"7. In case no operation is performed, neither nourishment nor cathartics should be given by mouth until the patient has been free from pain and otherwise normal for at least four days.

"8. During the beginning of this treatment not even water should be given by mouth, the thirst being quenched by rinsing the mouth with cold water and by the use of small enemata. Later, small sips of very hot water frequently repeated may be given, and still later small sips of cold water. There is danger in giving water too freely, and there is great danger in the use of large enemata.

"9. All practitioners of medicine and surgery, as well as the general public, should be impressed with the importance of prohibiting the use of cathartics and food by mouth, as well as the use of large enemata, in cases suffering from acute appendicitis.

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"10. It should be constantly borne in mind that even the slightest amount of liquid food of any kind given by mouth may give rise to dangerous peristalsis.

"II. The most convenient form of rectal feeding consists in the use of one ounce of one of the various concentrated liquid predigested foods on the market dissolved in three ounces of warm normal salt solution introduced slowly through a soft catheter, inserted into the rectum a distance of two to three inches.

"12. This form of treatment cannot supplant the operative treatment of acute appendicitis, but it can and should be used to reduce the mortality by changing the class of cases in which the mortality is greatest into another class in which the mortality is very small after operation.

"In employing rectal feeding, it is important to follow a definite plan, which an experience with a very large number of cases has demonstrated to give the best results with the least amount of annoyance to the patient.

"It has been found that any one of a number of reliable liquid predigested foods in the market is much better than a mixture of egg and various other foods which are frequently employed. The quantity should be small. Usually an ounce of predigested food, dissolved in three ounces of normal salt solution, is most

readily borne by the patient. It is usually best to give this every four hours, and if the patient is suffering from thirst, an enema of from eight to sixteen ounces of normal salt solution may be given half way between feeding until the thirst has subsided.

"A soft rubber catheter, No. 8, English, should be attached to a funnel or to an ordinary one-ounce glass syringe. It should then be thoroughly lubricated with oil or vaseline, and inserted into the rectum not more than two to three inches. Then the food should be poured into this funnel or syringe, and should be permitted to enter the rectum by its own weight. Many patients who are greatly disturbed if the food is forced into the rectum with a syringe, can be fed by the method just described, with perfect comfort. In case, however, the patient retains the nourishment temporarily, the rectal feeding is interrupted for twelve to twenty-four hours."- Modern Medicine.

CHOICE OF A General AnesthETIC; AND SELECTION OF METHOD OF ADMINISTRATION.-V. C. Pedersen succinctly discusses the question of general anesthesia, both in respect to the qualities of the several agents and anesthetic sequences used, and in regard to the method best suited for various types of cases. In the selection of anesthetics for routine use, it is recognized that nitrous oxide is the safest known anesthetic, especially when administered with oxygen. Ethyl chloride promises rivalry in this connection, but its employment is too recent to warrant a fixed statement at the present time. Ether is the next safest, and perhaps when the length and severity of ether operations is compared with that of operations suitable for the preceding two agents, ether is the safest of all. Ether has many advantages over chloroform, and is five times safer. The various mixtures of chloroform and ether, in point of safety, occupy a middle place between the two drugs themselves, the relative danger being greater the higher the percentage of chloroform. The conditions covering the selection of anesthetics for particular patients are discussed under eleven heads so concisely as not to permit of abstract. Medical Record, February 11, 1905.

PROSTATECTOMY.- In the weakest and most run-down cases, M. B. Tinker, Ithaca, N. Y. (Journal A. M. A., February 1I), has employed permanent suprapubic drainage. This is rapidly performed under eucain, and he thinks it is the safest of all procedures. Except in absolutely desperate cases, he believes prostatectomy under local anesthesia is safe as compared with the operation under general anesthesia. The use of adrenalin with the ordinary local anesthesia greatly prolongs and adds to its efficiency, prevents the pain and congestion following, and renders the operation almost bloodless. The knowledge of the nervous anatomy of the parts is, of course, absolutely essential, and the course of the pudic nerve and the long pudendal nerve close to the base of the tuberosity of the ischium are important. He favors the use of Young's tractor, and recommends allowing sufficient time for the anesthetic to act before making the incision. With sensitive or nervous patients he finds it often better to use a little nitrous oxide gas or primary ether anesthesia, as the infiltrating solution cannot reach the parts involved in the deeper enucleation. These parts, however, are supplied by the hypogastric plexus of the sympathetic and the discomfort is not necessarily great. He reports a case in which he thinks this method of operation was directly life saving.

EMPYEMA OF FRONTAL SINUS.-W. Freudenthal, New York City (Journal A. M. A., February 11), describes the diagnosis, treatment, etc., of chronic frontal sinusitis. He points out that most cases will improve under intra-nasal treatment, and this should be exhausted before resorting to more radical measures. The diagnosis is not always easy. The symptoms may be absent or deceptive; even the best and safest way, that of probing and washing for pus, has its difficulties, and one is likely to get into the fronto-ethmoidal cells or fail to find the canal altogether. The anomalies of the frontal sinus are also to be considered. His conclusions are substantially: (1) Regarding the conservative treatment of these cases, we should endeavor to be as conservative as possible. He refers with approval to the views of Kuttner of Berlin on this point. (2) In operative cases, Killian's method seems to give the best results at present. (3) The first

opening into the frontal sinus must always be below the outlined bridge, and only after exploring the sinus should another above it be made. (4) In the latter case we leave a bony bridge which aids toward improving the cosmetic effect. (5) Closing the external wound immediately after the operation is by far preferable for such cosmetic effect. He reports cases illustrating the operation and its results.

MEDICAL TREATMENT OF DEEP-SEATED HEMORRHAGE. F. Hare urges the use of amyl nitrite in hemoptysis. In thirteen attacks of hemoptysis, twelve tuberculous, and one cardiac, the bleeding ceased in all but one in three minutes. The writer thinks that the sudden fall of the blood-pressure permits some coagulation and plugging of the leak, and that this is usually adequate to resist successfully the subsequent rise. The rationale of the treatment is evidently identical with that in which the administration of nitroglycerin is the central feature. Interstate Medical Journal.

PRUDENCE.

ON SOME RELATIONS OF MEDICINE AND SURGERY TO JURISC. Beck says that the medical profession is a noble one, but that its members are apt to neglect their duties as citizens as far as they are not of a hygienic character, and their indifference to legal points is one of the most conspicuous sins of omission in this direction. The law requires of the physician only that he should exercise reasonable skill and knowledge, but disappointed or litigious patients often demand much more than this, and involve the practitioner in legal contests. The various complications and sequelæ occurring in the course of the treatment of fractures afford a fertile field for the dissatisfied, and the Rontgen ray has furnished a means of diagnosis and observation during the progress of these cases that cannot be disregarded, especially as it is beginning to find a place in the courtroom as well. as well. The matter of giving professional testimony in accident cases is extremely important, and requires good judgment to estimate the degree of disability and to detect malingering. Complicated medico-legal questions also arise when chronic diseases like osteitis, arthritis deformans, or malignant

growths develop after an injury. Great difficulty in recognizing the etiological factor is found in the wide field of the so-called traumatic neuroses, and it is sometimes impossible to determine whether an injury was not simply an exciting cause for the manifestation of a disease which had existed before in a more or less latent stage. The most precise scientific knowledge alone is not sufficient, but must go hand in hand with common sense and self-control.- Medical Record, Feb. II. 1905.

THE TREATMENT OF NÆVI WITHOUT OPERATION.— A. Frattini describes his method, based on the principle of Monteggia and resuscitated by Piorani. He employs a six-per-cent. solution of corrosive sublimate in flexible collodion, and after shaking the solution, applies it so that it just encroaches upon the healthy skin surrounding the nævus. A current of air is blown over the collodion to accelerate its evaporation and prevent spreading. The application is repeated every third day until the eschar is separated, and the raw surface is then covered with an antiseptic dressing. The author has treated over thirty cases of various forms of nævoid growth by this method with success.- British Medical Journal.

THE DIAGNOSIS OF GASTRIC AND DUODENAL ULCER. The diagnosis of ulcer of the stomach or duodenum is inferred from various symptoms and signs, none of which, either individually or collectively, afford irrefragable proof of the existence of this lesion. Epigastric tenderness, for instance, is often conspicuous by its absence, presumably owing to the ulcer being situated on the posterior wall, inaccessible to ordinary methods of investigation. According to Dr. Mendel, of Essen, valuable confirmatory evidence may be obtained in doubtful cases by the simple procedure of tapping lightly with a percussion hammer over the epigastrium, with the thighs flexed on the abdomen in order to secure muscular relaxation. In the healthy individual, no painful sensation is produced by the tapping, but in the presence of an ulcer, percussion gives rise to more or less acute suffering, most marked just over the site of the lesion. Even ulcers on the