and Harrison concluded that operation upon one kidney benefited the functional condition of the other.

In the British Medical Journal, October 17, of the same year, Harrison proposed incision of the kidney as a treatment in acute suppression of urine, and in acute nephritis with tenderness on pressure over the kidney, with slow disappearance of casts and albumin. In April, 1899, Edebohls reported six cases of nephropexy upon movable kidneys, the seat of chronic nephritis. Favorable results upon the nephritis in cases 1, 4 and 5, led him to undertake the operation in case 6 for the deliberate purpose of favorably influencing or curing the nephritis. He concludes his paper as follows: "My own favorable experience warrants me, for the present, in regarding chronic nephritis affecting a movable kidney as an important indication for nephropexy."

In June, 1899, Ferguson reported two operations, one was for supposed stone in the kidney, but the pathological report showed chronic interstitial nephritis. Decapsulation was followed by cure. The second case was characterised by chronic pain over the right kidney, with acute exacerbations, but without albuminuria. Septic kidney was suspected but not found. Decapsulation was followed by relief of pain. In this paper Ferguson proposed operation for chronic nephritis.

Israel, June 12, 1899, reported fourteen operations upon the kidney, for the treatment of nephralgia or renal colic and of renal hematuria. Of these cases, three died from nephritis, two were failures, in three the symptoms recurred after long intervals, and six completely recovered. In January, 1902, Israel made the following statement regarding his operations:

I have never attempted to cure with the knife, any form of nephritis whatsoever. On the contrary, my intervention had for its sole object the removal of the distressing or dangerous symptoms of colic and profuse hemorrhages arising in connection with nephritis.

Pousson, October 21, 1899, reported three personal cases of operation upon the kidneys in nephritis, and collected 22 cases from the literature. Edebohls, May 4, 1901, published a further paper in which he said:

I am now prepared to go a step farther and propose surgical intervention for the purpose of attempting a cure of chronic nephritis, whether the affected kidney be movable or in place. When the inflamed kidney is not movable, and operative fixation of the organ is, therefore, not indicated, I shall content myself with entirely denuding the kidney of its capsule proper, and thus affording free opportunity for the formation of new

vascular connections, on a large scale, between the bloodvessels of the kidney and those of its fatty capsule.

Harrison, October 19, 1901, reported three additional cases, one of nephrotomy for pain in acute nephritis, one of renal puncture for suppression in acute congestion, and one of incision and drainage for cystic degeneration. Edebohls, December 21, 1901, reported in detail his operations upon nineteen cases of nephritis. without mortality. Of these nineteen cases, three disappeared from observation within four to six weeks. In one case (of unilateral nephropexy) no cure resulted. Three years later the opposite kidney was removed, after which the patient lived for five years with only the operated kidney, and died at the end of that time, after undergoing a hysterectomy. Seven cases had been operated upon within less than a year preceding this report and judgment upon them was suspended. The remaining eight cases are reported as cures, having been under observation for periods varying from one year to eight years and four months. subsequent to the operation. In seven of these cases the time from operation to the complete disappearance of albumin and casts from the urine, varied from one to twelve months and in one case it was not definitely determined.

In March, 1902, Primrose reported a case of chronic nephritis with albuminuria, hyaline, granular, fatty and epithelial casts, edema, anasarca and ascites. Paracentesis abdominis had been performed nine times. November 21, 1901, the capsule of the right kidney was incised. This was followed by an increased. excretion of urine with a lessened percentage of albumin. December 20, 1901, decapsulation of the left kidney was performed. After recovery from a pneumonia, which followed, great improvement in the patient's general condition was observed. Sixty-twodays after the second operation the urine contained only a trace of albumin with a few casts, the anemia had nearly disappeared and there was no return of the edema or ascites.

Guiteras, May 17, 1902, reported two operations performed respectively one month and two weeks previously, but he wisely refrains from drawing any deductions from them. In a personal communication dated February 14, 1903, Dr. Guiteras says: "As yet I have drawn no conclusion." He makes no statement of the subsequent history of his two cases.

Edebohls, March 28, 1903, published a further report of his experience. In addition to the nineteen cases already mentioned, he tells of thirty-two others operated upon during the year 1902. These new cases were all far advanced and some of them were operated upon only because the operation was demanded by the

patient, or by his physician. In this latest communication Edebohls summarises the results of all his operations as follows:

Summary of results of renal decapsulation for chronic Bright's disease in the author's fifty-one cases, embracing forty-seven operations upon both kidneys and four operations on one kidney only; seven patients died within seventeen days after operation. Seven patients died at periods after operation, varying between two months and eight years; the average period of life after operation being one year and eight months. Two patients do not show improvement satisfactory in every respect. Twentytwo patients are in various stages of satisfactory improvement and progress toward health, at periods varying between two months and fifteen months after operation. The urine of several of these is at present free from albumin and casts. They have not, however, passed the probationary period of six months of normal urine, before the expiration of which no patient is entitled to a place on the list of cures.

One patient, after a cure extending over a period of four years, again has chronic Bright's disease. One of her kidneys only was operated upon. Nine patients were cured of chronic Bright's disease, and remain cured at periods after operation, varying from one year and nine months to ten years, the average duration of cure being over four years. Three patients disappeared from observation after leaving hospital, and no trace of them can be found.

Through the courtesy of Dr. Eugene Wasdin of the Marine Hospital service, I am permitted to read his condensed report of a case operated upon by him. This report is of unique interest, as containing an account of what I believe to be the first autopsy following the performance of Edebohls's operation:

CHRONIC BRIGHT'S DISEASE, ARTERIOSCLEROSIS, AND MITRAL

STENOSIS.

W. K., age 32. History of syphilis for twelve years: Presented abdominal fluid, great cardiac uneasiness, difficult breathing, urine reduced to 200 c.c. in twenty-four hours; sp. gr., 1.008; albumin, 20 per cent. volume. Although the general condition, contraindicated the operation, it was determined to decorticate the kidneys as a symptomatic measure. The right organ was exposed and the capsule reflected from the cortex over twothirds of the surface, and the flaps sutured to the muscular walls. Venous hemorrhage was quite free for twenty-four hours. During the first twenty-four hours, the urine increased to 1000 c.c.; sp. gr., 1.008. During the next few days the secretion became greatly increased, 3500 c.c. in twenty-four hours. All symptoms, of course, improved. For two months his condition was such that it was hoped no further operative interference would be

required, but at this time, the general symptoms recommenced, dizziness, headache, and the like. The urine gradually diminished in quantity to 500 c.c.

The left kidney was then decorticated, the organ being left free. Again the amount of urine at once increased to 2500 c.c., and symptoms improved; but, again, there was gradual failure to secrete and the man died of uremic coma.

Autopsy limited to kidneys. The first organ decorticated; the right, presented a firm fibrous envelope closely investing the kidney and forming a very tough capsule that could be removed only with difficulty, and which was very slightly supplied with bloodvessels. The left organ was in process of the same change, the kidney being again invested with a firm, tough membrane, which appeared to compress the organ. To neither kidney was there any newly formed blood supply through adhesions. Kidneys incised showed a chronic interstitial nephritis; the organs. much reduced in size, with a number of retention cysts in cortex.

Results of operation in this case, no results as a curative measure for chronic Bright's disease. Good results as a measure to relieve symptoms of imminent danger from suppressed urine and uremia. Its immediate result is diuretic, the duration of which depends upon reparative changes about the kidney. Contraindications as a curative measure,-any organic change in the organs, capable of causing death per se, i.e., arteriosclerosis, heart valve disease, and the like. Cases in which it may be expected to succeed curatively,-in uncomplicated parenchymatous nephritis, and glomerulo-nephritis. To relieve suppression, it should be used in all cases.

I am indebted to Dr. Eugene A. Smith for the opportunity of reporting the following case. Miss H-, age 21, teacher, on April 3, 1902, gave following history:

Two years ago she noticed a swelling of both lower eyelids, which was shortly followed by swelling of the feet and legs; and, finally of the entire body. After persisting for two weeks, the swelling disappeared. During this period the patient complained of severe pain in the left side, with occasional pain in the right side. In September, 1900, she was treated in the hospital for cystitis, apparently with success. Since then she has had many recurrences of the pain, which was of a cutting character and worse at night. In March, 1902, she had a severe attack of vomiting, with intense pain. Such attacks were frequently repeated for two weeks. After their subsidence, she noticed at swelling of both lower lids, which nearly closed both eyes. April 4, she passed 900 c.c. of smoky acid urine. Sp. gr., 1.010; 9.0 gms. urea, abundant albumin, renal epithelium, hyaline and granular casts. April 21, Dr. Smith decapsulated the left kidney. The operation was undertaken on the probable dignosis of kid

ney stone, but an apparently typical large, white kidney was found, and no stone.

The operation was followed by general improvement, and the passing of a largely increased quantity of urine, but the latter contained a large amount of albumin and a goodly number of casts. Two days after the operation, the quantity of urine rose to 1152 c.c., and from then until May 25, the daily quantity varied between 1330 c.c. and 2224 c.c. On July 20, 1902, the quantity was 1500 c.c.; sp. gr., 1015; reaction acid; urea, 13.5 gms. There was a large quantity of albumin, and also hyaline and granular casts, cylindroids, red blood-cells, and leucocytes.

Although the hospital records are somewhat vague upon this point, Dr. Smith informs me that from the time of operation there was a very marked diminution in the quantity of albumin, and that during the entire subsequent period of observation this quantity never approached that which was constantly present before operation.

On February 25, 1903, Dr. Smith's patient was seen again, and the following notes taken:

No headaches, strength good, appetite good, bowels regular, color better, rosy. Urine usually in good quantity, but sometimes diminished. Feet and legs a good deal swollen each night, as high as the knees; eyelids sometimes puffy. She does considerable work, but tires easily. Has occasional slight pain over hips, but usually free from pain. She exercises freely in open air, but sometimes does so reluctantly.

An examination of a single specimen of urine shows the following: amber color, alkaline, sp. gr., 1.012; considerable albumin, no sugar. The sediment contains hyaline, granular and epithelial casts. In view of the amelioration of all symptoms which followed this operation, Dr. Smith is considering the advisability of decapsulating the other kidney.

Edebohls's explanation of the beneficial effects of decapsulation upon the nephritic kidney, are based upon his observations in three secondary operations upon kidneys, upon which nephropexy had previously been performed. I quote the following:

At the second operation, upon the same kidney, the following conditions were noted as results of the first operation: first, the formation of strong connective tissue adhesions or bands attaching the kidney to its surroundings. Second, the existence in these connective tissue adhesions or bands, of very large and numerous blood vessels, running between the kidney and the adjacent tissues. This fact was forcibly brought home to my assistants and myself by the necessity of ligating artery after artery of considerable size, in dividing these adhesions. Third, the pre