under observation for two or three days without a definite diagnosis having been arrived at; she was then brought to my clinic for further examination and possible operation. There was no history of any injury or previous ill health, although, on close questioning, her mother thought there might have been slight enlargement of the abdomen for about six weeks before she complained of the sudden pain and urgent symptoms. When I first examined her she presented the appearance of a fairly healthy child, slightly cachectic. In the right side of the abdomen was a smooth, ovoidal, distinctly fluctuant tumor, extending downwards and backwards in the loin, where it Lower part Kidney Case 4.-External appearance. Reduced to one-half actual diameter. seemed to originate. The ascending colon was displaced forward to the median line; a few enlarged veins were noticed on the surface of the abdomen overlying the tumor. The tumor was dull on percussion, quite freely movable, apparently encapsulated, and on palpation gave evidence of fluctuation. Examination of the urine was negative. A diagnosis of sarcoma of the right kidney was made and a nephrectomy advised. Chloroform was administered, and Langenbeck's vertical trans-peritoneal incision made over the most prominent point of the tumor, about an inch and a half from the outer border of the right rectus, the patient's body being well elevated and inclined. toward the left side. The abdominal wall was thinned from pressure atrophy, and we immediately came down upon a tumor which presented a smooth regular surface, to which the ascending colon was intimately adherent; also several points of omental attachment. With the finger the tumor was readily enucleated. When very near its anterior and lower border, what seemed to be a dense fibrous cord prevented its being lifted from its bed. Upon clamping and dividing between forceps, this firm band was found to be the ureter. Several smaller bands of adhesion between intestine and surface of tumor were ligated and divided, and the tumor was readily brought through the incision, pedicle clamped with forceps, and tumor cut away. The divided ureter was cauterized with 95-per-cent. carbolic acid, ligated with fine silk, and dropped into the abdominal cavity. The pedicle of the tumor, containing the renal vessels, after being freed from the adipose tissue, was secured by a double silk ligature, cut short, and dropped into the abdominal cavity. The cavity occupied by the tumor was packed with strips of iodoform gauze, the ends of which were brought out at the upper angle of the wound. There was scarcely any hæmorrhage, the patient suffered but little shock, and the operation lasted twenty-five minutes. The wound was flushed with sterilized water and closed with interrupted silk sutures. Over this the usual antiseptic dressing was applied. Patient reacted well; the tension upon the stitches was so great that two or three of them partially cut out and some infection took place along the stitch wound, but notwithstanding this slight infection she made an uninterrupted recovery. Her bowels moved regularly, she urinated without the necessity of a catheter, and her appetite was good. Microscopical examination of the tumor was made, showing it to be a small spindle-cell sarcoma. The tumor, which presents an irregularly ovoidal form, seems to have originated from the upper and posterior portion of the kidney, just within the capsule, and as it extended downward and backward pushed the kidney forward toward the median line, and as it encroached still further by pressure compressed the ureter, destroying the functional activity of the kidney so that the remaining portion of that organ was rapidly transformed into fatty and sarcomatous tissue of rapid growth which gave the apparent fluctuation under palpation. I am indebted to Dr. M. L. Goodkind for notes of the following case which occurred in the practice of Dr. Frank Cary: A child, male, 21⁄2 years of age, American parentage. Absolutely no syphilitic or tubercular history; no history of new growths in the family. In May, 1892, there began to develop tumefaction of the right side, which increased to such an alarming extent that the parents, who had been having faith cures and Christian scientists, decided finally to call in a regular physician. Dr. Cary was called. He at that time found enlargement in the right lumbar region extending toward the anterior abdominal wall; this enlargement did not seem to be painful on palpation, but was slightly indurated and extremely hard. He examined the urine carefully, and found no abnormal constituent. The child was well developed, well nourished, but began to emaciate rapidly. There was no gastric, intestinal, or urinary disturbance. The tumor began to increase in size, and grew until the abdomen became enormously distended, veins enlarged, and about the umbilicus an inflammatory area developed. This condition continued until March, 1893, when the child, growing rapidly weaker and weaker, died. Post-mortem examination revealed medullary sarcoma of the right kidney the size of a child's head. Very little of the kidney substance was to be recognized. The growth was adherent to the liver and to the mesenteric attachment of the intestine. The mesenteric glands and the retro-peritoneal glands were intensely infiltrated. The heart muscle contained a sarcomatous deposit. The calvarium was not opened, on account of the objection of the parents. Medication in this case consisted of syrup of iodide of iron, etc. CONCLUSIONS. From the literature of this subject I think we may fairly deduce the following conclusions: 1. These new growths of the child's kidney are often congenital. 2. They are usually unilateral; when bilateral it is from secondary infection of the other kidney. 3. They are primarily extra-renal, and surround rather than infiltrate the renal tissue. 4. Round-celled is the most common form of these sarcomas. 5. They are of exceedingly rapid growth, and destroy life by exhaustion. 6. They are uniformly fatal when treated medically, the duration of life being from four to twelve months from the time the disease is first observed. 7. Nephrectomy offers the only hope of cure or prolonging life in these unfortunate cases. 8. More accurate early diagnosis and prompt operative interference has lowered and will continue to lower both the primary and secondary mortality. 9. The extra-peritoneal route is preferable when the tumor is small. 10. When large, a trans-peritoneal incision is imperative. II. It may be either transverse or vertical; considering the nerve supply of the parts, the transverse would seem the better. 12. The operation of nephrectomy in these cases is justifiable, and we are not doing our duty as surgeons to our little patients if we withhold the only chance they have for life. THE EMPLOYMENT OF CARDIAC SEDATIVES IN HEART DISEASE. BY H. A. HARE, M.D., Professor of Therapeutics in the Jefferson Medical College of Philadelphia. The writer desires in this article to call attention to the treatment of heart disease in its various forms by the use of drugs utterly different in their physiological and therapeutical effect from digitalis or other cardiac remedies of a stimulating character. He refers chiefly to the use of aconite, veratrum viride, and gelsemium, and, while he is well aware that these drugs have been largely used for such a purpose by others, he is also confident that they are not employed by as many of the profession as so useful a method deserves. We are inclined to believe that a diseased heart needs stimulation rather than sedation. It has often seemed to me that those who use nitroglycerin for its stimulant power over the heart were in reality getting good effects because it acted as a sedative. . There is no doubt that digitalis is much abused in heart disease. We see it prescribed for the patient in whose chest a cardiac murmur exists, without any effort on the part of the physician to determine whether it is really needed. In other words, digitalis is used as if it would grow a new valve and so remove a murmur by stopping a leak, when in reality the murmur must always exist. The object to be attained is the preparation of the heart so that it can make up for the leak by greater and more accurately adjusted effort. In many instances a condition of nervous flurry seems to seize upon the heart muscle which is exposed to the irritation of a leaky valve. These nervous flurries are divisible into two classes: first, those in which the demands of the system are greater than the heart can meet, and in which the heart fails because it cannot stand the strain; second, those in which the heart is able to meet the demands made upon it upon ordinary occasions, but becomes nervously upset.-Just as in one case a firm fails because it cannot meet its obligations, and in another case it fails because at the critical moment its members lose confidence and go to the wall. The first class need rest and digitalis; the second class need rest and aconite. In other words, the first must have aid or perish, the second need quiet confidence to weather the strain. The two following cases illustrate these varieties of cardiac difficulty: J. A—, a merchant, aged 48, married, and healthy till three years ago, when he had la grippe. A close questioning recalls to his mind that at the age of 21 he had rheumatic fever, and that his |