when you reach him he is much better; there has been an amelioration of the symptoms, and so he refuses operation, and may be at the same time you have a gangrenous form of appendicitis to deal with. I do not think we should be guided entirely by the symptoms, as you all know they are often misleading.

In regard to one of the gentlemen speaking about operating in the country, and not being able to observe aseptic or antiseptic precautions, I think he is somewhat mistaken. The only advantage of a hospital is its increased facilities, both to the operator and patient, that is all. We can operate in the country on these cases, and look after our asepsis or antisepsis, too; and if you have not sufficient assistance, you can get help, though it may be unskillful, and often save your patient, where by waiting to send away for a surgeon they will probably die.

DR. FELIX P. MILLER, Midland, said, in closing: I want to say that I agree with what has been said in the main, but just a few questions I want to answer Drs. Weaver and Nicks, as regards the country cases. Not many of you live any more in the country than I do. I am three hundred miles from Fort Worth. We have no hospital near us, but we have prepared a place where we can give our patients fairly good opportunities for recovery, in case we have to operate. Just be careful as to sterilizing everything that you are going to need. We have four physicians in our town; we can all help one another. We had a case of acute suppurative appendicitis and needed help, so got a trained nurse from Fort Worth. As to our fear of the laity from censure regarding operative work, we should never hesitate on that account.

This case, R. W. C., I do not say he got well, because I do not believe he is well. I insisted on an operation, and I believe it would have been the best thing; I am sure he is going to have another attack, because he has been uneasy in that region ever since. He is away now from the surroundings that give him a favorable chance of recovery, and when I have insisted on operations, I have never had the laity to censure me; that is what they employ me for, to give them the best advice I can, and if I do not, they have a right to censure me. It seems that the laity are becoming more educated regarding appendicitis than some of the physicians. I would advise Dr. Jenkins to read Dr. Ochsner's book; it is well worth the expense, and it will help him to answer some of the points that he is in doubt about and that we have been discussing. When you have a case of suppurative appendicitis, how do you know what is going on in that abdomen from the symptoms alone? You will never find two cases with exactly the same pathological conditions.

DR. J. F. Y. PAINE, Galveston: In one of Dr. Barr's cases he referred to

the tissues of the appendix as being so friable from inflammatory changes as to make it impossible to close it by suture or ligature, consequently packed around the aperture with gauze for the purpose of drainage. I had a similar case last year, one of suppurative appendicitis complicating pyosalpinx on the right side. After removing the tube it was found that the tissues of the appendix would not sustain either a suture or a ligature. The appendix was, therefore, ligated as tightly as the tissues would stand, cut off, leaving a short stump, and turned into the cœcum and the walls of the cœcum closely approximated over it by a sero-serous suture. The result was in every respect satisfactory. I can not recall the author of this suggestion.

RUBBER IN WINDOWING PLASTER CASTS IN COM

POUND FRACTURES.

HUGH CROUSE, M. D.,

VICTORIA, TEXAS.

The necessary immobilization in treating compound fractures induces marked difficulties in securing aseptic results. Plaster of paris windowed to secure drainage is replete with septic possibilities. The constant discharge, the moisture of copious flushing, together with the warmth of an inflamed limb, gives us the triad needed for rapid bacterial development. Three years ago, while treating a compound fracture of the tibia, induced by direct force where extensive laceration existed, excessive fragmentation of the bone also being present, the Gross treatment resulted, despite constant assiduous care, in septicemia, fatal in its extent. A week or two after this unfortunate experience, being called to attend a gentleman aged sixty-six, suffering from a compound fracture of the tibia, induced by the kick of a horse, on noting the extensive laceration of soft tissue, the septic condition of the wound and marked comminution of the bone, I attempted to utilize a suggestion made me by a dental friend, Dr. George Tyng, of Victoria, namely, the packing of dental crown rubber, known to the trade as Samson's No. 2, in windowing the cast on redressing the case the following day. Fragments of rubber were cut and placed in commercial chloroform, sufficient of the latter being used to form a semi-gelatinous paste. Absorbent wool was worked into this until a meshed mass resulted. Taking strands of this rubber-laden wool, the plaster cast having been windowed sufficiently to give an inch of healthy uninjured tissue around entire circumference of the wound, the skin having been previously shaved, sterilized and well dried, layer after layer were rapidly packed by the aid of a dural elevator between the cast and skin until at every point a snug filling

existed. Then, by using a plain chloroform solution of the rubber, the entire area was rapidly veneered until a smooth rubber mass extending from near the wound margin well out onto the cast existed. The entire cast was then shellacked, the wound within a few moments being aseptically flushed and then packed with a 5 per cent iodoform gauze, as a drain, covered as usual in handling wounds with sterile gauze and cotton, bandaged, and the limb reswung to afford chance of change of position. For the first two weeks the dressings were removed daily, the wound copiously flushed with weak, antiseptic solutions and dressed antiseptically. Subsequently, on alternate days, the wound was dressed. The temperature of the patient came rapidly to normal, and remained so. Eight weeks later the cast was removed and was found to be sweet, clean and dry. The absorbent wool and bandages about the limb and interior of cast were not charged with wound discharges and were free from the usual foul odors, filthy appearances one is accustomed to find while using the cast as illustrated in cut No. 1, recommended by Helferich, Gross, Wythe, Hamilton, Estes, Stimson, Keys, Jr., and others. Further experience has led to but few modifications of the original method. In some cases, where the wound is extensive, necessitating wide windowing, I strengthened the cast, by not alone doubling back and forth the plaster bandage, but re-enforced this with two or three pieces of No. 10 to 12 telephone wire. The exact location of wound and extent of windowing is indicated by taking a couple of pieces of tin, having them X-jointed, then four other pieces formed so as to slide over the ends, these sliding parts being perforated on the top to permit the passage of a pin. These are all sterilized with the instruments used in the primary handling of the case. After the wound is dressed, the limb shaved, vaselined, covered with absorbent wool, the latter being preferred to cotton on account of its resiliency, despite moisture, the X-jointed tin strips with their tin-laden sliding pieces are placed, the slides slipped to give the area you desire to cover in windowing and the cast put on with the usual precautions, care being taken alone in allowing the pin points exit to secure their aid in locating the

amount of healthy space desired about the wound on opening the cast the subsequent day. After the cast has been cut around the pins which can indicate a narrow or wide space by simply spreading or closing the X, the strips are caught at the joint, bent, and the ends readily removed from under the cast, by traction. Instead of shellac, lately I have been using silex, a liquid glass. Dr. Hoff, of Ann Arbor, Michigan, Professor of Dental Surgery in the University of Michigan, has used rubber for several years in handling compound fractures of the inferior maxillary, windowing from the inside of the mouth. I have used the technique I have described in several types of cases outside of compound fractures, such as Anderson's spit operation in correcting severed tendons, such as the tendon Achilles and the extensor tendons of the hand, also exsecting operations about tubercular joints with marked success. In comparison with the old methods, the cast as heretofore used demanded frequent changing, each time endangering the position of the re-uniting bone, on account of the accumulation of discharges which frequently induced skin necrosis and resulting ulcers; the casts were septic and malodorous; double windowing being demanded for counter drainage; a puncture being forced upon one in order that the tube should have a dependant point for drain. This method is septic, permits exact windowing, permits frequent inspection, does not demand cast removal until bone continuity is seemingly good, is cosmetic, delivers us from penetrating healthy tissue for counter drain, allows copious flushing,-the ideal treatment in septic wounds,-permits constant immobilization, does not demand frequent change. I do not claim exact originality in this technique. I simply commend it to you and ask a trial of the method.

DISCUSSION.

Gentlemen, in this

Previous to reading his paper, Dr. Crouse said: paper I do not claim to be original exactly, because I believe that Dr. Hoff, Professor of Dental Surgery in Ann Arbor, Mich., has utilized this method before me in handling fractures of the inferior maxillary. As far as I am able to discover, though, he has never published his technique; but I wish to give him credit for it, nevertheless.