THE ILIAC EXTRAPERITONEAL OPERATION FOR STONE IN THE Lower URETER in the MalE. H. A. Fowler, M.D. Annals of Surgery, December, 1904.

The comparatively short time since removal of stone in the lower ureter in the male has been considered feasible, and the relatively small number of such cases reported, makes the addition of two further cases successfully operated upon of considerable interest.

Case 1, age 36 years. When 11 years old had first attack of severe pain in left kidney region. Since then has had no further pain, but repeated attacks of hematuria. Following his last attack of hematuria he had marked symptoms of vesical irritability which lasted for several days. All examination except the cystoscopic was negative. The cystoscope showed atrophy of the left ureteral orifice and distinct atrophy of the left side of the trigone. The left ureter was not functionating, and introduction of ureteral catheter met with an impassible obstruction 4 cm. from the ureteral orifice. Subsequent radiographs confirmed the diagnosis of calculus at the above point.

An extraperitoneal iliac urethrolithotomy was done, the stone bearing portion of the ureter being easily exposed. After removal of the stone the incision in the ureter was closed and a strip of gauze inserted down to the ureter. The wound healed perfectly without any leakage of urine.

The second case was that of a man aged 32 years. For 22 years he had suffered off and on from attacks of colic in the right kidney region. During the last attack the pain was localized in the penis. During late years increased frequency of urination and urethral symptoms were marked. This frequency increased to such an extent and the condition became so distressing that it was for this symptom that the patient sought relief. Examination wsa practically negative, including the cystoscopic, but the x-ray showed a stone in the lower portion of the ureter.

The stone was successfully removed by the extraperitoneal iliac route as in the first case, the incision in the ureter being sutured. Wound healed without leakage of urine.

The symptoms of vesical irritability in both cases are noteworthy, leading in both instances to a search for vesical calculi. The prominence of vesical irritation also in other reported cases leads Dr. Fowler to believe that when kidney colic is associated with bladder symptoms it suggests strongly stone in the lower ureter. The writer calls attention to the necessity of recognizing these cases before the destructive kidney changes take place, as so often occur.

Once a stone has remained impacted in the lower ureter any length of time the chances of being finally passed into the bladder are remote. Fowler has collected 24 cases of stone in the lower ureter operated upon. With regard to choice of operation, the extraperitoneal route is undoubtedly the best method of reaching and extracting calculi from the lower portion, as it has generally been held to be for the upper three-fourths. It permits examina

tion of the entire length of the ureter and the kidney pelvis, which should never be neglected, as other calculi or a stricture of some portion of the canal may be present. The method combines so small a risk with so great a technical simplicity that the mortality should be even less than for nephrolithotomy. Calculi in the intravesical or intramural portion of the ureter are best reached by the suprapubic intravesical route, but those impacted in the juxtavesical and paraischial portions should be removed by the iliac extraperitoneal route.

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UNDESCENDED TESTICLE. Walter B. Odiome, M.D., and Channing C. Simmons, M.D. Annals of Surgery, Decebmer, 1904. This condition merits prominence on account of its comparative frequency and importance from a surgical standpoint. There exists a wide variance in the opinion of surgeons as to the proper method of treatment and of pathologists as to the significance of the condition. The writers' paper is based on a study of 77 cases.

The terms undescended testicle and ectopia should not be confounded. In the former the organ has been arrested in its normal course of descent and the latter is used to designate a malposition of the organ which in its descent has deviated from the normal

course.

The frequency of undescended testicles in adults is difficult to accurately compute, but the most reliable statistics would seem to indicate an occurrence of one in every 900. These figures are probably a little too low. Undescended testicle is, of course, much more frequent during childhood. Various authorities place the limit of age, after which descent is unlikely to occur, from the first to the fourteenth year, the chances of descent becoming much less with each succeeding year.

The precise cause of arrest of the testicle in its normal descent is difficult to determine, but it is invariably due to some defect in development during fetal life. Heredity has been considered as an etiological factor, but the writer considers it of little consequence. An undescended testicle may be classified according to the position which it occupies, as an abdominal inguinal, pubic or pubescrotal retention. One variety may, however, readily pass into another. The inguinal variety is by far the most common, occurring in 51 cases out of the 77 cases reported, and is most prone to the various complications and inflammations. The comparatively fixed position makes it impossible for it to escape the force of blows, while the sudden and violent contraction of the abdominal muscles, by pressure on the testicle in the canal, is often a cause of most painful and severe inflammation. These attacks may recur with such frequency as to incapacitate the individual for his work.

An undescended testicle is almost invariably imperfectly developed as regards size, consistency and minute anatomy, and it is agreed by all observers that such a testicle is incapable of the formation of spermatozoa in a great majority of cases. Occasionally in undescended testicles the function of spermatogenesis is established for a time, but it persists for only a brief interval of years and then is lost. All double cryptorchids who have been reported to be the fathers of children have been very young men.

An individual with one testicle normally developed and situated in the scrotum is in no way affected as to the bodily development and the power of procreation. As regards complications, inguinal hernia is by far the commonest, with the exception of attacks of inflammation. It occurred in 57 per cent. of the writers' series. Corner has stated that a hernial sac is to be found in 70 per cent. of the cases.

Inguinal hernia is more apt to become strangulated when associated with arrested testicle. Torsion of the spermatic cord is not an uncommon complication. Operative interference is always indicated, and orchidectomy is usually necessary. The liability of the undescended testicle to become the seat of sarcomatous degeneration is of great importance, about 12 per cent. of the cases of malignant diseases of the testicle being in those abnormally placed. Metastases, as a rule, occur early, and death usually results within a year after the appearance of symptoms.

The treatment of undescended testicle varies according to the age of the patient, the frequence or absence of complications, and the severity of symptoms in a given case.

In uncomplicated cases without symptoms the condition can be neglected until the child reaches the age of 11 or 12 years, as up to this time there is some chance of the testicle descending spontaneously. The chance of its descending after this age is very small. Operations for transplanting the testicle to the scrotum are most frequently attended with good results at this period of childhood. In many cases the testicle by manipulation can be withdrawn from the canal and placed in the scrotum. If this is possible, gentle massage and traction should be tried daily. If hernia exists as a complication, operation is to be advised considerably earlier in life than in simple cases. No child with double undescended testicle should be allowed to reach the age of puberty without an effort being made to bring the organs to their normal position.

If the deformity is single, the importance of its correction is lessened, but in no case, single or double in children, should orchidectomy be done unless the testicle is hopelessly degenerated. No treatment is to be advised for abdominal retention. In adults with double arrest, if an attempt at orchidopexy is unsuccessful, the organ may be returned to the abdominal cavity. Orchidectomy should be done only as a last resort.

Under the Supervision of José L. Hirsh, M.D.,, Baltimore.

A CURE OF CHRONIC NEPHRITIS FOLLOWING RENAL DECAPSULATION. Augustus Caille. Archives of Pediatrics, October, 1904. The patient is a girl seven years of age, who was four and onehalf years of age at the time of operation. The child had a history of several attacks of nephritis previous to operation. At the time of entrance in the hospital she had all the evidence of chronic nephritis-urine scanty and dark, containing albumen, all forms of casts and renal elements, blood, and pus.; her eyes were puffy and her abdomen contained fluid; her heart was markedly enlarged, the apex-beat being in the sixth interspace, an inch to the left of the nipple line. Decapsulation of both kidneys was performed by Dr. Edebohls. At the operation both kidneys were of the large white variety, being three times larger in bulk than normal.

Convalescence was uneventful; primary union of both wounds. The study of the subjoined table is very instructive; it gives the urine examinations before operation, which show that in an average of eight examinations the quantity of urine in 24 hours was 700 c. c.; the specific gravity 1017; the total solids in 24 hours 27 grams; urea 8.5 grams; albumen 0.103 per cent.; hyaline, granular, and epithelial casts; few pus-cells and occasionally blood. About one month after operation an average of eight examinations showed: Quantity 750 c. c.; specific gravity 1021; total solids 37 grams; urea 18 grams; albumen 0.07 per cent.; large number of granular casts, fewer hyaline; few renal cells and pus-cells.

Examination two years after operation: Specific gravity 1021; no albumen; no casts; few leucocytes. At this time the child is in very good physical condition; no more headaches or edema.

The result of the operation is a cure; the patient's general health all that could be desired, and the urine practically normal.

Regarding the indications for operation in acute and chronic nephritis, the author states as follows: "During my professional career, now extending over 30 years, I have made the following observations regarding kidney infection: Nephritis following acute infectious disease in children has a tendency to complete recovery. Children who survive the acute stage, but continue to show albumen and renal elements for several months, also frequently make a complete recovery. In a certain percentage of cases recovery does not take place. I have records of seven of my patients who developed nephritis following scarlitina-diphtheriameasles under my personal observation and who subsequently died of kidney insufficiency-one at the age of 5, one at 6, two at

IO, one at 15, and two at the time of the first confinement after marriage at 21 and 23 years of age. In view of the uselessness of medication in chronic nephritis the proposition to treat Bright's disease surgically should be met without prejudice.

"From my observations in this case and in other cases which have come under my notice I would not hesitate to advise inspection of the kidneys through lumbar incision in cases in which an acute nephritis not secondary to heart lesions does not clear up in a reasonable time-say from six to eight months-and would further advise decapsulation of one or both kidneys should they appear swollen and enlarged, with the hope of preventing an acute nephritis becoming chronic and incurable."

Edebohls claims that his operation is beneficial by reason of an increased blood supply. This is as yet not proven. It is probable that some of the virtues of decapsulation of the kidneys are due to massage incident to handling of the infected organ.

AN INVESTIGATION OF THE INFLUENCE OF LABORATORY FEEDING ON 216 INFANTS WITH DISEASE OF THE GASTROENTERIC TRACT, WITH ESPECIAL REFERENCE TO THE WEIGHT INDEX. Maynard Ladd. Archives of Pediatrics, October, 1904.

The influence of laboratory feeding was studied on 216 infants with disease of the gastroenteric tract, all under one year of age. These consisted of 131 cases of fermental diarrhea, 20 cases of chronic intestinal and gastric indigestion, 18 cases of ileocolitis, 15 cases of acute gastric and intestinal indigestion, nine cases of acute intestinal indigestion, nine cases of chronic intestinal indigestion, nine cases of chronic gastric indigestion, four cases of acute gastric indigestion, and one case of severe stomatitis, which was primarily responsible for the infant's general disturbance. The acute cases were ill on the average of 17 days and the chronic cases three months before they came under treatment. They were kept upon laboratory milk for lengths of time varying from 1 to 31 weeks.

As an aid in comparing the influence of feeding upon infants of different ages and stages of development, the nutrition of each infant at the beginning and at the end of treatment was judged by the estimation of its weight development. This was calculated from the weight index, which is simply the ratio of the weight of a given infant to the weight of the average normal infant of the same age. Judged by this standard, over 50 per cent. of the cases had a weight development of only 40 to 50 per cent. when first seen. As to the results of the treatment, the series is divided into four groups:

Group I. Cases which maintained or increased their weight index while on laboratory milk and entirely recovered from the acute gastric and intestinal symptoms for which they were brought to the clinic. This group comprised 109 cases, or 50.4 per cent. The group as a whole gained 8 per cent. in weight index, or a