cæcum, the plastic exudate being subsequently absorbed." Perhaps my experience is singularly fortunate, but I learn through our journals that Dr. St. Clair Smith, of New York City, has had a similar one. I have no question that many of our old practitioners can rise up and bear similar testimony.

Dr. W. N. McArtuey (old school) Medical Record, New York, May 2d, 1896, reports twenty-four cases treated medically without a death. With such testimony from both schools it seems only fair that the medical side should have a hearing.

We freely admit the value of surgical aid. We frankly acknowledge it must be given early in cases when indicated. We only plead that discrimination is to be used, not dogmatic assertion that there is never any alternative.

All must admit that the diagnosis of appendicitis is sometimes obscure, we do not have always plain symptoms of this morbid condition. We have often enough evidence of peritonitis, but the tenderness is not always located at McBurney's point when there is unquestionably appendicitis present. I have no fear of appendicitis up to a certain degree and when it is capable of control. I have great dread of a shiny bloated abdomen. As Dr. R. T. Morris aptly puts it, such an one looks like a great big ripe boil and needs the treatment usually received by boils. But some boils do better without being lanced. I have a much higher idea of nature's powers than some have. There are cases where a little more trust in the vis medicatrix nature would greatly benefit the patient. However, I do not allow my patients to reach that stage of peritonitis when I see them early enough to prevent it. Most effusions into the pleura need evacuating, but there are instances in tuberculous patients when the effusion limits the tuberculous process. Here again, it is discrimination that is needed. How are you to discriminate in appendicitis? An inflamed appendicitis is like a runaway horse, if you have strong lines and a clear road you can let him go awhile and see if you cannot control him. If you find you are becoming powerless and something is in the way, you may be obliged at once to resort to desperate and decisive measures.

I exercise eternal vigilance in every case of tenderness of the abdomen with febrile movement, however slight. I am very careful to get the early history of the case. I judge much by the vomiting. If it is simple and soon stopped I am greatly relieved. If it is continuous, uncontrolled by remedies and is bilious, there is danger that septic products exist. It is seldom that we cannot soon control the vomiting with appropriate remedies. The same may be said of the

pain. I seldom use opiates. A hop fermentation with plenty of opium on it generally suffices with the remedies to relieve the colic. Occasionally I will admit, I inject per rectum fifteen to twenty drops of opium in a little warm water. Once only have I been obliged to resort to a hypodermic of morphia. I only administer opium in some form pro re nata, and the re is seldom nata, usually once or twice in the course of some of the cases. In all my cases I have only seen one attended with diarrhoea. All others were absolutely constipated. I never use a saline cathartic, warm water enemata constituting my sole reliance to move the bowels. Never use cold applications to the bowels. An ice coil on the abdomen always make me shudder, and mentally I wish I could put the doctor who orders it to bed and make him take his own medicine. It will cause plenty of trouble if there were none there before. Obviously, I give only liquid nourishment from the time I see the case until all danger is past. I keep the patient absolutely still. I have seen the necessity for operation caused by abdominal strain before the child had well recovered. I have known a septic abscess burst internally with fatal result while the surgeon was lifting the patient from the bed to the operating table.

Internally, my main reliance is upon two remedies, Belladonna and Arsenicum alb. Belladonna relieves the pain, moderates the hyperæmia, limiting thereby the subsequent lesions, calms the nervous system and reduces temperature and pulse.

Arsenicum alb. reaches, I believe, the septic condition better than any remedy we have. It is early indicated by the special symptoms. It relieves vomiting more promptly than any remedy. It is far superior to Mercurious cor. (in my hands) although the latter may sometimes be clearly indicated.

Arnica is valuable also in septic conditions. Grauvogl's reference to the usefulness of this remedy in surgical practice I can confirm.

Veratrum alb. is valuable for the pain, and particularly in a diagnostic way. If it does not tone up the weak, wiry pulse and relieve promptly symptoms of collapse, operate as quickly as possible.

It is hardly fair to assume that all the cases I have encountered in the past thirty-one years were of the mild catarrhal variety, and for that reason they left no serious results behind them. I have had my full share of desperate cases. Only a few days ago I attended a lad with remittent fever who ten years ago was given up by his local physician as hopeless. He had the big, shiny, swollen abdomen with signs of collapse. He made an uneventful recovery, and has never had the slightest recurrence or untoward result of any kind.

In regard to the question of diagnosis, it will be remembered that many of these cases occurred before we knew the phenomena of appendicitis as well as we do now, but in the light of our present knowledge I am well assured of their exact nature. True we have, happily, had no post-mortems and an absolutely positive statement cannot be made; still I am confident, as we can be of almost anything, that they were cases of appendicitis. I am inclined to take issue with the surgeons on the matter of time limit. Some claim that if improvement does not set in after the lapse of twenty-four hours an operation should be at once performed. That does not seem to me to give sufficient opportunity either for diagnosis or to determine the results of treatment. Surely in a disease with confessedly seventy to eighty per cent. of speedy and uneventful recoveries without operation, and as Van Lennep puts it, in which ten to fifteen per cent. save themselves in spite of us, because nature shuts off the leaks by encysting the abscess which eventually evacuates itself, there is certainly some question whether an operation is indicated in every case. By good surgical judgment, there are, therefore, only five to fifteen per cent. that would die without surgical aid. I submit-is it not good practice to differentiate this small certain percentage of cases likely to prove fatal and operate only on these? Surely we cannot do that if we wait only twenty-four hours from the onset of the attack. I am willing to believe that we can make such a judgment with the best medical and surgical aid combined. There would be, it is true, no need of this if, as is asserted, there is never a death from early operation in appendicitis.

Some surgeons of large experience operate on a long series of cases successfully, but this cannot be said of the whole surgical profession. The graveyards will show nearly, or quite as many, could the testimony be taken who have died after operation, as of those who have died from want of operation, if Van Lennep's figures are true. Dr. Samuel Lloyd, Medical Record, May 2d, however, says he has collated the records of five hundred and fifty-eight cases, the greater number medical, and that the mortality was 295. There was a surgical mortality of only 13.6, and medical mortality of 77 per cent. It is evident there are still debatable points concerning appendicitis. I cannot agree with Dr. McArtney that "the safety lies. in the peritonitis." I want to see the peritonitis subside very soon. The peritonitis is the outward indication of the appendicitis, and the appendix is taking care of itself if the peritonitis is doing well. If it is growing worse, the appendix is getting into more and more serious trouble. Hence I rely greatly on the pulse and temperature.

Dr. Charles Adams says the pulse and temperature may both fall to normal after pus has formed. I think it can very rarely be said this is the case. The temperature may drop nearly to the normal, but the pulse keeps persistently up if we have an internal pus cavity. The facial expression to the practiced eye is very significant. One can almost tell at a glance how the patient is getting on by observing it. It is not easy to describe it. If the case is doing well, one line after another smooths out. If the disease is progressing, the facies abdominalis becomes more pronounced.

I cannot so definitely confirm the existence of a characteristic tongue in appendicitis. In my experience I have seen quite a variety of tongues, from the soft, flabby, easily indented one to the slick and red, beefsteaky organ.

But I am firmly convinced that with the same amount of careful study given to the disease, which it has had the last few years, we shall soon be able to diagnose with absolute certainty the operative cases very early. I admit we can do it in very many now, but there are some that tax very highly the diagnostic skill of the surgeon and clinician.

I trust I shall not be regarded from what I have said as relying on the indicated remedy in all patients with appendicitis. When my runaway horse gets beyond my control I want a surgeon experienced in these cases and I want him quickly.

ADENOIDS AND THE PROPER METHOD FOR THEIR REMOVAL.*

I

BY CHAS. E. TEETS, M. D.

Professor Laryngology and Rhinology, College of New York Ophthalmic Hospital,

New York, N. Y.

TIS not my intention to go into the etiology or pathology of adenoid growths, but more particularly to call to your attention the symptoms, and the results caused by these growths if not removed in early life; and the best method for their complete removal.

They are a mass of lymphoid and connective tissue similar to that found in enlarged faucial tonsils.

They are known by different names-adenoids or post-nasal vegetations, Luschka's tonsil, pharyngeal tonsil, third tonsil. We find this tonsil located in the naso-pharynx, sometimes filling up the

*Read before the Homoeopathic Medical Society, of the County of New York.

space so completely as to cover not only both posterior openings of the nasal passages, but also the Eustachian tubes.

It is well-known that adenoids, in the majority of cases, become reduced after a period of growth is over, and apparently disappear as adolescence is attained; but they frequently never entirely atrophy, but leave fibrous stumps in the vault of the pharynx and adhesions to the Eustachian tubes.

These stumps and adhesions produce post-nasal catarrh, by keeping up a constant irritation and causing a hypersecretion. Many of the diseases of the ear in adults are due to these stumps and adhesions. The symptoms of adenoid growths vary according to the amount of hypertrophy. Among the most common symptoms may be mentioned nasal obstruction, mouth breathing, snoring or loud breathing at night, restlessness, impairment of the voice and general debility. Occasionally we have as a result of these growths defective mental development, deformed chest, projecting teeth, arched palate, partial loss of the sense of smell, headache, partial aphonia and asthma.

John Dunn, of Richmond, claims that in the victims of adenoid hypertropy, hyperopia and astigmatism are particularly common, as are phlyctenular keratitis and conjunctivitis, catarrhal conjunctivitis, marginal blepharitis. He also states, that eczema of the lids is frequently directly due to the adenoids. The majority of the recurring earaches and pus discharges from the ear in children, persistently resisting the treatment directed to the ear, will be followed by prompt relief by the surgical removal of the growths. In fact, many of the ear diseases of adults are the result of adenoids, that had not been recognized and treated in early life. Recent researches have demonstrated that fact beyond question, and it is now admitted by the most advanced medical men that, aside from rupture of the ear drum, there is scarcely a symptom of defective hearing which is not traceable directly to these adenoids, or to the abnormal conditions of the nose and throat. I have taken particular notice that the cases of malignant diphtheria and those which terminate fatally. are the ones in which adenoids or enlarged faucial, or lingual tonsils were present. It is claimed by some authorities, that enuresis is caused by adenoids, and that the incontinence of urine will disappear when the growths are removed.

In view of these complications, how important is it that proper attention should be given to adenoids and their early removal urged; besides, at an early age these vegetations are soft and easily separated.