testines the peritoneum-and peritonitis was almost necessarily fatal. The peritoneum is now opened with impunity whenever occasion seems to justify it, and even as a means of diagnosis. If, after the opening is made, the diagnosis is confirmed, the operation, whatever it may be, is completed; if the diagnosis be not confirmed, or the condition be found to be incurable, the wound is cleansed and closed, and the patient is but little worse than if the abdomen had not been opened. This discovery of the comparative impunity with which the abdomen may be explored has opened to the range of the surgeon an entirely new field of work. All of the abdominal organs were a few years ago considered beyond the reach of surgical interference; now almost every one of them may be, and indeed has been, reached by the surgeon's knife and hand; and entirely new surgical operations, by which many lives have been saved, are the result, a few of which may be enumerated.

Operations upon the Alimentary Canal.-The number of successful operations which may be practiced for diseases of various parts of the alimentary canal has increased greatly. Beginning with the stomach, it is now not an unusual thing to open successfully the abdomen, seize the stomach, stitch it to the wall of the abdomen, open into it, and thus establish a means of conveying food into the system when the natural channel of the gullet has been occluded by disease at some point between the mouth and the stomach. In this way a person may be fed for any length of time, as has always been known; but the operation for opening the stomach, formerly so fatal, has now become comparatively successful.

By a very similar operation a cancer of the stomach may be removed, the opening caused by its removal closed with stitches, the organ returned to its place, and the abdomen closed, with a successful result. It is not an uncommon thing for the bowel to become closed at some part of its length by disease, or to become so twisted upon itself that its caliber shall be occluded, and the condition is necessarily fatal unless it be remedied. Only a few years ago these cases were treated medicinally, and those which did not recover, either spontaneously through the efforts of nature or as a result of general treatment, were lost. No surgeon dared to cut into a patient's abdomen, find out by actual exploration with the hand the exact nature of the obstruction, and endeavor to relieve it. These operations have now become exceedingly frequent. If, from the symptoms, the surgeon is led to believe that the bowel has become twisted upon itself, he opens the abdomen, first of all to discover if his opinion be correct; if correct, he gives what relief he can, and often directly saves a life. If the disease prove to be a stricture or contraction of some portion, he may be able to relieve the condition; if a cancer of the bowel be found, it may be cut out and the two ends above and below the

disease stitched together; if the condition be found to be entirely unrelievable (for the diagnosis of these troubles is exceedingly difficult), the wound in the abdomen may be closed and the patient's chances of recovery be none the less.

M. Kæberlé recently reported the most successful case of excision of a portion of the intestine that has thus far been brought to the notice of the profession. The patient was a girl, aged twenty-two years, who had suffered for a long time with symptoms of intestinal obstruction, though the symptoms were not such as enabled him to arrive at any satisfactory conclusion as to the exact pathological condition. As the trouble was steadily increasing in severity, and the patient losing ground from suffering and malnutrition, an exploratory incision was made in the median line of the abdomen. Four cicatricial contractions were discovered in the small intestine, involving between them about two metres of the bowel, and the whole affected portion was consequently removed rather than retire from the operation and leave the patient to certain death. The result was a perfect success, and established several points which were before doubtful. It proves among other things that considerable portions of the small intestine may be removed without interfering to any appreciable extent with digestion, and that, practiced under certain conditions, the operation is to be considered as perfectly legitimate.

The operation of excision has also been applied to cancers of the large intestine, the sigmoid flexure, and the upper part of the rectum. This operation, to which the name of "colectomy "has been applied, has now assumed a definite place in surgery. It dates from the time of Reybard, of Lyons, who in 1833 removed a tumor the size of an orange from the sigmoid flexure of a man aged twenty-eight years. In this case the tumor could be felt through the abdominal wall, far down on the left side, and an incision was made over it. The tumor was drawn out through this wound and excised with three inches of the adjoining intestine. The two ends of the bowel were stitched together and replaced within the abdomen, and the abdominal wound was completely closed. There was considerable local trouble for a few days, but on the thirty-eighth day the wound had entirely healed, and natural passages were restored. The operation thus successfully inaugurated in 1833 was revived in 1877, with some modifications, especially as to the best point for making the incision, and as to the best way of disposing of the cut ends of the bowel after the removal of the disease; since which time seven additional cases have been reported. There seems to be little difference in the mortality, whether the ends of the divided intestine be sewed together, dropped into the abdominal cavity, and the wound in the abdomen closed, or the upper end be stitched to the surface of the body at

the seat of the incision for the formation of an artificial anus. The latter is the simpler procedure, and the lower segment of the bowel, being closed with a ligature, is dropped back into the abdomen and left to nature.

A bullet-wound of the intestines has always been considered one of the most fatal of injuries. The following account illustrates the difference between the surgery of to-day and that of a few years ago, when to interfere actively in any way with such a case would have been considered hardly less than criminal. A man is shot in the abdomen between the navel and the pubes. He is not seen by the surgeon until nine hours have passed, when the abdomen is found distended and painful, and a wound of the intestine is distinctly made out. Opening of the abdomen gives the only chance of saving the patient's life, and this is done with all the modern antiseptic precautions. The intestines are examined, and five perforations of the smaller bowel and two of the mesentery are discovered. The edges of all the wounds are vivified with the scissors and all are sewed up with silk, rendered antiseptic by soaking in a solution of phenol. The abdominal cavity is then thoroughly cleansed of blood and fecal matter, and a drainage-tube inserted into the lower end of the wound. The patient died three days after. At the autopsy it was found that all the wounds which had been sewed up were healing nicely, but one had escaped observation and had caused death.

Hernia. The operation for the radical cure of hernia, or rupture, has attained considerable prominence. In many cases, by a comparatively trivial operation, which consists in the injection of a small quantity of an irritating fluid, like the tincture of white-oak bark, into the tissue over the canal through which the hernia descends, an amount of irritation is excited just sufficient to cause an adhesive inflammation in the canal, and thus close it. In this way a disease which a few years ago was only curable by a severe and dangerous surgical operation, and which on this account was simply treated with a truss, without any expectation of a cure, is now often radically cured. For this discovery, surgery is indebted to Dr. Heaton, of Boston, who practiced it successfully but secretly during his lifetime. Hæmorrhoids. The exceedingly common and troublesome disease known as hæmorrhoids, or piles, was formerly curable only by operations which removed the tumors, such as cutting them off with a knife, tying them off with a ligature, or destroying them with powerful caustics. This treatment also has been radically changed, and an equally efficient method of cure by injections has been discovered, which is almost painless, is devoid of danger, and free from the objections generally considered inseparable from a surgical operation.

Not only has the alimentary canal for its entire length thus been brought within the range of successful operative measures for the

relief of incurable disease, but all the other organs contained within the abdominal cavity have each in their turn been reached by the hand of the surgeon.

Operations upon the Liver. Abscess of the liver was formerly very fatal, owing to the unapproachable position of the pus, which, though beyond the reach of the surgeon, might at any moment be discharged into the abdominal cavity and cause death. A few years since it was found that a very fine hollow needle might be plunged into the liver with comparative safety; that to this an air-pump might be attached, and the abscess emptied of its contents by suction. This was in itself a great advance; but now, when an abscess is suspected, the needle is boldly plunged into the organ as a means of exploration. If pus is found, the region over the liver is cleansed with a disinfecting solution, the needle is allowed to remain as a guide, and an incision is made through the abdominal wall into the liver till the pus is reached. The cavity of the abscess is next washed out with a disinfectant, a large drainage-tube is inserted, and the wound is covered with an antiseptic dressing. This dressing is changed daily. Each time the tube is cleansed and replaced, and the abscess is forced in this way to close, as an abscess in any other part of the body would, by a gradual healing from the bottom.

Splenectomy. This is another of the great operations of surgery which have become more prominent within the past few years. Though at first invariably fatal, it now numbers several successful cases. The operation is seldom undertaken except for the cure of a fatal disease known as leucocythæmia, which is marked by a great enlargement of the spleen, and by a great increase in the number of white corpuscles found in the blood. The change in the blood is supposed to depend upon the change in the spleen, and it is thought that if the spleen could be removed from the body the patient's life might possibly be saved. The operation is performed by opening the abdomen from near the end of the breast-bone to the pubes, drawing out the enlarged organ, which sometimes fills nearly the entire abdomen, placing a ligature around the vessels that supply it with blood, and cutting it loose. Although never but once successful in a case of leucocythæmia, it has often been done in cases of other disease with a favorable result.

Nephrotomy and Nephrectomy.-The number of cases in which surgeons have cut into the kidney, or have taken out the kidney, is now very considerable, while a few years ago the operation was a rarity. The kidney is subject to many incurable diseases, and especially to the formation of stone in its substance. Such a stone can be reached in no way except by the knife. An incision is made through the loin down to the diseased organ, and it is laid open. If the disease be calculus, this may be removed and the kidney left in its place; or, if the kid

ney be found extensively diseased, it may itself be removed. Another affection until lately considered beyond the reach of help is what is known as floating kidney, in which the organ, on account of the laxity of its attachments, changes its position from one side of the abdomen to the other, and can easily be felt by the hands, first in one place, then in another. Such a condition is enough to render the sufferer's life of no value to himself, and justifies almost any attempts at relief. Up to a few years ago nearly all such attempts ended fatally. Now they are recognized as legitimate surgical operations, and are attended by a very fair percentage of success.

Extirpation of the Gall-Bladder.-Not at all an uncommon affection, and one which a few years since was entirely beyond relief, is the formation of gall-stones and their retention in the gall-bladder, where they cause an amount of suffering and inflammation often leading to death. In such cases the usual treatment now is to cut down upon the disease and not only to remove the calculus, but to remove the gallbladder with it, and such operations are attended by exceedingly good results.

Rapid Lithotrity.-The old and well-known operation of crushing a stone in the bladder by seizing it with instruments especially designed for the purpose has been signally modified by Bigelow, of Boston. Formerly such an operation was only completed after several sittings, and was attended by great danger of inflammation from the presence of the sharp fragments resulting from the crushing. The operation is now done at a single sitting, the calculus is completely crushed, and all the fragments are removed before the patient leaves the table. This operation of "rapid_lithotrity," as it is called, is not original with Dr. Bigelow, it having long been known though seldom practiced. But he has brought it again into popularity, and has added to the facility of its performance by the invention of a new instrument for drawing the fragments out of the bladder by the force of suction, after the crushing has been completed. The operation, as now practiced, constitutes one of the greatest advancements in the surgery of the bladder.

Drainage of Cavities in the Lungs.-To whom belongs the honor of first suggesting the bold plan of opening into cavities in the lungs of consumptive patients, and treating them on general surgical principles, is a question which will never be decided. Probably many men have considered the practicability of it without attempting it. Recently it has been accomplished with a considerable measure of success. The walls of such cavities are generally adherent to the chest-wall, and may be opened into without any immediate danger; and there would seem to be no reason in the nature of the case why, when such a cavity is laid open, cleaned out, drained, and properly dressed, it should not heal. The number of cases in which drainage has been resorted to is consid

erable, and, although only a few have resulted in the entire recovery of the patient, most of them have been sufficiently relieved to justity the operation. A soft drainage-tube is introduced into the bottom of the cavity, which is syringed out daily with carbolic acid, while the wound is dressed antiseptically.

Internal Illumination of the Body.-The desire to see within the body for the purposes of diagnosis is a very natural one to the surgeon, and with modern instruments much may be seen which formerly could only be guessed at. With the laryngoscope, for example, the whole action of the larynx, the production of sound, and morbid processes down to the bifurcation of the trachea, may be exposed to the eye; as with the ophthalmoscope the deeper parts of the eye may be examined. Milliot, in 1867, invented an instrument for lighting up the abdominal cavity so that its contents could be seen through the abdominal wall, but only used it on animals and dead bodies. His experiments led Lazare witch to apply the same thing to gynecology. He, however, failed to get light without at the same time getting an amount of heat which rendered the instrument both useless and dangerous. More recently Dr. Nietze, of Vienna, originated the idea of illuminating the interior of the bladder by passing into it a white-hot platinum wire, and the idea has been practically carried out by Leitner, the surgical-instrument maker of that city; hence the name Nietze - Leitner endoscope. The instrument consists of a platinum wire heated by electricity, and surrounded by a current of water to keep it from burning the tissues. Sir Henry Thompson, though speaking very cautiously, says there are some conditions the existence of which we sometimes suspect, but can not positively affirm to exist, whose presence may now be ascertained by this instrument. He refers to the identification of sacculated stone as the cause of existing and unrelieved symptoms; to the detection of growths removable by operation; and to the investigation of the nature of foreign bodies other than calculi which have become lodged there. He says he has recently seen a fatal case of vesical growth which might have been easily removed by operation; and in such a case the new endoscope may possibly render essential service.

Carbolic-acid Poisoning.-The almost universal use of carbolic acid as an antiseptic for the dressing of wounds has resulted in the knowledge of a peculiar form of poisoning. It has been proved that too much of the acid applied to an open sore may be absorbed into the circulation and cause death, with high temperature, a peculiar dark, smoky appearance of the urine, convulsions, and symptoms of hearttrouble. The peculiar diagnostic appearance of the urine is supposed to be due to an escape of the coloring-matter of the blood in the form of indicin. Carbolic acid, when taken into the circulation, is quickly eliminated by the kid

neys, at the expense of a great deal of irritation and congestion of the organ. The poisonous effects of the acid may occur in a certain small number of cases, in spite of the best management, and in such cases is the result of a rare idiosyncrasy in those affected. Several interesting cases may be cited in proof of this statement. One in particular, from the practice of Dr. Whiteford, which shows the peculiar susceptibility possessed by the members of some families, and also the small quantity which will sometimes suffice to produce symptoms of poisoning. Two children of one family came under his care suffering from ringworm of the scalp. The treatment in both cases was a two-and-a-half-per-cent. solution of carbolic acid applied in the form of a water-dressing. In both, symptoms of poisoning occurred, in one case exceedingly severe, and coming on very shortly after the first application, while in the other the symptoms were delayed for two days and were altogether less severe. Removal of the acid removed all the symptoms in both cases. To satisfy his mind that the acid was really at fault, and that the symptoms were not merely a coincidence, he repeated the experiment twice in each case-once to the scalp, as before, and again to another part of the body-with the result of bringing back the urinary and gastric disturbances and the other symptoms of carbolic irritation. In none of these applications did the size of the portion of the skin in contact with the acid exceed that of a half-dollar. The result of the study of these cases has been to diminish the strength of the solutions of carbolic acid, as well as the frequency of their application, and also to substitute other substances which answer the purpose even better and are attended with less danger, such as eucalyptus globulus, acetate of aluminum, and bichloride of mercury.

Erysipelas. The proof of the pathogenic nature of the micrococci of erysipelas has been given by Fehleisen, who has not only found them present in all cases of erysipelas examined during life, but also cultivated them, and with equal success inoculated the cultivated organisms in animals and in man. In small portions of skin excised from the diseased part in patients suffering with erysipelas he found in all cases numerous micrococci arranged in chains. They were especially abundant in the parts most recently affected; and here they were found most abundantly in the superficial layer of the corium and in the subcutaneous adipose tissue, filling the lymphatics and the lymph-spaces, while the rest of the tissue showed a cell-infiltration. Contrary to the older observers, they were never found in the bloodvessels. To prove that their presence was not merely accidental, Fehleisen cultivated some small excised portions of skin on gelatin, after carefully disinfecting the affected part, and succeeded, in the course of two months, in producing fourteen generations. The cultivated micrococci formed a whitish film, easily deVOL. XXIII.-48 A

tached from the surface of the gelatin, and consisting entirely of the specific micrococcus. Nine rabbits were inoculated on the ears with the pure and cultivated organisms. In one the effect was merely a slight elevation of temperature; in all the others, after thirty-six to forty-eight hours, the temperature rose, and a characteristic erysipelatous rash appeared and gradually extended to the root of the ear, and thence spread to the head and neck. Within eight days the disease had run its course, and the animal recovered. Not one of the animals died. The light-red color of the affected part, the absence of oedema or suppuration, and the presence of the micrococci in the lymphatics of the affected part (seen in one case where the ear was amputated during the height of the disease), showed that the affection was true erysipelas, and not septicemia.

More valuable still to show the etiological importance of the micrococci in erysipelas are the inoculations on man. (Such a proceeding was perfectly justifiable, when it is considered that many of the older surgeons have quoted cases showing the curative and beneficial effect of erysipelas when occurring in cases of a more serious nature, as cancer and lupus.) Fehleisen inoculated the pure and cultivated micrococci in seven patients, all suffering from severe and incurable disease. Six out of the seven cases showed, after a period of incubation varying from 15 to 60 hours, typical erysipelas, setting in with chills and high temperature, and running the characteristic course. In some the symptoms were very severe, in one there was threatening collapse, and one was complicated with pleurisy, which, however, soon subsided. As regards the therapentic effect, the inoculations are of some interest. One case of lupus was almost entirely cured. In another case the cancerous tumors completely disappeared, and there had been no recurrence.

The effect of antiseptics on the vitality of the micrococci was also tried. Two substances only were experimented with-carbolic acid and corrosive sublimate. A three-per-cent. solution of the former stopped the growth of the micrococci after a contact of 45 seconds, while the same effect was produced in 15 seconds with a one-per-cent. solution of the corrosive sublimate. The list of diseases due to a specific organism is thus increased by one.

SWEDEN AND NORWAY, two kingdoms occupying the Scandinavian Peninsula in Northern Europe, united indissolubly, by the Riksact of 1815, in the person of the sovereign. Succession to the throne is hereditary in the house of Ponte Corvo. The throne is to be filled, in case of absolute vacancy, by the joint action of the two Parliaments. The common affairs of both kingdoms are decided upon by a Council of State.

The reigning King is Oscar II, born Jan. 21, 1829, grandson of Marshal Bernadotte, and the fourth sovereign of the line.

SWEDEN. Constitution.-The legislative pow

ers are vested in the Diet, subject to the approval of the King, save in matters of political administration and taxation, the former of which is the exclusive province of the sovereign, and the latter that of the Diet. The Diet consists of two chambers, both elective. The franchise is limited by a property qualification. Area and Population.-The area of Sweden is 170,979 square miles. The population in 1880 was 4,565,668. The estimated population on Dec. 31, 1882, was 4,579,115. The mean annual emigration in 1851-60 was 1,690; in 1861-70, 12,245; in 1871, 17,450; in 1872, 15,915; in 1873, 13,580; in 1874, 7,791; in 1875, 9,727; in 1876, 9,418; in 1877, 7,610; in 1878, 9,032; in 1879, 17,637; in 1880, 42,109; in 1881, 45,992.

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Commerce. The imports increased from 82,469,000 crowns, in 1860, to 288,060,000 in 1881; the exports from 86,496,000 to 223,196,000 crowns (1 crown=26-8 cents). The imports from the United States in 1881 amounted to 9,820,000 crowns; exports to the United States, 355,000 crowns. The staple articles of export are timber, pig-iron, and grain. The leading imports are textile manufactures, coal, and colonial merchandise, the latter largely on the increase.

The length of railroads in operation in 1881 was 3,830 miles, of which the state owned 1,365 miles. The length of telegraph lines was 7,210 miles; of wires, 18,380 miles. The number of letters and journals carried by post in 1881 was 68,781,121.

The Army. The army is composed of five classes of troops: men enlisted for three, four, and six years, forming the guards, hussars, artillery, and engineers; the Indelta, who are enlisted for life and cantoned on the estates of the land-owners; the Gothland militia, not liable to service outside of the island; the conscripted troops, who are called out annually for 15 days; and the volunteer rifle corps, in 1881 numbering 11,065 men. The total strength of the army in 1883 was 182,572 officers and men, with 836 guns and 6,649 horses.

Finances. The ordinary receipts of the treas ury are estimated in the budget for 1884 at 21,270,000 crowns; the balance carried over from former years, 4,100,000 crowns; net receipts of the Bank of Sweden, 1.300,000 crowns; extraordinary receipts, 52,340,000 crowns; total, 79,010,000 crowns. The ordinary expenditures are estimated at 59,135,665 crowns; extraordinary expenditures, 8,221,335 crowns; expenditures on account of the public debt, 10,240,036 crowns; balance carried over, 1,412,964 crowns; total, 79,010,000 crowns. Not only a large part of the army, but a great number of the ecclesiastical functionaries, are paid wholly or in part from the produce of certain public domains. The expenses of public instruction are mainly borne by the communes and provinces.

Politics and Legislation. For many years past

the Government has urged upon the Diet the necessity of army reorganization, without avail, until finally the question has been allowed to rest. The great land-owners, who control the vote of the First Chamber, are not in favor of a change, because the charge of the militia at present bears not so much on them as on the farming class; while the Land-men's party, who are in the majority in the popular house, are averse to the new system because it would greatly increase the burdens of the people. The financial returns for 1883 are favorable for the first time in a long period, and allow of a reduction in the coffee duty instead of the accustomed increase of taxation. In 1883 the stamp-duties were enhanced, and the tax on the manufacture of spirits increased.

NORWAY. Constitution. - The Grundlov of Nov. 4, 1814, vests the legislative power in the Storthing. Laws passed in three Storthings can not again be vetoed. The King has command of the army and navy, and makes all civil appointments. Since 1869 the sessions of the Storthing have been annual. All propertyholders are electors. The members of the Storthing are elected indirectly every three years. After assembling they divide themselves into two bodies, three fourths forming the Odelsthing, which originates all bills; and the other fourth the Lagthing, which approves or rejects them.

The executive authority is exercised in the name of the King by a State Council, composed of two Ministers of State and at least seven councilors. Two councilors, who are changed annually, and one of the ministers, form a deputation residing near the person of the King, at Stockholm.

Area and Population.-The area of Norway is 122,869 square miles. The population in 1875 was 1,806,900, as compared with 1,701,365 in 1865. The town population in 1875 was 332,398, showing an increase of 24 per cent., against 4 per cent. in the rural districts. Emigration has assumed considerable proportions of late years, the movement being almost exclusively to the United States. The number of emigrants in 1871 was 12,276; in 1872, 13,865; in 1873, 10,352; in 1874, 4,601; in 1875, 4,048; in 1876, 4,355; in 1877, 3,206; in 1878, 4,863; in 1879, 7,608; in 1880, 20,212; in 1881, 25,976; in 1882, 28,804.

Commerce. The average annual value of the imports in the five years, 1877-'81, was 161,300,000 crowns (one crown = 26.8 cents); of the exports, 102,300,000 crowns. The imports in 1882 amounted to 160,475,000 crowns. The imports from the United States were valued at 2,569,000 crowns; the exports to the United States at 156,000 crowns.

The tonnage entered at Norwegian ports in 1881 was 1,976,462 tons, of which 1,306,960 were Norwegian. The merchant fleet, which in proportion to population is the largest in the world, comprised in 1881 7,977 sail-vessels, of 1,520,404 tons, against 1,007,908 in 1870, and