The other asserted advantage which I have, merely for purposes of convenience, placed second to the question of diagnosis is the claim that the kidney can be fixed by the hand in the abdomen, and the necessary manipulations for the removal of the stone thereby more rapidly and successfully performed.

No one, I think, will question the statement that the great difficulty in lumbar operations arises from the fact that the kidney has an unhappy tendency to glide away from the fingers when the patient is lying on the opposite side, and this combined with th occasionally very narrow ilio-costal space renders manipulation through the wound difficult and tedious. Anything, therefore which steadies the kidney must be beneficial, and the only point a issue really is, can this steadiness be obtained in no other wa except by a sectio-abdominis?

I think it can, and the alternative method is that mentioned b Mr. Thornton himself, of placing the patient almost flat on hi back, with the wounded side overhanging a pretty high table while an assistant applies to the front and opposite side of th abdominal wall steady and continuous pressure. By such a metho the kidney can be fixed, and when we remember that in any cas the stone must be removed by the loin incision, the adoption o such a method, if proved feasible, would render the abdomina wound unnecessary. Further, the so-called fixing of the kidne by pressure from within is not free from danger, it can only b obtained by traction on the fragile renal vein, and I need hardl delay to point out the possible catastrophe that might result fro such traction.

I have spent some time in considering these two reputed advan tages of Mr. Thornton's method, because they are, to my mind, th only ones of real importance; the others are hardly worthy of notic

His claim that his method prevents a patient with only on kidney being operated on, is simply puerile. It may prevent hi from having his kidney cut open, but it does not hinder th abdominal section, and simple as that operation is, a patient wit only one kidney runs a poor chance of surviving it. Again, I ver ture to state that the combined experience of this Academy woul fail to register more than half a dozen cases out of the thousand of bodies examined in the dissecting and post-mortem rooms, which only one kidney was found. So also the dangers of subs quent lumbar hernia, and of wound of the colon in the loin oper tion, are greatly exaggerated.

I think I am justified, therefore, in stating that I have shown that the claims which Mr. Thornton makes for his combined operation are based upon arguments that are at least open to question, and that the added dangers of the extra incision more than compensate for any possible advantages it may possess.

Before concluding, I would like to obtain the opinion of the Section on some details of the lumbar operation :

1st. Is Mr. Jordan Lloyd's method of sounding each calyx by a Child's sound inserted through the pelvis of the ureter feasible? At the very least I should say it must be extremely difficult in all cases where the ilio-costal space is narrow, as owing to the depth of the kidney the movements of the sound must necessarily be very limited, and even its mere introduction cannot be easy.

2nd. The stone having been found, how should it be removed? By section through the kidney substance, or by cutting into the ureter? Against the former is the danger of hæmorrhage and additional shock; against the latter the possibility of a permanent fistula.

I think a great deal of confusion has arisen in connection with this particular matter, by the very loose and unscientific way in which anatomical names are used. For instance, one writer says→→→→ "I cut into the pelvis of the kidney from the front." Now he could not do this, because the kidney has no pelvis, and if his statement means that he cut into the pelvis of the ureter from the front, I say that no surgeon in his sober senses would do it when he remembered that the renal veins and artery completely conceal nine-tenths of the pelvis, and that any attempt to do it would be simply the recklessness of anatomical ignorance.

What then do such statements mean? The answer is simplynothing; the operator cut something, and, let us hope, found the calculus, but what he cut we do not know, and probably never shall. I may add, that even such an accomplished surgeon and anatomist as Mr. Treves is guilty of this unpardonable mistake, as in his recently published work on operative surgery, having first carefully described the relations of the pelvis, calyces, &c., he subsequently lapses into the error of speaking one moment of the pelvis of the ureter and in the next of the pelvis of the kidney. Such a lack of scientific accuracy can lead to nothing but confusion, no one knows what is meant, and the value of all descriptions of such operations is simply nil.

I will now conclude by thanking you and the members of the

Section for the kind attention you have given, and as the object of my paper was to obtain information rather than to give it, I trust that the more experienced nephrotomists will give us their opinions on what I venture to call points of importance in connection with nephro-lithotomy.

ART. V.-Some Recent Aids to the Diagnosis and Treatment of Diseases of the Stomach. By H. C. TWEEDY, M.D. Dubl., F.R.C.P.I.; Physician to Steevens' Hospital.

Ar the commencement of last year's Session this Academy had the privilege of hearing from Professor Purser a dissertation on "The Modern Diagnosis of Diseases of the Stomach," which will long be remembered by all of us who were present on that

occasion.

The absolute clearness with which this complex subject was treated, and the closeness of reasoning displayed, following each point to its logical conclusion, were sufficient to account for the lasting impression left upon our minds, while the labour and research evidenced in every page render the lecture, now fortunately preserved for us in the Transactions of the Academy, a perfect storehouse of information for all who may wish to refer to the extensive literature of Diseases of the stomach.

Dr. Purser dwelt chiefly on the modifications the digestive process, as carried on in the stomach, undergoes in disease. In this paper I shall endeavour to lay before you very briefly some mechanical aids now at our disposal for the physical examination of the organ itself, for obtaining portions of its contents for chemical analysis, and for the treatment of some of its most common diseases.

I shall submit to your consideration two methods of physical examination which, as far as I am aware, are not employed here as frequently as they should be. Also two recent appliances-one for obtaining small quantities of stomach-contents for diagnostic purposes, and the other for applying electricity directly to the stomach.

The first mode of physical examination to which I would draw your attention is what has been termed the "Splashing Sound," or "Clapotement"-a method of examination much lauded by Riegel,

Read before the Section of Medicine in the Royal Academy of Medicine in Ireland, on Friday, December 18, 1891. [For the discussion on this paper, see page 68.]

Obraztsoff, Boas, and others who state that they find it gives better results than percussion.

This sound may be elicited by pressing repeatedly with the tops of the fingers in the epigastric region. Its lower limit rarely extends below the level of the umbilicus, unless the stomach be dilated, or else displaced downwards. It may be heard in healthy persons more or less plainly if they have taken a large quantity of fluid, or if the abdominal walls are relaxed, and not overloaded with fat.

This method has a double utility. In the first place, we may be able to ascertain by it the size and position of the stomach. If, for instance, we palpate very gently from below upward till splashing is perceptible, then we may in many cases be able to arrive at a fairly accurate conclusion as to the contour of the stomach; and not only so, but we may also get an idea as to the condition of its muscular layer, for let a healthy person drink 50 or 100 grammes of water we can detect no splashing, even when the abdominal walls are thin; on the other hand, if the muscular layer of the stomach be wanting in tone (although there may be no dilatation or retention of the food taken), the sound may be produced very distinctly by the above-mentioned quantity of water, or even by a smaller quantity.

Under some circumstances splashing may originate in the transverse colon; but in this case the splashing is found along a straight line, or along a curve which is slightly convex above, and may thus be distinguished from that originating in the stomach by the fact that the latter forms a convex line below, and ascends distinctly from the median line. Should these differences not be distinctly marked, we may inflate the stomach by means of a tube and double-rubber bulb. After insufflation of air the splashing sound in the stomach ceases, while that in the colon persists; but as soon as the air is allowed to escape from the stomach the splashing sound immediately reappears.

It

This artificial distension of the stomach by gas or air has been much employed on the Continent as an aid to diagnosis, with the object of enabling us to map out the contour of the organ, especially the greater curvature in a more accurate manner. was originally introduced by Frerichs and Mannkopf, who carried out the process by generating CO, by the separate introduction of solution of tartaric acid and bicarbonate of sodium Boas and others * Allgemeine Diagnostik und Therapie der Magenkrankheiten. Leipzic. 1890.

accomplish the same object, gradually inflating the stomach by means of the double-rubber bulb, attached to an ordinary stomach tube. This method, which was first employed by Runeberg, possesses striking advantages over insufflation by CO,.

In the first place the quantity of air employed can be accurately gauged and controlled, so as to increase or diminish it according to circumstances. Moreover, the estimation of the amount of air employed is of itself useful for diagnostic purposes, as a relaxed and dilated stomach requires much larger quantities of air than a healthy stomach with normal muscular tone. The outlines of the stomach are also brought into greater prominence, so that the portion of it lying against the abdominal wall can, as a rule, be palpated thoroughly and without undue haste, whereas in the carbonic acid method this can only be done while the development of the gas is taking place; for as soon as this process is completed the CO, escapes rapidly from above or below, and the stomach again contracts before a thorough examination can be made.

During artificial distension of the stomach with CO, or air, it sometimes happens that the stomach itself does not become enlarged, but that the outlines of the intestines become unduly prominent. This condition was first observed by Ebstein, and described as insufficiency of the pylorus. Boas and Ewald have demonstrated, however, that these cases are accompanied by an abnormally rapid fæcal evacuation, and both writers are of opinion that, aside from insufficiency of the pylorus, there is in such cases an accelerated discharge into the intestines of alimentary substances undigested in the stomach.

Numerous methods have been suggested with the object of demonstrating the size, position, and capacity of the stomach; notably those of Schreiber, Rosenbach, Fleischer, Jaworski, and others, all of which may be found fully described in Boas's recent work. Also the attempts at electric illumination of the stomach by gastrodiaphany, as lately proposed by Dr. Einhorn, by means of a Nélaton's tube, provided with an Edison's incandescent lamp, on the plan of Voltolini's method of illuminating the larynx.

These methods, however curious and interesting, are practically useless now that we possess in insufflation a procedure which is both certain and devoid of danger when practised under proper precautions. Boas lays down the following contra-indications to the use of air or CO2, as well as to the introduction of the sound:-(a.) Constitutional or local diseases in which the irrita