means. We visited her from time to time, each examination confirming the opinion that she was pregnant and that an operation was absolutely necessary to save her life. She went to the infirmary on September 26th, and on the 29th the operation was done. Not knowing the exact date of the last menstrual period, we fixed as best we could the date of expected confinement about the middle of October. From the appearance of the child I think we were right in estimating that the pregnancy had advanced to that period.

After the usual preparation for an abdominal operation, ether was administered and the abdomen opened. The incision was free, extending from about two and a half inches above the umbilicus to near the pubis. The tumor pretty much filled the abdominal cavity, extending to the diaphragm. Delivering it through the incision, I passed an elastic tube around the lower part of the fibroid mass to control hemorrhage. Gauze and aseptic towels were carefully packed about the tumor and into the abdominal cavity to prevent possible infection from the uterine contents. The child occupied the upper two-thirds of the tumor, and the lower onethird was a mass of fibroids. The constricting band being tightened, I freely incised the uterus. The placenta was in the line of the incision and was quickly separated, and the whole contents of the uterus delivered without rupturing the membranes, fortunately eliminating any possible infection from the amniotic fluid.

The child was handed to an assistant, who ruptured the membranes and tied the cord. In a short time it breathed, and was soon in good condition. There was but little hemorrhage from the incision, the constricting tube making the operation almost bloodless. The uterus was carefully washed out with sterilized water, and the gauze and towels removed from the cavity and fresh ones replaced. The broad ligaments were clamped and tied with silk ligatures.

The peritoneum on the lower anterior and posterior surfaces of the tumor was deflected, the vagina opened, and the whole mass removed. A strip of gauze was passed into the vagina and the peritoneal surfaces brought together with catgut. All ligatures and raw surfaces were covered by the peritoneal flaps, and were, when the stitching was completed, extraperitoneal. After spreading out the common omentum the abdominal incision was closed, using catgut for peritoneum, silk for fascia, and worm-gut for skin.

Duration of operation, one hour. Patient left table in good condition; pulse less than 100. The child, a male, weighed six pounds at birth. It is now more than ten months since the operation, and mother and child are well.

Drs. Bryan and Witherspoon assisted me in the operation, and Dr. Patterson administered the ether.

NEPHROLITHOTOMY FOR UNCOMPLICATED

NEPHROLITHIASIS.

BY CHARLES GREENE CUMSTON, M.D.,

BOSTON.

THE kidney is one of the abdominal viscera that of late years has attracted the attention of the surgeon, and many are the cases reported in which operations thereon have given most brilliant results. Although nephrolithotomy for renal calculi and nephrolithiasis cannot be precisely termed a modern operation, as Jacques Cousinot upheld that it could be performed as early as 1622, and in 1754 Borden put foward surgical interference as both possible and proper, still it is only within the past fifteen years that much. has been accomplished in this direction.

It is true that many operators have opened kidneys that were perfectly normal in patients presenting renal and lumbar pain of great severity and closely simulating renal colic, but these unsuccessful operations should not stop the progress in the treatment of these unfortunate patients, because nephrolithotomy is in reality extremely benign. A calculus may remain for a very long time within the kidney without ever giving rise to a single symptom, or may simply produce lumbar pain once or twice during the life of the individual, just as in cases of biliary lithiasis. But the intensity of the painful symptoms is not in direct relation to the size of the stone, and small calculi may give rise to various symptoms and to serious complications as well, while medium-sized or large stones may be perfectly well tolerated by the subject.

Now, in point of fact, a small calculus is often more painful and just as serious, if not more so, on account of its mobility being far greater than that of a large concretion.

A small calculus has a tendency to travel down into the ureter, and thus give rise to renal colic. If it becomes lodged in this canal it may be the cause of a hydronephrosis, anuria, or ascending pye

lonephritis. On account of its mobility it will irritate the kidney and produce hematuria, which is often frequent in occurrence and large in quantity, and Lécorché is of the opinion that small calculi made up of oxalate of lime are the cause of paroxysms of hematuria.

The symptoms of nephrolithiasis, when there is no dilatation of the kidney or suppurative process going on within the organ, are pain and hematuria. Renal pain is usually intermittent, and is rather more a sensation of lameness or a tearing feeling, usually extending to the lumbar and inguinal regions. In every type of renal calculus the pain is increased by walking or riding, and can in most cases be calmed by quiet, especially in the recumbent position. But it would appear from published cases and those that have come under the writer's observation, that small calculi, consequently the movable ones, cause more acute pain than large ones, and which is more frequently the result of very slight movements or exercise. The pain may even become continual, and some patients will suffer constantly for years. Walking and riding start up sharp paroxysms of pain.

Palpation and pressure over the lumbar region will generally give rise to pain. Percussion of the lumbar region can also provoke an attack or increase it if pain is already present. Jordan Lloyd says that a quick, sharp blow will always give rise to pain when the kidney contains a stone, but the writer cannot agree on this point, at least in every case.

Hematuria is a symptom which is nearly always present in nephrolithiasis, and, although not profuse, it often coincides with the pain and occurs when the patient has taken unusual exercise. It may occur either during or between paroxysms of renal colic; it appears early or late in the affection; but it is rarely, if ever, completely absent, especially in cases of small stones, and it thus may be considered as a characteristic symptom of the latter when it frequently takes place, is considerable in amount, and is accompanied by nearly constant pain. It may also be a very important symptom for the diagnosis of the presence of a stone in the kidney in those cases where there is a little obscurity as to the nature of the affection present, as well as determining which of the two glands is the seat of the trouble, when reflex pain occurs in the normal kidney. For the diagnosis of the latter a cystoscopic examination

should be made after the patient has taken a long walk, when we will be able to see small jets of blood escaping from the ureteral orifice on the affected side. In the female, the passage of the ureteral catheter and comparative analysis of the urine from the right and left kidney will be found of great help in cases of nephrolithiasis or when the stone is in the pelvis of the kidney or lodged in the ureter.

When the calculus enters the ureter it produces nephritic colic, which with all its symptoms is of much value to the surgeon, because it is a sure indication of nephrolithiasis. The same may be said of intermittent hydronephrosis, which indicates that the stone has become lodged in either the pelvis of the kidney ureter, producing a momentary obstruction to the free passage of the urine. Small calculi particularly, often become engaged in the pelvis of the kidney, on account of their mobility, and set up a pseudo-nephritic colic, which is due to a distention of the urinary gland.

Renal colic is sometimes the first symptom of nephrolithiasis, at others it only occurs some time after the localized paroxysms of pain.

Each one of the symptoms of nephrolithiasis-viz., lumbar pain, nephritic colic, and hematuria-has an intrinsic value, but is not in itself sufficient cause to justify the advisability of surgical treatment. But in a case which has passed through several paroxysms of nephritic colic and in which the usual pain, with or without hematuria, has baffled judicious medical treatment, the propriety of surgical treatment should be considered, because not only will an operation do away with the unbearable suffering of the patient, but it will be the means of preventing all the complications which can arise at any moment.

Statistics show that in operations performed when the patient presented anuria from his calculus the mortality is about 33 per cent., while if suppuration is present in the kidney it may be put at about 50 per cent. In those cases forming the subject of this paper-that is to say, a small stone in a healthy kidney-the physical signs are almost absent. The kidney, being normal in size, cannot be made out by bimanual palpation unless the organ be movable or slightly below its normal site.

Pain on palpation of the region of the kidney is present in the