renal organ are those in which the cystoscopic examination has shown two ureters opening and discharging normally and in which the organ when exposed is approximately normal in size and shape and occupies one or the other loin; when, then, the kidney is exposed for nephrectomy, the operator should endeavor to satisfy himself of the normal position of the hilum and normal relations of the ureter to the vessels, as well as the absence of any duplication of parts. Except in the presence of dense adhesions following a previous operation or old inflammatory trouble, this should always be possible.

The case to be reported is that of a young woman of 26, who first came under my observation in March, 1901. She had a rather large movable kidney on the right side and had had the usual symptoms for two or three years, but until this time had not known the cause of them. Besides being painful, the kidney was tender to the touch and appeared during the summer to increase somewhat in size. She had a sight mitral lesion and the signs of an incipient tubercular condition, and in September, 1901, she went to California, remaining for eight months. While there her general health improved greatly, and all signs of active trouble disappeared from the lungs, but the kidney continued to be painful, and in May, 1902, she returned to Minnesota for operation. Her temperature, which before going West had been 100, did not now go above 99 and was usually normal. The pulse was between 100 and 120 and the patient was extremely nervous; she was unable to sleep well and the extended hand with separated fingers trembled excessively. The appetite was not even fair. Repeated examinations of the urine failed to show the tubercle bacillus. Albumin was found only occasionally, and then as a barely perceptible trace. The urine was pale and below normal, both as to specific gravity and amount.

On May 27, 1902, she was chloroformed and the kidney was exposed. It was very long, measuring between six and seven inches, and seemed to be about one-half heavier than normal, and on account of its size I did a nephrotomy, discovering nothing abnormal. A tube and gauze were left for drainage and the kidney fixed in position by Senn's method.

Uor M

The results seemed very favorable, and so long as the urine escaped from the side the patient was relieved of every symptom. The pain and nervousness disappeared, the pulse and temperature remained at normal and the appetite was good. With the closure of the wound, however, there was a gradual return of all the symptoms. The amount of urine fell to 26 ounces in the twenty-four hours, but could be brought up to 40 by the use of 5 grains of urotropin three times a day. Albumin was absent. There was 75 per cent. of urea. Pain was at times complained of in the other loin. The kidney remained firmly fixed. It fluctuated in size from time to time so that even the patient herself could observe it.

It seemed plain that the kidney was the cause of the trouble, though its nature could not be determined. The variation in size suggested ureteral stricture, but cystoscopic examination with catheterization of the ureter failed to disclose any obstruction and the urine flowed freely from the catheter. It was also seen to escape normally from the left ureteral orifice. There seemed to be a little irritation about the right ureteral orifice, and it was felt that we had probably to deal with a tubercular kidney, although another sedimentation of the twenty-four hours' urine and examination for the tubercle bacillus failed to disclose it.

As the patient was continuously losing ground I decided on nephrectomy, and did the operation Nov. 25, 1902.

There were many adhesions as the result of the former operation. Over the lower half of the kidney, which had at that time been supported by gauze, these were so dense that the capsule was stripped back in freeing the kidney and tied together with what appeared to be a broad adhesion. The patient passed no urine after the operation and died uremic at the end of seven days.

An examination of the specimen after removal revealed the fact that the adhesions about the lower half had concealed a second pelvis and ureter and that the lower portion represented the displaced and fused kidney. A limited autopsy showed that there was no kidney in the left loin and that the lower ureter crossed the median line to the left side just

below the promontory of the sacrum, behind the rectum and in front of the great vessels, and that it then followed along the left wall of the pelvis and opened into the bladder at the normal site.

The renal mass is 611⁄2 inches long and 3 inches wide. It weighs 61⁄2 ounces, the weight of the normal female kidney being 4 to 6 ounces. The convex half is typically uniform. It is not lobulated nor does it suggest any abnormality except in its 'increased length. The same is true of the posterior surface. The inner half of the anterior surface, however, when freed from adhesions and stripped of its capsule, shows striking departure from the normal. Two hila are present, the upper triangular in shape and the lower roughly circular. Each barely extends to the concave border, being limited almost entirely to the anterior surface, a condition which is characteristic of the fused kidney. The vessels enter above and below the ureter instead of in front, as in the normal kidney, and are somewhat smaller than the normal.

Microscopic section of the organ shows throughout a marked congestion and a quite general round-cell infiltration, but little or nonfibrous tissue. Many areas show a considerable degree of parenchymatous degeneration of the cells of the tubules and swelling of the glomeruli. There is little difference between the sections taken from the two portions of the renal mass, though at the time of removal the cross section of that portion which had been subjected to nephrotomy presented a much more healthy appearance than the other, which looked decidedly pale.

SUMMARY.

1. According to available statistics complete absence or extreme atrophy of one kidney is found once in 2,650 cases ; horse-shoe kidney once in 1,000 cases, and the fused kidney exclusive of the horse-shoe variety once in about 16,000 cases.

2. The great majority of fused kidneys are misplaced, being usually in the median line and lower than normal. 3. The completely fused kidney with normal position and approximately normal outline is the rarest form of all.

4. Cystoscopic examination with catheterization of the ureters will prevent the error of removing the only organ present in all cases except those of fusion.

5. Horse-shoe and irregularly fused kidneys may be recognized on exposure by their abnormal shape or position, or by both.

6. The single remaining and rarest variety, that with normal outline and position, could probably always be at least suspected and left, if the ureter and pelvis are found shifted to the anterior surfaces.

DISCUSSION.

DR. A. McLAREN-I saw this case of Dr. Dennis' on several occasions. From the history of the case and from an examination there was nothing in the case to suggest anything but a normal kidney or two normal kidneys. I should feel that under the same circumstances any of us would be likely to do the same thing, just what was done in this case. As Dr. Dennis has stated in his paper, statistics show that a kidney of this kind is extremely rare, although we should always be on the lookout for it, but I have no doubt the mistake might be made by any one.

DR. A. C. STEWART-I had the mournful pleasure of taking care of a patient who died just in this way while in the hospital. The girl came into the hospital on account of congenital absence of the uterus. We made an abdominal examination and found a single kidney low down and fallen on a single ovary, and thought that was the cause of the pain and so removed the kidney. The kidney was of the variety that has been described and the girl died in nine days thereafter. The postmortem showed there was not a remnant of a kidney on the other side. Whether there were two ureters I am unable to state.

THE TREATMENT OF RECENT HERNIAS.

J. CLARK STEWART, M.D., MINNEAPOLIS.

Has not the time come when all adults having recent hernias should be advised to submit to the radical operation as soon as their condition is diagnosed?

This may sound extremely radical, but is it not good surgical common sense? Why should any adult be subjected to the annoyances and discomforts of the fitting and wearing of a truss, when it is admitted that only children are ever cured of a hernia by the wearing of a truss, and that in older subjects such treatment merely diminishes the dangers of the condition and postpones the date of a curative operation. Moreover, treatment by a truss not only does no permanent good, but actually does harm, directly, by causing pressure atrophy of the parts, and, indirectly, by imparting a false sense of se curity to the patient.

A man with a recently acquired hernia is certainly in better condition locally for the radical operation when first seen than he ever will be later, for if he wears an efficient truss there will surely be caused thereby more or less thinning and pressure atrophy of the parts, and the hernia is almost certain at some time or other to descend and so stretch the inguinal canal; while, if no truss is worn there will regularly occur enlargement of the hernia, stretching of the inguinal canal throughout its length and often adhesions of the bowel or omentum to the inside of the sac.

Certain occupations, moreover, requiring physical strength and activity, prohibit the wearing of a truss except under the penalty that the wearer is more or less crippled and outclassed when compared with able-bodied men.

It has, I think, been the regular custom of a large part of the medical profession to fit their hernia patients with a truss and let them wear it a longer or shorter time before offering