tion, exertion, or fever. Venous pulsation in the neck of a more frequent rate than that of the pulse has been noted in several cases, and was present in the above case of Jacquet. The vessels are generally thickened and tortuous, but this is by no means constant. The post mortem on Jacquet's patient showed no arterio-sclerosis. Pallor is common, sometimes from the condition of the blood, but Jacquet regarded it as chiefly due to an active vaso-constriction of the vessels in certain areas. This would also explain the coldness of the extremities and the parasthesia from which these patients suffer.

(2) The neurotic attacks vary in degree from a slight attack of vertigo to deep coma or typical epileptiform convulsions. During the attacks the pulse rate is still further slowed, or the pulse may be imperceptible at the wrist. In Kidd's patient the pulse disappeared at the wrist in two attacks for forty and ninety seconds. The heart was not examined during the attacks, but was repeatedly examined when the pulse was 30, and the pulse and heart sounds then exactly corresponded. An aura may precede the attack, which sometimes cannot be distinguished from true epilepsy. Other attacks may simulate petit mal. Differences in the pupils have been observed, and also loss of memory and a gradual mental deterioration.

(3) Disturbance of respiration is not present in every patient; it may take the form of Cheyne-Stokes respiration, dyspnoea, or irregularity of breathing. Slight dyspnoea on exertion is often present in the intervals between attacks due to emphysema.

The attack may

Digestive disturbances are common. come on after a heavy meal, or there may be dyspepsia, epigastric distress, vomiting, diarrhoea, or obstinate constipation.

Although most frequently found in elderly individuals, several cases under thirty years of age have been reported. Arterio-sclerosis is present in the majority. Syphilis and other infectious diseases seem to play a part in its etiology. Several cases are reported after pneumonia, acute

rheumatism, and typhoid fever. In one case a profound anæmia appeared to be the fundamental cause. Injury to the central nervous system or tumours may produce it. In certain cases no cause can be found.

The morbid changes must necessarily be very various. Extensive arterio-sclerosis especially, involving the coronaries and cerebral arteries and vessels of the medulla oblongata is the most common. In others there are no arterial changes, but fatty degeneration of the heart.

The pathology, too, has been variously regarded. Stokes and Adams considered the cardiac lesions as essential, these leading secondarily to anæmia or hyperæmia of the brain. Charcot concluded that the medulla was the seat of the disease. The nervous symptoms were explained by lesions. of this part of the nervous system, and the bradycardia as the result of irritation of the vagus. Huchard stamps the complaint as the cardio-bulbar form of arterio-sclerosis, bringing about an insufficiency of the heart and nutritional disturbances of the brain. Osler, in his lectures on Angina Pectoris and Allied States," explains the syncope and other cerebral symptoms as the result of transient disturbances of the cerebral circulation analogous to the temporary paralyses that occur in arterio-sclerosis.

The prognosis is always grave, as the patient may die during an attack; but permanent cure has taken place in young people when there has been no arterial thickening.

The treatment is unsatisfactory. Digitalis has no good effect. Amylnitrite and nitro-glycerine seem to give the best results. Hoffman's patient was cured by inhalation of oxygen. Kidd gave his patient thyroid extract, three grains in the day, afterwards increasing to fifteen grains daily, but he regarded it as doubtful how far it contributed to the improvement.

W. H. WYNN.

*Zeit. f klin Med., Band LXI.

SURGERY OF NEPHRITIS.

THE subject of operative intervention as a procedure in the treatment of nephritis is still in the debatable stage. A glance at the literature shows that there is ample material for consideration and study in the results and conclusions recorded during the past eight years; but that the subject has received general recognition and attention by the majority of physicians in this country is very doubtful. At the recent meeting of the British Medical Association at Oxford, the question of operation in Bright's disease was briefly alluded to as if hardly ripe for discussion.

As is so often the case, clinical results of an unexpected and satisfactory nature gave rise to a reconsideration of previously accepted views; practice preceded theory. In the light of fresh knowledge accidentally acquired, a new aspect was given to a hitherto obscure and seemingly hopeless subject. After full consideration, and with a definite object, operation was deliberately undertaken to relieve the symptoms of chronic or acute nephritis. Carried out tentatively at first, immediate results justified a further trial, and before long the question of operation, especially in chronic Bright's disease, was adopted with confidence and even enthusiasm by Edebohls in America and Pousson in France, with the intention either of curing the condition or of merely relieving pressing symptoms. Reginald Harrison, at an early date, advised deliberate incision or puncture of the kidneys for the relief of renal tension in acute nephritis, renal pain, and suppression of urine-a procedure which had been carried out some years before by Newman and Tiffany. The arrest of pain, albuminuria, and passage of renal tube casts, following the fixation of movable kidneys, was known for some time before its relation to the question of chronic nephritis was recognised, and Edebohls claims that it was his experience with this operation of nephropexy that induced him to propose and undertake surgical intervention for the purpose

of attempting to cure chronic nephritis. He has recently published the histories and results of seventy-two such cases operated upon by him.

the

Putting aside such affections as renal calculus, suppuration in connection with the kidney, tuberculosis, and such conditions as are wholly within the province of surgery, term "nephritis " includes, in this instance, those acute and chronic affections of the kidney which have, up to the present, been regarded as wholly belonging to medicine and to the care of the physician. It is only when the whole arsenal of therapeutic measures has been employed ineffectively, when every ordinary medical means has been utilised in vain, against the advance and progress of the local disease, that the field becomes clear for those surgical measures, upon the issue of which, as a forlorn hope, depends the relief of a desperate situation and the arrest of a commencing destruction of the kidneys which must lead, if unchecked, to an inevitably fatal result. Employed under these circumstances, the right of surgery cannot be questioned, but the conditions under which operation is undertaken should disarm all criticism of results. That they are successful sometimes is chiefly a matter of luck; that they are often failures is inevitable. The occurrence of successful cases prompts the surgeon to recommend operation at an earlier date, and the logical suggestion that surgery should be employed before the onset of grave symptoms is inevitable.

Operature measures are advocated in acute nephritis, including the acute manifestations which supervene on a chronic nephritis, and in chronic Bright's disease. In the first instance, the operation is directed simply to the relief of tension in the affected kidney. Undertaken in cases of acute nephritis, renal colic, hæmaturia, and acute suppression of urine, it consists in simple incision of the capsule along the convex margin of the kidney; the compression to which the kidney has been subjected is evinced by an immediate and marked bulging through the capsule.

R. Harrison (Lancet, 1896, I., p. 18; B. M. J., 1896, II., p. 1,126; Ibid., 1901, II., p. 1,369) records cases of acute nephritis upon which he has operated in this way.

Israel Mitteilungen a.d. Grenzgebieten der Med. und Chir., 1899, r., p. 471-510: and Deut. Med. Woch., February, 1902, p. 145) operated under similar circumstances. He is quoted thus by Edebohls: "As is apparent from what I have said, I have never attempted to cure with the knife any form of nephritis whatsoever. On the contrary, my intervention has for its sole object the removal of the distressing or dangerous symptoms of colic or profuse hæmorrhage arising in connection with nephritis."

Pousson (Gaz. hebdom. des science med. de Bordeaux, 16th March, 1902, p. 127) says: "I have operated only under the pressure of grave accidental complications."

A very brief study of the literature convinces us that the operation of simple incision of the capsule does all that is expected of it and is of undoubted value. When the operation on the kidney for the treatment of chronic Bright's disease is considered in the light of the writings and work of Edebohls, it is impossible to take any but a sceptical view of its rationale and value. Edebohls defines his position quite decidedly in his book, The Surgical Treatment of Bright's Disease (August, 1904). He has operated upon seventy-two cases for chronic Bright's disease: seven of these died as the result of the operation, and twenty-two subsequently from ulterior causes; twenty were improved, and seventeen cured. There is a history of each one of these seventy-two patients in his book, which we must admit appears to have been compiled ad captandum; but we are not convinced. We cannot assure ourselves that the diagnosis of the cases reported is quite above suspicion, and we feel that the obvious plan of removing a fragment of the kidney at the operation for microscopical confirmation of the diagnosis would have determined beyond doubt the value of the observations, and would have greatly strengthened the position assumed by Edebohls.

The object of the operative procedure-which consists in stripping off the capsule of the kidney-is to promote the formation of vascular adhesions between the surface of the denuded kidney and the peri-renal tissue, both of which,