vessels to dilate and delay or disturb sleep more than in others. An individual cerebral hyperemia and vagus irritability ought to be easily brought about by the rarefied atmosphere of the higher mountains hereabout, hence the medical injunction of caution in ascending to the higher altitudes.

After a time an equable vascular condition comes about in the brain, especially under the judicious prescribing of bromide of sodium by the physician, as I observed with patients who accompanied me to Colorado Springs some years ago and with patients coming to me at St. Louis from this state with insomnia and neurasthenia, returning to Colorado and continuing well. I think it is possible for nervous people to be benefited in this climate provided they forego much exertion while under treatment. It is a specially appropriate climate for the rest cure. There is nervous depression and irritability in most consumptives, yet they do well under proper medically regulated conditions here. The night sweats of phthisis is an expression of neuratrophia and nervous exhaustion. Asthma is a spasmodic neurosis that improves in this climate, and I have seen grave neuritides develop in it and some more serious organic nerve troubles. An ataxic miner who once came to me from the Gunnison country afforded me some amusement by revealing his ruling passion for gambling. Although he was a hopeless ataxic and his life was made miserable by his lancinating pains and uncertain sight and gait, when he saw from æsthesiometric examination that he could not discriminate the two points placed on his wrist two inches apart, and was told that at certain distances nobody could answer correctly with eyes shut, he wanted to buy the instrument, saying he could make a fortune out of it in the mines, for any one would be willing to bet they could do it.

The reception of the American Medical Association more than sustained the reputation Denver medical men and all of her people have throughout the Union for hospitality.

The public buildings of Denver, especially her court house, public schools, hospitals and hotel buildings, reflect great credit on the public spirit, liberality and enterprising progress of her people. That this is a goodly city and a goodly people goes without saying.

Pure air is always the same in chemical composition, but a volumetric study by competent authority of Colorado atmosphere and its comparison with that of other health resort localities ought to prove of value to the advisory and prescribing physician. The therapy of atmospheres and sunshine have not yet been exhaustively studied.

APPENDICITIS.

By JOSEPH EASTMAN, M.D., LL.D.,

Professor of Abdominal Surgery, Central College of Physicians and Surgeons,
Indianapolis, Ind.

The last word on appendicitis will not have been spoken until truth, which lurks between extremes of error, is more in evidence. The dictum "operate in every case as soon as the diagnosis of appendicitis has been made," smacks more of solicitation of business than solicitude for human life, and is scarcely less pernicious than that horrible compromise "surgery where medicine fails." The former would make an emergency of every operation, the latter would make every operation one of emergency.

WHEN TO OPERATE.

Great wisdom is requisite to know how to operate, but infinitely more to know when to operate. The operation of expediency, done by the right person, at the right moment and in the right way, is much to be desired. We are often able to confirm the diagnosis of the general practitioner, who knowing that surgery is essential to the cure of a surgical disease, has invoked our aid at the earliest possible moment. We find a change for the better at the end of twenty-four or forty-eight hours. We direct that the bowels be sterilized inside by free purgation with salines. This prepares the patient for operation, or further improves pulse and temperature, and enables us to select a time when infecting germs are weakened; enables us to select a place where we can procure absolute asepsis; enables us to secure an operation of expediency with almost no mortality.

Some theories to the contrary, appendicitis is at the onset caused by microbic infection. Surgical dissemination of the infection can not be prevented unless we give due consideration to such sound surgical principles as have been built upon bacteriology, referred to, and confirmed by, the crucial test of clinical experience.

The invasion of the peritoneal cavity when acute infection is present will always be taking a risk which is not taken when

bacteria have been weakened by maceration in their own excreta. Had we some subtle diagnostic acumen which would enable us to select the moment for operation in every case, prior to the rupture of the appendix and the escape of infecting germs, it would be well, but the diagnosis having been made, to operate at the moment when infection following the ruptured appendix is most virulent, is to accept a danger which it is possible to avoid. What experienced abdominal surgeon would think of operating during the acute stage of a pelvic peritonitis, involving tubes and ovaries? Again it has been proven that the most poisonous forms of bacteria may escape through the walls of an intestine weakened by disease, catarrhal inflammation, fecal impaction, etc., without rupture.

Admitted: Operation is the remedy for appendicitis. This should be impressed upon the physician and he again should impress it upon his patients. It should also be impressed upon them that a large per cent. of cases come to the abdominal surgeon sooner or later and that they had better come to him sooner than later. I mean by this that the physician should have a competent operator to confer with him at the very onset of the case, but by no means that the surgeon should operate at that time, except when the exigency of the case demands an emergency operation with its higher mortality. My opinions are based more upon the results of my work, and the work of such masters as MacBurney, Hunter McGuire, etc., than upon fickle theories or fancies, so common in the seidlitz powder surgical literature of the day. Here the law holds good that the adaptation of the remedy to the particular stage of the disease contributes in no small degree to our success. Delay may be advisable for three reasons: First, to prepare the patient better for the operation, and perhaps transfer him or her to a suitable hospital; second, to secure the advantages of an operation of expediency as against one of emergency-to operate in the interval of an attack; third in cases where the pulse, tympanites and general condition of the patient make it clear that operating would only give the newspapers a chance to publish a "death from a surgical operation." I have not yet been accused of surgical cowardice, but have known deaths due to procrastination after an operative procedure had been advised, the delay being clearly traceable to the libelous statement in a newspaper that

"a death was caused by an operation," the reporter of the sensational item not taking into consideration the almost dying condition of the patient caused by the disease for which the operation was advised, nor that the heroic surgeon was willing to sacrifice reputation, the outgrowth of a long life's work, to give a fellow being the only chance of life, nor that he might have stated to the friends that he could only offer one chance in a hundred by surgical effort. To operate on a hopeless case, and through the medium of the newspapers, cause fatal delay, thereby sacrificing perhaps three precious lives which surgery could have saved, forms a question which the conscientious surgeon may well take into consideration.

TECHNIQUE OF THE OPERATION.

To my mind there are two distinct operations: First, that in which we may reasonably hope to secure the appendix and remove it; second, that in which we simply open an abscess, drain it, and wait (until a suitable time at which time infection is less acute and then remove appendix and close the cecum). In abscess cases I am in the habit of making the incision in the usual place, a little nearer perhaps to the anterior superior spinous process of the ilium, cutting down to the peritoneum, but not through it, and then with a pair of curved scissors or with a knife with a long crooked handle going down between the "weather boards and the plaster, under the kitchen floor, then turning the instrument sharply, break through the floor under the cook-stove." The peritoneal cavity is only opened under the cecum where the pus is most frequently found, and at the point where the appendix has infected the parts. I get the best of drainage for pus and serum, and have seen portions of appendix washed out from such a cavity as that. In this way I do not go directly into the peritoneal cavity, nor do I expose the area of intestines to the pus from the abscess. I would protest most emphatically against any undue amount of search for an appendix unless there is intestinal obstruction, when the wall of abscess must be broken to find the cause, which may be only paresis in nerves of the inflamed area. The length of time the abscess has existed should be considered. The plastic exudate which walls off the pus may not be strong, or having been strong may have become weakened by contact,

decomposed pus breaking down the wall, and allowing the pus to escape into the pelvic basin or up the "water-shed," between the ascending colon and abdominal wall. When the abscess contains old pus it is less dangerous to hunt for and remove the appendix than when infection is acute. When it has been necessary to simply open, drain the abscess, etc., without finding the appendix, I am of the opinion that the greatest safety to the patient lies in keeping the patient under close observa

tion, and as soon as acute infection has passed, say three weeks, not waiting for a second recurring attack,* to open the abdomen, break up adhesions and deal with the cecum and appendix by the technique I here describe. This opinion is backed by a large experience and emphasized by a case of fatal hemorrhage from cecum, and by a case where the second attack was nearly fatal.

Dr. A. W. Patterson and Dr. Hodges, of this city, Dr. Ross, of Kokomo, Dr. Newcomer, of Tipton, and others are familiar *You might as well trust a dog with your dinner, as a ruptured appendix with the life of your patient.