peritoneum, not only to the kidney and to one another, but also to the surrounding parts, the result being that the kidney ceased to be movable, and became fixed in an abnormal position. The point of importance to be attended to in connection with floating kidney is that it cannot be reached by an operation from behind without opening the peritoneum, and is therefore not so favourable for nephroraphy as movable kidney. This should be borne in mind while operating. It is not possible, however, previous to the operation, to distinguish, by physical examination, the two conditions. Some authorities have expressed the opinion that floating kidney is more freely movable than movable kidney, and use this as a basis of diagnosis. This is an error. In not a few cases of movable kidney, the kidney can be pushed with perfect freedom up under the ribs, down into the pelvis, and for a short distance across the middle line. What greater freedom of movement could be shown? It is true that in some instances of movable kidney the excursion may be limited to an up and down motion in a plane parallel to the lumbar muscles. This is seen when the sac in which the kidney moves is formed by the adipose capsule, without the capsule being detached from its seat behind the peritoneum. Where, however, the peritoneal covering has become raised from the posterior abdominal wall, then less impediment is offered to movement, and so what was clearly at first a case of movable kidney gradually may assume the physical signs of the more mobile form, and may pass, according to some observers, from the class of movable kidneys into that of floating ones. Fortunately, floating kidney is a very rare condition, but nevertheless it must not be entirely overlooked where an operation is contemplated for the cure of the more common variety of displacement with mobility. APPENDIX. CASE I. Mrs. M'M., æt. 40. History practically commences 15 years ago, when she gave birth to her first child. From that time she has not enjoyed her previous good health. March 29, 1883, nephroraphy performed. Ten minutes before the anesthetic was administered, 1-6 gr. morphia was injected hypodermically. Aræsthesia by chloroform, and all antiseptic precautions. Having been placed on left side, an incision was made in the right loin, immediately external to the outer edge of the quadratus lumborum, and extending from the lowermost rib to the crest of the ilium, care being taken to avoid the diaphragm and pleura above, and the peritoneum in front. The tissues were divided down to the mass of fat surrounding the kidney, which was found to be freely movable behind the peritoneum. The kidney was not in position while I was cutting down upon the capsule, but was situated behind the anterior edge of the liver. As soon as the abdominal walls were divided Dr. Donald Macphail thrust his hand into the wound, and by a little manipulation succeeded in pushing the kidney into the incision, and retaining it in position. Two sutures were then passed through the adipose capsule, so as to retain it in position. The adipose capsule was then divided for a distance of about 31⁄2 inches, and the convex border of the kidney was exposed. The kidney was easily pushed backwards and forwards within the adipose capsule, but the thin fibrous capsule was not loosened. The organ appeared to be perfectly normal. Two thick chromic catgut sutures were passed deeply into the cortex of the kidney, so as to indicate its whole thickness. The needle entered the anterior surface, and passed out from the posterior aspect about half an inch from its convex margin. One suture was passed through the upper and the other through the lower part of the organ, and the kidney was allowed to slip back into the sac formed by the adipose capsule. The edges of this capsule were now carefully stitched to the deep edges of the wound in the parietes, and the sutures (8) cut short. Three superficial sutures were then introduced, and the sutures through the kidney were also passed through the muscles, fascia, and skin; the kidney was then drawn into position and a large drainage-tube placed between the convex margin of the kidney, which now filled the bottom of the wound, and the superficial stitches. These stiches were then tied and the sutures through the kidney were secured externally by means of buttons. Hæmorrhage was insignificant. On piercing the kidney some blood escaped from the needle wounds, and flowed into the adipose capsule. This was allowed to remain, in the hope that it would become organised, and so render the union of the parts more complete. The coaptation of the external lips of the wound was made as perfect as possible, while the deeper parts were kept separate by a large drainagetube, in order that a considerable granulating surface might form in contact with the body of the kidney. Wound was dressed with iodoform and antiseptic gauze, and an elastic bandage applied round the abdomen. Immediately after the patient recovered from the effects of the anesthetic, % gr. morphia was administered hypodermically. She bore the operation well. Treatment, small quantities of brandy and beef tea, a teaspoonful of each alternately every half hour. The external wound was completely united on the tenth, and the deep stitches came away on the fourteenth day. There was no suppu ration at any time either from the surface or from the deeper parts. The drainage-tube was gradually shortened after the eighth day, and the antiseptic dressings were discontinued on the fifteenth. Only on one occasion (on the second day) did temp. reach 100°, and only on three occasions was it over 99°. Pulse was never more than 90, indeed, very seldom over 80. The urine was remarkable in so far that it remained perfectly normal. The following table will show the quantities for the first 10 days after the operation: During the time these observations were made the patient was taking very little food, the quantity being reduced as much as possible for fear of causing vomiting. This accounts for the smallness in the quantity of urine. CASE 2, W. O., appeared to be very favourable for detecting the pulsation of the renal artery, on account of the thinness and looseness of the abdominal wall, but no trace of movements resembling pulsation could be be made out. The only other symptom is the occasional sudden suppression of urine, without any apparent relation to the position of the right kidSometimes it commences without the ney. organ being displaced, at least so far as can be detected by the hand, and there is no increase in the size of the organ during the time this symptom is present. The urine passed when the secretion has again become active does not differ from what is voided at other times. There was no urine passed between II A.M. on the 28th and I A.M. on the 29th Nov. Patient was directed to see that the tumour was in its normal position while in bed, and before rising to put on a close-fitting thin jersey and a broad elastic bandage round the waist, as was ordered for Case 3, and an air ring-pad was fastened to the jersey immediately over the kidney. The effect of this, together with careful attention to general health, has been remarkable. CASE 3. Mrs. M'D., Dec. 1881, nine months after her last delivery, the symptoms had become aggravated, so that she required to remain in bed while she was menstruating. On examination of the tumour it was easily made out to be a movable kidney; urine normal. Dec. 14, 1882: Symptoms now very marked. Complains of almost continual pain, usually localized in right lumbar region, but sometimes extending over abdomen. It is greatly aggravated during menstruation, but becomes very severe at other times quite independently of ovulation. At these periods other symptoms are present, which seem to indicate obstruction to the excretion of urine. They generally appear very suddenly, and usually follow some sudden exertion at a time when the kidney is misplaced. They may last only for a few hours and disappear almost as suddenly as they arose, or they may endure for a period of even 56 hours. The first indication of one of these attacks is a sudden diminution in the quantity of urine excreted, sometimes amounting to an almost total suppression of it. The suppression of urine is followed by a rapid increase in the size of the movable tumour The first indication of recovery is a sudden flow of concentrated urine, and a diminution in the size of the renal tumour, followed by the secretion of a large quantity of urine of a low specific gravity. Examination of urine before, during and after one of these attacks : 9, 10 116 1273 2 '61 10, I "" 10, 7 5'33 21'41 3' 3179 2'5 10'2 3'4 40°0 It will be observed that the specimen collected at IO A. M. was practically normal. About noon the attack commenced, and continued till about 7:30 P. M. At seven o'clock eight ounces of concentrated urine were passed, containing very nearly 6% of solids, and at twenty minutes to eight, 181⁄2 ozs. dilute urine, containing less than 2% of solids, were col lected. In none of the samples could any abnormal constituent be detected, and, on microscopic examination, nothing was observed worthy of note. The explanation of the condition of the urine is rather difficult. If we suppose that the suppression of urine is due to torsion of the renal vessels or of the ureter, then it would be expected that this condition would be limited in its effects to the movable kidney, and that the opposite kidney would perform double duty, and so prevent symptoms of defective elimination of urine. The increase in the size of the movable tumour at the time the symptoms are present, and its disappearance before they are relieved, indicate very clearly that the attacks are due to obstruction to the flow of urine through the ureters, rather than to a suppression of the secretion as a result of strangulation of the renal vessels. The flow of a quantity of concentrated urine just before the symptoms disappear, and the simultaneous reduction in the size of the tumour, are easily associated as results of a common cause-the relief of the obstruction. The concentration of the urine seems to be due to absorption of a portion of the water contained in it during its lodgement in the distended ureter and pelvis. The Movable Kidney. The kidney has shown a general tendency to diminish in size; at present (June, 1883) it appears to be about a third less than it was Jan. 1882. Continues freely movable, and when displaced does not recede so easily into its normal position as it did at one time. About a month ago she was very anxious that I should operate. Before operation, it was necessary to establish beyond doubt that the left kidney was healthy. The method of determining this seemed to be to procure separate samples of urine from each ureter. This might be done in two ways either by catheterisation of the ureters, or by compression of one of the ureters, while the other was allowed to remain patent. The method recommended by Glück, to ligature the ureter of the diseased kidney, to inject a solution of iodide pot., and to examine the urine passed from the kidney supposed to be healthy, although a certain method, is a very dangerous one. ance in the female than in the male, but I be- The advantages of catheterisation of the the ureters over the compression of them, as a means of procuring two separate samples of urine-one from each kidney-seem apparent. If the ureters were constant in their position under all conditions, compression would be easy of application and certain in its results. But they are not so. When the bladder is well illuminated, the orifices of the ureters are easily seen, as narrow, oblique, slit-like openings, about two inches apart. These openings are situated at the posterior angles of the trigon, nearly an inch and a half from the inner orifice of the urethra, and are united by a curved elevation, which, however, extends a little beyond them. The elevation referred to corresponds in position to the anterior lip of the os uteri externum. There are two methods by which the ureter may be compressed-(1) to press on it by the hand or a rounded lever in the rectum, as it crosses the common iliac artery on the left side, or the external iliac on the right side; (2) as suggested by Polk, by enclosing the ureter between the finger in the rectum and a catheter in the bladder. Dr. Polk describes it as follows: "The method I have to suggest is, to compress the ureter. It is easier of perform-cells, gives light equal to one candle. The method which I adopted was to introduce into the bladder a small electric lamp connected with a battery composed of two Grove's cells. The electric lamp (Fig. 1, A) is connected with the handle (B) by a thin rod (E), in which the wires from the battery run. The lamp, when connected with two Grove's F The rest of the apparatus consists of a speculum and the cathe ters. such as excision of the right kidney was out of The speculum is represented in Figs. 2 and 3. It is a hollow cone, made of vulcanite, the apex (H and J) of which is movable, and the small end of the remaining portion (G) is closed with a small glass disc. The apex is rotated out of its place by a handle(L). The method of using these instruments is as follows: The bladder is first washed out with a warm solution of boracic acid, so as to remove all urine. It is now distended with eight ounces of the boracic acid solution, and the electric lamp is introA+ duced through the urethra without being connected with the battery. It is imFIG. 1.-F. Electric lamp, full portant that the lamp size. A, B. Lamp and handle,. should be introduced before the circuit is completed, as, if this precaution be not taken, the lamp is apt to become heated, and may crack when it is passed into the fluid contents of the bladder. Two gum-elastic catheters should now be passed, and after them the speculum is introduced with the cover (H) in position, as represented in Fig. 2. The current is now passed through the lamp, the cover (J) of the speculum is rotated, as represented in Fig. 3, and on inspection the structures forming the floor of the bladder are easily seen. The speculum should be passed so far into the bladder that the small end, closed by the glass disc, is about a quarter of an inch beyond the inner orifice of the urethra. The ureters are easily seen, and may be catheterised. The bladder is then allowed to empty itself, the catheters being retained in. position, and the urine drawn off from each kidney separately. This method is of course only applicable to female patients, but may be used for any purpose where it is found necessary to examine the interior of the bladder. The catheters used have an eye at the point instead of at the side. FIG. 2.-Speculum, G. Cover (to protect glass disc FIG. 3.-Cover (J) rotated by handle (L). In position MODIFICATIONS OF THE OPERATION BY CHARLES BELL TAYLOR, M.D., F.R.C.S.E. The operation for convergent strabismus is usually attended with most favourable results, and provided that the tendons only of the internal recti are divided but little after-treatment is required. The method I have adopted in such cases is a modification of the late Von Graefe's operation, whose practice I had an opportunity of witnessing. Von Graefe used But to return to the case. to make an incision directly over the insertion note of the urine shows that an operation of the internal rectus, expose the tendon, and The following |