First, then, let us consider the most simple of cases: needles and foreign bodies in an extremity.

When a needle has been driven into an extremity, it should be removed at once, for fear of its migrating, and puncturing some vital organ. This can usually be done easily if an Esmarch's bandage is first applied to the limb, so as to render it bloodless to a point above the offending body. To prevent the unpleasant results which often follow the injection of cocain to produce local anesthesia, add to the injection 1-100 grain of nitroglycerin.

Contused joints: We are often called to see contusions about joints where the skin has not been broken, but such a state of swelling has occurred as to render a diagnosis impossible. This swelling may all be driven out by simply applying an Esmarch's bandage snugly, when the joint may be palpated, and all the bony landmarks ascertained as readily as in a healthy joint.

Skin-grafting: Skin-grafting has always been considered a most delicate and difficult operation, and the person supplying the grafts has been looked upon and considers himself a martyr to the cause in submitting himself to be flayed alive. As no machine for raising the skin grafts has yet been invented better than the razor, the operation is tedious, and requires an anesthetic. The grafts are always of unequal thickness and size, and a graft can very rarely be removed of sufficient size to cover the entire wound. But, by applying a cantharidal plaster of the size and shape required, a graft of equal thickness may be secured without an anesthetic, or much pain, in a few hours. This is transposed to its new location by a very simple method. After snipping around the edges, it is rolled up on a piece of rubber tissue, and floated for a few moments in a warm Thiersch or the physiologic saline solution. It is claimed that grafts may be kept" for twenty-four hours, and carried hundreds of miles before being used. It is then unrolled upon the surface which has been previously prepared to receive the graft by being scraped, thoroughly washed in a saline or Thiersch solution, and a compress applied for a few minutes to stop all oozing of blood. The graft or grafts should overlap the cutaneous margin of the wound. The rubber tissue is allowed to remain over the graft, and even pressure is made over this by a sponge-compress or gauze.

Umbilical hernia in children: Umbilical hernia usually occurs in a cry-baby, and its disposition is one of the direct and most prolific causes in perpetuating the trouble. Can it be cured without an operation? Yes, and by a very simple method. Place the child upon its back, return the protrusion to the abdominal cavity, draw up a longitudinal fold on either side of the hernia, thus inverting the opening, and while thus held a piece of adhesive plaster is tightly applied. The hernia should never be allowed to

come down. The mother or nurse may be taught to replace the strip. You will in this way cure your case.

Inguinal hernia in the child: Inguinal hernia, when not congenital, occurs also in the fretful child. If you will watch the abdomen of a child while crying hard, or in a fit of anger, you will see something of the force applied to these openings. Reducible inguinal hernia in the child can usually be cured without operation; and here the improvised truss of a pad and adhesive strips is the most comfortable and efficient truss. The same maneuvering may be adopted in applying the strips as above. Perhaps after the first strip is applied, a slightly convex button may be interposed between the first and succeeding strips.

Hernia in the adult: Every case of hernia in the adult, whether inguinal, femoral or umbilical, should be operated upon, unless the patient be too old or feeble to withstand the operation. By Bassini's method and the buried kangaroo tendon suture, the results are nearly perfect in inguinal hernia, and the recurrences and mortality almost nil. So do not waste time with injections and trusses, as they will disappoint you.

Hydrocele in the adult: Hydrocele in the adult is probably best treated by introducing a trocar, and scarifying the entire inner surface of the sac with the stylet, or by introducing a small curet while holding the testicle out of the way. But this must be done thoroughly to be efficient. A plastic adhesive inflammation is what is aimed at. Tissues thus denuded are in the most susceptible condition to take on this adhesive process, while following an injection the two opposing surfaces are covered with a thin film of necrotic tissue, or at least an albuminous one, which must first be absorbed before adhesion can occur.

Hydrocele in the child: Acupuncture with a bunch of needles is usually sufficient, although it may be necessary to repeat it a number of times. Part of the fluid will escape through the apertures produced by the needle punctures, and the remaining portion will usually be absorbed.

Appendicitis: Had man been so constructed that he could have worn his caudal extremity outside of his body, instead of in his belly, he might have been more nearly like the lower animals, but, like them, he would have been immune against appendictis. The latest theory regarding the functions of this mysterious organ is, that it is the plumb-line of the human body; but we, as operative surgeons, make use of it for a more noble and glorious purpose, that of making money. Appendicitis is as truly a surgical disease as is septic infection in any other region, for the three germs staphylococcus, streptococcus and bacillus coli communis, one or more of which is always present after a certain stage of the disease, are directly responsible for the destruction of the tissues, and were never known to be affected by medicine. Just what the materies morbi is, previous to the development of the germs, we have no knowledge; it may be an impoverished

blood-plasma, the degree of which may account for the greater resisting power of some cases over others. The position of the appendix in health, and in disease if not adherent, changes with the postural changes of the body, and, if long, it dips down into the pelvis in the erect posture to a variable degree; it may be caught between the fetal head and pelvic wall, and injured during parturition.

I have seen an appendix six inches in length removed, which would reach to the bottom of Douglass's culdesac. You remember the origin of the appendix is from the posterior surface of the cecum; hence, when we palpate it, we do so through its two walls; fortunately, it rarely contains any solid material, usually liquid or gas. McBurney's point, as you all know, is at the middle of a line drawn from the umbilicus to the center of Poupart's ligament. The iliac vessels lie half an inch below this line. It has been my privilege during the past few months to examine in various hospitals a large number of appendices, both normal and diseased, and I have seen many of these afterward removed, quite a number of which, I am sorry to say, should have been left in situ. In others, operation was deferred too long and fatal results followed. Just when to operate and when not to operate has long been a bone of contention among physicians and surgeons; but whenever in doubt, it is always wise to give the patient the benefit of the doubt, and operate. I believe it easier to diagnose the disease early than late, when the symptoms have become more or less masked, and often confusing.

In palpating the appendix, what tissues are we liable to mistake for it? First, the reflected edge of the cecum. Second, the ureter, which may be tortuous from a prolapsed kidney, which is said to occur in one person in every twenty. It is also claimed that the appendix is nearly always congested and swollen, if not inflamed, when the right kidney is prolapsed. Third, the tendon of the psoas parvus muscle, which is present in about five percent of cases.

Many claim that whenever there is tenderness at McBurney's point the appendix is inflamed, and that a normal appendix is never tender under pressure. This is a very delicate test, and one is apt to be misled in neurasthenic persons unless he examines very slowly and persistently. The lumbar plexus of nerves, with sympathetic ganglia, is also located in the region of the psoas muscle, and may be sensitive to pressure. The pain may be diffuse over the abdomen; it is often referred to the sacro-iliac region in the back.

There may be obstinate constipation or diarrhea. In the first condition, tympanites, diffusion of the tenderness, and often a necrotic appendix are found. Strong cathartics are frequently given in these cases, sometimes doing harm, and rarely any good. These cases are more difficult to diagnose than a circumscribed abscess. In the diarrheal form, nature is

making an effort to relieve the colon of its offending contents, and should not be paralyzed by opiates. The temperature may be very low throughout the disease, 100, 101 or 102 degress, and is of little importance in indicating danger. The respiration is of more importance, but still less than the pulse; if the respiration reaches thirty-six there is danger. But, as in most surgical diseases, it is upon the pulse that we place most reliance, and it is the surest guide when to operate; if it reaches 120, always operate without delay. I have seen quite a number of appendices removed through the median incision, but this should only be attempted when a median incision is made necessary by other causes; if there are not many adhesions, it is not very difficult to remove in this manner; but in most cases the conventional incision should be made, or may be made to supplement the median incision, the length of which should vary according to circumstances.

Prof. Edebohls, of New York, has recently adopted inversion of the appendix into the cecum, and taking one Lembert suture over the opening, instead of amputating and ligating the stump. I had the privilege of being. present at a private operation when he first did this operation. Afterwards I saw him invert many, one six inches long, which was accomplished very easily. He now inverts the appendix in every case in which he opens the abdominal cavity. All were done through the median incision. Personally it does not seem to me that it is proper to operate when there is simply tenderness and pain, nor to invert every healthy appendix, fearing that it may become diseased.

1278 Euclid Avenue

THE IDEAL WINTER CLIMATE

ROBABLY one of the essential matters about which a physician is least informed is the selection of a suitable climate for various ailments that are benefited by change of residence. This is because climatology is yet a slightly inexact science, and it is only of late years that data are being gathered from which to deduce really valuable conclusions. In our own climate, with its terrible excess of cloudiness and chill humidity during the winter (c. g., November, 1897, had three days sunshine, December none and January, 1893, two days), it is well known that diseases of the respiratory system largely predominate as the causes of sickness and mortality. Those afflicted with chronic respiratory disease or convalescing from acute disease of the respiratory system in our climate, if able to travel, usually do best if sent to the dry, warm and equable climate of Arizona and New Mexico. In that region almost any desired alt tude may be attained and yet the air is uniformly dry and bracing. A few cases seem to do best in the humid atmosphere of southern California and Florida, but most profit by a dryer region and the great southwest is fast becoming the nation's chief health-resort.