for stone, London, under the care of Mr. Frayer, to whom I am indebted for a history of the case. J. L. S., aged 62, a bus driver, had stricture for thirteen years which had been cut several times during this period. For years the patient had suffered from pain in the left renal region, associated with hematuria. The pain is severe and subject to severe exacerbations, when the patient describes it as shooting and throbbing, and on these occasions it radiates to the left groin and testicle. No actual sickness occurred during these attacks, but sometimes they were associated with nausea. Usually they last about an hour and a half and occur at varied intervals, frequently twice in twentyfour hours. Increased frequency of micturition (two or three times an hour) accompanies the attack. For the last two years blood has been seen in the urine, varying in quantity, usually enough to color the urine uniformly, but on one or two occasions it has been in large quantities (the patient speaks of half pints of pure blood). The urine has been frequently thick and foul, and the patient is in the habit of passing bougie and catheter morning and evening to keep his stricture dilated.

Pain. During and after micturition in the urethra towards the root of the penis.

Stream. Sometimes fair, usually sprinkling.

Freqency of micturition.-Day, six or seven; night, four or five.

Urine.-Alkaline, Sp. Gy. 1009; albumin, mucus and crystals of triple

phosfates.

No cystoscopic examination was made.

From the above clinical symptoms and history of the case Mr. Frayer advised operation and proceeded to perform nephrolithotomy, when, much to his surprise, he found an entire absence of the left kidney. An extraordinary feature of the subsequent history of the case is that all nephritic pain subsided immediately after the operation and the patient had no return of renal symptoms during the four months which had elapsed.

Case II.—I take some pleasure in reporting this rather extraordinary case occurring in Prof. Landau's clinic, Berlin, under the care of A. J. Main

L. H., a married woman, aged 28, had several miscarriages and complained for several years of pain in the right lumbar region, which radiated to the back and down the thigh. The pain was of a nephritic character with exacerbations of severe lancinating paroxysms, usually accompanied with nausea, which occurred three or four times in twentyfour hours. She had passed blood at different times. The patient said a diagnosis of stone in the right kidney had been made by two eminent physicians who had advised. operative measures. Upon investigation a history of syphilis was found, and the patient had been treated by her family physician for the same. On making a vaginal examination, the ovaries and tubes were found to be normal and the uterus was slightly enlarged but freely movable. Nothing could be elicited by palpation nor percussion, but upon deep pressure acute pain was produced. A cystoscopic examination was made and the bladder was

found to be in a healthy condition. On catheterizing the left ureter, nothing abnormal was discovered, but in the other an obstruction some distance from the bladder was found, and by careful manipulation the point of the catheter was made to pass the obstruction. When the urine began to dribble away, and after the removal of a quantity of urine, the patient expressed herself as having immediate relief. It was clearly evident that an obstruction of the ureter existed and it was thought to be a stricture and in all probability of specific origin. Subsequently the patient was treated by regularly catheterizing the offending ureter and the administration of antisyphilitic remedies, after which all nephritic symptoms completely disappeared.

It might be inferred that the symptoms, being of specific origin, would naturally disappear under proper antisyphilitic treatment, but the method employed for immediate relief would seem to justify the use of the ureteral catheter.

Case III.-I am indebted to Dr. W. B. Perry, of Baltimore, for a history of this case, which occurred in Chroback's clinic, Vienna: F. C., aged 30, a married woman with three children, for years had complained of pain in the left lumbar region, radiating to the back and thigh, which was intensified. during the monthly periods, and had suffered greatly during pregnancy with frequent micturition, tenesmus and burning of urine. She had been treated for catarrh of the bladder three different times. At the time she was seen all her urinary symptoms were increased and accompanied by a host of nervous and gastric symptoms. On vaginal examination, under an anesthetic, her genital organs were found to be normal. A cystoscopic examination was made and the lining membrane of the bladder looked quite normal, except at the trigone, which was slightly inflamed. The openings of the ureters were normal, but the urine could only be seen flowing from one. The ureters were catheterized and catheters allowed to remain in situ for six hours, during which time the patient was given plenty of water to drink. At the expiration of this period the urine collected from the left kidney was found to be less than one-fourth as much as that collected from the right.

An examination of the urine from the left kidney showed an acid reaction and specific gravity of 1.028. A few epithelial cells, crystals of triple phosfates, were found, but otherwise the urinary constituents were about normal. As regards the urine from the right kidney, aside from the increased quantity nothing abnormal was found.

An exploratory incision was advised and the patient prepared for operation. The lumbar incision was made and a very small kidney was discovered and removed, which measured 14 inches long by 1 inch in width. The patient made an uneventful recovery without any of the previous nephritic symptoms. A diagnosis had been previously made of atrophy of the kidney, which was verified at the operation.

From a review of what has been said we may learn, by means of the modern cystoscope, the following:

1. The condition of the vesical mucous membrane; the source and frequently the cause of hematuria.

2. The condition of the ureteral lips, and whether urine is being conveyed from both kidneys to the bladder or not. If not, we may learn which of the two is the secreting kidney, and observe the character of the jets of urine propelled from the ureteral cones, whether it be clear, murky or bloody. To collect the urine from each kidney separately, for further exam

ination.

4. To satisfy ourselves as to an existing constriction or obstruction of the ureter which would aid in guiding us as to what course we should pursue.

To decide whether one or both kidneys be affected and to what extent each may be involved, is a question that always confronts the surgeon who contemplates operative measures. Providing no obstruction of the ureter exist whereby the catheter cannot be made to pass beyond, I know of no greater aid to, nor better method of determining the character of the excretion, nor for estimating the quality and quantity of the excreting tissue that each individual living kidney possesses, than by using the modern cystoscope with the ureteral catheter adjustment. It would seem that cystoscopy of today is no longer an experiment. The surgeon who contemplates operative measures in any doubtful case of vesical or nephritic origin, before deciding what course he should pursue, would do well to exhaust the light that the modern cystoscope may throw upon the apparently dark field, often of obscurity, uncertainty and anxiety.

APHORISMS

You can't change a man's politics by putting a teaspoonful of medicine into his stomach after each meal. This fact holds good in other cases of mental disease.

It is curious to note how often chronic cholemia and "philosophy" have been confounded. For pessimism try Epsom Salts.

Too much is almost invariably too much, and yet to many people this truth only comes as a death-bed revelation.

Don't advise your patient to shun tomatoes because you can't digest them. This self-standard guides, or rather misguides, his prescription more often than the physician thinks; indeed, in some cases, enucleation of the I is the only way of cure.

No matter how unnecessary it may seem, make it a rule to always count your assistants after laparotomy.

Though not so stated in the code, more than one sign-plate to each square yard of office-front savors of self-assertion.

The most important of homeopathic "provings" is the proof offered by

that practice that the labor "does it" about as often as the drug.

An impressive appearance and a charming bedside manner are valuable possessions, but antitoxin has a better record in diphtheria.

To be believed in, believe in yourself, or look as if you did.

Don't scratch your head, metaphorically or otherwise, in the sick-room.