mal. There were no adhesions between it and the abdominal wall, but it was thought to be adherent to the diaphragm. The lower border was of firm consistence, while the upper part was soft and fluctuating. Over this latter point the abdominal wall was protuded so as to make the swelling evident on simple inspection.

Sulphate of quinia in hydrobromic acid was prescribed, and the galvanic current was applied to the abdomen, so as to act directly upon the spleen, with the object of inducing contraction of the fibrous coat of that organ. To combat some degree of active inflammation still present, the actual cautery was applied, as a counter-irritant, over the most prominent point. It was agreed that, if there was no decided improvement in a few days, the aspirator should be used to remove the softened mass of brokendown spleen pulp, pigment, and blood, supposed to be present.

Although, to a certain extent, this treatment proved beneficial, no marked reduction in the size of the spleen. was perceptible, so the operation was determined upon.

February 16, the patient reclining upon his left side, a large aspirator needle was introduced through the intercostal space between the ninth and tenth ribs, at a point two inches behind a line let fall from the left axilla and on a level with the middle of the eleventh dorsal vertebra. The skin and latissimus dorsi were pierced, the former tissue having been well drawn upward to the extent of over an inch, and then the ratchet of the aspirator was turned so as to create a vacuum, and the point of the needle carried in a direction toward the umbilicus, through the intercostal space into the spleen. At a depth of about 14 inches the instrument began to fill up rapidly with a dark, grumous fluid. This was forced into a wide-mouthed graduated jar, and exhaustion again effected, and so on until 8 ounces were evacuated. The needle then became clogged, and it was not determined whether all the matter was removed or not. It being considered preferable to repeat the operation, if necessary, rather than to exert any great degree of force, the needle was withdrawn, and the spleen allowed to resume its normal position, the entrance of air into the peritoneal cavity being thus effectually prevented.

The patient was at once relieved of pain, and the size of the spleen was manifestly reduced, its lower border

being an inch higher than before the operation. Rest in bed was rigidly enjoined, but no bandages or dressings were applied. At 8 o'clock P. M. he was perfectly comfortable; there was neither pain nor fever, and he had slept quietly several hours.

Prof. A. C. Loomis visited him next day, at Dr. Hammond's request, with special reference to the pleurisy, which was also present. A very extensive double pleurisy was found. He examined the region of the spleen and expressed the opinion that there had been acute inflammation of the organ and subsequent softening, and that the operation had probably, by removing the degenerated tissue, prevented the formation of an abscess and the death of the patient. The case progressed without an untoward symptom of any kind. He gained strength, and the uncomfortable sensations in the splenic region were so far lessened that, on February 27, he went to Baltimore to remain a few days before going home. In May no symptoms remained except those resulting from pleurisy, and those were gradually disappearing.

Microscopical examination of the substance removed showed that it was composed of broken-down spleen tissue, spleen pulp in a greater or less degree of disorganization, blood, and a large quantity of pigment free and contained in cells, the former greatly predominating. There were also numerous white-blood corpuscles. On allowing it to stand the pigment soon settled to the bottom of the vessel, forming a stratum one-fourth of the depth of the whole column.

After giving a resume of the clinical and pathological history of softening of the spleen, he calls attention to the large amount of pigment in this case, and concludes his paper with the following reference to the operation:

"There are several points of interest connected with the operation to which reference might be made. The most important of these is, I think, the comparative freedom from danger of the procedure when properly done. I have repeatedly, in cases of hypertrophy of the spleen, injected a drachm or more of the fluid extract of ergot into the organ without in any case observing the least untoward result. Care should be taken to make the opening a valvular one, and to puncture in an intercostal space, and where the spleen is in contact with the solid. abdominal wall.

"Again, the puncture should be made in such a way that the point of the needle enters the spleen at an acute angle to the surface. The flow of blood into the peritoneal cavity, even if liable to take place, is thereby greatly impeded. The great contractility of both the serous and fibrous coats of the spleen greatly militate against the liability to danger from this cause."

Intestinal Obstruction.

Its Diagnosis.-When a child becomes suddenly the subject of symptoms of bowel obstruction it is probably either intussusception or peritonitis. When an elderly person is the patient, the diagnosis will generally rest between impaction of intestinal contents and malignant disease. In middle age the causes of obstruction may be various; but intussusception and malignant disease, both of them common at the extremes, are now very unusual. Intussusceptious cases may be known by the frequent straining, the passage of blood and mucus, the incompleteness of the constipation and the discovery of a sausage-like tumor, either by examination per anum or through the abdominal walls. In intussusception the parietes usually remain lax, and there being but little tympanites it is almost always possible without much difficulty to discover, the lump by manipulation under ether. Malignant stricture may be suspected, when in an old person continued abdominal uneasiness and repeated attacks of temporary constipation have preceded the illness. It is also to be noted that the constipation is often not complete. If a tumor be present and pressing on the bowel it ought to be discoverable by palpitation under ether through the abdominal walls, or by the examination by the anus or vagina, great care being taken not to be misled by scybalous masses. If repeated attacks of dangerous obstruction have occurred with long intervals of perfect health, it may be suspected that the patient is the subject of a congenital diverticulum, or has bands of adhesion, or that some part of the intestine is pouched and liable to twist. If, in the early part of a case, the abdomen becomes distended and hard, it is almost certain that there is peritonitis. If the intestines continue to roll about visibly, it is almost certain that there is no peritonitis. This symptom occurs chiefly

in emaciated subjects, with obstruction in the colon of long duration. The tendency to vomit will usually be relative with three conditions and proportionate to them. These are, (1) the nearness of the impediment to the stomach; (2) the tightness of the constriction, and (3) the persistence or otherwise with which food and medicine have been given by the mouth. In cases of obstruction in the colon or rectum, sickness is often wholly absent. Violent retching and bile vomiting are often more troublesome in cases of gall stones or renal calculus simulating obstruction, than in true conditions of the latter. Fecal vomiting can occur only when the obstruction is moderately low down. If it happens early in the case, it is a most serious symptom, as implying tightness of constriction. The introduction of the hand into the rectum, as recommended by Simon, of Heidelberg, may often furnish useful information.

Its Treatment.--(1) In all early stages, and in all acute cases, abstain entirely from giving either food or medicine by the mouth. (2) Use anesthetics promptly. Under their full influence examine the abdomen and rectum carefully before tympanites has concealed the conditions. Administer large enemata in the inverted position of the body. If advisable, practice abdominal taxis. If you do not at first succeed, do it repeatedly. (3) Copious enemata, aided perhaps by the long tube, are advisable in almost all cases, and in most should be frequently repeated. (4) Fluid injections may be sometimes replaced by insuf flation of air in cases of invagination, since air finds its way upward better and is more easily retained. It is, however, somewhat dangerous, and has perhaps no advantages over injections with the trunk inverted. (5) Insufflation is to be avoided in all cases of suspected stricture, since the air may be forced above the stricture and there retained. (6) Saline laxatives are admissible in certain cases where impaction of feces is suspected, and in cases of stricture where fluidity of feces is advisable. (7) Opium must be used in proportion to the pain which the patient suffers. It should be administered hypodermically or by the rectum, and should be combined with belladonna. If there be not much pain or shock it is better avoided, since it increases constipation and may mask the symptoms. (8) A full dose of opium, administered bypodermically, will put a patient in a favorable condition

for bearing a prolonged examination under ether and attempts at abdominal taxis. (9) In cases of uncertain diagnosis it is better to trust to the chance of spontaneous cure, or relief by repeated abdominal taxis, than to resort to exploratory operation; or in desperate cases iliac enterotomy should be done. Operations for the formation of artificial anus in the right or left loin may be resorted to whenever the diagnosis of incurable obstructive disease in the lower bowel is made. (10) The operation for the formation of an artificial anus through the anterior part of the abdominal wall and into the small intestines should be resorted to only in certain cases of insuperable obstruction in which the seat of disease is believed to be above the cecum. (11) In all cases in which the precise seat of the disease is doubtful, but the large intestine is suspected, the right loin should be preferred. If the colon here be found to be empty, the peritoneum may be cautiously opened and a coil of distended small intestine brought into the wound. (12) Cases of intestinal obstruction are strictly surgical, and not medical cases.Dr. Jonathan Hutchinson, British Medical Journal.Detroit Lancet.

Therapeutic Results with Pilocarpin.

THE results of recent investigations are here summed up. Dr. Demme, of Berlin (London Medical Record), arrives at the following conclusions:

1. Pilocarpin is an effective diaphoretic and sialagogue in childhood.

2. It is borne very well, in appropriate doses, even by children of very tender years.

3. Unfavorable after symptoms are but rarely observed, and, probably, may be altogether prevented by the administration of small doses of brandy before the injection.

4. The conditions in which it is chiefly indicated are the parenchymatous inflammations of the kidney, with dropsy, following scarlatina.

5. Pilocarpin does not appear to exercise an influence on the heart's action.

The Hospital Gazette states that an important physiological effect of Pilocarpin, according to Dr. Zielewicz, of Posen, is its power to reduce animal heat. He has ob