the fragments may be small and so wedged in between the carpal bones and the lower end of radius as to render replacement difficult; besides, the lateral ligaments and structures which bind the ulna to radius are so torn and divulsed that they never again hold the ulna and radius in close apposition.

Another reason why a more accurate adjustment of this fracture is not secured may arise from the fact that an anesthetic is rarely given in adjusting the injury. This comes from the fact that it is hardly thought necessary, the seeming replacement only requiring a moment; besides, many of the patients being old we shrink from administering an anesthetic. The proper reduction often requires considerable direct force and pressure, and we fall short of this when the patient cries out with pain. To secure satisfactory results perfect reposition of the fragments before applying splints is imperative.

The deformity and swelling of the fingers and hands occurs in the aged, and is the result of protracted confinement in splints, coupled with the enfeeblement of the circulation. This must be avoided by allowing splints to extend only to the fingers, leaving them unconfined, and by keeping up motion in them just as far as possible from the day of injury until the splints are removed.

Next to the wrist perhaps injuries at the elbow are most liable to give trouble; a mistake in diagnosis and treatment may result in imperfect and unsatisfactory results. This joint has entering into it several bones, processes, and ligaments, which make it very complex. We may have a dislocation of the joint, a fracture of the condyles, fracture of lower end of the humerus, fracture of the olecranon, or fracture or dislocation of the head of the radius. Great care must be exercised or we will make an error in diagnosis, which oversight will lead to grave results.

In your examination under an anesthetic locate your bony prominences, the condyles, the olecranon, its fossa, the head of the radius. By careful manipulation see that the joint flexes and extends, and that the head of the radius is in place. If you have a fracture, crepitus will indicate it; if dislocation, reduction lessens the deformity and the joint will play. Dress all injuries at the joint, except fracture of the olecranon, with elbow flexed. Whether fracture or dislocation, you may certainly predict immobility and limited flexion of joint for some months, but wonderful resumption of natural function follows prolonged use in these elbow injuries. In the shoulder injuries we must

again be very careful to make a clear diagnosis. Fracture and dislocation must be differentiated. Locate carefully your bony landmarks; these must be your guides. The acromeon, the coracoid processes, and the head of the humerus, all in proper relation, make up this joint. Any deviation must be taken into account.

Fracture of the long bones are all easy of diagnosis but not always easy to keep in place after reduction, especially in oblique fractures. When a fracture of any of the long bones is first inspected after the splints are removed, frequently there will be considerable seeming deformity at the point of fracture; this is especially so in fracture of the shaft of the femur. Much of this deformity is more apparent than real. The large amount of provisional callous always thrown out around the point of injury, connected with the fact that the limb is very much reduced in flesh from pressure and disuse (nothing but skin and bone is left), will account for this. Time, and flesh on the shaft of the bone, will help the appearance wonderfully. Several times in my life I have been scared out of my wits at the first look after dressings have been removed.

Injuries at the hip joint are always serious and sometimes obscure. Serious oversights and mistakes are readily made in this region. The difficulty lies in the differential diagnosis between the different varieties of dislocations and diagnosis between fracture and some of the forms of dislocation. Let it be remembered that a fall on the hip in an elderly person, accompanied by pain, helplessness, eversion of the foot, shortening, and prominence of the trochanter may be set down as fracture of the hip, whether we have crepitus or not. It should be treated as a fracture; the confinement necessary to demonstrate whether we have a fracture or not is nothing as compared with the trouble which might arise if a mistake were made. Long confinement and imperfect recovery may be certainly predicted, and lameness for life is nearly always the result. Death frequently follows these cases in the very old and feeble. In the young, dislocations must be looked for after falls from horses or wagons, or from any considerable height; diagnosis generally easy, but have been overlooked, followed by lifetime lameness. In the hip injuries never fail to call in help if you are in doubt. An oversight resulting in the permannt disability of young persons will never be forgiven. I have not time to carry this subject further.

This paper would be incomplete if I did not mention the use of the X-ray in the diagnosis of these obscure injuries. It is certainly the

most important advance of the age along this line, and is destined to come into general use. So far it has been largely in the hands of the specialist. The expense of the outfit and the skill necessary to its application has limited its use, but we should never fail to avail ourselves of its aid in diagnosis in all obscure injuries whenever practicable. But I must tell you that suits for malpractice have followed its use, parties claiming to have been injured by a too long or too powerful exposure to the ray. We hope the trouble will disappear with a more perfect method of application.

Now to sum up: Since any of us are liable at any time to be confronted by a suit for malpractice the question, What shall be done to avoid trouble? becomes a vital one. Many physicians and surgeons advise making yourself law-proof by putting all property out of your hands. No man who resorts to this can maintain his financial standing in any community. Another class of physicians advise taking out an indemnity policy in some insurance company, you paying an annual premium, the company agreeing to defend you to a certain amount in any damage suit which may arise during the existence of the policy. Just how efficiently and how faithfully they might defend the suit I am unable to say. Whether you resort to any of these expedients or not I am sure you will find the following summary of the paper just read in your hearing helpful:

1. Do not undertake to practice surgery unless you have some training and skill in that direction.

2. If you undertake it, leave nothing undone to secure success from the day of your first visit to your last, when you remove the dressing. 3. Never warrant results; let it be clearly understood that failure is not impossible, even in uncomplicated cases, after the most faithful and skillful treatment.

4. Make your first examination just as carefully and thoroughly as possible under the circumstances; make a plain and truthful statement as to the result of your examination, of the trying nature of the injury, etc., to the family, guarding your prognosis well. Make this statement, if possible, in the presence of some honest physician, or better still some intelligent layman.

5. Let the patient and his family feel that in calling you it is presupposed that they know your ability in work in this line; if they are unwilling to assume the risk of final results then they ought to call some one else.

6. After your first examination, if you are in doubt as to the diagnosis or as to plan of treament, call a consulting physician at once.

7. In the treatment of charity patients and dead beats be especially on guard to protect yourself.

8. Remember the law holds you to the same accountability in the treatment of a charity patient as in the treatment of the rich.

9. Use only approved methods of treatment; leave the experimental treatment to the hospitals.

10. Treat your brother physician exactly as you would have him treat you. Never by word or act or look lend countenance to the suggestion of a damage suit, it matters not whether the physician be your personal friend or not. Express no opinion as to an unsuccessful result in any case treated by another physician unless he be present.

11. If in spite of your best efforts to avoid a suit one comes, never compromise or pay hush-money; fight to the death. Every physician should always stand ready to go to the assistance of his brother physician with his time and money if necessary in defending one of these suits for malpractice. There are many other things which I might say on this subject had I time, but I have already trespassed too long on your patience.

12. In closing, it may not be out of place for me to say that perhaps the wisest solution of the whole matter might be for each of you to "lay up for yourselves treasures in heaven, where neither moth nor rust doth corrupt, and where thieves do not break through nor steal." GEORGETOWN, KY.

NASAL OBSTRUCTIONS.*

BY DUDLEY S. REYNOLDS, A. M., M. D.

Nasal obstructions were formerly classified as deformities of bone development and morbid growths, the term catarrh being used to designate every form of inflammation of the Schneiderian membrane; and it is not uncommon to find in medical literature elaborate dissertations upon dry catarrh, just as if we might have dry rivers or other dry streams of

water.

Dr. Carl Michel, of Cologne, published in 1877 a treatise on diseases of the nasal cavities and vault of the pharynx wherein he described hypertrophy of the nasal bones and edema of the turbinates.

Since 1880, it may be fairly stated, the present state of knowledge concerning the nature of nasal obstructions and their influence upon both the general health and the special senses of smell, taste, and hearing has been developed. It is now thoroughly well understood that deformities in the bony framework of the ethmoid are often such as to permit even slight swelling in the Schneiderian membrane to block a considerable portion of the natural channels of respiration.

Children, the subjects of these deformities, frequently introduce foreign bodies into the nasal passages, and in some instances flies have been known to deposit their eggs in the nasal mucus. I have more than once observed maggots in the nasal passages. Chalky concretions forming rhinoliths are found. Mucocele, myxomata, fibromata, and other neoplasms are often found obstructing the nasal passages. Exostoses, sometimes of the ivory type, are occasionly found encroaching upon the orbit, or simply blocking the respiratory passages of the nose.

It is notoriously true that the growth of infants is often seriously retarded by nasal obstructions. In the vault of the pharynx it frequently happens that large gelatinoid masses, commonly described as adenoid vegetations, are found. Sometimes the middle or inferior tubinate bones project abnormally into the pharynx, and in the presence of rhinitis of any form the Eustachian orifices are closed and the hearing at once seriously impaired. In other cases, pressure upon the recurrent laryngeal nerve may develop asthmatic breathing. Medical literature teems with illustrations of the care of asthma by the removal of pharyngeal neoplasms.

* Read before the Kentucky State Medical Society, Paducah, Ky,. May 7-9, 1902