only use of aspiration in these cases is for the purpose of diagnosis. Not one of us would think of attacking a large acute abscess in any other region of the body and aspirating it alone. We might aspirate in order to be sure of pus, but then the next step consists of free incision and drainage. I saw a case in consultation in January in which empyema had followed pneumonia in a young man, twenty-one years of age. The chest was repeatedly punctured, large quantities of pus drawn off, and this was done every day or two until the patient died. At no time was any incision made. The patient died, as we might suppose, of septic poisoning due to absorption of the pus. The abscess was not drained. That is not treatment; it is diagnosis. As soon as you have found the pus, then your treatment should begin along the lines suggested in Dr. Elkin's paper. In many cases simple incision is quite sufficient; in many others, particularly the acute cases, a simple incision is not sufficient for drainage, on account of the fact that the ribs are either overlapping or are held so close together that the rubber tube is closed by the pressure of the inferior border of one rib on the superior border of the one below. In cases of that character the only thing necessary to do is to remove a portion of one of the ribs in order to make a free outlet for the pus. The acute cases rapidly terminate in recovery under that system of treatment.

The chronic cases of empyema, the cases with which this paper especially deals, are only to be treated with judgment by the radical operation, the removal of a number of ribs in order to allow the cavity to collapse and the walls to become adherent.

My patient, alluded to by Dr. Benedict, was a case of empyema in a child occurring in February last, and resolution failing to take place, I made an incision to let the pus out, and found after a few days that the ribs in this little child, four years of age, were so close together that I had to remove one rib in order to secure proper drainage. The patient is now well and running around; there is a little evening temperature. The drainage tubes were removed long ago.

Dr. R. M. Harbin, of Rome: I have been very much interested in Dr. Elkin's paper, especially, since it has been my lot to have had a few cases, one of which died. The ones that got well were aged two years, two and a half years, and twelve years, respectively. They were submitted to a simple operation with tube and drain in the ordinary way, and made perfect recoveries. Another case I had was in a girl, eighteen years of age, it having been a neglected case. I was called out of town with another physician to see her, and he told me that it was simply a case of serous effusion. I only took with me an ordinary aspirator. On introducing it I drew off a half pint of pus. Not being prepared to operate, and the family objected to it, it was deferred. Two weeks later I was again called to see the patient, and I used the needle to try to find pus, but could not find it. At any rate, I went ahead and made an incision in the pleural cavity; I got very little pus, and drained the cavity temporarily. I did not do a radical operation. She subsequently died. If the cavity had been drained in the beginning she evidently would have recovered.

Another case I was asked to see by a physician was twenty-two years of age, previous health good. It was a neglected case, nothing have been done for it, and there was consolidation of the lung. I introduced the aspirating needle six times without finding any pus, and not being able to find it, I declined to do a radical operation. The subsequent history of that case was interesting. About a month later the abscess caine to the surface, bulged between the ribs, and the doctor in attendance opened it as he would a simple abscess, and it discharged through that opening, and the man made a good recovery.

As to irrigations, I do not see the necessity for them. Unless you have a free outlet for the pus, irrigation would tend to remove the adhesions that are in process of formation to protect the parts of the pleural cavity. In view of the fact that many physicians have reported dangerous consequences from irrigation, I should be slow to resort to it.

Dr. A. C. Davidson, of Sharon: I was very much instructed in listening to the paper of Dr. Elkin, and I rise simply to speak of the wonderful conservative forces in nature. Soon after I commenced the practice of medicine I was called upon to treat a negro, a poor man, who was living in a cabin with no floor to it. He was lying down on a bed of rags. After careful examination, I concluded there was an accumulation of pus probably between the pulmonic and costal surfaces. Not being prepared to oper. ate, having no instruments at hand with which to do a radical operation, I opened it with a bistoury. There ran out from this pus cavity fully a quart and a half of greenish, nasty pus. I kept the wound open with linen tents. At the end of six months the negro recovered completely and is living to-day. I mention this case simply to show the wonderful forces of nature in curing such cases.

Dr. Elkin (closing the discussion): I have been very much interested in the discussion of my paper, and am glad that two or three points have been brought out which I desire to refer to. As I stated in my paper, thoracentesis or aspiration is not only a means of diagnosis, but often a preparatory measure to thoracotomy. In empyema, by aspiration, the pulse and respiration improve immediately, and, later on, the patient's general condition becomes so much better, you will not experience any trouble or danger from irrigating or flushing the pleural cavity with a normal salt or boric acid solution. I would not advise anyone to perform thoracotomy and empty a chest that contains two or three quarts of pus, and then irrigate the cavity, if the conditions of pulse and respiration contra-indicate it. The shock attending such a procedure as this would lower the pulse materially, and your patient might die from cardiac syncope. A patient with respiration of sixty per minute and pulse of 130, who has had an accumulation of pus in the chest for several weeks or months, is not in a good condition to be operated on. But you can relieve that patient by inserting an aspirating needle, withdrawing a quart or pint of pus, or as much as will afford relief; then, by proper diet and stimulation, at the end of forty-eight or seventytwo hours, you can make a thoracotomy. You make an incision in the sixth or eighth intercostal space, mid-axillary line, establish good drainage and irrigate at once the cavity with boric acid solution. If the pus is allowed to remain in the chest too long the lung is bound down by adhesions, and prevents this organ from expanding. It is absolutely necessary to get rid of all accumulation, and irrigation must be done so thorough that every nook and corner is washed out. The sooner and more thorough the cavity is irrigated the more rapidly the expansion of the lung takes place. As I stated in my paper, if the cavity left by an empyema is not obliterated within six weeks, some radical operation will have to be done, and, if this becomes necessary, I would recommend Schede's modification of Estlander's operation.

ACUTE OBSTRUCTION OF THE BOWELS.

BY FLOYD WILCOX MCRAE, MD., ATLANTA, GA.

I shall deal with acute obstruction of the bowels from a surgical standpoint, for I am convinced that the few cases which recover without operative interference but emphasize its importance. The results of operations for the relief of the various conditions that produce obstruction are all the while improving. These results, however, are not what they should be. The mortality is too great. When physicians come to a full realization of the importance of prompt and active interference, when they become willing to call immediate surgical aid, then will the mortality be reduced still further. So long as we are content to leave the cases to nature, and content ourselves with pumping our patients full of water or air, and giving them all sorts of drastic purgatives, just so long will we send more and more of these unfortunate victims to untimely graves. These are dangerous agents, and as a rule, they only serve to intensify the condition, produce greater shock, and an earlier demise.

Carefully prepared statistics show that less than 25 per cent. of these cases are amenable to medical treatment. Shall we, then, in the face of such statistics, confronted with such a mortality, persistently employ medical measures for four, five, six, eight, ten days, or longer, hoping for the improbable, but simply hastening the inevitable? It is only necessary to appreciate correctly the causes of acute obstruction to be convinced of the utter futility of medical treatment in any but exceptional instances.