that I will simply mention the following. No surgeon should to-day operate for suspected stone unless it is demonstrated by the radiograph. With good technique there should only be approximately 5 per cent. error in the diagnosis of stone. In the lower ureteral region it is absolutely essential for the cystoscopist and radiographer to work together, for in many instances the skiagraph catheter in situ differentiates between stone and extra-urinary bodies so frequently found here. With the combined cystoscopo-radiographic work and the collargol injection which Dr. Hepburn and I have carried out for over a year, it is surprising to note how many diagnoses of obscure kidney and ureteral lesions have been established. It is not at all uncommon to find a kinked ureter where the patient had presented all the symptoms of renal colic and a stone had not been found by previous radiographic examination. A kinked ureter is much more common than is generally supposed.

Gall stones do not deserve much mention for they are seldom found; only 3 to 10 per cent. when present show on the radiogram, as they are largely made up of organic salts.

The Röntgen ray findings in enchondroma, bone cyst, exostosis, sarcoma, carcinoma, osteomyelitis, tuberculosis, syphilis and periostitis when taken into consideration with the clinical evidence usually enables us to make a diagnosis prior to operation. In osteomyelitis and many of the bone conditions mentioned the location and extent of disease can always be determined, thus giving the surgeon a definite outline of his work. Where sinuses are present a bismuth injection leads us to the focus of the disease.

I will first show you a cinematographic view of the stomach. This is a product of Dr. Lewis G. Cole's laboratory and is as far as I know the only one of its kind in America. This film illustrates the gastric motor phenomena which has been so ably described by Dr. Cole in recent literature.

(Dr. Heublein did not read his paper but instead exhibited a large number of lantern slides showing X-ray plates, etc., of interesting conditions. He also showed moving pictures of the stomach in action.)

DISCUSSION.

THE PRESIDENT: The first gentleman on the programme to discuss this interesting paper is Dr. Thomas N. Hepburn of Hartford.

DR. THOS. M. HEPBURN (Hartford): Gentlemen: X-ray diagnosis, as demonstrated by such excellent pictures as these, is so wonderful that there is little left that one can say, except to congratulate Dr. Heublein on his excellent work. In particular, I wish to refer to the pictures of the urinary tract, demonstrating obstruction of the ureter with hydronephrosis. If Dr. Heublein will be good enough, I should like to have the slides, beginning with No. 15, put on the screen again. It is my privilege to work in conjunction with Dr. Heublein in the field of renal diagnosis. Inasmuch as it is a recent field, we have lately, with the aid of the X-ray and collargol injection of the ureter, discovered that ureteral disease is comparatively common and has been previously overlooked. These patients come into the hospital complaining of pain in the back. They usually have been treated as neurasthenics, or have had the appendix removed, and as most of them are women, very probably the right ovary and tube.

This picture I would like to show you in order to call your attention to the simplest form of renal pelvis, because it is rather seldom that you see an ordinary bivalve pelvis, as shown there. The other kidney

had the same sort of calyx as this.

Could I have the next slide? This, I should like to refer to, because it shows a much more complicated type of pelvis and calices. I feel that we cannot say which are normal calices until we have more slides to draw our conclusions from. Although the pelvis looks enlarged, it drains perfectly well; and there is no stricture along the ureter.

In our method of getting collargol injections, we vary somewhat from the usual method. Most people pass an ordinary ureteral catheter up to the point of stricture, and then inject with the collargol; but we use a dilating catheter, inserting it into the ureteral os until it fits snugly, and then let the collargol flow in, using the gravity method. Anywhere along the course of the ureter, you may see the stricture in the fluid column, which you would not see if you had a stiff catheter in there.

The next picture shows one of the reasons why the cystoscopist has to be very careful in making a diagnosis. If you were doing a renal function test for these two kidneys, you might force the catheter up against this kink and feel that you were in the renal pelvis. Very little phthalein urine would appear from the catheter. The kidney would have been secreting into its own pelvis, and you would have had a wrong impression regarding the parenchymal condition of that kidney. This, I think, shows the value of putting the dilating catheter in, rather than

passing a catheter through. That stricture there would not have shown up unless we had a fluid column, instead of the ordinary catheter column. This picture illustrates the type of operation to be selected, according to the degree to which the kidney parenchyma is destroyed. The outlines of these calices are not so clear-cut as in the previous slide.

This shows the next stage, a definite ureteral obstruction. Without going into the matter, I want you to notice the calices. They are spread out considerably, although it is not a cystic kidney by any means. There is still a good deal of parenchyma there, but you see the parenchymal tissue beginning to break down.

The next picture shows the last stage of the condition, where the kidney is completely cystic and the parenchyma is entirely destroyed.

These pictures help you to decide what you are going to do at your operation, whether to relieve the obstruction or do a nephrectomy. If you have these points clearly in your mind before going into the operation, it will help you a great deal.

I should like to refer to another point of renal diagnosis with regard to calculi; and that is, that it is absolutely essential, in taking pictures for renal calculus, to take both kidneys. Double renal calculi are exceedingly common; and also it is quite important to remember that renal calculi, if in the parenchyma, and you have infection, are very likely to return. Where you have a double renal calculus and cannot do nephrectomy, but have to do nephrotomy, it is important to tell the patient that there is a strong possibility of recurrence. It is also important for the surgeon to get a picture afterwards, in order to prove that the calculi are not there; because a patient may get a recurrence and fall into other hands. If the picture then taken shows calculi present, you may be criticised for not having performed your duty at the first operation, unless you have the X-ray to show that the calculi had been removed.

THE PRESIDENT: The next gentleman to discuss this paper is Dr. Orrin R. Witter of Hartford.

DR. ORRIN R. WITTER (Hartford): Demonstrations such as Dr. Heublein has given us more fully illustrate the value of the X-ray in diagnosis than any written article could do. We all appreciate the good derived from the original plate and the lantern slides, as reproduced. I cannot add anything to what has been said, but would emphasize one or two points. One is the value of a negative finding in the case of a kidney condition in which the entire clinical picture is of renal calculus with extreme pain and blood in the urine, the X-ray picture being negative. We appreciate the fact that sand and the smaller calculi, with more or less organic matter, will not show a distinct picture on the plate; and in many of these pictures, this would lead

us not to operate at once, and would urge us to more careful consideration as to whether the blocking of the ureter might be caused by an acute infection of the kidney. If we are still led to believe that it is a small stone or sand, we should appreciate the fact that it is almost impossible to locate and to remove the stone, if the patient is operated upon.

Regarding the shadow in the intestinal plates: I wish to emphasize the value of the two positions, the upright and the horizontal, in taking the picture. Particularly in ptosis of the bowel, the range of position is very considerable; and comparative plates are of great value, and should be taken in each case. Also in the large intestinal work, the possibility of a contraction constricting the lumen enough to give us the picture of a neoplasm or carcinoma must be considered. A series of pictures of this one region would often throw light on that, as the continuous peristaltic action would dilate at one point and constrict at another; so that what had seemed to be a pathological condition would be found to be simply the normal condition.

THE PRESIDENT: The next man to discuss this paper is Dr. Harry W. Fleck of Bridgeport. He is absent, and as he is the last discusser of this paper on the programme, the subject is now open for general discussion. Does anyone else care to discuss the paper?

DR. GEORGE BLUMER (New Haven): I just want to call attention to one or two points: one, in connection with the necessity of taking pictures of both sides. You occasionally find cases of renal stone with the pain referred to the wrong side. The second point is the value of negative pictures, on account of the fact pointed out a number of years ago by a German physician, that occasionally chronic interstitial nephritis is accompanied with typical attacks of renal colic. In such a case, a negative picture would be of the greatest value.

THE PRESIDENT: Is there any further discussion? If not, I will ask Dr. Heublein to close the discussion.

Dr. Arthur C. HEUBLEIN (Hartford): I always make it a point to go over both kidney regions in cases of suspected stone-both kidneys and ureters, and the bladder; because occasionally pain is referred to the opposite side, as Dr. Blumer has suggested. I saw one such case. Bilateral stone does also occur quite frequently. Tiny stones, of course, will not show on the plate; so whenever I render a report, I say, "No stone large enough to warrant operative interference." There is nothing that bothers a radiographer so much as to have a person come with a tiny calculus in his hand, and say, "You did not find this."

Pyelitis in the Adult.

CHARLES J. BARTLETT, M.D., New Haven.

Pyelitis is a fairly common disease both in adults and children. It is also one of the easiest of diseases to pass unrecognized. Either it is entirely overlooked or fully as often mistaken for some other condition entirely foreign to the urinary system. In this category are malaria, lumbago, a delayed puerpural sepsis, chronic appendicitis, etc. These errors in diagnosis have two explanations. First, a large proportion of all cases of pyelitis have no definite localizing symptoms. This is quite contrary to our usual notions of this disease. Secondly, it is the exception rather than the rule that careful microscopic examinations of the urine are made as a routine, and as long as this continues they are bound to go unrecognized. The necessity for early recognition of the condition is apparent to any one familiar with the appearance of the lesions occurring in the kidney. In an acute pyelitis the destruction of tissue is as a rule slight; the condition may be relieved by appropriate treatment before the kidney parenchyma is deeply involved. In the later stages with the usual complications the organ is beyond repair by any means.

a discussion of term, that is a This is for the

In this paper I shall not limit myself to pyelitis in the strict anatomical sense of the process confined to the pelvis of the kidney. reason that inflammation beginning here is prone not to restrict the anatomical boundaries of the pelvis. For a time it may be a simple pyelitis but sooner or later the kidney parenchyma is apt to be involved and the condition becomes a pyelonephritis; and from the clinical standpoint the differentiation between a pyelitis and pyelonephritis is often impossible. I shall speak only of the disease in adults because pyelitis in children is to be considered in the next paper.

The relative frequency of pyelitis is shown by autopsy records. In a study of 20,770 such records from different Austrian hos