BRITISH MEDICAL ASSOCIATION

NEWS.

PROCEEDINGS OF AUSTRALASIAN BRANCHES.

New South Wales.

A SPECIAL general meeting of the Branch was held at the Royal Society's Rooms on Thursday, August 14th, 1902, Dr. G. E. Rennie (president) in the chair. There were 43 members present.

The HON. SECRETARY read the circular convening the meeting.

The PRESIDENT announced the election of the following members :-Dr. G. P. M. Woodward, Sydney; Dr. H. S. Capper, Potts Point.

Dr. FURNIVAL moved the following resolution-"That the establishment of a defence fund is desirable for the protection of members who may suffer financially through resigning medical contract appointments at the instigation of the Branch, and that a committee be appointed to draw up a scheme for consideration at a future meeting," and said he had felt for some time past that the action of the British Medical Association with regard to the Australian Natives' Association and proprietary lodges had been to a certain extent hampered by not having such a fund as this, which could be utilised in assisting medical men who were compelled to

give up some of their lodge appointments. If

there was a fund which could assist a man to keep going, at any rate for a time, it would be invaluable. It should be remembered that some men with families depending upon them would think twice before sacrificing themselves. As far as his position was concerned in the lodges he had given up, he was not very materially concerned, but there were others who would be seriously embarrassed if called upon to give up some of their appointments. It would not cost much to start a fund to provide at least a portion of the income forfeited. All the medical societies should be represented upon the committee. There were about 700 medical men practising in New South Wales, and half of them were engaged in lodge practice. He thought the subscription should be £2 2s for members having lodge practice, and £1 1s per annum for those not in lodge work. No man could come upon the fund unless he had been called out by the Branch. He thought this matter should be dealt with seriously and earnestly, as it meant either success or failure in the matter of fighting for the rights of the profession, and would give the medical men such a weapon as would be of the very greatest benefit. He hoped that the scheme foreshadowed would be elaborated by the committee he desired to have appointed.

Dr. ANGEL MONEY seconded the resolution, and said he thought the scheme deserved earnest consideration, and he hoped that such a fund would be started.

Dr. MACPHERSON said he desired to support the resolution. He understood that Dr. Furnival resigned the lodge because the other medical officer was connected with the Australian Natives' Association. He thought Dr. Furnival was to be commended for his action; there were, however, other members who were not prepared to do the same.

Dr. McDONAGH said that before taking action they should be sure of their ground. Temporary help could only be given in certain cases. In his opinion lodges ought to be a thing of the past. A fund might be started on insurance lines. He was heartily in accord

with the spirit of the resolution, but was of opinion that it was impossible to give adequate compensation.

Dr. BRADY said he thought such a fund should be started, and was sure that donations would be given by those interested. He was prepared to donate a sum as well as give an annual subscription.

Dr. BOWMAN said this resolution was of importance, especially to the younger men of the profession. He felt sure that the older men would give donations as well as annual subscriptions. Dr. Furnival's action was a noble one. He had given up several lodges on the principle that the profession should not have anything to do with the A.N.A. or its medical officers. The starting of this fund would be a distinct advantage to the branch in the fight. He felt sure that all lodge doctors would become subscribers to the fund.

Dr. MCKAY said if the Association was to be a power it must have money. He thought this matter was one of insurance. The scheme deserved every consideration, and could be made very successful.

Dr. BINNEY said he would like to ask Dr. Gill if the functions of the Medical Union embraced this question.

Dr. GILL said the funds of the Medical Union could not be made available for the purpose mentioned in the resolution. The income of the Medical Union was about £300 per annum, and the expenses so far only about £50 or £60. The accumulated funds amounted to something over £2000. The scope of the Medical Union was so different to the present proposal that it was not possible to include the two in one society. The resolution was agreed to unanimously.

Dr. FURNIVAL proposed that the following constitute a committe to discuss the matter:-The President and Hon. Secretary of the New South Wales Branch British Medical Association, President of the Medical Union, President of the Sydney and Suburban Provident Association, Presidents of the Metropolitan, Eastern Suburbs, Western Suburbs, Northern Suburbs and Newcastle Medical Societies, and the mover, with power to add to their number.

After discussion this was agreed to.

Dr. COLLINS moved the following resolution:-"That it is desirable that a scale of fees for medical examinations for life assurance be determined on, and that the Council be requested to formulate a scheme for consideration at a future meeting," and said his reason for bringing this matter forward was that he found a great division of opinion as to the fees paid for examinations in life insurance. He had recently been asked to act as medical referee to a company, but had declined the honour, as he did not consider the fees adequate. The scale was for policies up to £100, 10s 6d each report; from £100 to £1000, 21s; and for over £1000, £2 2s each. The report in each case was a lengthy one, numbering about 60 questions. He thought if the fees were cut down the report should also be reduced. (Dr. Collins) thought in the case of the smaller amounts a certificate should be considered sufficient. He hoped the Council would formulate some uniform scale of fees.

He

Dr. MACPHERSON seconded the resolution, and said when he was in practice at Glen Innes he had an experience of proposed cutting down of fees. The Independent Order of Foresters made overtures to him to take business at 10s 6d fees, but he refused, and the other medical man doing the same the company got no business either in Glen Innes or Inverell; however, when he came to Sydney he found that the 10s 6d fee was the fee offered by several societies.

Dr. McDONAGH said, being chief medical officer of a society, he knew the difficulties in the way of laying down a uniform scale of fees. In many cases a proponent was examined, but did not complete the business in the prescribed fortnight; that necessitated another examination.

He did not think that such second examination should be charged for at full rates. The guinea fee had been the precedent, and should be adhered to as far as possible. He did not believe in a sliding scale.

Dr. HANKINS said, inasmuch as this resolution provided for the Council formulating a scheme, he would like to say what had been done so far. The Council were of opinion that if the industrial societies were content with a simple certificate, without filling up the usual report form, a fee of 10s 6d might be accepted, but for all full reports one guinea should be charged. It must be remembered that the industrial business was growing, and it was manifestly unfair to ask medical men to fill up these lengthy forms for 10s 6d.

Dr. MCKAY said this was simply a question as to management. The societies were managed by business men who knew their business, and would not be likely to pay for an inferior article; it was therefore necessary for the profession to stand firm, and have a uniform fee of one guinea for all examinations.

Dr. ARTHUR said if a one-guinea fee were demanded, perhaps the societies would simply engage and pay two or three men to do the work.

Dr. SHELDON said the conditions suggested by Dr. Arthur already obtained in some of the societies.

The resolution was then put to the meeting and carried.

Dr. FIASCHI moved "That a special committee be appointed to define the ethical relations between the medical profession and the press; such committee to consist of Drs. Manning, Quaife, Scot Skirving, Clubbe, Morgan Martin, Worrall and Fiaschi; also that their report be forwarded to every member of the branch, and brought for discussion at a special general meeting in October next," and said his reason for bringing forward this matter again was the fact that the laws with regard to the press were not written. He thought the committee would be able to lay down certain rules for the guidance of the profession.

Dr. ANGEL MONEY said he had not an opportunity at the last meeting of speaking on this subject. He should like the committee to deal with all questions of ethics, not only their relationship to the lay press, which, after all, was only a minor point. Some of their most distinguished members have been guilty of unethical conduct. Some have an advantage by the positions they occupy. One man may steal the horse, while another may not look over the fence. He desired to see this matter set at rest, and he thought the only way would be to lay down certain rules for their guidance, so that they might know what may be done and what may not be done. He had seen paragraphs and advertisements appearing time after time, and no action taken, whereas other men were brought up on the least pretext.

The PRESIDENT explained that a resolution bearing on the question of advertisements in the lay press had been passed several years ago at a meeting of the Branch.

Dr. WILKINSON said he thought there were a great many more matters of ethics which ought to be dealt with as well as the relations of the profession with the lay press. In his opinion, if articles were to appear in the press, then the name must appear to make them of any value. It would, of course, be outrageous if a man were to discuss another man's case in the press; but where matters of public health were concerned, who was better able to discuss them than the profession? If we desire the public to take an intelligent view of consumption, how were we to educate them except through the press, or by lectures? The composition of the committee did not commend itself to him. He did not believe in the committee; a report would be brought up, and then the whole question must still be left very much to a man's honour. He thought there should be a court

of ethics established, to consist of five members. To this court all questions of ethics should be referred. He would, therefore, move as an amendment

"That the New South Wales Branch should establish a court of ethics, consisting of five members, to which all matters appertaining to medical ethics shall be referred for consideration and report. That a subcommittee be formed for the purpose of carrying out this resolution."

Dr. MCKAY seconded the amendment, and thought the suggestion a very good move. There would be five men who would not take any cognizance of personal matters, but would deal with the case on its merits.

Dr. BRADY said it would be difficult to arrange the machinery for such a court. Many details would have to be dealt with, such as the duration of the appointment to the court and how often they should be elected. He did not think the proposal workable.

Dr. McDONAGH supported the amendment. He thought Dr. Wilkinson's idea a happy one. We would have men to adjudicate upon cases who would be above suspicion. He did not see any difficulty in arranging for the working of the court. We were a company, and could appoint a sub-committee to deal with all matters relating to ethics.

Dr. BINNEY said it was not only the relations of the Sydney medical men with the press, but also of those living in the country which had to be considered. The Council was elected by the whole body of the profession, and therefore had the confidence of all the members. The committee, such as suggested to-night, would only represent a very small proportion of the members. He (Dr. Binney) thought the Council would be the proper body to deal with the question, therefore he would move a further amendment-"That the Council be asked to define the ethical relations between the medical profession and the press; also that their report be forwarded to a special general meeting in October next."

Dr. LUKER Seconded Dr. Binney's amendment, and said they could not expect all the members to abide by the decision of a small meeting of members. He thought it should be left to the Council.

Dr. BRADY, in supporting the amendment of Dr. Binney, said the Council was the Parliament of the profession; a committee appointed by a small meeting could not carry the same weight.

Dr. FIASCHI, in reply, said there could not be any doubt that the principles should be written down. If the rules were passed they could be made very broad, and would not include trifles. As to the objections of having a special committee, he had suggested that the special committee should act so as to relieve the Council of any extra work, As far as he knew, the committee was representative of the profession.

The PRESIDENT then put the amendments and resolution to the meeting, and they were all negatived.

The regular monthly meeting of the Branch was held at the Royal Society's Room on Friday, August 29th, 1902; Dr. G. E. Rennie (president) in the chair. There were 54 members present. Visitor: Dr. Metcalfe, Norfolk Island.

The minutes of the previous general and special general meetings were read and confirmed.

The PRESIDENT announced the nomination of Dr. McDouall, of Callan Park.

Dr. WILKINSON gave notice of a question as to advertising in the Australasian Medical Gazette.

Dr. HERSCHELL HARRIS exhibited-(1) A case of hypertophied scar of neck treated by X-rays; (2) a case of depressed nose treated by paraffin injection.

Dr. GOODE Congratulated Dr. Harris on the successful result of his application of the X-rays in the case he had exhibited that evening. It was interesting and highly gratifying to note how the hard granulations had disappeared under the treatment, and also to note the increase of the small blood vessels in the surrounding tissue.

Dr. ANGEL MONEY also congratulated Dr. Harris on the case shown. He, however, considered that it would be necessary to have many more cases as evidence of the successful treatment by such means before they could pronounce decidedly in favour of the use of the X-rays in the removal of such scars. A history of these scars tends to show that they sometimes disappear of themselves in some unexplained way.

Dr. BINNEY referred to a case in which the expected improvement in the shape of a depressed nose through the injection of paraffin wax had not followed the treatment, and he suggested that the operator should protect himself against legal proceedings should the operation not result in an improvement in the deformity. Dr. RENNIE read a paper on "Meralgia Paræsthetica." (See page 446.)

Dr. WILKINSON thought there was some difficulty in explaining the condition. In Bernhardt's cases it had frequently been a sequel to typhoid fever. He had known a case to continue for years, the chief symptom being loss of sensation, resisting all treatment in the most persistent way. Iodide of potassium had only very partially relieved the symptom. The condition had extended to the perineum, and even to the testicles. The attack had followed typhoid fever. He thought at first that it was due to a bone infection, an osteo myelitis, such as frequently follows typhoid fever, but he thought subsequently that it was a purely nerve condition.

Dr. RUSSELL NOLAN stated he himself, when in South Africa, had experienced a similar sensation of numbness, and had attributed it to having inadvertently compressed some nerve, but after awhile he had felt no more of it. Listening to the description given by Dr. Rennie had enabled him to recognise an old friend in the disease.

Dr. ANGEL MONEY was not sure that the sui generis of the disease had been quite made out. The anaesthesia was a very marked symptom in it. But there was frequently also present a burning sensation like that present in paralysis agitans. The disturbance was frequently so marked that patients not aware of the true cause were apt to regard it as a forewarning of some serious nerve disorder. He was sure that they all felt indebted to Dr. Rennie for having brought the disease so prominently before them.

Drs. RENNIE and CRAGO read notes on a case of Cerebral Hydatid, and also further notes on a case reported previously. (To appear in a future issue.)

Dr. BRADY remarked that it was a good plan the putting back of the pieces of bone, and he would like to ask Dr. Crago why he had not on the second occasion done as he had in the first in this respect. In an operation for general meningitis the speaker had followed the plan, and on subsequent examination it had been scarcely possible to point out where the piece had been taken out.

Dr. HINDER read a paper on "Complete Prostatectomy and the Bottini System." Specimens were exhibited. (See page 439.)

Dr. MAITLAND said the thanks of the meeting were due to Dr. Hinder for again bringing before their notice the interesting question of the operative treatment of enlarged prostate, and he was to be congratulated on the results of his cases of enucleation. He (Dr. Maitland) had done the operation by both routessuprapubically and through the perineum-and he preferred the perineal route in suitable cases; that is, in

large adenoma of the prostate it was best to do a suprapubic cystotomy first, then enucleate through the perineum. This operation had these advantages: that (1st) there is less bleeding, as the prostatic plexus is somewhat deficient on the under aspect of the prostate; (2nd) the wound is kept clean, the bladder and urethra not being opened below. The advantages of the preliminary suprapubic were: (1st) the bladder is drained; (2nd) a thorough exploration is made, so that there is no possibility of missing a vesical calculus in a postprostatic pouch, as happened in the case Dr. Hinder mentioned; and (3rd) pressure downwards with the fingers of the left hand introduced through the suprapubic wound greatly facilitated the perineal enucleation. With regard to Bottini's operation, he had never done it, and he never would. The technique of the operation itself he would not attempt to criticise; but a surgeon should be able to judge whether an operation is opposed to surgical principles or not. If this were not so, it would be necessary for them to make the same mistakes as their ancestors before being able to avoid them. This operation is unpopular in England. Maunsell Moullin, in his work that Dr. Hinder has referred to, admits to having done the operation once, and the only man in this country who did the operation was the late Dr. Lillie. Dr. Maitland was familiar with the Bottini incisor, and considered that there are grave surgical drawbacks to its use. First, the operation is

done in the dark. Information as to the vesical contour of the prostate can be obtained in some cases by the cystoscope, but this instrument is not of the value in these cases it was thought it would be, (1st) because of the difficulty of introduction, and (2nd) if it were introduced the light was often shut off by the prostatic outgrowth. This was pointed out by Dr. Hinder himself in a previous paper; but even if the prostatic contour were seen, the floor of the prostatic urethra could not, and it was here the incision was made. Frendenberg's improvement on the instrument that Dr. Hinder used was no better in this respect. A further drawback to the operation was insufficient drainage Dr. Hinder said that he did not drain in these cases. The urethra is ineffectual as a drain for the bladder. There must be considerable destruction of tissue in Bottini's operation, and to leave this in a closed sac was opposed to surgical principles; it was opposed to all bladder surgery, and was a piece of surgical neglect for which there was no excuse. A further objection to the operation was the danger of hæmorrhage, and the fact that it did not come on at the time of the operation, but later when it was unexpected, when the sloughs began to separate, made the danger all the greater. Another objection to the operation was the possibility of contraction. They were all aware of the liability to contraction after a burn, and contraction must nullify the efficacy of the operation. A further objection to the instrument was that you did not know how long to make your incision. There is an indicator to tell you how long you have made the incision, but how are you to know how long you ought to make it? You cannot see the area of operation, and you cannot feel it. Dr. Hinder himself had pointed out that examination per rectum does not give you a correct idea of the size of the prostate, as the growth is mainly intravesical. There were other objections, viz., the danger of perforating the rectum, suppression, absolute retention, perforation of the urethra. These complications had all happened to those who use this instrument-Willy Meyer or Frendenberg. He felt strongly that if this cautery was to be used on the prostate that the area of operation should be under the direct eye of the operator; and, further, that opportunity should be given for a thorough digital examination of the bladder and prostate.

Dr. GORDON CRAIG said the report of the cases by Dr. Hinder carried conviction. He could not agree with the objections against the method raised by Dr. Maitland. Secondary hæmorrhage was, however, a serious condition to be encountered. He had had such a case of furious bleeding, and this only ceased after a black slough had come away. The advantage of treating cases in the early stages was obvious.

Dr. HINDER, in reply, said that Dr. Craig's remarks were to the point, and hit the nail on the head. He was thankful to Dr. Maitland for his criticism, but hoped he will not take it ill if he disagreed with him on a great many points. He stated that Bottini's, or rather Frendenberg's, modification of that instrument was falling into disfavour, and that it was not used at all in Great Britain. On the other hand he (Dr. Hinder) maintained that the instrument had been very much revived the last few years, and the fact that considerable ingenuity had been exercised in modifying it in the minor details was proof positive that the instrument was being appreciated. Recent journalistic literature, both American and Continental, had dealt with the instrument and its results at considerable length. Schlangintweit had devoted an article of considerable length to one detail only in connection with the use of the instrument. It was an instrument which if used as it should be used, and, as was indicated in his paper, in properly selected cases, was certain to be attended with very gratifying results. He was sorry to say that the cystoscopic prostatic incisor, the instrument which meets with Dr. Maitland's approval, is one which may be theoretically a good one, but practically is of no service because as soon as an incision is made there is slight bleeding and the cystoscopic part is valueless. The argument that the cut is made in the presence of foul urine was specious, but not good. The body was accustomed to these toxins, and the additional dose, as a matter of fact, did no harm, or what a great amount of harm would arise after suprapubic removal of the prostate. However, the proof of the pudding lay in the eating of it, and in only two or three of his cases did he drain through the urethra, and only one had a rise of temperature to 101 and he was suffering from pyelitis. The series of 20 cases

The

published by Willy Meyer, which Dr. Maitland quotes have since amounted up to 50. It must be remembered, however, that he did not select them, but purposely set out to give the operation a full trial by using this method for every case he came across. speaker's contention was most emphatically that the instrument should only be used for selected cases such as he mentioned. He had so far selected them, and the results have been everything that could be desired. He was sorry to say that time would not permit him to reply further, but it must be remembered that no single operation was a cure-all for every case of prostatic hypertrophy; each case demanded consideration and must be dealt with after the method which was best suited to it.

Dr. WORRALL exhibited 2. Lipoma of Fallopian tube.

1. Hydatid of rectum.

1. Hydatid cyst of anterior rectal wall the size of a hen's egg, containing two living and one dead daughter cysts.

The patient was aged 39. The operation was undertaken for retroversion with fixation of the uterus, which bimanual examination, prior to operation, made out to be due to "a prolapsed, adherent peculiarly hard and irregular left appendage." Operation showed this mass to be the left appendage adherent to the hydatid, which simulated in appearance and was at the time thought by me to be a malignant growth. In extirpating it the lumen of the bowel was opened up for two and a half

inches. The opening was afterwards carefully closed with interrupted silk sutures. The patient recovered easily. Apparently this hydatid was single. No evidence of hydatid disease elsewhere could be discovered.

2. A bilateral, pedunculated lipoma, the size of a large hazel nut, growing from the anterior and outer aspect of each Fallopian tube. The patient at 30 was stout, but not obese. Married 10 years; never pregnant. The operation was undertaken for retroversion with fixation of uterus and appendages. The left ovary being the seat of a cyst the size of a large walnut, was removed with its tube and the lipoma. The right appendage was separated from adhesions which bound it to the peritoneum of Douglass' pouch, and only the lipoma removed. As far as I have been able to discover, there is only one other recorded case of lipoma of the Fallopian tube.

COUNCIL MEETING.

The Council met at the Association Rooms on Friday evening, September 5th, 1902. Present Drs. Rennie, Crago, Jamieson, Hankins, Worrall, Hinder, Foreman, Fiaschi, and Dick.

The minutes of the previous meeting were read and confirmed.

Dr. H. C. McDouall was elected a member of the Branch.

A letter was read from the Inspector-General of Police, stating that Mr. Toose, optician, had removed the word "doctor" from his signboard as requested.

Letter was read from the Balmain Dispensary with reference to the A.N.A.

Letter was read from a member calling attention to gratuitous ambulance instruction being given at the Newington College by the Civil Ambulance lecturers.

Resolved that the chief brigade medical officer be asked to bring the matter before the medical committee. Letter was read from Dr. Hugh Kirkland with reference to paragraphs appearing in the general newspapers. Letter was read from Dr. Parry, of Picton, with regard to an objectionable circular sent out by a neighbouring practitioner, also hon. secretary's letter in reply.

Questions asked by Dr. Wilkinson.

Letter from the hon. secretary to Dr. Wilkinson and his reply were read.

Answers to the questions were then discussed and agreed to.

Fees for Life Assurance. -Resolved that it be a recommendation to the general meeting that for certificates of health merely 10s 6d, and for filling up the ordinary detailed schedule £1 1s, should be the minimum

fee.

Dr. HINDER brought up the question of the Western Suburbs Medical Association and the local lodges.

Dr. JAMIESON read a letter from Dr. Booth, of Broken Hill, with reference to the reorganisation of the British Medical Association.

The HON. TREASURER reported the following credit balances:- General account, £208 14s; Gazette account, £75 148 9d.

Accounts amounting to £21 68 11d were passed for payment.

Resolved that the canvasser for advertisements for the Gazette be sent to Melbourne, and that his fare be paid. The HON. TREASURER asked for permission to recover certain outstanding subscriptions.-Authority given. Resolved that the balance of the conversazione fund be donated to the library.

South Australia.

THE monthly meeting was held at the University at 8 p.m. on Thursday, August 28th, 1902. Present: Drs. A. A. Hamilton (president) and 27 members.

Minutes of last meeting were taken as read.

The PRESIDENT reported the result of the recent deputation to Hon. J. L. Parsons.

Exhibits: Drs. GILES and SYMONS showed some cases. Dr. MARTEN and Dr. H. SIMPSON NEWLAND showed1. Renal calculi in the kidneys of a sheep.

2. Two fibro-adenomata (one of unusual size) from the same breast.

3. Two rodent ulcers removed from the right and left cheek of the same patient.

4. A right-sided pyo-salpinx existing with a cystic ovary of the same side.

Dr. LENDON showed specimens illustrating stricture of the appendix :—

1. An appendix removed from a girl of eight years who had recently had two attacks in three months. The appendix was somewhat difficult to find, as the cæcum could not be brought outside the abdomen, but it was ultimately recognised as lying in the retro-cæcal fossa: a loop of silk was passed through its mesentery at the base, and the apex gradually separated from its adhesions, leaving, however, the extreme tip behind. On opening it there was found a stricture in process of formation.

2. An appendix removed from a single woman of 28 years during an interval of quiescence, after the third attack in 15 months. The tip was adherent both to the abdominal wall and to the outer side of the cæcum. On laying it open there was found a stricture which would just admit the passage of a bristle about three-quarters of an inch from its extremity.

3. An appendix removed from a married woman of 36 years of age, upon whom oophorectomy had been performed some eight years previously. It shows an impermeable stricture, and a bulbous apex containing in its cavity minute concretions. (Exhibited on behalf of Dr. J. A. G. Hamilton.)

4. Also the front of the chest of a child who succumbed to perforation of a typhoid ulcer, showing congenital, or absence of portions of the ribs.

Dr. JOSEPH C. VERCO showed a left kidney with a large solid growth attached, removed by operation from a young woman, the details of which will appear in a future issue.

The discussion on Dr. J. C. Verco's paper on Appendicitis" at the last meeting was opened by Dr. J. A.G. HAMILTON, who said: "I had not an opportunity of reading Dr. Verco's paper before making these few notes, as the August number of the Australasian Medical Journal had not come to hand; but as the title of the paper was "Appendicitis or Perityphlitis" it leads one into temptation to wander a little beyond the subject of the two cases cited. First of all, I think it is a pity that this condition should be called by a double-barrelled name, as almost all inflammatory conditions around the caput coli originate in the appendix; so I think 'Appendicitis 'a better title than Perityphlitis.' The case cited by Dr. Verco, in which the appendicular abscess pointed under the liver, contained a useful object lesson. If this organ confined its vagaries to its own particular fossa it would be much easier to deal with; but abscesses connected with it point under the liver, in the pleura, in the pelvis, in the loin, down the thigh, and even when the appendix is somewhere near its

natural position we expect to find pain in connection with inflammatory conditions of that organ referred to the right iliac fossa, but as a matter of fact the pain is often referred to the other side or other regions of the abdomen. This is particularly the case in women. It is often very difficult to make a differential diagnosis between inflammatory conditions of the pelvic organs and appendicitis. In gynæcological practice one frequently finds the appendix involved in inflammatory conditions of the pelvic organs; so much so that in every abdominal section, no matter for what purpose, I have made it a point to carefully examine the appendix. During the last few weeks I have operated on four cases of appendicitis, in all of which the symptoms pointed to the pelvic organs rather than to the appendix. In one case the pain was referred to the left iliac fossa, and was thought to be due to adhesion, as the lady had had a double salpingo-öorphorectomy done nine years previously and had complained of pain over lower part of abdomen, but chiefly in left side, ever since operation. In this case a very much thickened and enlarged appendix was found at back of cæcum, and firmly bound down to posterior peritoneum. The appendix was divided at its proximal end, and carefully stripped down to its tip and removed entire. In another case the woman had laceration of pelvic floor with retroflexion and prolapse of the uterus. She complained of constant and severe pain in right iliac fossa; this was thought to be due to the uterine condition. After repairing the pelvic floor, the abdomen was opened with the object of suspending the uterus. The appendix was found in much the same condition as the other case. An attempt was made to strip it after dividing it at its proximal end, but the tip, which was very much enlarged, was so firmly fixed behind that the appendix broke away in pieces. An incision was made in the loin, and the tip pushed out and removed through the incision in that position. I think that all morbid growths of the abdomen are better explored without delay, especially if the symptoms are obscure, and we cannot satisfy ourselves of the exact nature of the condition. This is particularly the case when the symptoms such as pyrexia, rapid pulse, etc., point to an acute, if not purulent, inflammation. With the present-day improved technique an abdomen can be explored with little danger, and that waiting for symptoms to improve or grow worse, I think, costs many lives. I think it will be generally admitted that an immediate operation is called for when there is any suspicion of the presence of pus, whether the pus is situated in the usual position for an appendicular abscess or not. Time will not allow me to fully discuss the muchvexed question, 'When is the best time to operate for appendicitis?' but I should like to say a few words on this question. I strongly hold with the American teaching that the sooner the operation is done in the acute stage the better. Treves says that the death rate from operation in the acute stage comes out at about 20 per cent., but it must be remembered that the teaching in England is to give the expectant treatment a trial and wait for operation until the symptoms are urgent. On the other hand Carstens, in the Journal of the American Medical Association, says: 'Statistics of cases operated on as they came along, easy cases, severe cases, purulent cases, and those actually moribund, gave a mortality of only 8 per cent. He quotes 227 cases of appendicitis. Of these 160 were operated on, with 14 deaths, or about 8 per cent., while 57 were treated medically, with 11 deaths, or a mortality of over 20 per cent.' He also points out that over 60 per cent. have recurrences, while the patients operated on are, as a rule, cured, so that we see that statistics on this subject are entirely misleading. John B. Murphy, in the International Journal of Surgery, says that the mortality from appendicitis is 10 per cent.,