a fragment obliquely from above downward by means of the chain saw; the assistants make extension and the upper end of the lower fragment is rotated forward, and the upper end of it removed obliquely in the reverse way to the one above, so that the two angles fit each other; we drill holes one inch from each end and draw through a loop of silver wire, and the two ends are united into the loop; we place a silver splint externally, which has perforations through which we drive a few small nails; the tourniquet is removed and any spurting points seized and ligated, and the capillary oozing is controlled by irrigation with water at a temperature of 130° F.; a drainage tube is placed through the wound, as we expect considerable serum for twenty-four hours; the muscles are closed with catgut, and the skin closed by interrupted silk-worm gut; then hot water is again passed through the drainage tube; the wound is closed, covered with silver foil, gauze and bandage, and placed in a plaster cast with a window externally for drainage and dressings.

APPENDICITIS.

This is a strong young man who was taken sick thirtysix hours ago with severe pain in the abdomen, and vomiting; the patient entered the hospital last night with instructions from his physician for immediate operation; patient entered vomiting, very sore over region of the abdomen and especially sensitive over the appendix; also rigid muscles on right side. With this history you will seldom err in diagnosis. Will say that temperature was 101° F., pulse rate 100; the latter points are not so important as the former in diagnosis; instructions were left to wash stomach to control vomiting, and salt solution per rectum for thirst, and to prepare abdomen for operation, with special instructions not to give any food or cathartic. We find patient's condition much improved, vomiting relieved, pain not so severe, but still rigid over region of appendix; while the temperature is one degree and a half lower, pulse is about the same; we have patient on the side and inject 4-10 grain of cocaine hydrochlorate into the subarachnoid space between the third and fourth lumbar vertebræ; we now make a three-inch incision along the outer border of the rectus, as we anticipate pus, and with this incision we can better protect the abdominal cavity

from infection. We use large abdominal pads around internal to the cecum; now we gently lift the cecum, which pulls into view the base of the appendix; the distal portion in enclosed in omentum, which is also bound down, and evidently contains pus; we place a forcep on the appendix near the cecum, then ligate the mesoappendix, and place a purse string suture of silk around the base of the appendix, which is now separated, and the base invaginated; the appendix is dissected out of the omentum which has surrounded it to prevent the infection from becoming general. I find that I can occasionally remove an adhered appendix better by first separating from the cecum. We now stitch the mesoappendix over the inverted stump of the appendix to make it stronger; the life-saving omentum is brought over the cecum; we close the peritoneum with No. 3 catgut, then place interrupted silk worm gut through all the structures, which draw them together; after the several layers of fascia have been closed with catgut sutures, the ordinary dressing of silver foil and gauze is placed over the wound and retained in position by means of oxide of zinc adhesive material with tapes attached, over which we place an ordinary many-tailed bandage. This patient will return to the ward with instructions to give salt solutions per rectum, and very little food per stomach for first few days.

ENLARGED PROSTATE.

This case is one of an unusual amount of interest; he is 54 years of age, and has suffered during the last four years with difficulty in passing urine; he gets up about four times during the night, and voids it often during the day; he has four and a half ounces of residual urine; I find by passing the finger in the rectum that the prostate is very much enlarged. He is placed under medullary narcosis. Many authorities have recommended teaching the patients to use the catheter, which is open to many objections, as it is often a very difficult and dangerous thing to do; many operations have been recommended for this condition; the safest one with the lowest mortality is the Bottini; this operation was advised about thirty years ago, but has not been used by genito-urinary surgeons much until the last few years; the results on a whole have been very good, with a low mortality. We attach our instrument to the storage

battery, and gradually turn on the current, and notice the amperemeter to see that everything is in working order; we place about six ounces of sterile water in the bladder to hold the folds out of the way; we now introduce the Bottini instrument into the bladder, turning the beak

backwards, finger in rectum, making the instrument fit over prostate; we now notice that the water flows freely and the current is turned on to forty-five amperemeters, and we turn the screw cutting one and a half inches posterior, then return the blade and turn the instrument,

making a similar incision on the front and both sides; it may be necessary to use the catheter a few days, but this will relieve the obstruction and overcome his difficulty.

FRACTURES OF BOTH BONES OF THE LEG.

The next case is one which I am especially anxious to call

to your attention. To relieve his pain we place him under medullary narcosis. On examination we find both bones fractured at the lower third with the upper fragment prominent, the lower fragment drawn upward and behind by the sural muscles, and I have found it very difficult to

overcome this deformity by the ordinary methods in practice; it is to this point I wish to call your attention; we place the tenotomy knife subcutaneously on the inner side of the tendon Achilles, about one inch above its attachment; we will now be able to hold the bones in normal position with any kind of a splint, and the tendon will repair as soon as the bone; we enclose the leg in a permanent splint of plaster of paris, as we consider this the best.

DEFORMED NOSE.

The last case is so simple that he does not need even a local analgesic. This nose has always been affected with a saddle-back deformity due to the absence of a bridge posterior; you will notice the bridge is on a level with the inner canthus of the eyes; the assistant places a forcep on each nostril to support the parts as we fill in with paraffin, so as to prevent it obstructing the nostrils; the needle is introduced so that the point passes beneath the deformity; the syringe is filled with paraffin, which has a melting point of 109° F., and is now attached to the needle, which has been kept warm with moist gauze, and injected gradually at the same time; I mold the parts and keep the paraffin in the center line; we now place the needle from the opposite side, and make a second injection. You can readily see the marked change, which improves his appearance very much, which is of great importance to every individual. 615 Parrott Bldg.

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