarbonate or Citrate of Potash may be administered for many weeks at a time to keep the urine constantly alkaline. A small stone of recent formation in one of the calyces may undoubtedly be so reduced in size as to fall into the renal pelvis and pass on to the bladder by persevering with the alkali.
The experience of Contrexeville treatment proves that often small stones are passed into the bladder and through the urethra after a six weeks drinking of the waters at this resort.
Oxalate of lime calculi have, in a similar manner, been got rid of by a course of the Wildungen waters, or by the steady administration of the Acid Phosphate of Sodium, as already mentioned. Urotropine is always indicated where the presence of the stone has produced suppuration or pyelitis, and this drug may be advantageously combined with the acid sodium phosphate. Piperazin is much less reliable, though formerly much extolled as a lithontriptic, and Piperidine Acid Tartrate in r5-gr. doses is recommended as a powerful uric acid solvent.
Rest in the treatment of renal calculi has received much less attention than formerly owing to the frequency with which operative treatment has been carried out. Absolute rest in bed has in many instances been followed by a complete disappearance of all the symptoms, probably by securing the stone in some fixed or encysted position in one of the renal calyces. It must always be resorted to when hitmaturia has been severe.