When, however, the stone continues to produce severe wearing pain or hematuria, and where its irritation of the renal pelvic membrane keeps up a suppurative pyelitis, operative procedures should not be delayed. These consist of Nephro-lithotornv, Nephrotomv, or Nephrectomy. The kidney should be exposed by an incision in the loin from the external border of the erector spine below the last rib, extending downwards and forwards in front of the anterior superior iliac spine. The organ is brought out through the wound and carefully palpated, and an incision is made through its convex margin or a stone, if detected by touch, is directly cut down upon and removed. The renal substance is next closed by catgut sutures after washing the cut surfaces with hot Boric solution. Where suppurative conditions exist the kidney itself may require drainage and drainage must in any case be provided for in the loin wound.
f , on exposure of the kidney, the calculus is found to he lodged in the upper part of the ureter it may he pushed back into the! renal pelvis and removed by incising this part of the organ (pyelotomy).
Should the kidney he found to be the scat of several stones which have caused widespread suppuration or hopeless disorganisation of the entire gland. the major operation of or removal of the whole kidney should be carried out, hut only if the other kidney has previously been found to he functioning in a normal manner. Whether the surgeon starts with the intention of performing a total removal of one kidney or not, he should previously make a determination of the renal adequacy by Kiimmel's or Wright's method, or the ureters should be catheterised from the bladder.
After the removal of a calculus either from the kidney, ureter, bladder or urethra the probability of a second formation occurring should not he lost sight of. The composition or reaction of the urine should be periodi ally altered for some weeks at a time by the administration of alkalies when the stone is found to he made up of uric acid or urates, and if of oxalate of lime the acid phosphate of sodium should be given.