the urethra, and it is arrested at the "neck" of the bladder by a spasmodic contraction-not stricture. The same thing can occur to a lesser degree, however, in the rectum. A few moments rest, and the so-called stricture (?) disappears, and the sound enters the bladder. If a stricture per se had existed the same-sized sound could not have been introduced. Just as well say that a stricture exists in every anus, for just so soon as an instrument touches the sphincter muscle, it involuntarily contracts and for the moment prevents the passage of same. A neo NEOPLASTIC CAUSES are discussed by some authors. plasm can, of course, block up the lumen; but is this to be understood as a stricture of the gut? If an operation is to be done, would it not be done for the removal of the neoplastic growth, rather than for the cure of a stricture? CONGENITAL STRICTURES of the rectum have no pathology, and all such should, in the opinion of the writer, be classed as malformations of the rectum. DYSENTERIC STRICTURES of the rectum are spoken of by all authors in great unanimity. It has never been the good fortune of the writer to see one of this character. Dr. Woodard, formerly Surgeon-General of the army, in one of his reports said that no soldier of the civil war had ever applied for a pension upon the ground that he had a stricture of the rectum caused by dysentery. Considering that such a case would have been an ideal one, and that much dysentery prevailed in both armies during the civil war, the Surgeon-General's statement is a queer one, isn't it? I have often seen a proctitis produced by dysentery, but careful treatment always cured it. SYPHILITIC STRICTURE. As long as fifteen years ago the writer claimed that fully 60 per cent. of these cases-stricture of the rectum-could be ascribed to syphilis. He has no reason at this date to change his opinion. Nor does he refer to the disease caused by local contagion, as by the presence of or extension of chancrous pus, but to the later manifestations of constitutional syphilis. He is aware of the fact that this assertion has been challenged and denied by a number of writers, yet his clinical observations in hospital, public and private practice have confirmed him in the belief that if any change in the estimate is made, it should be higher, not lower. So characteristic are these cases in a clinical way that he wonders at a disagreement. At his college clinic it is nearly a daily thing to observe a case of stricture of the rectum the result of syphilis. Outside of any history of the disease, the landmarks are so clear cut as to prevent an error in diagnosis. MALIGNANT. It must be conceded that a malignant growth would encroach upon or include the walls of the rectum. And yet when an operation is considered, it would be one looking to the cure of cancer, rather than one for stricture, which was but one of the results of the malignancy. GONORRHEAL. If the mucous membrane of the rectum is subjected to gonorrheal pus, a proctitis results, with the same accompanying symptoms of gonorrhea in the urethra. But it must be admitted that these cases are very few, and even if a stricture resulted, it would only embrace the mucous membrane. INFLAMMATORY. As has been said before in this paper, inflammation is the seat of all strictures, wherever found. TREATMENT. Some authors speak of internal medication and a dietary treatment of stricture of the rectum. The writer must in all honesty say that he is unable to comprehend how either internal medication or diet can affect in the least, from whatever cause, a stricture of the rectum. GRADUAL DILATATION. By gradually dilating a stricture, either in the urethra or rectum, some success is attained after a while. This plan is better suited to stricture in the urethra than in the rectum. The trouble is that by persistent dilating fresh inflammatory action is excited, hence more deposit of lymph. However, a number of writers have spoken of the plan with some favor. RAPID DILATATION. The writer has for many years practiced a method which seems to be peculiarly his own in the treatment of stricture of the rectum, viz.: 'by rapid divulsion. His plan is to introduce a bivalve rectal speculum and forcibly dilate the stricture to the full extent of the speculum. This method has been severely criticised, writers claiming that all manner of dire results would follow such an operation. The writer desires to say that he has practiced this method in fully one hundred cases, and has never met with a death, a torn gut, sepsis, nor any other dire result. He claims to accomplish at one sitting what it would take months or years to do by gradual dilatation. Of course, if a stricture is located in the upper or movable rectum this method is not used, but if in the immovable rectum, below the meso-rectum, where the finger can well engage it, the method can be recommended. PROCTOTOMY. Perhaps the most favored way of operating upon a stricture of the rectum is by doing a proctotomy, either internal, partial or complete. The writer prefers a complete internal operation. There are several ways devised by operators for completely excising a stricture of the rectum. Some prefer the perineal, others the sacral route. The operation has much to commend it, but it does appear that if this amount of surgery is to be done, it would be better to do a lateral entero-anastomosis, after the manner of Bacon. He brings down a normal loop of the sigmoid and anastomoses with the rectum below the stricture. (For discussion, see p. 661, December, 1902, issue.) SPLENECTOMY; TWO SUCCESSFUL CASES.* BY MOORE MOORE, M.D. MEMPHIS. THE cases which I wish to present to the association today are typical of conditions with which all of us have to deal to a greater or less extent. The spleen has been a source of worry and trouble and mystery to the medical profession for all time. Its functions have not been well defined, and even to this day we are unable to satisfy our own minds as to its work. The pathology of the spleen is as uncertain as its physiology, especially as regards the best course to pursue in its treatment. Among the conditions with which we have to deal are: (1) The simple hypertrophy or splenic anemia, as is well described by Osler; (2) the primary hypertrophy of the spleen, followed secondarily by atrophic cirrhosis of the liver and ascites, *Read before Tri-State Med. Assn. (Miss. Ark. & Tenn.) Memphis, Nov. 12, 1902 as first described by Banti, of Florence, in 1894; (3) hydatid cysts; (4) sarcoma; (5) amyloid degeneration; (6) rupture, or trauma of the spleen; (7) leukemia; (8) the wandering or floating spleen; (9) the malarial hypertrophic spleen, or ague cake, as it is familiarly known. The splenic anemia which is easily confused with the malarial spleen, according to the statistics, gives very favorable results from splenectomy. Banti's disease, if operated upon in the earlier stages, before the secondary changes take place, gives a mortality of about 20 per cent., which may be considered very good. Numbers 3 to 6 are comparatively rare, and may be summed up with the simple statement that the best results are derived in these cases from splenectomy, and seem to yield a very respectable percentage of recoveries, which varies so greatly in the hands of different operators, that nothing very reliable can be given. Leukemia is the only one of these conditions in which operation is contraindicated, and there seems to be no question as to the course to be pursued, all agreeing that the leukemic condition means a nearly always fatal result from the operation, the mortality being fully 90 per cent. As stated by Coley, leukemia may be considered as being an absolute contra-indication to splenectomy. This brings us now to the two types with which we most frequently meet, numbers 8 and 9. The wandering spleen in course of time begins to tug at the stomach, by means of the gastro-splenic omentum, causing a dilatation of that organ, with the symptoms incident thereto. The pedicle of the spleen is apt to undergo torsion, sometimes being twisted upon itself at an angle of 90, 180 and sometimes 360 degrees, which produces somewhat of a strangulation of the organ, and decided congestion and enlargement. Pressure upon the abdominal viscera on account of its size and displacement is going to cause some trouble, and in the cases reported, and in others which I have seen, caused no little disturbance of the pelvic organs by its final lodgement in that cavity. Sometimes it is fixed in position by adhesions, but very often can be liberated from the pelvis and returned to its normal position. In these cases splenopexy has been practiced to some extent, but the results have not been as satisfactory as a removal of the organ. It is in this condition, and the malarial type, that abscesses of the spleen are encountered. J. Bland Sutton, in a report of cases, tells us that the mortality from splenectomy in the wandering spleen should not be materially greater than from ovariotomy, and that the patient should be just as well following this operation as following ovariotomy. The experience of others has not been quite so favorable, but the majority of writers agree that a mortality of from 5 to 10 per cent. in this condition, is about as great as should be expected. And this is decreasing as the technique of the operation is better understood. The condition The malarial spleen is the result of a chronic malarial condition, which has existed for an extended length of time. Very often this will yield to medical treatment, greatly assisted by a change of climate to a higher altitude. may then subside and give no further trouble. tumor has existed for a number of years and shows no disposition to yield, and the patient is showing the effects of the wear and tear upon the system, I might say that it becomes our duty to advise him to submit to an operation for the removal of the organ. If the adhesions be not too great to warrant operative procedure the results will be very satisfactory, and the patient will not be any the worse for the loss of that portion of his anatomy. The gland many times is already functionally disabled, and is no more than any other mass lying in the abdominal cavity. These cases came for consultation to Dr. Crofford at the Sanitarium, where they were operated upon by him. Case I. Miss G., aged 19. Entered the sanitarium April 28th. She gave a history of a tumor in the abdomen and pelvis, which was known to have existed for several years. Her home was in the Eastern portion of Arkansas, and she had been no more subject to malarial influences than the average citizen of that district. She had a very decided disturbance of the nervous system, which was especially marked at the time of her menstrual period. She was apt to be found in convulsions at any time, but more so at this time than any other. She was pretty well developed, and showed little evidence of anemia, but I regret to say that no blood count was made before the operation, so, of course, it would be of little value |