the left kidney-and a dilated ureter between the ureteral pelvic junction and the point 3 cm. above the posterior inferior spine, with some constriction below this. Pyelotomy for stones was performed under paravertebral anesthesia in the usual manner. An anterior pyelotomy was done, removing innumerable very small stones and a large amount of pus. Tube was left in kidney pelvis which was uri. gated for six days. The anesthesia was fairly successful. Her blood-pressure on admission was 134 systolic, dropping to 118 immediately after operation and soon rising to the normal 130. Urine showed no pus on admission and is clear on discharge. Urea nitrogen before operation 12.88, blood sugar .105, plasma combining power 53. On the third post-operative day patient suddenly developed a cough which was relieved by morphine. The following day she developed a similar cough, no physical signs were found to account for this. Convalescence has been uneventful with this exception.

Summary of Results. All of the operations performed as described above were difficult cases with serious destructive lesions of the kidney. The kidneys were the site of marked adhesions in every instance and two of them had been operated upon before.

All of the cases were prompt to notify us if they suffered pain and it was necessary to give i of ether to two of them. Whenever the peritoneum was pulled upon in all of the cases except the last there was more or less complaint. Only one case complained of pain when the pedicle was clamped. This was obviated by injecting some procain solution into the pedicle.

There is much less bleeding noted than that observed with any inhalation anesthesia. There was no case of shock except that of the bilateral polycystic kidney case which was in desperate straights when operated upon.

On account of the fact that the anesthesia lasts for 6-8 hours, there is much less pain after operation and in some cases no pain at all. This is a most important consideration as a small amount of pain suffered while the patient is in the condition of postoperative slump is very liable to cause shock.

Untoward Effects.-The greatest disadvantage of any injected anesthesia is that no part of it can be removed. Therefore it is important to have it injected slowly and to stop at the first evidence of toxicity. It must be made of pure drugs recently dissolved and it is our custom to boil it about an hour before it is used to absolutely insure its sterility.

We have had two cases in which the patients felt a little faint after the drug was administered. This was not severe enough

to make the use of caffeine or other stimulants necessary.

Death. One death occurred in this series. The case was one of bilateral polycystic kidneys in one of which there was abscess formation. The woman aged 40 entered the hospital in a serious condition and was operated upon as an extreme emergency The infected kidney was drained releasing about vi of foul smelling pus. Death occurred 18 hours later from shock.

case.

Conclusions. It is not proper to draw conclusions from an experience as limited as ours has been with kidney operations. We have, however, formed some very definite impressions which may be of interest to the reader.

(1) We feel that the greatest hope for the future development of surgery upon the diseased kidney, lies in the perfection of less toxic drugs for the induction of regional anesthesia and methods of introducing them. (2) The operation itself should be painless. If the anesthesia is insufficient to bring this about there should be no hesitancy in administering sufficient ether to accomplish this result.

(3) There is apparently about 1/10 the amount of bleeding noted in an operation under regional anesthesia as compared to any inhalation method. This fact and the

GEORGE EDWARD BARNES, B. A., M. D., Herkimer, N. Y.

Not only in regard to the treatment of disease but in regard to many other things

one often hears such statements as "Results are what talk" and "The service that a thing renders determines its value." But so difficult is it for most people to knew exactly what constitutes actual "results" and "services" that these statements would

more nearly represent the present ability of people to evaluate matters if they were worded thus: "What people think are results is what talks" and "What people think is the service that a thing renders determines their estimation of its value." People patronize a thing not so much according to its real worth as according to what they think it is worth. That is necessarily so in great measure when no reliable authority can be followed as a guide. In regard to the popular determination of the value of different treatments of disease two improvements are needed: A greater knowledge on the part of the people and a recognized authority that can be followed in a general way. A greater knowledge of the people is gaining some headway thru the work of special organizations, thru lay publications and thru Hygeia published by the American Medical Association for the people, etc. A recognized authority that could be followed by the people should be nothing less than a very thoro medical practice act that would make it impossible for all kinds of quackery and charlatanism to offer their plausible nonsense to the people. A sufficient knowledge on the part of the people (particularly of their law-making representatives) would inevitably lead to a proper medical practice law.

There is little doubt that people in general more often form an erroneous than a correct idea about the results of treatment of diseases. Here is one of many experiences illustrating that idea. Some time ago, in discussing these matters with a quite well-informed neighbor, I remarked that there is no treatment that can cure measles and she at once declared that there certainly is. She had an idea that essentially every person who has measles owes his recovery to some medicine that he has taken and if that were not so there would be no object in having a doctor in case of measles. I explained the matter and then looked in my books to see whether I could find any statement that she might accept as authoritative. I found the following paragraph introducing the subject of the treatment of measles:

"There is no existing specific treatment of measles of which we have knowledge, and nothing is known which alters materially its clinical course. Proper management is concerned with supporting the patient, meetthey arise, and attempting by all measures ing serious symptoms and emergencies as possible to prevent the occurrence of those complications upon which the final issue so frequently depends."

If supposedly well-informed people do not know what it is possible for scientific medicine to do in cases of a familiar disease like measles, how much less must they know about what it is possible for all sorts of illusory quackery to do in cases of measles, etc. Indeed, how much less must they know of what it is possible for all sorts of quackery to do in those very, very prevalent but obscure emotional and nervous ailments which constitute more than half of the total cases of sickness and which constitute by far the greatest part of the clientele of all sorts of quackery. An outstanding and deceptive trait of all forms of quackery is to claim that all improvement in their cases is due to their particular treatment, disregarding totally all other factors that bring improvement. Every one so far as possible, the people generally, legislators, doctors, and quacks, should know the difference between apparent or supposed results and real results of any treatment. I analyzed this subject in one of two expostulatory letters

on

Christian Science published in the Herkimer Evening Telegram, March 15 and April 19, 1922. I wish to quote from part of the latter letter as follows:

"This matter of 'results' which we hear so often mentioned in connection with all sorts of methods of treatment is, indeed, of the highest importance. People should know what constitutes a real result. A result implies an actual cause and to be able to judge between real results and imagined results it is necessary that one should be familiar with the relation of cause and effect existing between many matters involved in any case. Observe that when thing number two occurs after thing number one it does not mean that number two is necessarily the result of number one or, in other words, that thing number one is necessarily the cause of number two. It is necessary to observe the distinction made in the study of logic between the terms post hoc (after this) and propter hoc (on account of this), that is, it is necessary to distinguish sharply between the causal relation and the mere temporal relation, between things that occur in the exact, scientific relation of cause and effect on the one hand and things that merely happen to occur one after the other on the other hand. If you should be standing with a friend in the morning, facing the east, and he should with much ostentation and mysticism command the sun to rise and if the sun should forthwith rise, you would know, notwithstanding all suggestions and appearances to the contrary, that the rising of the sun was due not to your friend's command, but to the ordinary course of nature's events. Much technical scientific knowledge is often necessary to enable one to distinguish between these two categories of causal and mere temporal relations. Errors without number are being made in this line all the time. Judgments are made without sufficient knowledge of the facts involved and without correct logical reasoning. It is often a very difficult task to investigate the causal relation between things but it is exceedingly easy to assume the existence of a causal relation between things that occur in succession and apparently people often take particular pleasure in just such thinking and they are quite positive in their assertions. It is not necessary to mention Barnum's famous saying. Real logical, scientific, constructive thinking is hard; careless assumption is certainly easy.

"Let us apply these ideas about the causal relation to the 'results' obtained by various methods of treatment.' Improvement following any kind of treatment may wrongly be considered to be the result of that treatment in three chief, particular ways: 1. Thru some change caused by nature not connected with the treatment-the natural course of events, usually nature's own reparative processes. As a matter of fact, most diseases tend to improve or be cured without any treatment and when some form of treatment has been given in such cases and improvement or restoration to health has taken place it is very easy to say that the improvement is due to the 'treatment' instead of to the natural recuperative powers of human tissues. Anybody can in this way obtain credit for 'cures' if he devises any kind of 'treatment' and gets people to take it. This fact accounts for the heralding of the 'cures' produced by all sorts of absolutely ineffective, unscientific forms of treatment when it is claimed that that particular, invariable method of treatment will cure nearly all diseases or will cure some diseases in all people under all circumstances. This applies to Christian Science, for there is inherent in it no distinctive power which can influence disease. Of course, the only treatment that can produce real results in cases of this group is scientific medical treatment because it is based on the individual pathology of the patient and because its means are selected to suit the individual conditions.

"2. Thru some suggestion given (a) to people who are more or less sick on account of affective or emotional disturbances and (b) to people who are excessively suggestible.

"In the cases in the 2 (a) group the function of certain organs is disturbed by affective (emotional) currents which pass. from the brain. The most frequent mental activities of this sort have to do with great concern about a matter of love or business or health. When a person in this condition receives any kind of treatment whatsoever, even a kind word or a slap on the back, he may feel better simply because the idea of the thing that is bothering him is replaced more or less by the idea of the treatment or other thing and the disturbing affective currents therefore become altered, and the essential point to be observed here is that this improvement may take place not on account of any distinctive power possessed by the