the lesion to be bilateral. At present I am convinced all might have been saved by an early nephrectomy. In a sixth case in which nephrotomy was performed for stricture of the upper ureter death resulted from pneumonia.

"The seventh death in this series occurred in the case of a young woman, aged 24 years, who had suffered for years from left-sided renal tuberculosis. Several weeks before admission septic infection occurred and resulted in a mixed pyonephrosis. At operation the kidney was found distended with pus, the cortex being studded with innumerable tuberculous foci. The operation consisted simply in incising and draining the pus cavity. She died four days later from uræmia.

"The eighth death of this series occurred in a profoundly septic woman with a perinephritic abscess, the result of a neglected unilateral blood infection (septic infarcts).

"The ninth death in this series, and the only death which occurred from a simple exploratory incision, was in a case of huge inoperable malignant tumor of the right kidney. The patient was a man, aged 51 years, who had suffered from symptoms. of renal growth for eight months and was markedly prostrated by repeated hæmorrhages. On exposing the tumor by a large König incision it was found to be highly vascular and its surface covered by large adherent veins. The pedicle was so short that it could not be safely ligated. The operation was therefore abandoned. The patient never rallied from the exploration, which was the immediate cause of death. In all probability he would have lived several weeks longer if he had not been subjected to operation.

"The only death which occurred in my series of traumatic cases was that of a man who had received a heavy blow on the right side, resulting in a complete

rupture of the kidney and a fracture of the liver, with extensive intra- and extraperitoneal hæmorrhage. At operation the abdomen was first opened and the liver hæmorrhage checked. The renal region was next explored, but the condition of the patient would not permit further operative procedures other than gauze packing. He died in a few hours of shock and loss of blood.

"The two deaths which occurred as a result of double decapsulations were both cases of advanced chronic nephritis. In both instances death resulted from an increase in the uræmic symptoms. There was no local infection.

"Decapsulation in Nephritis.-While I have never seen a cure result from decapsulation in chronic afebrile nephritis, I have observed marked improvement in two instances. The first was that of a middle-aged man who was admitted to the City Hospital suffering from mild symptoms of uræmia, probably accentuated by a recent alcoholic debauch. The urine contained a fairly large percentage of albumin with granular and hyaline casts. After double decapsulation the albumin diminished and the granular casts disappeared. His general condition improved greatly, and he was discharged in excellent condition. He was watched for several years by a member of my house staff, who made frequent examinations of the urine. He was able to continue his occupation as a worker in the city morgue, and only had a recurrence of his symptoms after indulgence in alcohol.

"The second case was that of a boy, aged eight years. For four months he had suffered from headaches, œdema of the face and legs, and ascites. He had been repeatedly tapped, and the legs had been incised for the cedema. The urine. showed the signs of a diffuse nephritis. After double decapsulation all the symp

toms improved rapidly. The oedema disappeared, the ascites diminished, the headaches cleared, and his general health improved. The change was so striking, occurred so promptly after the operation, and presented such a marked contrast to the progressive deterioration of health before operation while under medical treatment, that it convinced me that in this case at least the operation had been of decided benefit to the patient.

"My experience with decapsulation in acute cases, particularly in cases of subacute septic infarcts, has convinced me that it is of great value.

"New-growths.-Twelve cases of newgrowth were encountered in this series. Of these, three were carcinomas, two hypernephromas and one adenoma; two were cases of solitary cysts, three of polycystic kidney, and in one no accurate diagnosis could be made, although the history suggested a rapidly-growing hypernephroma.

"Of the cases of carcinoma, one developed in a man aged 33 years. The kidney was removed. The pathological diagnosis was adenocarcinoma involving onehalf of the organ, but not perforating the capsule. He is now well, seven years and eight months after operation.

"The second case was one of epithelioma of the pelvis, which also contained a large branching stone. The growth had extended beyond the capsule and involved the renal vein. The patient was a feeble, elderly woman over 60. She recovered from the nephrectomy, but died shortly after of general metastasis.

"A third case occurred in a retired naval officer aged 59 years. A small carcinomatous nodule was found in the upper half of the right kidney. He recovered from a nephrectomy and remained well for about a year, after which he gradu

ally failed and died, probably of visceral metastasis.

"Tuberculosis.--Nine cases of primary tuberculosis of the kidney were operated upon. Of these, four were early cases, the lesions being multiple and small, and five were late, there being in addition a tuberculous or mixed pyonephrosis.

"Two of these, one early and one late case, were operated upon by nephrotomy and drainage. Both of them occurred early in my experience, and both patients. died within two weeks of the operation. The reason why these kidneys were not removed was that in one, the early case, 1 believed from the history that the condition was septic and bilateral. In the second case, a late case, I believed that the condition of the patient would not warrant a nephrectomy. I am now convinced that my judgment was defective in both instances. Seven cases were subjected to nephrectomy, and of these six recovered, and when last heard from five were in good or improving condition, one having died two years after operation from general tuberculosis.

"Calculus. The group of calculus cases furnishes an interesting series. In my former report made to the Academy of Medicine, being impressed with the number of errors which occurred in the diagnosis of stone, I made a careful analysis of 36 cases in which the histories led us strongly to suspect the presence of a calculus in the kidney or ureter. In 21 cases, or 59 per cent., only did the operation confirm the diagnosis. With a view to finding out, if possible, the reason for this large percentage of error, I made a chart recording the presence or absence of all the chief symptoms or signs generally encountered in calculus cases and compared the grouping of these symptoms in the two classes.

"As a result of this study it was hoped

that the errors during the last three years would have been less glaring, but on reviewing our records it is found that in only 52.6 per cent. of our recent cases of suspected calculus did the operation prove our diagnosis correct. The number of errors is discouraging, and it may not be a waste of time to apply the same analysis to the recent series of cases and by combining the two groups attempt to throw some additional light on the subject.

"The number of cases which in their onset, early symptoms and subsequent history led us to believe stone to be present in the kidney or ureter were 57. Of these, in 32 instances stone was found at operation; in 19 no stone was found, but some other definite lesion which furnished a reasonable cause for the existence of the symptoms, while in 6 no lesion was found.

"In three other instances shadows were found near the tip of the transverse process of the fourth lumbar vertebra; on the right side twice, on the left once. In these three instances exploration proved negative. In one the shadow was thought to be due to calcification of a broken-down lymph node from a previous appendicitis, as the ureter kinked by a dense band of inflammatory tissue.

was

"If we follow the advice of Dr. Cole and reject all plates which do not show the structure of the bone, the outline of the psoas muscle and the transverse processes of the lumbar vertebræ, and look with suspicion on all shadows which do not have well-defined edges, only four errors would be recorded in this series of cases.

"Several sources of error must be considered in plates of the pelvic cavity, namely, calcified lymph nodes, phleboliths, calcareous masses in the sacrosci

atic ligament and calcified appendices epiploicæ, which have not to my knowledge been observed before.

"If we include all cases examined, the X-rays gave positive evidence of the presence or absence of stone in 79 per cent. of our cases. If we exclude the imperfect plates and those in which the edges of the shadow were not distinctly defined, it gave accurate indications in 91 per cent. of the cases examined. If, in addition, we exclude the ureter plates, the results would be accurate in every instance, and we must therefore regard it as the most reliable means of examination which we possess.

"Ureteral catheterization proved valuable in confirming our diagnosis, in definitely determining the side of the lesion. and in estimating the competence of the opposite kidney. It has been of positive value in certain instances by enabling the surgeon to touch a ureteral stone with a metal catheter or bougie in the female. It has also been useful with the X-rays by introducing a catheter bearing a metal stylet into the ureter, to determine the probability of a given shadow being within or without the canal, although this might lead to error if the object causing the shadow lay in front or just behind the ureter, as in my case in which a calcified appendix epiploica lay just in front of the terminal portion of the ureter.

"From a careful review of the symptoms in these cases I feel justified in stating that there is no single symptom or sign, nor any group of symptoms or signs, that is absolutely pathognomonic of renal or ureteral calculus, unless the calculus lies in the lower ureter and can be seen or touched by a metal bougie or catheter.

"The most important factors to be considered in making a diagnosis are pain, tenderness, hæmaturia, the results of ra

diography, cystoscopy and ureteral catheterization. While vomiting, vesical irritability, pyuria, fever and the presence or absence of a renal tumor are important and will often help us to confirm or lead us to exclude other pathological conditions, too much reliance must not be placed upon them in the diagnosis of calculus. While pain and tenderness were present in practically 100 per cent. of our cases of stone, it must not be forgotten that they were also present in a large percentage of the cases in which no stone was found. That calculus may, and often does, exist without pain is evidenced by the statement of Bruce Clark, who reported 24 autopsies upon calculous patients, in 13 of which there had been no subjective symptoms during life. Hæmaturia was known to be present in 45 per cent. of our stone cases, but it was also present in 41 per cent. of the cases without stone. Spontaneous hæmorrhage occurring during rest and sleep generally means new-growth. Hæmorrhage following active exercise or jolting and accompanied by characteristic colic, in the

absence of other demonstrable pathological conditions, is strongly suggestive of calculus.

"In this connection it may be interesting to note that on five occasions I have observed calculus disease in both kidneys.

"All of the patients in whom stone was found suffered severe pain, with frequent and painful micturition, and had hæmaturia. In the three examined with the cystoscope a pouting and oedematous ureteral orifice was seen; in one the ureteral catheter met with moderate resistance, but easily passed the stone to the kidney pelvis. All had shadows with distinctly defined edges. All of the stones were more or less oblong. In one of the negative cases the shadow was distinct and characteristic, and was due to a calcified appendix epiploica. The others were more or less definite; three were round. In the case with a markedly everted ureteral meatus from which blood emerged, but which could not be catheterized, there is reason to believe that a stone may have been present at the time of examination and been passed before or during the operation."

handled with rubber gloves and preserved in a weak bichloride solution.

Paraffine has the advantages that it is well borne by the tissues, is cheap, easily worked, and not likely to be broken like glass. Occasional failure comes from septic cases, panophthalmitis or idiosyncrasy. Difficulty also arises from using too large spheres, improper closure of the wound, injury around the optic nerve, too soft paraffine, lack of asepsis.

The operation is done as follows:

Under general anesthesia the skin about the eye and face is cleaned with soap and water, alcohol, æther and bichloride solution. The sac is flushed with 1: 5000 bichloride solution. A double layer of gauze with an opening over the eye is placed over the face and æther cone. This prevents contact of the hands or sutures with the cone, hair and face and aids in the maintenance of a clear field of operation. Infection is sure to be followed by failure. The conjunctiva is divided close to the limbus, dissected back beyond the insertion of the recti muscles, which are picked up on a strabismus hook, grasped by small forceps and separated from the surrounding tissue. The globe is enucleated in the usual manner. A paraffine ball is dipped in sterile water, if necessary, cut to the proper size and placed in Tenon's capsule. The superior and inferior recti are sutured together, likewise the two lateral recti. An additional suture is placed so as to include each muscle at the crossing of the two loops. Tenon's capsule is closed by a catgut pursestring suture. The conjunctiva is then closed with pursestring, making in all three layers over the ball. A firm gauze dressing is placed over the eye. This is changed daily for four or five days. A pressure bandage lessens the subsequent chemosis, which lasts from five to seven days.

one of the most frequent causes of incurable blindness belongs, as is well known, to the causes of blindness most easily prevented.

2. The ratio of ophthalmias of the new-born to the total blindness in Switzerland was in 1895 almost 7 per cent. (136 to 2107 blind). It is certain that this percentage could be materially reduced through proper prophylactic measures, and could even be brought to a minimum, as has been done in individual cantons.

3. Most of these measures, including the most important ones, are to be used both before and after delivery, and accordingly the most important task of preventing the blindness falls to the midwives. Their relation to the eyes of the child, as has been recognized in the most advanced countries, forms a most important part of the civic regulation of midwifery.

4. In the different Swiss cantons there is the greatest divergence in the methods of protecting the eyes of the new-born, ranging from complete neglect to the latest prophylactic measures of therapy and hygiene. The standardizing of these measures in all the cantons, on the basis of the most advanced methods, is absolutely necessary. As a sample of the best regulations of midwifery are those of the cantons of Bern, Freiburg and Zürich.