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anatomical point of view that in cases of diabetes mellitusand other diseases the tubercle bacillus involves secondarilythe lung. Von Hansemann calls this disposition, but wemust certainly first of all term it nosos, since it is a questionof proved deviation from the normal. This can also beillustrated by experiments. In a frog anthrax bacteria do notproliferate. As soon, however, as we place the animal in anincubator-i.e., weaken the cell power by heat-we are ableto make the animal susceptible to the inoculation of anthrax.In this case the parasite is only a parasite of the diseasedcell and this kind of infection I have termed nosopara-siticism. Thus we must describe as " iiosos " the molecular

change which we can no more observe through the micro-scope than we can the course of a chemical reaction, the out-come of which we judge only by the result. The cell is

subject to the same vital fluctuations as Brown has assumedfor the organism. The Brownonian theory has had no specialvalue for practice, it is true, because at that time it was

impossible to base a system of therapeutics on theseobservations so as to be of practical use. But it must be

acknowledged that his theoretical deductions can be appliedto the vitality of the cell. This theoretical explanationis, in all circumstances, of decisive importance for thera-peutics and already physicians are beginning to direct atten-tion to this view in the study of therapeutics. Thus,A. Menzer says : ’’ The solution I have attempted to give tothe question of the etiology of acute articular rheumatism isderived from the theory of a correctly interpreted noso-parasiticism." This question has grown to be of specialimportance for pulmonary phthisis. We cannot here enterinto the subject of infection by tubercle bacilli ; only onething is certain-namely, that the bacillus is destroyed ifthe cells become healthy and only does harm when the cellsare diseased. Even before the discovery of the tuberclebacillus this fact was proved by dietetic and open-air cures,as described in the excellent work of the two Dr. Williams,father and son, and Freund, again, has shown lately that thefunctions of the tissue of the lungs are impaired by abnormalimmobilisation of the first rib and that then the tuberclebacillus can begin its work.At the present day pharmacodynamics teaches that there

are indeed drugs which do not merely act specifically upon atissue as phosphorus acts upon the formation of bone, butthat there are also cell excitants, such as cantharidin, which,without themselves having any effect on the bacteria, canbring about the cure of diseased tissues, so that the noso-parasitic bacilli are destroyed. But here begins a branch ofscience which, like the theory of immunity and serum

therapy, occupied the end of the nineteenth century, and thewaves of discussion still run so high that it is as yet un-suitable for a historical survey. Let it be said that these

investigations of the present century afford us a guaranteethat we are following the road of progress in therapeutics.

AbstractsOF

INTRODUCTORY ADDRESSES, ETC.DELIVERED AT THE

MEDICAL SCHOOLSAT THE

Opening of the Session 1904-05.

VICTORIA UNIVERSITY OF MANCHESTER.INTRODUCTORY ADDRESS BY WILLIAM STIRLING, M.D., LL.D.,

PROFESSOR OF PHYSIOLOGY AND HISTOLOGY, DEANOF THE FACULTY OF MEDICINE, VICTORIA

UNIVERSITY OF MANCHESTER.

IN opening the course of physiology Professor Stirlinggave an address on Salerno, the Oldest Home of Medicine inMediaeval Europe. Although in the time of Horace Salernowas famous as a health resort and in mediaeval times it washonoured as the " Civitas Hippocratica." its origin as a schoolof medicine was unknown. It reached its high-water markof fame from 1000 to 1200 A.D. and thanks to the discoveryof the famous Herbarius manuscript in Breslau by ProfessorHenschel in 1837 and to other more recently discovered manu-scripts and also to the " Collectio Salernitana " of S. Renzi

and the later discoveries of P. Giacosa a great deal was nowinown of those who taught, and what they taught, in theoldest school in Christian Europe in which medicine was

’’taught, professed, and practised." Whether it owed its

origin to clerical or secular influences it was in its best daysi lay institution. Thus early had medicine in Salerno freeditself from the influence of the clerics. The policy of theLateran prevented Italy from becoming a united kingdomunder the Lombards and thus left Southern Italy an easyconquest to those virile warrior Normans, the sons ofTancred de Hauteville, who had conquered Apulia beforebhe middle of the eleventh century. Robert Guiscard" the Wily " in 1060 " obtained amongst his new pos-sessions the science of Salerno " and he did all hecould to foster the prosperity of his capital. His suc-

cessors, especially Roger the Great Count of Sicily, andRoger II., conferred many privileges on the city and thelatter framed a code of laws regulating the practice ofmedicine. These laws took a more definite form under theautocratic Frederick II. in the thirteenth century whoforbade the practice of medicine in his dominions without aRoyal licence given after examination in the King’s Courtby the Masters of Salerno. The Masters of Salerno conferredthe degree. Thus Frederick guarded carefully against anyinterference by the Church and made himself the source ofall real power. In this regard the Faculty of Salerno differedgreatly from the faculties of medicine of Bologna and Paris.About 1140 the first State examinations for a licence topractise medicine were instituted. The candidates had tofollow a precribed course of study, the object being to protectthe laity from the dangers incurred through the ignoranceand inexperience of the physicians. Frederick II. was indeeda great law-giver and spoke of himself as " law animate

upon earth." The student had to give his attention forthree years to logic and after these three years he had tostudy medicine for five years, and if he wished to be a

surgeon he had to spend an additional year in studyingthe anatomy of the human body and thoroughly to be

experienced in the way in which operations were success-fully performed and healing was brought about afterwards.To this end Frederick commanded that a human body shouldbe dissected once in five years. Previously to his timestudents had to be content with the anatomy of the pig asset forth in the work of Copho the younger. One of the yearsof study had to be passed under an experienced physician.Perhaps this represented the period of clinical instruction-something corresponding to an apprenticeship-the scholar-accompanying the physician on his daily rounds. Frederickalso made important ordinances for the preservation of thepublic health. He ordained that graves should be dug acertain depth, that hides and carcasses of dead animalsmust be thrown into the sea or into a river at leasta quarter of a mile from a town, and that slaughter-houses must be erected outside the city walls. Hislaws relating to druggists and apothecaries were speciallystringent both as regards the price of drugs and theiradulteration which seems to have been prevalent even inthose days. Even the number of the physician’s visits andthe payment per visit were regulated. After graduating-i.e., after laying his hand on the closed and then the openbook and his betrothral to medicine by the ring-the graduatewas crowned with laurel and dismissed with a kiss of peace.Frederick also took care that every applicant should be a"loyal" subject. The term " magister" was the earliesttitle used and the first mention of "doctor in physica "Renzi found to be in 1200 A.D.Not the least remarkable of Salerno’s claim to honour is

that she admitted the fair sex to study in her school andgranted to them after due examination the title of magisteror doctor of medicine. The Breslau Codex makes it plainthat the famous Trotula or Tortula-probably the wife ofJoannes Platearius, the prior or praspositus of the school-wrote extensively not only on gynaecology and allied subjectsbut also on many diseases not directly connected with thissubject. Many articles by her are given in the famoussecond article of the Breslau Codex entitled" Tractus de

Ægritudinum Curatione," which belongs to the latter part ofthe twelfth century and is the first encyclopædia of medicinedealing with all subjects save surgery. Not the least

interesting of the tractates in this codex is that ofArchimathagus (1100), "De Adventu Medici ad EgrotidiumLibellus." The ethical code therein laid down would hardlyin all respects meet with the approval of the Royal Colleges ofPhysicians of to-day but it throws a remarkable light on thestatus and practice of the profession at that time.

1072

The description of the phenomena of diseases,-their treat- T

ment, and the materia medica bulk largely in the literary productions of Salerno. The "Antidotarium of Nicolaus c

Prsepositus "

(1100), even to the second half of the fifteenth n

century, formed the basis of the legal Codex Medicamen- n

tarius of Southern Italy and with the writings of Matthew dPlatearius and the " Circa instans " formed the quarry from which most of the subsequent pharmacopoeias were con-

structed. The most famous and best known of the works c

issued from Salerno is the " Regimen Sanitatis Salerni- t

tanum," dedicated about 1100 to Robert "Rex Anglorum"- r,

i.e., to Robert who did not become King of the English, r

Over 200 editions of this work, which has been translated r

into all learned languages, are known, the last English 1edition being that of Dr. Ordronaux in 1871, and the one pre- t

viously to it that of Sir A. Croke in 1830. The first printed c

edition was published in Montpellier in 1480. It is written iin rhymed Latin hexameters and deals with the six non- r

naturals of Cralenic medicine-viz., air, food, exercise, sleep, excretions, and the passions, tThe fame of Salerno as a medical school was established 1

long before that of either Paris or Bologna and more than ihalf a century before Irnerius taught in Bologna. Perhapsthe persistence in the use of the Greek language in Southern iItaly was no inconsiderable factor in conserving the Greek itraditions of the medicine of Hippocrates and Galen. Thesouthern parts of Italy were in constant communication withConstantinople which before its fall was the centre of Greekculture. Græco-Latin civilisation was not extinguished inSouthern Italy with the fall of the Roman empire. Even tothe thirteenth century Salerno shone amidst the darkness ofscience "as does the firefly on a night in summer." It isrecorded that even in the ninth century there were famousSalernitan physicians, while later bishops, nobles, andwarriors travelled from afar to profit by the skill of itsmedical men and it was described as " Urbs antiqua,celebrata per orbem."The decay of Salerno as a medical school set in at the end

of the twelfth century, when the city was taken and sackedby Henry VI., when its teachers were scattered, and thoughrevived by Frederick II. its fate was sealed. Even Eo-idibusCorboliensis late in the twelfth and early in the thirteenthcentury records its decay from its high estate-a conditionof affairs hastened by the establishment of other schools ofmedicine, such as those of Bologna, Montpellier, and Paris,and also by the inroads of Arabic doctrines. Lingering on,"unhonoured and unsung," it received its coup de grâce onNov. 29th, 1811, by an edict of Napoleon. Thus was

extinguished by decree this famous home of medical studyand science. Salerno kept the torch of learning brightlyburning for several centuries, transmitted Grasco-Latinworks from the East to the West, introduced many drugsused by the Arabians, and set an example to all future uni-versities in the liberality of its teaching-opening its portalsto Jew and Gentile alike, to men and women of every creedand race who chose to avail themselves of its privileges.

!

INTRODUCTORY ADDRESS BY J. LORRAIN SMITH, M.A.,M.D. EDIN., PROFESSOR OF PATHOLOGY AT THE

UNIVERSITY.

Professor Lorrain Smith said : The decision which has

recently been taken by the university to divide the depart-ment of pathology into two sections has been the directresult of the rapid growth of the subject in recent years.For a considerable period the department in this schoolhas taken a leading place in bringing about the expansion ofpathology, especially in its applications to public health,and under the new arrangements Professor S. Delepine willcontinue his work in a department devoted to bacteriologyand comparative pathology. To him will fall the duty ofteaching students of public health and he will at the sametime be provided with the means of applying bacteriologicalmethods of investigation to the problems which arise in

public sanitary administration in Manchester and its neigh-bourhood. In the department the direction of which has beenentrusted to my care. the student will receive instruction ingeneral pathology and morbid anatomy. A knowledge of thepathological changes in the human subject of disease retainsall its importance for the student who intends to practisemedicine and this occasion affords a fitting opportunity forthe consideration of pathology in relation to cognate subjectsin the medical curriculum. In studying pathology thestudent finds himself in the same field as the clinician. Thesame subifct is studied-but from a different noint of view.

rhe clinician studies the signs of disease and the mode oftreatment with the purpose of discovering and applying thesure. When the study is carried a stage further and themethods of physical science are applied to discover thenature of the changes in function and structure in thediseased tissues and organs the investigation becomes patho-logical.The ultimate unity of pathology and clinical medicine is

clear, however, and it is futile to attempt to divorcethem from each other. The pathologist must in duemeasure be familiar with clinical medicine and the clinicianmust keep in his mind’s eye the guiding light of pathologicalresearch. Pathology is ultimately an experimental science,but the study of disease must in the first instance passthrough a preliminary stage in which the facts regarding itsoccurrence and form are merely observed. At this stage itis investigated in the hospital ward and in the post-mortemroom. When sufficient knowledge has accumulated to givesome clue to the cause of the disease the investigation istransferred to the laboratory. In the laboratory patho-logy is studied as a biological science. The facts andmethods which the student has learnt in the earlier

years of his course are applied to new problems butno new tissue is found in pathological structures thatis not present in the normal body. No new chemicalprocess is seen that has not been already exemplified innormal metabolism. In the laboratory where the conditionsare under our control it is possible to study the obscurebut all-important first stages of the process of disease. Itis in this way that pathology progresses as a science and inorder to master the subject a student must pass through acourse of study which gives him the means of following thedevelopment of the science in all its stages. Pathologymust be studied both in the hospital and in the laboratory.Among the recent developments of pathology which call

for the student’s attention one of the most striking is that ofclinical pathology. This branch of pathology comprisesobservations on cases of disease, in the making of whichthe observer requires familiarity with laboratory methodsand appliances. The best example is the clinical pathologyof the blood. The blood is studied by chemical andmicroscopical methods in relation to almost every form ofdisease. We may learn, for example, not only the presenceof bacterial infection in the circulation or in the tissues butalso the degree of resistance which is offered to the invasion.We may further find in these phenomena the clue to theprinciples of treatment. Again, the study of malaria andallied conditions resolves itself into a microscopical study ofthe blood. Similarly the large group of diseases affectingthe constituents of the blood is studied by the methods ofclinical pathology. This branch of the science is dailyincreasing in importance and requires the most earnestattention of the student. It is most appropriately studiedin relation to cases in the hospital wards.When we turn to the study of pathology as a natural

science we have to consider its relation to the sciences withwhich the student has become acquainted in the earlier yearsof his course. During the period in which a student is

working at these sciences he ought to be forming in hismind the standards according to which his life workis to be carried out, but it is the unfortunate experienceof teachers to find that often relatively little permanentbenefit has been derived from this early discipline. Thisresults from the hurried way in which the subjects aretaken up and dismissed one after the other. When the

, inevitable examination is passed the knowledge which astudent has acquired is often rapidly lost and there is too

little result for the amount of work done. The present. curriculum is crowded with disjointed subjects. Some pro-

cess of conservation is required to prevent the dilapidationof knowledge. It was formerly the custom of examining

boards to examine the student when he came up for biidegree in the earlier as well as in the later subjects of the- curriculum. This mode of conserving the student’s know-iledge has become impossible but no means have yet been

discovered to effect the purpose of this old regulation.) The study of pathology as an experimental science in

the final period of the medical curriculum to a certain3 extent prevents the educational waste to which I haver referred. In the recent study of immunity under the3 guidance of Ehrlich, of the pathology of inflammation as

it has been taken up by Metchnikoff, and of cancer as it hasbeen explained by Farmer, we find ready illustrations of the

. way in which pathology keeps alive in the student’s mimd the

1073

physiological, biological, and botanical knowledge which hehas already acquired. The study of pathology might become 1

more valuable in this respect were it possible to teach the student the subject by introducing him directly to research. lIt is difficult to see how this could be done with the average student. He has neither the time nor the experience required for profitable work at research. Students who take I

special courses and post-graduate students do find it 1

possible, and it is to them of inestimable value. The case of the average student is to some extent met by practical teaching. This is, however, only a partial solution of the 1

difficulty. Practical teaching lacks the stimulus to spon- itaneous observation which is characteristic of research inor does it provide the same incentive to conserve

and to use the knowledge derived from cognate sciences. JThe impulse to pathological research arises not only from the intellectual desire to pursue the scientific investigation <

of the subject but also from the practical demand for the imeans to break the power of disease. The student who masters pathology in all its aspects and

who is able to apply all the learning of the schools in his daily work of preventing the ravages of disease will often wonder that knowledge so important and so desirable is sodifficult to attain. Our immediate perceptions do not carry us very far ; but to investigate the facts and processes 1which lie beyond the reach of our immediate senses we can 1apply the experimental method. Patient investigation by athis method gradually adds to the sum of our knowledge. lThere is no ground for pessimism. We must pass through the earlier stages before we reach the later ones. Many of the conclusions to which we have Jnow come may require to be modified, but further progress is possible only because we have already <

reached the present stage. We cannot adopt the views of (

the distinguished president of the British Association for the aAdvancement of Science who remarked in his opening 1address that the beliefs of all mankind about its material

surroundings are not only imperfect but fundamentally i

wrong." Still more depressing is his explanation of this tcircumstance. "Presumably, however, this is either because too direct a vision of physical reality was a ahindrance and not a help in the struggle for existence, because falsehood was more useful than truth, or else

because, with so imperfect a material as living tissue, no (

better results could be obtained." To discuss what is meant

by ’’ direct vision of physical reality" would involve us inmetaphysics. It is sufficient to know that it is a method of

knowledge which is denied to the scientific investigator. iThe far-reaching discoveries which occasioned Mr. Balfour’s 1remarks do not differ from the former results and Idiscoveries of physical science. They have been reached by the same methods as those applied in the earlier stages of the science and by these methods the progress of the science will still continue. The announcement of a far-reachingdiscovery in any of the natural sciences is hardly a fitting ]opportunity for proclaiming the defects of the scientific imethod. It remains rather for investigators to continue jtheir work with a yet firmer assurance, persuaded that scientific knowledge does not suffer from defects which it is (

their duty to eliminate. ____

LONDON (ROYAL FREE HOSPITAL) SCHOOL OFMEDICINE FOR WOMEN.

INTRODUCTORY ADDRESS BY MISS M. C. MURDOCH, L.R.C.P.,L.R.C.S. EDIN.

IN welcoming the students Miss Murdoch said that theywere wanted, that Medicine was ever in need of fresh brainsand hands, and that if they worshipped her in spirit and intruth Medicine would amply repay them for any privationswhich they might endure in her service. They steppedto-day with ease into some of the finest laboratories inLondon and all the recent equipments of science, an inherit-ance undreamt of by the women of 40 years ago. Theywould have to face the great realities of life, especially athospital; they would lose many illusions but gain many newtruths. She referred to the great loss which the schoolwould sustain in the resignation of Mr. Stanley Boyd asanatomy lecturer. He had been their lecturer and friendfor 22 years and they parted with him with sincere regretand most grateful thanks. Continuing, Miss Murdochsaid:-

I wish to give you a few practical hints to ease youalong the thorny but happy path of a medical student’s life.

You need at least seven or eight hours’ sleep. When you goto bed forget all the cares and worries of the day, readsome light literature, and get your work off your mind for atleast half an hour before bed-time. Use up odd moments for

sleep during the day, get into the habit of sleeping while allsorts of noises are going on, because the world cannot bekept quiet every time you are tired. Have a cold or tepidbath every day. Visit your dentist twice a year. Nomedical student ought to suffer from a purely prevent-able disease like toothache. Your clothing should be warmbut light. Three layers ought to suffice, each layer thickerin winter than in summer. Silk !or a mixture of silk and woolis as good as flannel next the skin and not so irritable.Do not adopt any uncommon style of dress. Keep to thefashion of the day without devoting too much care and

thought to it. The great unthinking world judges byexternal appearances and the whole body of medical womenis condemned because a few are careless. Never buy vourclothes in a shop or establishment where sweating goes on.We women are much too careless about this matter, but wemust stand by our fellow women and see that they get fairplay. Go and see Mrs. Lyttelton’s play Warp and Woof,where the overworking and long hours in dressmakers’establishments are shown up. Do not lay up for yourselvestreasures of indigestion and physical deterioration bybeing careless about your food. I should like to see

a large and ample refectory built at the Royal FreeHospital such as exists in most of the men’s colleges inLondon and the provinces. Eat good, easily digested foodat regular hours. England is beginning to learn that herfuture greatness lies in the kitchen and she is beginning tolearn how to cook. Let milk, eggs, fruit, and vegetablesenter largely into your diet. The heavy meal of the dayought to come in the evening when you have time to restafter it. Let me beg you never to sit in close, stuffy rooms ;have your windows open always, night and day. When

practicable, have your meals in the open air. When you arein the country go without a hat ; expose your head and hairto the sunshine and the wind, and both will grow stronger.Have your muscles in good order ; exercise freely in the openair. Join all the athletic clubs in connexion with the school,play tennis, hockey, and golf, cycle, ride, skate, andwalk. Try not to stoop while you are reading ; breathe

deeply always and you will find that it rests your spine tosit up straight.An ideal day would consist of eight hours’ study, eight

hours’ sleep, and eight hours’ play, but here, I am afraid,it means nine or ten hours’ study and six or seven hours’play. Read with a friend when you can. If possible donot study by gas or electric light, but have a nicelytrimmed kerosene lamp. Read big books, read widely-donot trouble with cram books ; you are here to read foryour life-purpose and not for examination only.

Let me preach to you the Gospel of Relaxation," asProfessor James of Harvard University calls it. We suffermuch from Americanitis, a straining of every nerve to racefor the best place. The cure is to relax. Do not keep thatworried look on your face ; if you relax the muscles thatcause it your mind will at once feel more peaceful. Whenyou have a holiday lay aside your medical books entirely, liedown on the heather or the bracken, let those elastic bedssupport you, and become at one with the drowsy, hummingnature around you.Do not be that monstrosity, a narrow-minded doctor.

London is a storehouse of mental food and you must takeadvantage of it. If you love pictures you have only to chooseyour gallery; the best musical and the best dramatic art is tobe had in London. If you love old china, old furniture,curios of any sort, look them out at the British Museum, theWallace Collection, or the South Kensington Museum. Acquiresome of your own and study them. Find out the historicalspots, ride on the omnibuses and electric trams and knowyour London. Go out into the world, be in it and of it,keeping your head steady and clear in the midst of muchillusion and delusion.

In speaking of friendship I would urge you to realise andnot to idealise your friends. They are very human, justlike you, and do realise that there is no such thingas a perfect friend, and so save yourself many heart-burnings and disappointments. Buy a good daily paper andread it. Interest yourselves in what women are doing allthe world over. Read your "Englishwoman’s Year-book"-note how women inspect factories and ameliorate the lot ofthe workers by enforcing the laws, how they lecture all over

1074

tile country on U111C;dl, MMilual, anu. Other Subjects, nuw

they are ministers and lawyers in the United States ofAmerica and foreign countries, although not in England.Join a suffrage society and realise that when men andwomen cooperate in the work of a nation that nation reallysucceeds. Join the debating society and speak often at themeetings. Avoid having your mental balance upset by aspirit of pessimism that there is in the air. Yet I would not

have you optimistic; let us see our faults and mendthem; choose the via media. Hear a good lectureor sermon every Sunday but carry your Sunday spiritinto every day of the week. I need not warn womenstudents against alcohol; it is not one of their sins,but your bodily and mental vigour will be at a much

higher level if you abstain entirely. Realise your responsi-bility in life, avoid the light and irresponsible word which isremembered and comes back years afterwards. When youcome into your kingdom-i.e., when you graduate-do notabuse or misuse your authority. Your degree has been givenyou not to make you think you are superior but to make youalways courteous and ready to help others. What is known as"side" is out of place here, whether it be "side" of intellect,of birth, or of money. Try to control not only words anddeeds but your thoughts. When an unworthy thought comesinto your head try to replace it at once by a good one. Donot worry about other people’s thoughts, you will have

enough to do to control your own. In conclusion I shallwish you a healthy mind in a healthy body, and those of youwho know what perfect health is will understand that mywish for you is the summum bon2cva of every life.

A CASE OF GIGANTIC RENAL CALCULUS,ILLUSTRATED WITH REMARKS ON CASES WHERE

RENAL STONES FORM OBVIOUS TUMOURS.1

BY A. MARMADUKE SHEILD, M.B., B.C. CANTAB.,F.R.C.S. ENG.,

SURGEON TO ST. GEORGE’S HOSPITAL, ETC.

THE subject of this communication may be well intro-

duced by my briefly relating the details of a case which I

believe is unique in the history of surgery.An omnibus conductor, aged 39 years, was admitted into

St. George’s Hospital on Feb. 15th, 1904. He was a stout,muscular man, with no appearance of ill health, but wassuffering from severe pain in the abdomen and becomingrapidly worse, with signs of collapse. He was under the careof Dr. H. D. Rolleston. The following history was obtained.In 1890 the patient had his first attack of h&aelig;maturia and

pain in the left loin. Several attacks occurred subsequentlybut did not at any time cause him to lie up. In November,1903, he was admitted into St. George’s Hospital under Dr.Rolleston for a further attack of h&aelig;maturia of seven days’duration. There was then pain in the left loin, but the kidneycould not be felt, the patient being somewhat stout ; theurine was acid and contained blood and pus. The symptomsentirely passed away and it was decided to await more urgentsymptoms before operating. The patient improved and wasdischarged after being in hospital for 14 days. Early inJanuary last the patient had a severe bout of pain andh&aelig;maturia which laid him up for three weeks. On Feb. 10tha further attack commenced, obliging him to discontinuework: there was no h&aelig;maturia, but he had great pain anddiscomfort in the left renal region ; a swelling was thennoticed for the first time. The temperature was 101&deg; F. andthe pulse was 104. Filling the left flank and loin was a large,rounded, firm swelling, very tender, not moving with respira-tion. The urine was acid and contained no albumin or blood.There was no leucocytosis. The diagnosis was very dubious,the opinions rather inclining to a _large malignant tumourwith intrarenal haemorrhage.

Operation was performed on Feb. 19th. An incision, fiveinches in length, was made through the left semilunar lineand on dividing the abdominal wall an abscess containinga quantity of pus and two small stones was immediatelyopened. There was localised peritonitis and one of thestones had escaped anteriorly. The kidney was greatlyenlarged and firmly adherent to the surrounding parts. The

1 A paper read before the Medical Society of London on Oct. 10th1904.

:olon was flattened and noticeably adherent anteriorly.Chere was a ragged hole in the lower and anterior aspect of,he sac through which pus, urine, and small stones had

scaped. An enormous stone, which was subsequently found,o weigh more than a pound, was now felt and removed withiome difficulty. The kidney was then gradually separatedand its pedicle was tied. After its removal there were foundtwo small stones in its substance. The wound was thoroughly.rrigated with saline fluid and sponged as dry as possible ; aarge drainage-tube was inserted through a counter-openingin the loin and the anterior incision was closed. Thewhole of this great stone lay in the " shell of renalsubstance under the dome of the diaphragm and protected bythe ribs. The inferior part of the tumour, which alone couldbe felt, was composed of dilated renal calyces containing pusand urinous fluid. The difficulties of the operation were verygreat. Pus and urinous fluid were pouring from the diseasedmass over the intestines and wound. The dilated shell ofrenal substance was rotten, lacerable, and intimatelyadherent to the parts round, especially to the intestine, sothat it was extracted with the greatest difficulty. The

pedicle was indistinguishable. The parts where the renalvessels ought to have entered were clamped and on cuttingaway the tissues the vessels were secured. They were

ligatured en niasse with strong, stout silk. The operation,though performed with all possible speed, lasted one hour andthe patient at its termination was collapsed but to no seriousextent.The after-treatment consisted in saline and nutrient

enemata, a small quantity of laudanum being used with therectal injections. The bowels were opened on the second dayand fluid nourishment was then given by the mouth. Thetemperature and pulse became practically normal. The onlytrouble in the after-treatment was the anterior wound which,of course, was long exposed to a flow of septic pus. Itinflamed and suppurated in several places, but by dint ofgreat care on the part of the house surgeon and dressers thiscomplication was successfully overcome. The patient is nowback at work and in good health.

This great stone, when weighed fresh by the museumattendant and soaked in blood and fluid, with sand anddetritus, was declared by him to weigh 19 ounces. Whenweighed dry with critical care on chemical scales some weeksafter removal it weighed exactly one pound and half anounce. Its measurements are as follows: long diameter,five and a half inches ; circumference at the largestpart, about ten inches (see illustration). A large facet is

present where the stone lay against the vertebras. The com-

position is probably oxalate and phosphatic, but I deferredcutting the calculus until it had been exhibited. A quantityof sand and small gravel-stones were lost in the operation.It will be seen that portions of the stone are broken away,so that the weight above stated is really a little below themark. Obvious comments on this very striking case are theslightness of the symptoms, and it is significant that the manwas able to do his work as an omnibus conductor until ashort time before admission. His vehicle plied in the Gray’sInn-road which is not celebrated for its smoothness ! Every practical surgeon well knows how protean are the

signs and symptoms of renal calculus. It has happened toall operating surgeons to meet with cases where painand h&aelig;maturia were present in a marked degree and to cutinto the kidney with the confidence that a stone would befound, but they have been deceived. Again, some of themost agonising and severe symptoms are associated withsmall rough calculi not larger than an almond or a hazel nut,while the novice may be surprised on operating upon a casewhen the symptoms are but slight to be confronted with astone of portentous dimensions, the size and presence ofwhich were far from being previously realised. The curiousnerve pains, the attacks of sickness, and all the other

phenomena attending renal stone have been amplified and,

written about by authors and it would only be wearying forme to repeat them here. A word may perhaps be introduced,

. however, regarding the utility of the x rays as a means ofdiagnosis. I think there can be no doubt but that theefficacy of the Roentgen rays in the diagnosis of these cases

r depends a good deal on the skill and experience of those whoapply the method. It has twice occurred to me to see

the shadow of a stone depicted by one performer where: another had failed, and there are doubtless minuti&aelig;

connected with the process which call for great technical-

skill and long experience. Given, however, the presence oftypical symptoms are we certainly to conclude that no stone