Remarks.-Symptoms all vesical and urethral; no vesical pain or hematuria; palpation impossible. Diagnosis made by cystoscopy; x-ray not employed. Nephrotomy instead of nephrectomy as, although the kidney was much damaged, there was no general

septicemia, and the competency of the opposite kidney had not been satisfactorily established.

CASE III.-Pyonephrotic Stone Kidney. (Fig. 1.) age 40.

Fig. B.-Calculi from cellular tissue, outside of pelvis and ureter.

Symptoms. (a) Pain of dragging character in the right infracostal region associated with movable body in the right abdomen. Pain varied with the appearance and disappearance of movable body. Ten years previously operation had been performed and a small calculus removed from the right kidney; since when the pain

has been as described, associated with the movable body. (b) No hematuria.

(c) Urination slightly more frequent than normal. Urine freely purulent; contains bacteria and some albumin; urea output normal. Microscopically, cells from renal tubes seen.

Physical Examination.-Right kidney palpable and usually movable; not markedly tender. X-ray picture reveals the presence of two stones, one involving almost the entire pelvis.

Operation. Kidney exposed and found to be little more than a pus sac containing stones. Nephrectomy.

Remarks. Symptoms distinctly renal; pain and pyuria. X-ray diagnosis positive. Cystoscopy not performed to estimate the opposite kidney, but on account of the showing of the urinary examination, together with the existence of nothing more than a pus sac on one side, the presumption of the competency of the opposite kidney is fairly established. Nephrectomy is performed both on account of the small remnant of kidney structure and in order to shorten convalescence, the patient being in bad general condition.

CASE IV.-Pyonephrotic Stone Kidney. (Figs. 2 and 3.) -, age 13; February 1, 1907.

Family History.-Mother had never been considered strong; subject to colds of a protracted character.

Symptoms. (a) Pain.-Present condition began one year ago with an attack of pain of a severe, boring character, located in the upper left quadrant of abdomen. At that time he passed large quantities of foul-smelling urine which was very cloudy and contained a thick, tenacious material. This attack cleared up under treatment.

Present attack began last August and resembled the previous It seemed to follow an ordinary cold. The principal evidence was seen in the cloudy, thickened condition of the urine. . In December last pain reappeared in the left side and abdomen. (b) No hematuria.

(c) Urine freely purulent; great frequency of urination.

Physical Examination.-Paipation; large and readily palpable left kidney. No cystoscopy; r-ray shows suspicious shadow, which is indefinite.

Examination of Urine.-Large quantity of pus; bacteria; some albumin. No tubercle bacilli.

Exploratory operation determined upon.

Operation.-February 9, 1907. The kidney is readily exposed by a lumbar incision and is found to be enormously enlarged; it feels little more than a pus sac or cystic tumor. The ureter is greatly thickened. The kidney and as much of the ureter as possible removed. Recovery uninterrupted. The urine clears up until it becomes perfectly transparent and normal.

Examination of Specimen.-Section of the kidney showed simple ulceration and abscess formation. Almost the entire kidney substance outside of the abscess is réplaced by inflammatory fibrous tissue through which are areas of round-cell infiltration and exuded leukocytes. A few glomeruli are present, but the tubules of the cortex are completely atrophied. There are no evidences of tuberculosis.

Remarks.-Pain directed to kidney. Marked vesical symptoms. Uncertain x-ray result. Question between tuberculosis and stone. Gross appearance of specimen strongly tuberculous, which the pathological examination, however, disproved. (See Fig. 3.) CASE V.-Tuberculous Kidney. (Figs. 4 and 5.) twenty-eight.

, age Symptoms.-(a) Pain.-Severe in character in right kidney, and reflected downward toward the thigh. Irregular in duration. (b) No hematuria.

(c) Urine purulent.

Urination markedly frequent during attacks of pain; less frequent between times. Vesical pain during urination. Condition grew progressively worse while patient was under observation and urination became so frequent that incontinence occurred.

Family History.-One aunt who died of tuberculosis. Physical Examination.-Palpation: right kidney not palpable, left kidney negative. Right ureter thickened and enlarged.

Cystoscopy.-Bladder capacity 4 ounces. Urinary jet from right side purulent. An ulcerated area is seen surrounding the right ureteral orifice and another in the upper quadrant of the bladder.

Urinary Examination.-No tubercle bacilli found.

Operation rejected at first, but conditions grew gradually worse, complicated by febrile attack.

Operation. Kidney exposed through a longitudinal lumbar incision. An abscess was found in the anterior surface of the kidney and several cheesy areas near the cortex. Ureter much thickened. The kidney was obviously tuberculous.

The patient was turned to the opposite side and a small, longitudinal incision made along the opposite kidney, which was palpated with the finger and found to be, as near as could be judged, normal in contour and size.

The affected kidney was then removed with a portion of the ureter. Patient left the hospital in five weeks.

Report of urine from remaining kidney after operation.

Quantity in twenty-four hours, 1,440 c.c.; urea, 28.16 grammes; albumin, a trace; some pus in the urine; very few cells; no tubercle bacilli.

Examination of specimen shows an abscess in the anterior surface. Pelvis markedly dilated. Microscopically, shows groups of tubercles with cheesy centers extending into the cortex.

Diagnosis of tuberculous nephritis and suppuration involving the ureters and pelvis of the kidney (pyelonephritis) was made. Two years following operation patient was seen and found to be much improved in general health, having gained in weight twenty pounds.

Remarks.-Predominant vesical symptoms. The presence of tubercles in the urine not established before operation, but general appearance of kidney justified diagnosis of tubercle. The presence of the other kidney being established, the extensive involvement of the right kidney, with pyogenic infection, called for its radical removal. (See Fig. 5.)

CASE VI.-Tuberculous Kidney. (Fig. 6.) twenty-six; January 13, 1906.

Family History.—Negative.

age

Symptoms.—(a) Pain.-Present complaint commenced last April with sudden, sharp and severe pain in the upper quadrant of right abdomen and right lumbar region extending downward to the symphysis pubis. This pain lasted for variable intervals and has come on every few days. There has also been pain of a burning character during and after urination; the urination has been increased in frequency and the quantity of urine has been greater during the paroxysms.

Abstract of Symptoms.-Sharp paroxysm of pain in lumbar and abdominal regions; burning and frequent urination.

(b) No hematuria. Pyuria.

Physical Examination.-Right kidney is palpably enlarged and tender; right ureter thickened. Left kidney cannot be felt by palpation.

Cystoscopy.-Bladder wall thickened, but no areas of ulceration. Left ureter is seen acting freely.

An unsuccessful attempt is made to catheterize the ureters. The right ureteral mouth is so contracted that a catheter cannot be introduced.

Examination of Urine Before Operation.-Urine pale amber, cloudy, no odor, acid; albumin, marked trace; specific gravity, 1,015; many pus cells; cubical epithelial cells; tubercle bacilli found.

As the indications pointed toward an active surgical lesion in the right kidney and as cystoscopy had demonstrated an active functionating kidney on the left side, ureteral catheterism having been unsuccessful, exploratory operation determined upon May 7, 1906.

The right kidney is exposed through an incision in the right lumbar region and the kidney is found to be markedly enlarged and extensively diseased. There were many cheesy areas and large foci of necrotic tissue. In the lower pole there is evidence. of advanced disease. (See Fig. 6.) Kidney removed. Wound heals slowly; but patient sustains operation fairly well. Patient discharged from hospital May 19, 1906, improved in general condition.

Remarks. It is evident that the remaining kidney is also diseased, but, on account of the removal of the most active focus in the left kidney, it is hoped that the ultimate result will show itself in improvement in the remaining kidney.

CASE VII.-Rupture of the Kidney. (Fig. 7.) forty-five.

age

Patient was struck by wheel of large baggage truck in the right side, between pelvis and ribs. Contusion of right side. A large, rounded mass palpable in kidney region. Severe pain and tenderness.

Symptoms.-Urine contains bright red blood. Five days after injury urine continues to show abundance of blood and some leukocytes, and enlargement over kidney is much more marked; general condition has gradually failed.

Operation. Incision over right lumbar region. An enlargement is exposed the size of a child's head which, when opened, is found to contain the kidney and free blood clots. Complete rupture of the kidney is found; the hemorrhage continues with profuse flow, on which account it is necessary to clamp the vessels, and kidney is removed.