of usefulness is one of the future helps to be looked forward to in the treatment of all these bacterial infections.

Most cases of acne, boils and common pus infection of wounds are due to staphylococcus. Any of these, when chronic, may be treated with bacterial vaccine, according to Prof. Wright's opsonic theory. Though the opsonic index is desirable, and no doubt often a vaccine made from the germ in the particular case would give better results, it is perfectly practical to give a patient a mixed staphylococcus vaccine, which can now be obtained from the pharmaceutical houses or from any good bacteriological laboratory.

The ordinary dose of staphylococcus vaccine is 200 to 1000 million of dead germs, and the interval between doses one week to ten days. The technic of giving the vaccine does not differ from that of giving any other hypodermic injection.

Louisiana State Medical Society Proceedings.

(EDITED BY PUBLICATION COMMITTEE).

P. L. Thibaut, M. D., Chairman.

Some Recent Experiences in the Surgery of the Kidney with Special Reference to the use of the Gauze Sling in Fixation of the Kidney.

By DR. J. A. DANNA, New Orleans, La.

It was my intention when the title appearing on the program was handed in, to report my experiences with 15 cases of kidney surgery that I have had occasion to observe recently, with such remarks and observations as each case might have brought forth. However, when I got down to the work of writing down in the form of a paper, all that I would have liked to have said I saw that it was impossible to crowd into a paper to be read within 20 minutes, all the material at hand.

I will confine myself therefore, to a subject that has interested me very much during the last seven months, and which I have used in seven cases. While in Philadelphia last October, it was my

good fortune to see Dr. Jno. Chalmers Da Costa, Professor of Surgery in the Jefferson Medical College, do an operation for movable kidney, and was struck by its simplicity, the ease with which it could be done, and the thorough and lasting manner in which the kidney was fixed to the lumbar muscles.

After exposing the kidney fat through a lumbar incision the kidney was dissected loose from the fat, and after cutting away part of the fat in front and behind it, was brought out through the wound. The capsule was now incised at the convex border and peeled off to the hilum, and a few sutures put through it, puckering it to prevent its slipping back over the kidney. A strip of iodoform gauze was now passed as a sling around its lower pole and the kidney returned within the abdomen and pushed up under the diaphragm, being effectually held against the abdominal wall by means of the sling. The wound was now packed with more gazue, going down to the lower pole of the kidney at the bottom of its upper angle, and a dressing applied. This sling of iodoform gauze consisted of two strips sewed together at their ends with 10 day cat gut so applied that the sutures would be over the hilum or that part of the kidney furthest away from the exterior. Thus after due time had elapsed for the absorption of these cat-gut sutures and the ends were pulled on, they came away readily, leaving the kidney in a sling of granulation tissue which came in contact with a similar layer of granulation on the kidney surface, the two cementing together to permanently fix the kidney. The whole procedure required little longer than it takes to tell it, and looked so easy that I resolved to try it at the first opportunity.

The first occasion I found to use this method was after removing four stones from the pelvis and calices of the kidney of say, Case 1. The stones were removed through an incision in the kidney substance at a point where it had been much thinned by distension. This incision was closed with cat-gut sutures. Feeling that the kidney must now be fixed so as to be in easy reach in case of the development of a urinary fistula, I decided to use this method of fixation. Stripping of the capsule I refrained from, owing to the fact that the kidney substance was very thin in some places, and my sutures would hardly hold without the additional

strength of the capsule. I also felt that the use of a second sling around the upper pole would permit of still better controlling the movement of the kidney and keeping it against the abdominal wall. I therefore used two slings, one around each pole and pushed it up under the diaphragm by digital manipulation and relaxation of the upper sling, and pulling on the lower, thus bringing the lower pole of the kidney up against the abdominal wall in the upper angle of the wound and as nearly as possible to its normal physiological position. Though the slings themselves acted as drains, I inserted a rubber tube cigarette drain down to the incis ion in the kidney substance and sutured all the wound except sufficient of the upper end to permit of the passage of my slings and drain. I tied the lower to the upper sling over a roller of gauze which was placed across the wound, thus effectually tying the kidney as it were, up against the abdominal wall, much as a ship is moored to a wharf. After six days the drain was removed. After twelve days the slings were removed with little pain or difficulty in extraction. Fearful of possibly pulling the kidney down out of its new position, I made certain to steady well the lower sling while I pulled out the upper first one half and then the other, pulling the two halves of the lower slings out last. Patient never had a drop of urinary leakage and is now perfectly well.

Case 6 was identical with this one, except that he had but one stone, and with the same procedure and good result.

Case 2 was a nephropexy for movable kidney. In this case I followed the steps of the operation as I had seen it performed with the modification that I did not cut away any of the fat, and used two slings. It seems to me that it does not look exactly right that we should be removing kidney fat from a patient whose very condition of movable kidney is said by the most competent authorities to be caused by a lack of support, owing to the absence of an adequate amount of healthy fat surrounding it. Again, while I believe in fixing the kidney to the abdominal wall, I think we should endeavor to surround it on its free aspects with a type of tissue that would not be so apt to give us later a dense, tough, unyielding cicatricial fibrous capsule that might later in life so squeeze the kidney, as it were, as to impair greatly its function.

For this reason perirenal fat is much more desirable than retroperitoneal cellular tissue.

As to the use of two slings instead of one, it seems to me that not only will two slings better hold the kidney in position than one, but they would also double the amount of surface for the formation of active granulations to act as two shells in which each pole of the kidney respectively lies.

Cases 3 and 5 were identical with Case 2, and all resulted well. Case 4 is probably the most interesting of all, as it gave me an opportunity two months after having done the operation of testing the strength of the adhesions fixing the kidney in position.

This was a case of stab wound of the kidney where, after suturing the wound in the kidney I replaced it with two slings and without stripping the capsule. Two months later it became necessary to remove the same kidney, owing to the formation of a small traumatic aneurysm which had ruptured in the pelvis and gave rise to the most alarming hemorrhage. So firm were the adhe sions that had formed between the kidney capsule and the surrounding structure that I was obliged to peel the kidney from its capsule in order to get it out. In other words, the adhesion of the capsule to the surrounding parts was firmer than its adhesion to the kidney itself.

To my mind no better proof of the efficiency of the operation could be submitted, and if I was a believer in it before, I now became an enthusiast.

Case No. 7 is the last case in which I have used this method, and it here comes forth prominently as a measure accomplishing an object difficult, if not impossible of accomplishment by any other means known to me. In this case as in Cases 1 and 6 (where a stone or stones were found), a nephrotomy and pyelotomy was done to explore the kidney for a suspected stone, which was not found. The condition was one in which the kink in the ureter had given all the symptoms of stone.

We, therefore, had to deal with a kidney that must be fixed, a ureter to be stretched and an incision in the pelvis and the kidney substance, which required the insertion of a drain. No method of suture could so easily and so effectually accomplish all these

objects. Yet this fixation has cured a patient of kidney colic, who had been suffering for three years.

Those of us who have done or seen the usual operation of suturing the kidney to the muscles of the back will agree with me that for simplicity, rapidity, ease of performance, absence from any danger, thoroughness and permanence of fixation of the kidney, it has the nephrorrhaphy beat to a standstill. Moreover, this is the only operation that will reduce the kidney to its normal physiological position and not leave it exposed between the fibers of the lumbar muscles, subject to the slightest traumatism in this region. Furthermore, no appliance or special abdominal pad is required to keep the kidney from getting loose immediately after the operation, and we are not in constant fear that the few sutures that hold the kidney might cut through and make our operation a failure. This operation is practically the operation introduced by Senn years ago, and I claim only the privilege of reporting my experience and expressing my humble opinion. For that reason I say nothing of its use in Edebohl's operation.

DISCUSSION.

DR. E. D. MARTIN. The important point about the operation is that it allows the kidney to become more adherent. Other operations are just as successful, if they are done just as carefully in the beginning. There is another method which is used some, which is good, especially when the same incision is used. I have done it only once myself. The peritoneum is brought up under the kidney, and a pouch is formed, which make it doubly secure.

I want to say a word about the cases operated on. There is often a tendency to go too far. I think a good rule to adhere to is not to trouble a kidney that does not trouble the patient. I know of a case where the kidney has been in the pelvis for ten years to my knowledge, and has given no trouble to the patient. These floating kidneys are not apt to give trouble. In some of the obscure cases, it might be well to look in this direction.