248 Anatomy Applied to Medicine and Surgery. 



crest of the ilium, about two and a half inches behind the 

 anterior spinous process. In the normal kidney a needle 

 inserted horizontally inwards, at either of these points 

 would transfix the colon, but, when this operation is war- 

 ranted, there is present a tumor, large enough to push the 

 bowel in front of it, so that it would be out of the way 

 during the operation. The lumbar incision for such oper- 

 ative work on the kidney as nephrorrhaphy, or anchoring 

 a movable kidney ; nephrolithotomy, or removal of a stone 

 from the kidney; nephrotomy, incising the organ; or 

 neph.rectomy, complete removal of it, may be made in the 

 loin, starting about one inch below the last rib and run- 

 ning obliquely downwards toward the crest of the ilium 

 and dividing the same structures as mentioned under lum- 

 bar colotomy. Should, for any reason, more room be re- 

 quired, it may be obtained by adding a transverse cut, ex- 

 tending towards the middle line, from near the lower end 

 of this oblique wound. In nephrectomy, when the kidney 

 cannot be dealt with from behind, it may be approached 

 through an abdominal incision Langenbuch's, placed in 

 the linea semilunaris, half above and half below, the level 

 of the umbilicus. The intestines are drawn to one side, 

 and the colon made out, where it covers the kidney. The 

 perirenal fat is exposed after dividing th$ outer, rather 

 than the inner layer of the meso-colon, since the latter 

 layer contains the vessels for the nutrition of the intestine, 

 and gangrene of the bowel might ensue were this layer 

 divided. The edges of the incised meso-colon may be su- 

 tured to the edges of the peritoneum at the abdominal 

 wound, thus allowing the operation to be performed with- 

 out any danger of infecting the general peritoneal cavity. 

 One advantage of the abdominal operation is that the pre- 

 sence of the other kidney may be established, since cases 

 are on record where there was only one kidney present, 



