primary cancerous deposit, which carries off the patient by cachexia or otherwise.

Cancer of the kidney is almost always encephaloid (soft); scirrhous, colloid, and other forms being mentioned as curiosities in surgery. No time of life is exempt from an attack of primary cancer of the kidney. Children under four years seem especially liable, and old age the next most frequent epoch for its appearance. As a rule only one kidney is affected. The disease may advance until the mass has reached a size large enough to fill the whole abdomen, and a weight. of twenty to thirty pounds. It always seems to begin in the cortical substance, extending thence to the pyramids. The kidney-substance as such becomes absolutely obliterated, no trace of it being left in the large cancerous mass, which, like other specimens of soft cancer, is usually lobulated, harder in some parts than in others, of different consistence in different specimens, giving obscure or real fluctuation in parts, often containing large cavities filled with clots, fluid blood, or cancer débris, possibly pus, "a strange, distempered mass" (Hey). Cancer of the kidney, like that of the liver and testis, is commonly filled with numerous large, thin-walled vessels which readily break, forming blood cysts and clots of large size. Kidney-cancer sometimes grows out through the renal vein and advances into the ascending Here portions of it may be broken off and be carried along in the general circulation to form infarctions in the lungs. When the cancerous mass sprouts out into the pelvis of the kidney, its large, thin-walled vessels are apt to give way and occasion that symptom so characteristic of cancer- profuse, spontaneously recurring hæmorrhage, often filling the bladder to distention with clots.

cava.

The disease may commence as a single cancerous nodule, or as an infiltration. When the tumor reaches large size, it usually forms inflammatory adhesions with all the surrounding viscera. The colon lies in front of it, the other viscera are crowded aside. The pressure of the cancerous mass may cause caries of the vertebræ. The ureter is often occluded. When the disease in the kidney is primary, secondary deposits are apt to occur in the rest of the body. The lymphatic glands in the hilum of the kidney and the vertebral and mesenteric glands are often involved, sometimes forming a considerable tumor of themselves. Sometimes the primary seat of the cancerous growth is in the lymphatic glands or other tissues about the hilum, whence, spreading, the kidney becomes implicated. Maxon thinks that this is the commonest method of onset of primary renal cancer.

Symptoms. The most constant symptom of primary renal cancer is a tumor, which sometimes in adults, more often in children, attains enormous proportions before death. This tumor is first noticed in the flank above the crest of the ilium, growing forward and upward. It usually feels irregular but smooth (lobulated), and sometimes gives the

sensation of deep fluctuation at points. It may be entirely painless to pressure. The resonance of the colon passing in front of it may often be made out. Pain in the back and hypochondrium, in the region of the kidney, of the nephralgic character, is usually complained of before the tumor appears, perhaps not till later. The pain is usually intermittent in character, and not often very intense. It may be wholly absent. Hæmaturia is a sign of great value when present, but its absence has not the signification which has been given to it. It may be absent throughout the disease, or appear for a time only at the beginning or at

the end. It is rarely continuous throughout, tending, as it does, to be irregularly intermittent without appreciable cause. Often during the paroxysms it is very profuse, perhaps clotting in the ureter or bladder, and causing considerable inconvenience and pain. If distressing feelings have been present, some alleviation of them is apt to follow profuse bleeding. When hæmaturia is abundant and paroxysmal without provocation, in the case of renal tumor, cancer should be suspected. Vesical irritability may be the only pronounced symptom,

leading the careless observer to overlook the kidney and to search for the seat of the disease in the bladder.

Among other symptoms there may be ascites, anasarca, and great development of the cutaneous abdominal veins, from pressure of the tumor upon the large venous trunks within the abdomen. The size of the tumor may cause functional derangements of the stomach and bowels. Vomiting sometimes appears early. The urine presents no characteristic diagnostic features. It is idle to place any reliance

upon the appearance of so-called cancer-cells in the urine, or upon the hope of finding a shred of cancer-tissue, since such a shred, starting at the kidney, already softened and partly decomposed by the ulcerative process which loosened it, would become wholly indistinguishable as a portion of cancer after traversing the ureter and remaining soaked in urine in the bladder for even a short time. In children the disease is more rapidly fatal than in the adult. It rarely lasts over a year. The tumor grows to an immense size, not infrequently filling the whole abdomen. The patient emaciates rapidly and dies. Fig. 104 is an excellent representation of a child with advanced cancer of the kidney. It is rather too extreme to be typical.

Adults with cancerous kidney usually die in two or three years, but many drag out more than double that length of time (Roberts). Cancerous cachexia is more liable to be marked in the adult than in the child.

The diagnosis in the male is with ascites, hepatic or splenic tumor, or renal tumor of other nature (hydronephrosis, pyonephrosis, hydatid). In ascites fluctuation is distinct, both loins are flat, the dullness may be made to change by position. A kidney-tumor is immovable, feels solid in parts, only one flank is flat on percussion. A tumor in connection with the liver does not have the colon in front of it. A kidney-tumor can usually be separated from the liver unless adhesions have formed; perhaps a line of resonance will exist between them. A splenic tumor does not have the colon in front; it grows more upward than downward; resonance may be heard in the flank behind it; its border may be felt stiff and thinnish; deep percussion will elicit the bowel-sound beneath (for the spleen is not a very thick organ); the history will show previous malarial poisoning.

For diagnosis with other renal tumors, the previous history, preseuce or absence of cachexia, existence of pus or hydatids in the urine, sudden decrease of the tumor after free urination, etc., form the distinguishing points.

Treatment. The hæmaturia, if excessive, calls for treatment, as may also the nephralgia. As the disease is so often confined to one kidney for a length of time, without infecting neighboring glands or other parts, if the case is recognized early, nephrectomy is the proper treatment.

OTHER TUMORS IN THE KIDNEY.

Many other forms of tumor occur in the kidney, such as myosarcoma, adenoma, cavernous angeioma, lymphadenoma, villous papilloma, syphilitic gummata. The villous growth yields hæmorrhage; some of the others do the same, others not. A diagnosis is difficult even when a tumor can be felt. Treatment is palliative, with extirpation reserved for the cases which seem to justify it.

NEPHROTOMY.

A slightly oblique incision, three and a half to four inches long, is made from behind forward in the ilio-costal space, commencing over the outer edge of the erector spinæ muscle. The incision is about the same as the oblique incision for lumbar colotomy. After dividing the deep fascia and all the muscular structures in the line of the incision, keeping the posterior part of the wound the deepest, the edge of the quadratus lumborum will be seen, and may be divided if broad and in the way. The deep lumbar aponeurosis is cut through, and then the deep fat around the kidney is come upon, perhaps considerably condensed and modified by inflammatory changes. The abscess of the kidney or cyst for which nephrotomy is being performed is reached by cutting or tearing through the condensed fat, is then punctured and freely opened with the knife or Paquelin cautery, the finger introduced into the pelvis of the kidney to break down partitions and search for stone. Then the cyst or abscess wall may be sewed into the abdominal wound with silk, small drainage-tubes being left outside between the cyst-wall and the fresh wound if required, or a large drainage-tube may be inserted into the kidney and the wound partially sutured, especially the front part of the superficial incision.

The operation is not a serious one. I have performed it several times upon the more damaged of two suppurating kidneys when both were diseased, and have always seen the patient rally well and find relief. If the ureter is obliterated and enough kidney substance left to secrete urine, permanent fistula remains. A flat rubber bag fitted to

the loin and connected with a drainage-tube inserted into the fistula makes this condition bearable by the patient. If the abscess does not get well, and pus continues to be abundantly secreted, nephrectomy may be subsequently called for to save the patient from exhaustion.

NEPHRECTOMY.

Nephrectomy is the entire removal of the kidney by a cutting operation. There are two recognized operations, the lumbar and the abdominal. Lumbar nephrectomy is usually preferred. The peritonæum is not opened, and natural drainage is easily effected on account of the posterior and therefore dependent position of the wound. It is the only operation usually allowable after previous nephrotomy when the latter operation has not effected a cure, but has left a disorganized suppurating kidney which fails to get well under drainage. For stone in the kidney when nephrolithotomy is not applicable, lumbar nephrectomy is the proper operation, as it is also for rupture or wounds of the kidney or ureter when the case is sufficiently severe

to demand more than palliative measures or drainage. For cysts and small tumors, the lumbar operation is also preferable, and for very painful floating kidney when nephrorraphy will not answer.

Abdominal nephrectomy is called for when the diseased kidney is very large or much displaced downward, and in most cases of cancer when any operation is allowable.

Nephrectomy should not be performed until all other means of relief are exhausted, and when life is seriously threatened either immediately or remotely. A patient with only one kidney to rely upon is always in more serious danger from the occurrence of any kidney disease than if he had two organs, although one of them may be structurally unsound.

Lumbar Nephrectomy.-A transverse incision, running in a slightly oblique direction downward and forward, is made in the ilio-costal space, about four inches long, and never nearer than half an inch to the twelfth rib, for fear of opening the pleura, which sometimes descends below the rib. A second liberating incision may be made if necessary vertically downward, starting near the posterior extremity of the first incision. This second incision may not be needed, and may be left until after the kidney has been exposed and employed if required to make more room for getting at the pedicle.

When the capsule of the kidney is reached, by tearing through its fatty envelope, if there has been little or no previous inflammation around the kidney, the organ may be separated with its capsule from the surrounding parts by a careful use of the finger. If there has been much perirenal inflammation-notably in cases of the so-called scrofulous kidney, and after previous nephrotomy-the kidney proper must be shelled out from its own thickened capsule, which latter is usually firmly attached to the surrounding parts.

The pedicle is secured by passing a strong double-silk ligature with a long aneurism needle between the ureter and the vessels. The latter are ligated in mass, the other half of the double ligature being employed to secure the ureter. The ligatures should be placed as deeply as possible. The kidney may now be drawn out of the wound by forcibly elevating the twelfth rib, another ligature is thrown around the entire pedicle close to the kidney, including the ureter, and between this and the other two ligatures the pedicle is carefully snipped away with blunt curved scissors.

All bleeding points in the wound must now be carefully secured with ligature, all the ligatures cut short, and the pedicle dropped into the wound. Antiseptic irrigation should be employed and a large drainage-tube used, the wound being brought together with deep and superficial sutures and treated antiseptically as to its dressings. The drainage-tube should be kept in a short week, and then be removed by being gradually shortened from day to day and made smaller. The