the side of the nose, the absence of fat over the maxillary sinus in front, the thin nose. All her features, except the eyes, are indicative of adenoids. Her eyes are bright and intelligent. We will ask her to close her mouth, and try to breathe through her nose. She does the latter with perfect ease. Her mother says she does not snore at night.

Inspecting the nose, we note a fairly straight septum, normal turbinates, no excessive secretions, and we can see through to the posterior wall of the pharynx. With a post-rhinoscopic mirror we obtain an excellent view of the postnasal space, and find that it is very nearly devoid of any lymphoid hypertrophy. There is certainly not enough present to demand removal for any, cosmetic effect upon the facial bones, which is the only consideration that lands her here six to eight years late. Now, what cause operated to give this girl such a homely face, her parents so much disappointment, and the child herself a minimum of prospective pleasure in life? Gentlemen, in my opinion it was adenoid growths. She undoubtedly had mouth-breathing from early infancy caused by them. This continued through childhood up to within a very short time ago, when they began to atrophy. Now they have about disappeared. The damage, however, has been done and cannot be repaired except in as far as the dentist's art goes. If she had come here six or eight or more years ago she would have been given the use of the space that nature intended for the passage of the air current during

respiration, and she would have developed a symmetrical, if not a beautiful, face. CASE 7

Here is a new case today. This little girl says she is eight years old. She looks bright and intelligent. She comes alone, complaining of her nose running all the time. She says both sides. run, but we see it is only the left side that is discharging. Inspection shows that the right nasal cavity and the nasopharynx and oropharynx are in a healthy condition. In the left nasal cavity we see inflamed mucous membranes, and a considerable quantity of yellow pus, which we trace un to its appearance between the middle turbinate and the outer wall. We know that this pus may come from the frontal sinus, the maxillary sinus, the anterior ethmoid cells, or the middle meatus itself. Let us see if we can get any help from transillumination. Darkening the room, and placing the lamp under the frontal sinuses, we see that each one is flooded with light. Placing the lamp in the mouth we see that the right maxillary sinus also is flooded with light, while the left one is not-it is absolutely dark. It is probably filled with pus that is discharging into the nose. We will investigate this case further day after tomorrow, when the child's mother comes with her, getting a definite history of her trouble, washing out the maxillary sinus through the ostium maxillare or introducing a small trocar through the inferior meatus of the nose should her history and further investigation warrant.

"O wad some power the giftie gie us
To see oursels as ithers see us."

For the past year I have associated with all kinds of medical people, good, bad, and indifferent; and, to a certain extent, I have seen the prayer of Bobby Burns answered.

A medical man looking at things medical from the outside must, of necessity, see them differ

Read at the Aberdeen District Medical Society at Aberdeen, S. D., September 20, 1904.

ently from what he sees them when he himself is engaged in the work, and especially will he see them differently when he is the object of the investigation. The things which most impress an active man pale into insignificance when he becomes the passive object of such activity. The rapid, brilliant, spectacular operation, the snapshot diagnosis, the long list of titles, whether won by merit or graft, have little meaning for a man who feels that his life insurance may be

collected next week. Looking at things from a quartering viewpoint for so long, has perhaps left me a little cross-eyed; nevertheless, I have a few disconnected ideas that I want to talk about.

This is an age of hurry and rush, and we physicians fall in line easily, much to our own detriment, for, of all classes of people, a quiet, easymoving manner is of most benefit to a physician. The Greek philosophers gave the palm to equanimity as the fundamental quality of success and human power, and it is no less true to-day than it was in ancient Athens.

The hurry habit hurts both physician and patient. The physician misses the little things, overlooks them, and his diagnosis is but partial; the patient thinks his case unimportant, and lets a serious malady go too far, or seeks another physician. The mental effect on the patient may be much greater than we think. I had various physicians calling on me, and I know they made or marred the day for me. I will mention two. One came dashing up to the door in a 20 H.-P. auto, with a toot that echoed and re-echoed up and down the Mississippi hills. He came down the hall like an express train, and into my room in a breathless condition, cried "Hello," and muttered something about how sick the fellow next door was, and out he went, saying good-bye from somewhere down the hall. The other gentleman came in unannounced, stepping softly and speaking in a natural voice. He stayed no longer than the first, but he was soothing and quieting. He said little, but seemed to understand and to make me feel that I was the principal object of his thought. He seemed to know just how I felt and to say,

"I have eaten your bread and salt,

I have drunk your water and wine,

The deaths you have died I have watched beside And the lives you led were mine."

In passing, I want to notice one man in particular. He is slow and methodical almost to a fault. He never looks at a patient unless that look can be a thorough one. He weighs all possibilities, and insists on all means being used to make his diagnosis sure. He never jumps at conclusions, and he takes his time to make up his mind; if the patient can't wait, he can go elsewhere. To see him use a stethoscope is a reve

lation: the patient's and his own stool are adjusted properly; he sits down in an easy position, places the stethoscope on the chest, closes his eyes and listens, first on one side, then on the other, and it seems that he will never finish, but when he is through you feel that he has seen the bottom. Of course, you will say the general practitioner can't go into things so thoroughly. I don't say that he can or that he can't, but the thorough, slow-going, positive fellows are the ones who are at the top.

Next a word about surgery and surgical methods: I am an ardent supporter of surgical treatment, for what shall it profit a man if he shall gain the whole world and retain his appendix? However, I do think that with many men the pendulum has swung too far, and they use surgery where they should not. In the older hospitals and clinics the slaughter of the innocents is something frightful. Every woman who has a pain anywhere below the clavicle looses one or both ovaries, and you can scarcely meet a woman over thirty who has not had some operation upon her genitals, and many of them will say that they are worse than before, and not a few of them are nervous wrecks, and date their breakdown from the time of surgical interference, whether from errors in diagnosis, in technique, in catgut, or what not,-something was wrong. We may be thankful that few of these cases spring from our work here. Surgical work here is young, and of necessity mostly emergency work, but as we grow older in surgery, we shall be able to avoid the sins of commission which older hospitals and clinics daily exhibit. It seems to me that a plea for more conservative surgery is in order, and to consider whether care in diagnosis keeps pace with our easy and safe methods of operating.

Does "cured" on a patient discharge-slip three weeks after operation mean cured three months or three years later? It is results that we are after, and when we don't get them, we become a by-word and a hissing to the laity. A man's bad results in medicine are soon buried and forgotten; his bad results in surgery are likely to be explained to twelve good men and true, who may forget the patient, but they will never forgive the doctor. As I have observed, the technique of operating varies with each surgeon. Of course, the general principles are the same in all. I wish to notice

only a few points. Most surgeons are insisting upon a more thorough preparation of the patient. about to undergo a major operation. The skin over the site of operation is not the only thing to be prepared; the kidneys are flushed out with. large quantities of pure water; the skin is rendered more active by steam-packs and alcohol rubs; the bowels by salines and diet, the preparatory treatment lasting from three to five days, and it is claimed that this length of time can be taken off the time usually required in bed after the operation, and that very little sickness follows the anesthetic. One of old has said that it was not what goes into a man, but what comes out of him, that defiles him. These gentlemen would. have us believe that it is neither what goes into nor what comes out that defiles, but what remains in him, and therefore they sweat and physic him.

Stitch abscesses have caused a lot of trouble with some surgeons recently. Some gentlemen claim it is the catgut, and one said catgut couldn't be sterilized. I watched him operate. He scrubbed very laboriously for twenty minutes in green soap, then in alcohol and bichloride, and, as an after-thought, took a plunge in carbolic acid solution, covered his head with a sterile. cap, put on rubber gloves, after asking three nurses if the gloves had been boiled the required. length of time; and then when he got a clot of blood on his fingers he wiped it off on his gown, just as a boy wipes his fingers on his "pants." I thought he needed a surgical conscience worse than he needed a sterile catgut. I was told afterwards that he had trouble in all his longer operations, no matter what sutures he used.

Another man washed his hands in soap and water. If bichloride was handy, he rinsed his hands in it, for a bluff, as he said, but after cleaning up he kept his hands where they should be, and it was said that he never had a stitch abscess. There is no question but some of the catgut we have been getting is vile, but I can't believe it is as much at fault as the bacteriological conscience of some surgeons.

The different antiseptics used are as varied as the men who use them, each having his hobby, but the men who use only soap and sterile water seem to be getting as good results as the others.

A wide difference exists as to the length of time a patient should remain in bed after a lap

arotomy. Some insist on two to four weeks, and a very light diet; one keeps them on liquids, others let the patient up as soon as he feels like it, say, in from five to eight days, and feeds them freely as soon as the anesthetic sickness passes off. The latter seems to have the best results.

The question, of nutrition is one that I believe we are overlooking to great extent. "Light diet," says the doctor, and when pushed as to what he means, we find that it is avoidance of meat, especially pork. We tell our patients to eat well and get fat, which usually amounts to their eating large quantities of meat and beans, and coffee and pie, whether or not they digest any of them. I remember a gentleman in the Southwest, a consumptive, whose doctor had him on what he called a reconstructive diet, which consisted of a cup of cocoa before he got up in the morning, three heavy meals, and an egg-nog at ten, at three, and at bedtime, and a gallon of milk to be sandwiched in between meals and lunches. Nothing was said about what the "heavy meais" should be, so he ate any and everything as long as the quantity was great. It took all the poor fellow's energy to get rid of the waste products of his food, most of which had very little food value to begin with. I couldn't help but think, when he started on the trail, unmarked and endless, that if his doctor had read up a bit on diet and used common sense in his forced feeding, the boy might have had a fighting chance.

That this question will bear investigation is proved by the numberless health-foods on the market, many of which have an enormous sale, while few of them have half the food value of easily digested things which can be prepared in any kitchen. This question of nutrition is at the bottom of a great deal of our work. Many of the diseases which we treat with large doses of various kinds of "dope" would respond much more readily to proper food. We often think that a patient who is eating well and does not complain too much of pain in the stomach, needs no attention along that line, forgetting that what is in the intestinal canal is as much outside of the man as if it were on his skin. I believe there is no field in medicine where as much work is needed, and where as much may be learned to benefit ourselves and our patients, as in the disorders of digestion.

ST. BARNABAS HOSPITAL

MINNEAPOLIS

GUN-SHOT WOUND OF THE KNEE IN THE SERVICE OF DR. A. E. BENJAMIN

Mr. T, aged 30, was injured while out hunting by an accidental discharge of a shotgun in the hands of a friend. This friend was about three feet in the rear when the accident occurred. The shot, No. 8, passed directly through the left knee. The injured man was taken to the hospital as soon as possible, and arrived there about

Gunshot wound of knee two months after injury.

two and one-half hours after the injury. He was very weak from the loss of blood. The wound of entrance was directly back of the external condyle of the femur. It was about 22 inches in diameter. The wound of exit was over the outer portion of the patella. This was much smaller, being about 14 inches in diameter. The shot had evidently missed the popliteal artery, as the circulation seemed to be fairly good in the

leg. The wound was filled with splinters of bone, shreds of tendon and fascia, blood clots, and shot. The useless and disconnected fragments of bone were removed; also some of the shot and shreds of tendon. There was apparently an extensive injury to the joint and lower extremity of the femur, as the shaft of the femur presented in the posterior wound and the leg was adducted. The external ligamentous supports of the joint had been lacerated. The patella had been injured at the outer side, as bone fragments were removed from it. The fragments of the articular surface of the external condyle of the femur were allowed to remain, and the wound was packed with gauze. An extensive operation was not performed because of the shock and hemorrhage. Hypodermoclysis was employed. Next day the patient was in fairly good condition, although his pulse was 110 and very weak; temperature 101. Saline enemas were given, and a great deal of liquid food and water was allowed. He gradually improved. On the fifth day the hemoglobin estimate was 35 per cent; white blood count, 4,800. On the ninth day hemoglobin was 52 per cent. The leukocyte count was 11,250. The white blood count gradually became normal, and the hemoglobin was about 72 per cent when he left the hospital three months after the injury.

An x-ray photograph was taken about two weeks after the accident, which illustrates the extent of the injury. An oblique fracture of the inner condyle of the femur and a gunshot wound. to the external condyle is noted. A plaster-ofparis cast was applied as soon as the hemorrhage and excessive oozing ceased. An external splint for support was incorporated in the bandage. An operation was performed five weeks after the injury to remove the remaining shot and dead bone, and trim up the lower end of the femur. The serum from the joint cavity and some pus continued to discharge through both openings. By the use of carbolic acid and alcohol, the slight infection ceased. The discharge then became almost all of a serous character. Bone was deposited in the space between the fragments containing the articular surface of the external condyle and the shaft.

At the present time (31⁄2 months after the injury) occasionally a little serum escapes from