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dried; to get out of bed to stool from the first day; sit upon a chair and walk with crutches as soon as they felt inclined to do so, which in none was later than the tenth day.

These were all cases of simple fracture, and of interest only as to treatment, comfort and liberty of the patient and the final results. The treatment was as above stated in all by the double angular plaster method; as this method of application of the plaster of paris has not as yet been used by many of the profession, it might not be out of place to say a few words as to the method of application. The first step is to flex the limb at knee and hip to a point of nearest natural muscular relaxation; the splint is then applied in the usual way, except in two or three sections, as may be necessary or desired. When two sections are used after flexing and placing limb in position, the lower section is applied first; beginning at the base of the toes, going up the limb in usual way and making the angle at the knee and stopping near site of fracture; allow patient to rest a few minutes, and plaster to set firmly; then make the necessary extension and counter-extension to bring the fragments in apposition; then apply the upper section by beginning where the lower one stopped and going up in the usual way to the ensiform cartilege; the patient is made more comfortable by carrying the cast well up over the lower border of the ribs; when three sections are necessary or desired the lower and upper sections are applied first, and allowed to set, leaving several inches bare at site of fracture; then make your extension, adjust the fragments and apply third or middle section, reinforcing at both welding points by a few extra turns of plaster roller; when this has set firmly, patient is placed in bed until the plaster is thoroughly

dry; when he may move in any desired position at will. In this cast from toes to ensiform cartilege every muscle connected with the movement of this limb is fixed so there can be very little muscular contraction; with very little assistance he can get out of bed; the limb being in almost a natural sitting position, he can be made comfortable in a chair; having two angles, it is impossible for eversion or inversion of the foot to occur; these angles serve further as points of fixation and prevent shortening, and further draws the limb out of the way in walking with a crutch, so the only drawback is that it must be watched to see that swelling of the limb does not occur to the extent of obstructing circulation; should such an event be threatened, lay the cast open and apply a roller bandage, and we still have the nearest an ideal comfortable appliance that has hitherto been devised for such fractures, as it gives the patient the freedom of any desired movement without pain or self-injury and takes from him all the horrors of confinement in bed for six or eight weeks, and if properly set insures good results with the least worry to the physician.





It is my intention to present very concisely my experience with this most treacherous of surgical diseases, together with some deductions as the result of my work and observations.

I have had prepared with great care by my assistant and coworker of several years, Dr. L. S. Hardin, the statistics of all cases of appendicitis operated on to date.

I am greatly indebted to Dr. Hardin, not only for these statistics, but also for the valuable and accurate records which he has compiled and kept of my surgical work. But for his valued help I could not present here a record of my work of sufficient accuracy to be of assistance to the members of this Association in making reasonable deductions therefrom.

The suggestions that I shall make and the deductions that I shall submit are the evolution of my experience and observation up to this time, and I reserve the right to change any or all of them as further progress demands.

I hope none of us will ever arrive at that station in medicine and surgery that stops all further development, viz., a feeling of satisfaction that in doing one's best, one is doing the best.


It is not my purpose to enter into the diagnosis of appendicitis, other than to call attention to a few of the more important features.

As my opportunity for observation of abdominal diseases has increased, my respect for diagnoses of "colic" and "acute indigestion" has steadily decreased. Marked or persistent abdominal pain means some definite pathology, susceptible of positive determination by accurate, scientific methods of examination.

That we can not always be sure of what the trouble is, I fully admit, but we can, at least, in such cases be honest. enough with ourselves and our patients to say so and not lull them into a state of false security by a diagnosis of "colic" or "acute indigestion." I have been impressed with the number of deaths from "acute indigestion" reported recently in the daily papers. These reports simply mean that some one has blundered.

The cardinal diagnostic points are pain, general or local, muscular tension on light palpation, tenderness on deep palpation, with or without an appreciable tumor.


I wish here to reaffirm with increased emphasis what I have so often said before, that appendicitis is first, last and all the time a surgical disease, though not always under all conditions an operative one.

Early diagnosis and prompt surgical intervention in all cases would reduce the mortality of this dreadful malady to less than 2 per cent.

In no other tissue does pathology develop so rapidly. These manifestations of fierce virulence are simply astounding, and can scarcely be believed by those unfamiliar with the disease.

Operation. I have great respect for the abdominal wall, and it has been and is my constant endeavor to preserve its integrity and prevent post-operative hernia. It is so easy to leave conditions that must eventuate in ventral hernia, an exceedingly difficult thing to correct.


A direct incision through all the layers, severing as it does not only the lateral abdominal muscles, but the branches of the eleventh and twelfth dorsal nerves that innervate the rectus, if drainage must be left, induces hernia in quite a large per cent. of cases.

Walling Off-Toilet.-Another point of great importance is packing round the infected area to prevent spreading the infection to the healthy peritoneum. Experience has proven that local toilet or limited infections is far the safest.

Drainage. Properly placed cigarette drains are real life preservers. In dealing with colon bacillus or other intestinal sources of infection, when in doubt, drain. The converse is true of pelvic infections.

After-Feeding.-Much suffering, prolonged convalescence, or even death, may be prevented by proper diet. I allow only water for first twenty-four hours, then albumen, broths, etc., for forty-eight hours longer, gradually and guardedly increasing light articles of diet, excluding milk and eggs.

I supplement with rectal feeding whenever necessary. Detention in Bed.-Even after an ideal McBurney operation and healing, I keep my patients in bed two weeks. Where drainage is left, I keep them in bed till healing is complete, usually three weeks, often longer.

Peritonitis.-Frank Park, nine years. Three days before operation, marked pain began in abdomen; subsided on second day to begin again that afternoon with increased intensity, and so continued until operation on third day.

Dishwater fluid escaped when abdomen opened; intestines matted by plastic lymph; appendix sloughed off at cecum, and cecal opening closed by plug of necrotic tissue. Five to ten feet of collapsed intestine removed, when dark area of two or three feet was found, adhesions causing

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