derstand that a person with cirrhosis of the liver has not necessarily his death warrant signed, and that if the condition is recognized early there is hope for relief by surgical means.

The second procedure referred to in the beginning of my paper is, it seems to me if the view of its advocates proves correct, of even greater importance than the one just described inasmuch as the disease itself is vastly more common. The principle involved is the same as the one just described, viz.: the relief of the obstructed circulation that occurs in chronic interstitial nephritis: in the small contracted kidney of the pathologist,

a

or

condition that is regarded as leading sooner later, and usually fairly early, to a fatal termination. Dr. Edebohls, of New York, who has given this subject more investigation than any one else, has advocated a surgical procedure, which he designates decortication or decapsulation, energetically and is entitled to whatever credit is attached to it if it proves successful. It was no sudden inspiration, however, on his part, but logical deductions from a number of observations extending over a number of years by different men, supplemented by cases of his own in which it was noted that abnormal conditions existing before certain operations disappeared unexpectedly as the result apparently of the operation undertaken for another purpose.

The first recorded observation bearing upon this point I find quoted in the Trans. of the American Surgical Association for 1885 by Dr. Louis McLane Tiffany, of Baltimore, from the "Bull. de Therap. of 1881-101, p. B. 4 3," where a French surgeon whose name is not given, incised the fibrous capsule of the kidney and effected a cure of a nephritic colic. In 1889 Dr. Tiffany reported to the same Association another case similar in many respects and expressed himself as regarding the relief of the nephralgia as due to releasing tension from a large cicatrix in the capsule of the kidney caused by the absorp tion of a large gumma.

In 1896 Reginald Harison, of London, exposing the kidneys in suspected renal calculi, found the capsule so tightly swollen that he punctured it in several places for the direct purpose of relieving the tension and found that a previously existing albuminuria with casts was cured. He repeated the procedure in three instances with favorable results in two. These were the first cases in which the statement was made that chronic Bright's disease could be cured by relieving tension.

Prof. Israel, a German surgeon, advised incision of the kidneys for hematuria, renal colic and nephritis and carried them out with favorable results. Then came operations instituted for the purpose of fixing movable or floating kidneys to the abdominal parietes posteriorly, and in cases in which this operation was carried out on kidneys affected for several months with Bright's disease, as shown by examinations of the urine, it was found that the conditions indicating the disease of the kidneys in the course of weeks, or months, disappeared entirely and the patients recovered. In performing the operation for the relief of floating kidney, Dr. Edebohls, as detailed at length in the Annals of Surgery for February, 1902, stripped the kidney of its capsule to a considerable extent, and used the freed capsule to fasten the kidney to the abdominal wall. He asserted that the disease of the kidney, shown to exist previous to the operation, disappeared. He then proposed that the operation should be done on kidneys not floating, which were the seat of chronic Bright's disease as a therapeutic measure and carried it out in three instances—in two of which a temporary cure, at least, was achieved; whether permanent or not, time only can show; less than two years have elapsed since the first of these operations was undertaken.

In a paper read before the Association of Genito-Urinary Surgeons on April 29th of this year, Dr. Ramon Guiteras, of New York, discusses the subject on the same

lines as Edebohls, and-without venturing an opinion myself, not having done the operation on the living subject, I must say I am deeply impressed with its possibilities. Two of Dr. Edebohls' cases were upon subjects who had had the operation of nephropexy performed previously, and he found a very profuse collateral circulation established between the denuded surface of the kidney and the surrounding parts; the quadratus lumborum muscle and the perirenal fat; that arterial circulation was towards the kidneys, and that the veins were correspondingly enlarged. We understand, of course, that the procedure is in the experimental stage, but it behooves us to be on the alert for something that will help us in the treatment of this very serious disease.

The operation in its initial steps does not need to be dwelt upon at length-it is the usual procedure for nephropexy-or for nephrotomy and allied operations. The kidney may be brought out upon the back, or the decortication may, with more difficulty, however, be made with the organ in the depths of the wound. This consists in making a small incision through the capsule on the convex surface and then introducing a small probe-pointed director through the opening, dividing the capsule upon it all along the convex surface and around each end nearly or quite to the pelvis, then very gently separating the capsule from the surface of the kidney throughout its whole extent, cut it away, replacing the kidney in its bed and closing the wound in the usual way by layers. I must refer those who care to study up the steps to the article in the Annals of Surgery above cited.

A point that has struck me as of extreme importance not alone in its bearing on the operative procedure, but as a factor in the course of the disease, is that Edebohls has found that Bright's disease may be unilateral, only one kidney be the seat of the disease. I would have liked to enlarge upon this feature, but I have already

encroached so much on the time of other speakers that I can only refer to the importance in every case, in the light of this knowledge, of catheterizing the ureters as a preliminary step to the operation, to ascertain if both kidneys be diseased, and if not, which one is to be operated upon.

25

A CASE OF EXTENSIVE RESECTION OF THE

INTESTINE.

GEORGE R. HARRIS, M.D.,

NORWICH.

The removal of large portions of the intestines, with recovery of the patient, are becoming much more common than in former years, and when there is an abundance of time in which to prepare your patient, with plenty of assistance and good light, this operation is robbed of many of its difficulties; but when, on the other hand, the operation is performed in an emergency, after having brought your patient a long distance in an ambulance, he being more or less exhausted, with a violent peritonitis in progress, it is an entirely different thing.

These circumstances, together with the extreme length of the intestine removed, and the apparent complete recovery of my patient, is my reason for reporting this case. The History is as follows:

On September 11th, 1901, I was called, by Dr. Ashley, of Colchester, to Salem, Conn., about twelve miles from Norwich, to see a man who was said to be suffering with an obstruction of the bowels, possibly intussusception.

On arrival, found the doctor in attendance. Patient was Mr. B. L. P., aged 33, U. S., married, sculptor; a man weighing about one hundred and forty pounds; dark complexion, black hair, smooth face, fairly nourished, but with little fat and very muscular. He gave the following history:

Family history negative. Had the usual diseases of childhood. Typhoid fever eight years ago; perfectly well ever since, except for several years he has had, at times, attacks of severe pain in the abdomen.

In 1897, in Paris, had an attack which lasted about fifteen minutes, and was relieved by massage.

Two