doubt it will also be radically taught in the medical schools. We must not forget, however, that the physician is called to remedy the evil after the injury is done, and that a great deal of suffering and regret could be spared if all parents, as well as all teachers, had the knowledge to enlighten those under their care. Again we must point energetically toward general instruction as the only means of a better future.

Hypocrisy and conceit raises its voice everywhere, whenever an attempt is made to regulate prostitution and thus protect the people against contamination with VENEREAL DISEASES. Popular sentiment in many countries recognizes the fact that venereal disease is a sanitary problem, which should be dealt with by the public health authorities exactly like any other communicable disease affecting the general welfare. In our own country popular sentiment seems to be in opposition to any regulation, and even to any protection. The reasons alleged against such laws are various. It is claimed that they would recognize, legalize, and induce an undue familiarity with prostitution, that they would legalize the act of illicit intercourse, and thus degrade the community. Absolute ignorance of the facts. adds that such laws would offer impunity to the transgressor.

No one can deny that prostitution does exist in the United States about in the same proportion as in other countries. It makes no difference so far as this undeniable fact goes, whether the authorities recognize and legalize it or not; whether we choose to imitate the ostrich, who puts its head into the sand to escape the danger and then imagines it is safe, or whether we investigate the odious question thoroughly. No law has ever been able to wipe prostitution out of existence. Rigorous restrictions further clandestine prostitution, drive it into other channels, and even into the precincts of the family itself. Under the present system, the unfortunate beings who have, it is true, sunken deep under a powerful stress of temptation, often as victims of adverse circumstances, are delivered to the none too tender mercies of the average policeman.

In the course of time just retribution comes to every offender. The wealthy and dominating classes do nothing

to protect an honest but poor young girl when she is obliged to earn a living. When she finally falls into the clutches of vice again nothing is done for her protection. Then she turns around and takes, unconsciously, her revenge by propagating disease. And those who claim, proudly, that they require no protection, do not know when their own daughter in turn will be infected with the wily gonococcus, inoculated with the syphilis, endure untold agonies, give birth to hereditary-inflicted, horrible-looking children, in spite of being virtuous, and having suffered only the legalized approaches of a legitimate husband.

Whoever knows how venereal diseases are distributed to the so-called guilty, as well as to the innocent, even to the unborn baby, whoever knows what their consequences and devastations are, will also know that the State is in duty bound to do whatever is possible to offer protection against venereal diseases, and if some guilty one escapes the horrible punishment, which is in no proportion to the so-called crime, so much the better.

It must be acknowledged that the laws of regulating prostitution and restricting venereal diseases, as they are for the various countries, do not reach by far the ideal of what could be done, and as for our country, where the best is needed, we ought to have a law that will protect the public yet work no hardship upon the poor victim of ignorance or temptation or unjust social conditions or personal calamities. Again, we need general instruction but also humane treatment; no subjection to petty officers, their whims, brutalities and blackmailing propensities; no imprisonment for disease, but kind and rational treatment and equal rights for all.

A movement like the one started by Fournier, and originating the league against syphilis, can do a great deal of good, by inducing the proper factors to study the question and by the dissemination of knowledge, so very needful to the subject, and by creating the necessary public opinion. Without good, practical, and, at the same time, humane laws, however, very much cannot be accomplished.

Finally, we can only express our hope that the unification of the public sanitary service under a Federal Board of Public Health will soon be an established fact. Uniform,

reliable and valuable statistics, comprising collection, digestion, tabulation and graphic representation of experiences at different places under different conditions, and proper dissemination of such information, a uniform education of the physicians, general instruction of the public in regard to the important sanitary questions and hygienic facts, beginning with the children in the schools, and a concentrated attack upon disease and other evils will be a natural consequence. Then it is possible that the miserable past and the insufficient personal and public hygiene of the present shall be replaced by a brilliant future.

APPENDICITIS.-ITS CAUSES.

By WINSLOW ANDERSON, M. D., M. R. C. P. London, etc. Professor of Abdominal Surgery and Gynecology, College of Physicians and Surgeons of San Francisco; Surgeon in Chief of St. Winifred's Hospital, San Francisco, and Consulting Surgeon to the California General Hospital, San Francisco.

It is claimed by many writers in the medical journals and in the lay press that appendicitis is decidedly on the increase. At first thought this would seem to be true. But are we not better able to diagnose appendicitis now than we were 20 years ago? We remember very well that our English and Continental confrères a few years ago, marvelled at the frequency of appendicitis in America. Some doubted the cases reported, others concluded that our dietary was to blame. Now we find that the disease is increasing (?) rapidly in London. Can we question their diagnosis, or are they imprudent in their method of preparing food stuffs, or in eating them? The truth is, the London and Continental physicians and surgeons are now better qualified to diagnose the disease and to operate successfuly than they were 10 years ago. This is undoubtedly the cause of the apparent increase of appendicitis. At St. Winifred's Hospital, in San Francisco, we have had considerably more than 100 cases of appendicitis within the past few years, but does that necessarily mean an increase in the number of cases? Medical men of twenty years' practice can easily remember many cases of "inflammation of the bowels," of "abscess formation" of undiagnosed origin, of "liver diseases," "kidney diseases," gangrene of the bowel," "abscess of the fallo

pian tube," "broad ligament abscess," pyothorax, peritonitis, blood-poisoning, ptomaine poisoning, etc., and many other ascribable diseases, which were, in many instances, due to appendicitis with ulceration or gangrene, resulting in the formation of a localized abscess that buried itself under the liver, or found its way into the psoas sheath, or on account of the attachment of the appendix to the right ovary (appendiculo-ovarian ligament) infected. the tube, ovary and broad ligament. Neglected cases of appendicitis then were largely responsible for many diseases that were ascribed to different causes. Some medical writers seem to think that a meat diet is particularly conducive to appendicitis. There seems to be no special physiologic reason for this assertion. Other medical writers believe that modern food stuffs such as "new process flour," which is ground very fine, are responsible for the disease. This assertion seems as improbable as the meat diet proposition. Some writers attribute appendicitis to the coffee-drinking habit. But here again we fail to find any well grounded reason for this supposition. Others again claim that the eating of nuts and fruits must be responsible for the increase of the disease.

Among the more probable causes of appendicitis we must consider predisposing as well as the more exciting factors. Among the predisposing causes the position of the appendix undoubtedly has much to do with it. The appendix, situated posteriorly and in the lower portion of the cecum, as it is, favors gravitation of liquid injesta into it, thereby keeping it filled more or less all the time. The weight of the bowel pressing upon the appendix may readily interfere with the proper blood supply of the single appendicular artery. Constipation and sedentary habits will increase this pressure. Movable kidney seems to bear some etiological relation to appendicitis. Indigestion with diarrhoea must be looked upon as a predisposing factor. Catarrhal inflammations of the bowel and cecum undoubtedly the most frequent predisposing as well as exciting cause of appendicitis. Previous attacks must always remain a strong predisposing cause to a second attack. At least one in three, or 30 per cent. Deaver says 67 per cent of all cases of appendicitis recur within six months to two years. Constitutional disturbances must

also be looked to as etiological factors. It has been particularly noticeable in San Francisco that whenever we have had a severe epidemic of influenza we have always had more cases of appendicitis. Tuberculosis is undoubtedly responsible for some attacks of appendicitis, but when as many as half or three-quarters of all cases are ascribed to tuberculosis, we must say that such has not been our experience. We have also seen well-marked cases of appendicitis co-existing with an attack of rheumatism. We have known of appendiceal pain with undoubted inflammation of the appendix when there has been very little rheumatism present elsewhere in the body. Brazail and Frazer have also quoted several cases in which rheumatism was apparently the cause of the appendiceal inflammation. In these cases salicylate of sodium seems to be a specific. Chronic dysentery, enteritis, typhoid fever, gastro-enteritis, dysentery, eruptive fevers, all play a part in the predisposing causes of inflammation of the appendix. Age and sex will also be found to be etiological factors. Appendicitis is most prevalent between the ages of fifteen and thirty. About seventy-five per cent of appendicitis is found in people under thirty years of age. Very young children occasionally have appendicitis, and very old people may become affected. Males, according to Fitz, Deaver, and others, are four times more liable to appendicitis than females. The explanation of this is an anatomic one, namely: the fold of peritoneum (appendiculo-ovarian ligament) passing from the appendix to the right ovary, affording additional blood supply to the appendix, thereby preventing gangrene when the appendicular artery is occluded.

Exciting Causes-The exciting causes of appendicitis may be enumerated as disturbances of digestion, acute indigestion, over-eating, hurried and insufficient mastication causing direct injury to the cecal walls, thereby setting up catarrhal inflammation which extends to the appendix. Virulence of the bacillus coli and other micro-organisms also set up morbid processes resulting in appendicitis. Traumatism, such as kicks or blows over the appendix, must be considered causative, and so must exposure to severe weather. Particles of hardened fæces (enteroliths or coproliths, concrements formed within the appendix from