FUSED (HORSE-SHOE) KIDNEY.

BYRON ROBINSON, CHICAGO.

In this short article I present the legends and illustrations of two fused (horse-shoe) kidneys, Nos. 8 and 38. The importance of any surgical procedures on such anomalous organs is amply evident. The picture with the legends tell the story.

From these legends and illustrations the surgeon and physician may draw instructive lessons. The signification is to be able to diagnose venel anomalies. During the past decade I have collected the illustrations of 63 fused (horse-shoe) kidneys. The accompanying two illustrations are typical of the variation of the anomaly.

Fig. 8. Fused (Horse-Shoe) Kidney. Renes arcuati distal (distal renal fusion). Explanation of illustration signsZ right and Y left renal mass. A.R., arteria renalis. V.R., vena renalis. 2, ureteral pelvis. 3, proximal ureteral isthmus. Presentation-Ventral renal surface. Isthmus renalis-X, parenchymatous. Location, at distal renal poles, also ventral

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to aorta and vena cava, however, dorsal to the ureters; i. .g they are located on opposite sides of the isthmus. The isthmus renalis intervenes immediately between the vasa abdominalia magna (dorsalward) and the uterus (ventralward). Both ureters and isthmus lie ventral to the great abdominal vessels which separate it from the vertebral column. Dimensions; maximum. Hilus renalis. Located bilaterally and symmetrically on ventral surface of each lateral circumference extensive, indefinite. Diameters, major and minor maximum. Sinus Renalis-Practcially absent or a plane surface. Ureter proprius-Bilateral ureteral unicity and symmetry (as to form, position, dimension). Form (isthmus, dilation) marked. Dimension normal. Course, practically normal. Pelvis ureteris-Bilateral pelvic duplicity and nonsymmetry (as to form, position, dimension). Location, on ventral surface of each lateral mass. Form, irregular. Dimension, limited. Calyces preteris-Not exposed. Bilateral calicular duplicity and nonsymmetry (as to form, position, dimension, number). Location, on ventral surface of each lateral renal mass. Distribution, irregular over extensive renal area. Form, abnormal. Dimension, length and diameter increased or diminished. Vasa renalia-Right, 3 renal arteries. 2 renal veins. Left, 2 renal arteries and 1 renal vein. Practically bilateral renal vascular duplicity. Vasa renalia all enter hila except one distal renal trunk, which courses dorsal to the vena cava and penetrates, like poniard, the dorsal renal surface. Arteria renales, paired, vena renales, unpaired. The proximal vasa renalia possess greater dimension (length, diameter) than the distal. Renal arteries lie dorsal to renal veins. A remarkable vascular factor exists in that a single renal arterial trunk (A Re) divides one branch supplying the left renal mass and the other the right. This is significant as ligation of the renal trunk would compromise bilaterally the circulation of both renal masses. The position of the four renal arteries emerging from the abdominal aorta is within the embryonal renal region. Topography-Holotopia, distal poles excessively medianward. Skeletopia, abnormally intimate with the vertebral column. Syntopia, abnormally intimate with vasa abdominalia magna. Idiotopia, the distal renal pole is rotated excessively medianward and the proximal renal

pole is rotated excessively externally lateralward. Symmetry -Nonsymmetrical. The chief renal mass tends leftward and proximalward. Surface, lobulated, fissured. Form, elongated, crescentine. Dimension-Equivalent to two normal kidneys. Position Distalward renal dystopia. Rrom the Northwestern Medical Museum through the courtesy of Professor Robert Zeit and Professor P. T. Burns.

Fig. 38.-Fused (Horse-Shoe) Kidney. Renes arcuati distal (distal renal poles fused). Presentation-Ventral renal surface. Isthmus realis-Parenchymatous. Location, at distal renal poles. It lies ventral to the vena cava and aorta, but dorsa to the ureters. The isthmus intervenes immediately between the vasa abdominalia magna (dorsally) and the ureters (ventrally). The great abdominal vessels and ureters (ventrally). The great abdominal vessels and ureters lie on opposite renal surfaces. Both ureters and isthmus are located ventral to aorta and vena cava. Hilus renalis-Bilateral unic

ity and nonsymmetry (as to position, form, dimension). Location, on ventral and ventro, medial renal surfaces. Boundary margin definitive with limited circumference. Sinus renalis-Right renal excavation of limited diameters. Left renal excavation, marked in diameters. Ureter propriusBilaterally single and nonsymmetrical (as to position, form, dimension). Course, abnormal. Location, on ventral surface of bilateral mass. Form (isthmuses and dilatations) and dimension usual. Pelvis ureteris-Bilateral duplicity ? and nonsymmetry (as to position, form, dimension and in relation to vessels). Locaton, on ventral surface of each bilateral renal Form, abnormal. Dimension medium. Calyces ureteris-Not exposed. Bilateral duplicity and nonsym? metry (as to postion, form, dimension, number and relation to renal vessels). Location, on ventro-medial renal surface. Form, abnormal. Dimension, increased in diameter. Number, right 3, left 3 - ? Vasa renalia-Right, 2 arteries and 3 veins. Left, 4 arteries and 1 vein. Bilateral duplicity and nonsymmetry (as to number and position). Nonpaired, irregularly located. Veins located ventral to arteries. One renal trunk divides, each branch supplying a lateral renal mass. Vasa renalia enter hila except a proximal vein and distalward. Skeletopia, excessively intimate with the vertebral column and promontorium sacrum. Syntopia, excessively adjacent to vasa abdominalia magna and vasa iliaca communis. Idiotopia, distal poles of bilateral renal masses abnormally rotated medialward. Form-Crescent. Symmetry-Bilaterally nonsymmetrical. Surface-Lobulated fissured. Dimension-Not equivalent to two normal kidneys. Position-Distalward congenital renal dystopia. (After Garre and Ehrhardt.)

Periscope of Medical Progress.

ACUTE SUPPURATIVE PERITONITIS.

In the Oration on Surgery, read at the fifty-eighth session of the American Medical Association, at Atlantic City, W. H. Wathen, Louisville, Ky. (Journal A. M. A., June 8), discusses at length the action of bacteria in the intestines and pelvic organs in their relation to the production of local and

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general peritonitis. He insists on the importance of encouraging phagocytosis and of avoiding everything that can inpair its effectiveness. The opsonic treatment, he thinks, can be of little use in peritonitis, owing to the time required for determining and securing the proper vaccine; the infècting microbe can not be identified until after operation, and there is often found a mixed infection. He sees more promise from the use of horse serum and more yet from the colonic absorption of normal saline solution. "While other means," he says, "increase leucocytosis and phagocytosis, it is possible that the rapid and continuous stimulation of the blood and lymphatic currents by colonic absorption of saline solution may finally supercede all other methods, not only in acute peritonitis and prompt operation for the removal of infecting foci are essentials; delay, purgation and opium are condemned. Wathen emphasizes the following as especially important in the operative treatment of all perforations into the peritoneal cavity, and of diffuse and general peritonitis from any cause: Operate as soon as a surgical diagnosis is made and avoid purgation and opium before and after the operation. Give no food or liquid, but empty the stomach by lavage, and remove fecal matter from the colon by rectal enemata. 2. Operate rapidly, and, if possible, treat the foci of suppuration by suturing gastrointestinal perforations, or bladder wounds; by cholecystectomy or cholecystotomy, by appedectomy; or by the removal of the uterus or its adnexa, always remembering to avoid peritoneal traumatism so as to protect peritoneal resistance to bacterial invasion and toxemia. 3. Expose or handle the intestines as little as possible, and do not separate adhesions or irrigate or sponge the peritoneal cavity. Establish drainage from the bottom of the pelvis, and, if indicated, also drain the site of the infection, using a large split rubber tube with cr without gauze, with the patient in nearly a sitting position. 4. Pour into the peritoneal cavity, before closing the abdominal wound, hot horse serum or saline solution to stimulate leucocytosis, and, when patient is returned to bed, use salone solution by rectum, after Murphy's method, and, if necessary, use the horse serum or saline solution subcutaneously. 5. Enterotomy is never indicated, except in some delayed cases of intestinal