of secretion, which may occur during a first catheterization (I had one case where the kidney did not secrete for seventeen minutes, then began to secrete normally), or from actually impaired kidney function. This catheterization being unsatisfactory, I repeated the operation the following morning, using a new catheter for the left side. The left kidney secreted one ounce of pus ladened urine in twenty minutes, the right secreting healthy urine, but short of the normal amount. The case was plainly one of suppuration, and the patient showing constitutional symptoms, left nephrectomy was done, in spite of the fact that the right kidney was not secreting normally. 1 report this case to show that the catheter while at fault in the first operation proved its efficiency in the second. The patient died from uremic poisoning. The post mortem examination failed to show inflammation of the left ureter or pelvis, due to catheterization, although the catheter had been introduced and left in seventeen hours, withdrawn and a second introduced and left for some twenty minutes. Microscopical examination of the specimen showed a sarcomatous kidney.

In a case I examined for Dr. Deuschle, Aug. 24, 1906, the patient complained of "right kidney pain,” frequent urination-getting up at night as often as fifteen times-and a slight irritation of the urethra. The patient was running an evening temperature of 101 degrees, and the urine drawn from the bladder was said to contain pus. The patient was five months pregnant, which rendered cystoscopy difficult and uretereal meatoscopy impossible. The bladder refused over three ounces of water, and the cystoscope when introduced stood nearly at right angles with the long axis of the body. This necessitated hugging the trigone with some force, which made the interureteral ridge bulge forward, displacing the ureteric orifices below and on the far side of the artificially produced truncated cone. By pushing the catheter over this crest to a point I judged to be the proper distance from the mid line, I infolded the mucous membrane, bringing the orifice in line, which allowed the introduction of the catheter without further difficulty. An unsatisfactory cystoscopy showed the walls of the bladder covered with a feathery deposit, which I took for the surface markings of a cystitis.

Ureteral catheterization yielded from the right kidney, in eight minutes, two ounces of urine which at first ran in an almost continuous stream, then began to drop at intervals; from the left kidney, half an ounce in the same time, which dropped intermittently. Shortly after catheterization, the patient enjoyed relief from the "right kidney pain," which lasted nearly twenty-four hours.

Drs. Coons and Jones examined the separated urine with the following result: Right kidney-Urine, pale yellow. Granular cloudiness. Red blood cells very few. White blood cells few. Epithelia, a great number of small oval cells, also round and tailed cells. No casts, no tubercle bacilli, no pus. Many motile bacilli. Sp. Gr. 1005. Left kidney-Color reddish yellow, few small oval cells. No casts, no pus, no tubercle bacilli, no bacteria. This case seemed to me to be one of hydronephrosis, possibly transient in nature, perhaps caused from pressure. Nearly three months have elapsed since the examination and the patient's husband reports that his wife has remained better since the operation was performed.

In conclusion I wish to refer to the papers of Drs. Bremerman and Ayres of New York City, read before the Medical Society of Norwich, Conn., Oct. 19, 1904, and the Urological Society, New York City, June, 1904. They report having cured by lavage of the kidney pelvis and ureter some twentysix pyelonephritic patients, whose urine contained albumen, pelvic epithelial cells, and epithelium from the tubules; they also refer to a number of cases of beginning nephritis which were greatly benefited by the same treatment, begun originally for an ascending pyelitis. In the discussion Dr. Pully of New York City stated that he did not think that chronic Bright's was ever cured by surgical means or the lavage treatment, but that good results followed lavage in pyelitis, the pelvis and ureters being cleansed of irritating substances; and in cases of parenchymatous and diffused nephritis, where lavage tended to restore the normal condition by reflexly influencing, as a counter irritant does, the blood supply of the kidney epithelis to more vigorous action, thus reducing internal pressure and capular tension.

BY T. E. COURTRIGHT, M. D., COLUMBUS, OHIO.

Having written a paper some months ago upon the subject of female sterility, I thought it might be considered prudent and profitable to prepare one on male sterility.

Since being engaged in general practice for more than a score of years, and all the while deriving more pleasure and profit from obstetrics and gynecology than any other branches of medical science, it is but natural to have been very frequently called upon to account for the state known as sterility. Perhaps it could not be any more timely, when we are hearing so much from the public and press about race suicide.

I have been prompted to thoroughly investigate this subject by the brevity with which it is treated in medical literature and the almost perfect silence on the part of medical societies.

Given a pair intellectually and financially prepared to have and support an ideal Roosevelt family, and yet entirely unable, owing to some physical defect, surely should appeal to our sympathy! Anatomical and physiological defects in the male only which operate as causes of sterility will be considered in this paper.

Sterility in its narrowest sense exists when the man possesses no spermatozoa, or diseased or dead ones. In the broader sense, he may be said to be sterile when, ownig to physical deformity or other defect, he is unable to deposit healthy semen deeply enough in the vaginal cavity to insure its entrance into the womb. Sterility may be further defined to be absolute, relative, permanent or temporary.

Absolute when there is a total absence of spermatozoa in the semen. Relative when there are living spermatozoa, but failure on the part of the individual through some physical defect to deposit the seminal fluid safely in the womb. Permanent when due to some incurable complaint. Temporary when due to some curable or self-limited disease.

The etiology is extensive and peculiar to this condition. The treatment is difficult and unsatisfactory in the main. The

causes may be classed under three headings: Deformity, disease, and cachexias. Deformities such as phymosis, absence of the penis, partial development, double penis and imperforate penis, are among the deformities most frequently met. A few unique cases of deformity of the male organ occur in the course of every physician's experience. I recall one congenital case in which the penis was so much deformed that during erection and ejaculation the semen was not deposited deep enough in the vagina to insure its retention. I can conceive of how this condition might arise from traumatism.

Phymosis is quite a common cause of sterility. In one of the cases occurring in the experience of the writer, the preputial orifice was only large enough to admit a small sewing needle. In order to secure a condition approaching cleanliness, this patient was obliged to use daily antiseptic irrigations. The treatment is circumcision.

Epispadias (two varieties), glandular and penile, may be congenital or acquired. Glandular epispadias occurs on the dorsal surface of the glans or just behind it. While penile epispadias is found on the dorsal surface of the penis, it is usually immediately in front of the symphysis. Epispadias is a deformity rarely met with, there being less than a halfdozen cases reported in the literature. I have never met with a case in my own practice. So far as I have been able to learn, only one case has been reported when the epispadias occurred midway between the symphysis and the glans. The theory of the etiology is that it is due to rupture of the urethra in consequence of urinary retention by the absence or retarded formation of the glandular urethra. The treatment consists in establishing a new urethral canal by the method recommended by Thiersch.

Hypospadias is that congenital malformation in which the urinary orifice is found on the ventral surface of the penis at various points between the glans and scrotum. This condition as usually met with is congenital, although I have been informed that artificial hypospadias was practiced by French surgeons during the early centuries for the purpose of preventing conception. I can not vouch for the truthfulness of the above statement. Three principal varieties of the deform

ity exist: Glandular, penile and perineal. Three additional may be added to include the mixed forms of hypospadias: Glandulo-penile, peno-scrotal, and perineo-scrotal. Prince A. Morrow states that "Hypospadias is not only the commonest of all urethral malformations, but at the same time one of the most frequent of the entire body." Bonisson says it occurs "once in every three hundred cases of sexual diseases." I wish to cite a case coming under my care some months since— One of glandular hypospadias. The penis was small, foreskin imperfect, usually retracted, the meatus entirely absent from the normal location; the urethral opening being at the posterior half of the inferior surface of the glans. During micturition, the patient retracted the foreskin, while the urinary stream flowed out at a right-angle with the axis of the urethra. The treatment of hypospadias is strictly surgical, and Duplay's method is doubtless the best.

He divides the operation into three successive stages. First: Straightening the penis and forming a glandular meatus. Second: Formation of a new urethral canal from the extremity of the glans to the neighborhood of the hypospadic opening. Third: Junction of the two portions of the canal.

URETHRAL STRICTURES.

Urethral strictures frequently cause impotence, followed by sterility. This is especially true of tortuons, or very tight anular strictures. If the stricture is very tight and well

Tobacco. It is a well known fact that tobacco is a sexual sedative. I do not know that the excessive use of tobacco alone has ever rendered a man sterile, but I have observed that a man once fertile became sterile after using tobacco, alcohol and morphine to excess for some months.

Recent investigation shows that x-ray workers are rendered temporarily or permanently sterile. Tilden, Brown and Osgood, in the American Journal of Surgery, state that "Men by their presence in the x-ray atmosphere incident to radioformed in the urethra, the fluid is ejaculated into the urethra, very little and sometimes not any passing beyond the stricture during the erection, but may be squeezed out of the urethra after the parts become relaxed. If the stricture is very tight