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KIDNEY SURGICAL TECHNIC. —Anterior pyelotomy was first described by Kapsammer, who claimed that it was not followed by fistula. Rosenstein1 claims that there is no more risk of injuring vessels than by the posterior route. Aberrant vessels, or branches, commonly pass behind the renal pelvis. In some cases the entire upper branch of the renal vein may pass posteriorly to the pelvis. Rosenstein believes that the anterior approach to the kidney is the natural one; the pelvis is reached by retracting or separating the artery and veins. The injury to the kidney is less with this approach than with a posterior incision. A better view is obtained of the pelvis, especially in the obese patient with a short, thick torso, and if there is perinephritis or peripyelitis. There is less hindrance to the outflow of urine following an anterior incision, and the danger of forming a fistula is less.

EXTERNAL GENITALIA Meyer52 reviewed the work of replacing undescended testicles and reported a series of cases in which operation was performed by Torek's method. Many hypotheses have been advanced concerning the etiology of undescended and ectopic testicle, the most important of which concern the function of the chorda gubernaculi, the length of the spermatic vessels, the size of the inguinal canal, the size of the scrotum and the prenatal posture.Histologic examination showed that spermatogenic cells are present and function in about 10 per cent of all cases. The interstitial cells, which have to do with the development of the secondary sexual characteristics, are always abundantly present. Such conditions are almost constant, and therefore the undescended testicles should always be saved.Secondary complications occur. Malignant degeneration is not as common as is generally believed, and fear of it is not an indication for orchidectomy. Chronic inflammation, the presence of

KIDNEY ANOMALIES. —Surraco1 reported a case of crossed ectopic kidney The right kidney was normal and in good position. The left kidney which is the one usually displaced, was crossed and partially fused with the lower pole of the right. Both kidneys had lost their normal shape; the pelves were on the anterior surface and the ureteropelvic junctures were lateral to the kidneys. The ureter to the left kidney crossed the median line at the level of the second sacral vertebra; this is important embryologically as it suggests the area in which the ureteral bud found its first obstacle in its ascending progression.[Ed. Note.—Ectopic kidneys of this type do not usually cause symptoms, but at times, owing to their bulk and situation, there is considerable pain. Caulk2 reported a case in which suspension and fixation of the kidney to the lumbar fascia partly relieved pelvic pain

TESTIS AND VAS DEFERENS TUMORS OF THE TESTIS. —Keyes44 states that a high mortality rate accompanies the treatment of malignant tumors of the testis by orchidectomy only. It is emphasized that for more successful treatment earlier diagnosis and more extensive operation or treatment by radiant energy must be made. Five conditions must be considered in the differential diagnosis: syphilis, hematocele, hydrocele, tuberculosis and cryptorchidism. Gibson and Kutzmann in their radical operations found that in only 50 per cent of cases could all malignant nodes be removed. Colley reported seventy-eight cases treated with serum; only twenty-two patients survived more than four years.Keyes reports a case in which there was marked emaciation, a large testicular tumor, and extensive secondary masses in the abdomen. Orchidectomy was performed one week after treatment with radium packs. The abdominal masses subsided in several weeks, and ten years later the patient was living and well.

NEPHRITIS Rovsing25 reports 157 cases of nephritis treated surgically by himself and other Danish surgeons over a period of thirteen years. These cases are divided into four groups:1. Interstitial nephritis and perinephritis are associated with paroxysmal attacks of hematuria and pain, and no albuminuria is present in the intervals. Macroscopically, perinephritis fibrosa, with more or less adhesive growth of the membrana propria to the sclerosed fatty capsule, is found. Anatomically, interstitial nephritis is found. These cases are at times associated with a uric acid or oxalate diathesis; they are forerunners of those in Group 2.2. Interstitial and usually granular nephritis and perinephritis with hematuria, pain and constant albuminuria. Often there is contracted kidney and high blood pressure in such cases.3. Cases of diffuse parenchymatous nephritis (tubular nephritis, chronic nephrosis). Two cases of this group were unilateral.4. Glomerulonephritis. As a separate group are listed cases of

KIDNEY Surgical Technic.—Pérard1 stated that fistulas are rather common following operations on the kidney and renal pelvis. To avoid a pusproducing fistula after operation on tuberculous kidneys, the ureter should be anchored to the skin. If a fistula should occur, it may be destroyed by the use of cauterizing agents. Certain fistulas cause large, deep, pus cavities which must be opened and healed by the use of tampons. Fistulas following ordinary pyogenic infections are quite rare and generally, if they do not respond to treatment, are due to the presence of a foreign body. Fistulas due to perinephritic abscesses continue if drainage is poor. Treatment consists of opening the abscess wide and breaking down any pockets that may be present. Urinary and pus fistulas can then persist only if there is a stone in the kidney, pelvis or ureter, or if there is ureteral obstruction in cases of hydronephrosis.Urinary

URETER CALCULI. —Cathcart27 reported a case of ureteral stone of unusual size and weight. A man, aged 48, had had appendectomy for severe pain in the right side of the abdomen. During convalescence the same type of pain continued as before operation. Two years later a diagnosis of right ureteral stone was made, and after two attempts the stone was successfully removed. Five years later the abdominal pain again appeared on the right side. For six months the patient had had an uncomfortable, heavy feeling in the right lower portion of the abdomen. A roentgenogram of the kidney and urinary bladder revealed a shadow extending from the transverse process of the third lumbar vertebra to the wall of the bladder. At operation the kidney was freed from its bed and the pedicle was ligated and left loose in the wound. Through a right lower abdominal incision the ureter was

KIDNEY STONE. —To the various types of urinary calculi usually described in the literature Braasch1 added another form of lithiasis which is not generally recognized, and which from its nature may be termed "hysterical lithiasis." This unusual demonstration of an abnormal psychologic process is manifested by symptoms simulating those of acute renal colic. In order to make the deception complete, a stone will be produced by the patient shortly after the colic, which on casual observation may be mistaken for renal calculus. Nine cases of this unusual form of hysteria have been recorded at the Mayo Clinic; eight of these patients were women. All gave a history of having passed urinary calculi repeatedly; one patient claimed to have passed more than 200 stones. Examination of the specimens invariably showed the presence of inorganic material, which made the diagnosis of foreign body certain. Three of the patients were morphine addicts.

It is generally recognized that the removal of urine from a chronically overdistended bladder is often followed by untoward symptoms, or death. If the bladder is emptied rapidly and completely at one time, the sudden reduction of the intravesical pressure results in immediate congestion throughout the urinary tract, with resulting edema and hemorrhage, which may be so severe as completely to suppress renal function by increasing the pressure within the renal capsule to a point incompatible with glomerular and tubular function. Even though the process may not go on to complete suppression of urine, the congestion and edema make the urinary tract a fertile field for infection, a complication which is borne very poorly by this class of patients, and is the undoubted cause of many of the fatalities.O'Conor1 has shown that, coincident with emptying the bladder of residual urine, there is a decided fall in blood pressure.