equipment, and can scarcely provide competent and independent examiners, to conduct examinations in the scientific subjects on the lines of the more recent methods of instruction.

The Act of 1872 proved an important factor in causing a diversion of students from American to Canadian schools.

The ever-increasing proportion of Canadian graduates added yearly to the Medical Register is a marked feature of this period, and is worthy of special notice. An analysis of the Medical Register of 1875-thirty years ago-shows that of the whole number of practitioners, 78 per cent. were American graduates, 14 per cent. were British graduates, 2 per cent. were Canadian graduates, and 6 per cent. were Nova Scotia licentiates. A similar analysis of the Register of 1904-5 gives widely different results. Of the whole number, 53 per cent. were Can+ adian, 44 per cent. were American, and 3 per cent. were British graduates. The change in favor of Canadian schools is still more strikingly illustrated by an analysis of the additions to the Register from 1895 to 1904. Of the number added, 85.5 per cent. were Canadian, 14.2 per cent. were American, and 0.3 per cent. were British graduates. During the year 1904-5 the additions to the Register were exclusively Canadian graduates.

The predominance of the American graduates, numerically, has come to an end, but their influence, always exerted for good, will be felt for years to come; and it is pleasing to observe that the many evils which resulted from a lowering of the standard of medical education in the United States did not sensibly affect the status of the profession in Nova Scotia. This has been duein some measure to our geographical isolation, but chiefly to the circumstance that, from the earliest period down to the present time, the students from this province who went to the United States to obtain a qualification, have almost invariably selected the best schools in Boston, New York and Philadelphia.

The burden of maintaining and improving the status of our guild in this province and throughout our great Dominion is now fairly placed on the shoulders of Canadian graduates.

I fear, Mr. President and gentlemen, that I have rather overtaxed your patience, but trust that I have made it clear that our profession in this part of Canada has had a long and everwidening history, and hope I have shown, by the citation of definite facts, that the profession in this province has, to say the very least, fully kept pace with the general progress of the country.

"TWO CASES OF NEPHRO-LITHOTOMY."*

BY HADLEY WILLIAMS, M.D., LONDON, ONT.

The object of this paper is a plea for early operation for stone in the kidney.

The weekly journals contain scarcely anything on this subject, yet it is of considerable interest to the profession when we consider that one out of every three cases will die and that an operation, if undertaken early, promises much success. The condition is not so frequent in Western Ontario, but neither is it so rare as we are led to believe. I have two patients operated upon within the year; another who passed a stone of undoubted renal origin; and two other cases, so far refusing operation, who are undoubtedly suffering from renal calculi. Both of my cases were, at one time or another, diagnosed as lumbago, neuralgia, and hysteria (but one would rather believe this to be due to carelessness in the examination of the urine than ignorance on the part of the physician)-yet it must be remembered that there are cases, post-mortem, where a kidney has been found almost totally destroyed by huge, branching calculi, whose presence was unsuspected during life.

Case 1.-I. S., male, age 42 years, farmer. Referred by Dr. Smith, of Aylmer. Complained of a constant, dull aching pain in the right loin with gastric disturbance, increased by exercise or riding in a carriage, becoming on occasions acute and agonizing ; a month was the longest interval of peace. This had lasted five years and the patient attributed the trouble to an injury, over the region of the right lobe of the liver, received at that time.

The urine was examined during and after attacks, and always gave, with few modifications, the following analysis: Reaction acid; sp. gr., 1.030; large number of red blood cells; pus; oxalates and urates in abundance. There was frequency of micturation, worse after exercise or jolting, and the average daily amount was 36 Dr. Smith suspected stone, with which I concurred. During the operation there was great difficulty in bringing the kidney to the edges of the wound for examination. Counter pressure by an assistant was of no value as the organ lay deeply behind the ribs. Only by packing the lower angle of the wound with pads could the kidney by brought down until it rested on the edges of the divided lumbar fascia. It was then thoroughly palpated and a hard substance easily felt. With the aid of a needle thrust into the pelvis from behind, a stone was located lying above

* Read at Annual Meeting of Ontario Medical Asso., Toronto, June, 1905.

the entrance of the ureter, but not obstructing it. An incision, parellel with the ureter, was made in the pelvis and the stone removed with forceps. The little finger was then inserted, the pelvis and calices explored, the wound closed with a continuous Lembert silk suture, two strips of gauze and a tube placed in position, and the whole returned. No vessels were tied and no hemorrhage took place. The tube was removed in three days, the gauze on the fourth, urine ceased to come through the wound on the ninth, and complete healing was affected on the twelfth. The average daily amount of urine the week prior to operation was 32 ounces. The first week after, 40; second week, 30; third week, 45. Patient left the hospital in five weeks and made an uninterrupted recovery. A few fleeting pains have been felt from time to time since, but are of no importance and he has increased twenty pounds in weight.

The stone is composed of oxalate of lime, weighed 101⁄2 grains when removed, and 81⁄2 grains when dry, and is about the size of a finger nail.

Case 2.-Mrs. T., female, age 36 years, St. Thomas.

Referred

by Dr. H. Arnott, of London. Complained of an aching pain in the right side extending across the abdomen. becoming acute and even agonizing with gastric irritation, especially after much walking or riding in a buggy-even after a short railway journey had to rest in bed for some days. Frequency of micturition was marked during the daytime. Gave a history extending over seven years; treated at first for lumbago; six years ago for tubercular trouble in apex of right lung; two and a half years ago a surgeon, diagnosed tubercular kidney; urine examined daily, for ten days, gave an average analysis. Reaction, acid; sp. gr. 1.022; pus; marked quantity of red blood cells. Examination for bacillus of tubercle negative. As the kidney was freely mobile, enlarged and quite easily felt, we decided to operate. The diagnosis of stone by Dr. H. and Dr. D. Arnott was received with some reserve on my part as no crystals were found in the urine, and the case seemed as much tubercular as one of calculous. As guinea pig injection would have taken some time we proceeded with the operation. The kidney was easily found. Its surface showed signs of renal inflammation, was much larger than normal and cystic in the centre. It was brought well up into the wound until it rested on the edges of the lumbar fascia. Palpation gave some evidence of a stone which a needle verified. It was removed through a vertical incision made at the back of the pelvis; with the incision about one ounce of turbid fluid escaped which had formed a cyst of one of the calices above the stone. After the little finger had explored the interior of the kidney in every direction, a plain cat-gut continuous Lembert suture was applied. The drainage and subsequent treatment were similar to the previous case.

No

hemorrhage whatever took place. The average daily amount of urine before operation was 17 ounces; the first week after 37 ounces; second, 30; the third, 38. The stone weighed 35 grains, was pear shaped, flattened and very rough, an inch in length and three-quarters of an inch in width, I am not quite sure of its composition. No urine whatever came through the loin, and the wound gradually closed after the fourth day. (Here, then, are two successful cases taken early, before the advance of serious kidney disease.)

The symptoms which lead one to suspect stone are, broadly speaking, two in number: "the character of the pain and the character of the urine." It is obvious that where a renal tumor is present from a hydro- or pyo-nephrosis, or some other condition due to stone, one's attention will be drawn to the kidney immediately. The conditions which simulate renal calculus are many, but, even after investigation, tubercular disease easily takes the first rank and is frequently difficult to differentiate. The urine in both these cases showed an acid reaction, pus, blood, oxalates and urates in the first, no crystals whatever in the last. Quite prominent also were frequency of micturition, more marked during the day, with pain in the loin affected by exercise, and causing considerable irritation of the stomach. A thorough history of a case is of the utmost importance and a systematic examination of the urine, not only during the attacks but for sometime after, for the bleeding may be very minute or even absent altogether. In my two cases the X-ray utterly failed to give a shadow, though the utmost care was taken to obtain one. Uric acid is said to be the only calculi which will, on all occasions, give this test. My own experience is too limited to either assert or deny this statement.

I have also a uric acid calculus passed by a gentleman, age 76 years, who for some time gave a history of stone in the kidney. It is rough, half an inch in length, quarter of an inch in thickness and oval in shape, which was passed under great suffering. Cases where a stone of such a size successfully navigates the' ureter are unfortunately rare. The stone that only weighs 81⁄2 grains is the smallest removed from the kidney that I can find in the literature of nephro-lithotomy, except one mentioned by Ia. Cobson in his table of twenty-one cases. After the operation the urine increased in both cases for the first week, lessened the second and increased again afterwards. This immediate increase seems to point to a good workable condition of the opposite kidney, which is of the utmost importance to the life of the patient. The kidney can be better examined if brought well out of the wound and made to rest on the edges of the lumbar fascia, where the surgeon can see every part, and palpate under the best conditions for stones are frequently missed by an incomplete exploration. The opening into the pelvis from behind is associated with no

bleeding, comparable to cutting through the kidney substance, and heals just as readily and perhaps with less danger. Great care is necessary to make the incision "clean cut," and large enough to allow removal of the stone without tearing, so that the edges can be more accurately approximated by the continuous Lembert suture. The hemorrhage from incision of the kidney proper, in some published cases, has been severe enough not only to delay the operation considerably, but even to threaten the life of the patient; though one is aware that there are cases of large, branching calculi, which cannot be removed in any other way. Examination of the pelvis of the kidney by the finger seems a most satisfactory method and its accomplishment quite easy; though, with the needle and the finger combined, a stone is still liable to be missed altogether. The formation of a permanent urinary fistula, so much to be deplored, depends in the main, to whether the ureter is obstructed or free, yet attention to details, such as accurate ligature of the kidney, and early removal of the tube, are of considerable importance. Nephro-lithotomy, if undertaken early, gives excellent results with a minimum of danger to the patient. Neither of these two cases had a bad symptom, which of course, was due more to the favorable condition of the kidney than any particular care on my part. And yet, this operation should not be lightly undertaken and without exhausting every means at the surgeon's command. Dickinson, twenty years ago, gave a mortality of 69 per cent. Recently, Ia. Cobson, in his operative surgery, 14 per cent., the kidney being in various stages of destruction, and of all cases a mistake of over 30 per cent. in diagnosis. There must be more exhaustive examinations of the urine, and the possibility of tubercular disease of the urinary tracts. Agonizing, pain, with blood in the urine to-day, are not sufficient for a nephrolithotomy to-morrow. To my knowledge, and against my advice, a patient has suffered a large incision in the loin, the lifting of a normal kidney from its bed, and an exploration, for a pain that was evidently hysterical and for blood in the urine, whose only source was the accidental contamination of a menstrual flow. But, when the diagnosis is made, and the patient understands the risks of delay, as well as the favorable chances of recovery (when taken quite early) nephro-lithotomy offers, not alone the only method of relief, but the certainty of much success.