same time washing out the organs by copious draughts of Poland water or Londonderry lithia. Piperazine, in doses of grs. v to grs. viij three times a day, is highly commended. Exercise is to be insisted on. When gravel is phosphatic, order strychnine, the mineral acids, and rest at the seaside. When oxalate of lime is found, restrict diet, use the mineral acids, recommend travel or rest amid new surroundings, and give an occasional course of sodii phosphas, 3ss three times a day, drunk in Buffalo lithia water. Nephritic colic is relieved by hypodermatic injection of morphia and atropia, the hot bath, diluent drinks, or the inhalation of ether. After the attack wash out the bladder with an evacuator. If a stone impacts in the ureter, perform the operation of ureterolithotomy. The diagnosis of this impaction is often possible only by exploratory laparotomy. If the symptoms point to stone in the kidney, medical treatment having been used without avail, and there being no evidence of organic disease of the other kidney, make an exploratory lumbar incision; feel the surface of the kidney with the finger, sound the inside of the organ with a needle, and if a stone is detected remove it (see Nephrolithotomy, p. 709). Dr. Keen is of the opinion that operation should not be performed if the urea is below I per cent. If, after nephrolithotomy, suppression of urine occurs, cut into the other kidney, as in half of all cases a stone will be found lodged there.

Abscess of the kidney is caused by traumatism, by calculus, by stricture of the urethra, by disease of the bladder, by the union of miliary abscesses, or by pyæmia. The symptoms are pus in the urine (this is usual, but not invariable), hæmaturia in traumatic cases, and pain running into the groin. Constitutional symptoms of suppuration exist. The treatment in the early stage is rest, morphia, purgation, anodynes, and ice-bags to the loin, followed in forty-eight hours

by hot fomentations.

When the diagnosis is clear, incise the loin, open and stitch the kidney to the abdominal wall, or, if the organ be badly damaged, remove it.

Pyelitis and pyelonephritis, which affect usually only one gland, are caused by urethral stricture, by stopping of the ureter by blood-clot, by vesical paralysis, by stone in the bladder or in the kidney, and by enlargement of the prostate gland..

Symptoms.-A patient who has, or who has had, retention of urine develops high fever often preceded by a chill; headache, stupor, and dry tongue are noted. Unlike acute Bright's disease, there is neither oedema nor dry skin, convulsions do not occur, and the urine is plentiful and contains pus and, but rarely, blood. The prognosis is very bad. The treatment is to remove the obstruction if possible. If the urine be acid, give liquor potassii citratis; if alkaline, give benzoic-acid. Gallic acid, eucalyptol, and small doses of copaiba or cubebs are recommended. Quinine is used to stimulate the patient and to lower fever. The bladder is to be washed out every day with boracic-acid solution (gr. iij to 3j). Cups, dry or moist, and hot sand-bags or bran-bags are to be applied to the loin. Alcohol may be sparingly administered.

Perinephritis.-The symptoms of this condition are rigidity of the spine, the inclination being toward the affected side, flexion of the foot, and often pain in the knee. The symptoms resemble those of hip-joint disease in the second stage. Suppuration may or may not take place. The treatment is wet cups to the loin, ice-bags to the loin, rest, purgation by salines, morphia for pain, and, after the acute stage, potassium iodide internally and ichthyol locally.

Perinephric Abscesses.-Primary abscess is caused by chills, traumatism, acute febrile disturbances, or by pus flowing from some other part, as the spine. Consecutive abscess is secondary to kidney inflammation, suppuration, calculus,

tuberculosis, or cyst. In the consecutive form the symptoms may be masked by the malady to which perinephric abscess is secondary. As a rule, in perinephric abscess there are found the constitutional symptoms of suppuration. The local symptoms are a deep aching and paroxysmal pain intensified by lumbar pressure. Edema of the corresponding foot and lameness are not unusual. Edema of the skin is usual, but fluctuation is rare. The exploratory incision will settle a doubtful diagnosis. The treatment is to lay open the abscess, wash it out, and drain.

Hydronephrosis is a condition of the kidney in which an impediment to the outflow of urine is caused by obstruction in the ureter, the bladder, or the urethra, the calyces of the kidney becoming over-distended with urine and the glandular tissue being absorbed by pressure. This condition may be congenital, and is due usually to twisting of the ureter or to imperforate meatus, both kidneys being involved. The causes of the acquired form are the pressure of pelvic growths or pregnancy, inflammation or tumor of the bladder, stone in the bladder, kidney, or ureter, twisting of the ureter of a movable kidney, enlargement of the prostate gland, and stricture of the urethra. This acquired hydronephrosis may involve both kidneys, all of one kidney, or only a part of a single gland.

Symptoms and Treatment.-Hydronephrosis is most frequent in females. When tumor is absent there may be no symptoms, or there may be pain in the back and abdomen, frequent micturition, a persistent or intermittent diminution in urine, or even occasional anuria. A tumor may be found in the loin, which growth is dull on percussion and may come and go, a large urinary flow being noted when it disappears. Hydronephrosis may last a long while if only one kidney be involved, but death is not far distant if both glands suffer. Death occurs from anæmia, from pressure on

adjacent organs, or from rupture into the peritoneal cavity. Treatment by aspiration may cure, but the operation may have to be done repeatedly. Tapping on the left side is performed just below the last intercostal space; on the right side the tap is made midway between the last rib and the crest of the ilium. If repeated aspirations fail, perform a nephrotomy, stitching the edges of the cut kidney to the surface and irrigating. If a permanent suppurating fistula ensues or if the organ is found extensively damaged, nephrectomy is to be performed, provided the other kidney is in reasonably good condition.

Pyonephrosis, or surgical kidney, is a condition in which the pelvis and the calyces of the kidney are distended with pus or with pus and urine. The whole kidney may be destroyed. This condition has the same causes as has hydronephrosis, for it is in reality usually an infected hydronephrosis. In some cases the inaugural malady is pyelitis which causes blocking of a ureter.

Symptoms and Treatment.—At first the symptoms are those due to the obstructing cause, plus pyelitis. Pus may appear in the urine in incomplete obstruction, or it may intermittently come and go. Constitutional symptoms of suppuration are soon manifest. A tumor may appear in the loin, like the tumor of hydronephrosis. If only one kidney be involved, and if the disease is due to blocking of a ureter, recovery is to be expected. The treatment in the early stages comprises removal, if possible, of the cause of obstruction and the employment of measures directed to the cure of the pyelitis. If obstruction is not complete, palliative measures may be employed for the tumor. If fever is continued, if there is great visceral derangement, if pain is severe and constant, and if the tumor continually grows, perform a nephrotomy, stitching the organ to the surface if possible, or removing it if it is hopelessly disorganized.

Operations on the Kidney.-Nephrotomy means incision of a kidney, but the term is also applied to the exploratory exposure of the kidney without incision. The instruments required are scalpels, a blunt-pointed bistoury, dissectingforceps, toothed forceps, a grooved director, hæmostatic forceps, spatula, metal retractors, a fountain syringe, an Allis dissector, Hagedorn needles, and an Abbé needleholder. If looking for a stone, have a large hare-lip pin to sound with, forceps and a scoop to remove the stone, and a periosteum-elevator to scrape away adherent calculi. The patient lies upon the sound side, a sand pillow being placed under the loin. The incision is made half an inch below the last rib and close to the outer border of the erector spinæ mass, and runs obliquely downward and forward toward the iliac crest for three inches, the incision being enlarged later if required. Divide the skin, the superficial fascia, the fat, the external oblique, the posterior border of the external oblique, and the outer edge of the latissimus dorsi. This incision exposes the lumbar fascia. Push aside the last dorsal nerve and incise the lumbar fascia, when the perirenal fat will bulge into the wound. Two distinct layers of fat exist. Tear this fat through with dissecting-forceps or with an Allis dissector to expose the kidney, which can now be opened while it is forced into the wound by the hand of an assistant making abdominal pressure.

Nephrolithotomy.-In this operation the incision is the same as in nephrotomy. Feel the kidney for a stone, or, if this procedure fails, explore with a needle or a pin. Morris suggests that first the organ be well drawn out. If no stone be found, open the pelvis and explore with the finger. If a stone be detected, open the kidney-tissue, loosen the calculus with the nail, and remove it with the finger, with a scoop, or with forceps. After removing the stone, stop renal hemorrhage by pressure and hot water, or in some cases