In case pathological constituents are found, cystoscopy and catheterization of the ureters should be employed. In his cases Rovsing found infections of the urine from the staphylococcus aureus, staphylococcus albus, streptococcus py ogenes, and bacterium coli. The entire clinical picture did not differ in these eases from that in the aseptic forms of nephritis. Neither was there any differ ence in the chemical constituents of the urine or of the appearance of the kidney when it was exposed. The results of op eration in these cases were very much more satisfactory, however, than in asep tic cases, and Rovsing believes that his cases show definitely that unilateral chronic nephritis may be of infectious origin; that it may affect a greater or smaller part of the kidney, or that we may have a double partial infectious nephritis. Stripping off the kidney cap sule, which gives such favorable results in cases of aseptic interstitial nephritis with perinephritis and severe pain, also has a favorable influence on inflamma tory processes. In luemorrhagic cases he believes that splitting the kidney will give favorable results in the milder in fections, such as by the bacterium coli, but it is dangerous in the more virulent infections. Resection of the diseased part in case of local infectious nephritis which entirely resembled chronic aseptic nephritis led to cure in two of his eases.
"Further investigation is needed to prove the value of Boysing's suggestions. Up to this time infection with ordinary pyogenic bacteria has not been consid ered such an important etiological factor in cases of chronic nephritis, though it might have been suspected that the cases following scarlet fever, erysipelas, and other forms of infectious disease were of this character. The careful study of this class of cases which Rovsing suggests, if carried out by competent observers, could not fail to give important results. If further study of such cases proves that we can find such definite indications for operation as are above suggested a great advance has been made and un doubtedly many lives will be saved. The skepticism of many surgeons as to the advisability of operating in every case of this kind seems warranted from our present knowledge, and, until definite grounds have been shown from more careful study of large series of cases by competent men, routine operation for chronic nephritis in any case cannot be considered an established surgical pro cedure." By persevering effort the author has been enabled to see or get word from all the patients operated on by him. so that he could present the status up to date. The first renal decapsulation ever performed for the relief of chronic Bright's disease was done by him on June 10, 1S92, and the patient was permanently cured. This ease, together with reports of the five preliminary operations which led up to this pro cedure, was published in the Medical News of April 2, 1S9S. Subsequent papers giving reports of other cases of his own and a resitm6 of the work of other surgeons in this field were pub lished in the Medical of May 4 and December 21. 1901. and of April
26. 1902. From 1S92 to 1901, inclusive, the writer personally operated on 19 cases, and the year 1902 on 32 cases. Of this total of 51 cases. 29 were in males and 22 in females. and the average age was 34 years. In 32 cases the Bright's disease was far ad vanced. In 41 of the eases the period which had elapsed between the first recognition of the disease and the opera tion varied from 1 month to 19 years. The general average of this period was 3 years, and in 32 cases it was fully 4 years. Nearly all the cases were tended by cardiac or other tions. Of the 51 cases, 29 were of chrouie interstitial nephritis, and in all but 9 only one kidney was operated on LI were of diffuse nephritis and S of parenchymatous nephritis. If only one kidney was affected by Bright's disease, he said. the patient suffered very little, mid the condition might be discovered only accidentally.
The chances of success for the opera tion are enhanced by the patient's re maining in bed for a week previous to it. This gives the heart a rest, if car diac complications are present, and affords the best facilities for any pre liminary treatment that may be re quired, as well as for systematic in vestigation of the quantity and condi tion of the urine. There are three con ditions the presence or absence of which affect the facility with which the opera tion may he performed: 1. Great length and obliquity of the twelfth rib. This difficulty must be overcome by posture and a modification of the incision. 2. Obliquity or firm appearance of the kid ney. When there is firm fixation it is generally necessary to incise the capsule at any point that can be reached. For separating the capsule the rubber-cov ered index finger is the best instrument. 3. The firm or more or less weak at tachment of the eapsnle. Great caution and gentleness should characterize all attempts at (leen psulation. In this operation there is often considerable danger of destroying some of the al ready diminished working tissue of the kidney, and it should never be per formed except by surgeons who are already more or less familiar with renal surgery in general. The danger is greater from the condition present than from the operation itself. The pro cedure, however, should not be too pro longed; so that one hour should be the limit for the decapsulation of two kid neys. The writer has often found half an hour sufficient for operating on both organs. A "team operation" has been proposed. with two surgeons each work ing on a kidney, but this would hardly be feasible, as two operators, each with his necessary assistants. would inevi tably interfere with the prompt accom plishment of each other's work. An other expedient suggested is that only one kidney should be deeapsulated at a time: but this too, is to be deprecated, as the time that the patient would be under an anaesthetic for two separate operations would necessarily be longer than for operating upon both kidneys during one period of anaesthesia. George Edebohis (Medival News, March 7, 1003).