in the second edition of his book.

The writer has used this plan regularly, in those cases (a large majority) in which it seems fitting, since the end of 1890. In April, 1891, he demonstrated it in the presence of Drs. W. F. Arnold, U. S. N., J. F. Keeney, U. S. N., J. S. Hope, U. S. N., M. M. Brewer, S. B. Jenkins and J. N. Jackson. Since then at least 400 doctors have seen it at his clinic at the Polyclinic.

These facts are mentioned as a matter of priority; since Dr. Edebohls, of this city, quite independently thought of the plan, and used it three years later (in 1894) in this city. A recent pleasant note from this gentleman to the writer says, "You have, of course, clearly the precedence over me in inversion of the stump of the appendix, and, as far as I know, priority in this procedure."

The steps are as follows:

1. A continuous Lembert suture of silk is made to surround the appendix, running like a purse-string or gathering-string, in the superficial layers of the cæcum, one-fourth inch from the appendix. This suture is not yet tightened, though the first half of a surgeon's knot is made ready.

2. The appendix is divided, leaving a stump of variable length, but never shorter than a half-inch.

3. This stump is stretched for a moment, gently, by introducing through its calibre a closed pair of slender, mouse-tooth forceps passing them into the cæcum, and gently opening the blades. Thereby any stricture from swelling of mucous membrane or from plastic deposit, will be stretched and the next step

be the easier in consequence.

4. The stump is seized at the extreme of its free end by a similar finepointed pair of mouse tooth forceps, and the stump is promptly invaginated-turned "outside in" as a glovefinger might be. finger might be. So that when completed, the forceps and appendix-end are one-half inch inside the cæcum. 5. The suture is now tightened, during which step the forceps are withdrawn. Sometimes it is a help to insert a probe or grooved director, between the open jaws of the forceps, prior to withdrawing the latter in order to prevent the appendix drawing itself out again with them.

For

In this, as in so many points of surgical technique, attention to smallest details is worth while. instance as the appendix, the cæcum, and the surgeon's fingers are all wet and slippery, time will be saved by holding the viscera, during invagination with dry sterile gauze.

Again, during the stretching of the canal, alluded to, the cæcum must be pressed between thumb and finger near the appendicular attachment. Consequently, no fæcal contents can jet out during the instant of stretching.

Of course, it is plain that not invariably can the above plan be used; for example, when the appendix is gangrenous from end to end, or has entirely sloughed away. Occasionally, from extreme softening of the cæcal walls, it seems wise to place two rows of the circular purse-string suture; the second to lie a quarter inch outside the first.

When from inflammatory deposit the cæcal or appendicular walls are almost as rigid as a pipe-stem, it is plain that invagination might not be

feasible, nor closure by purse-string suture. However, a moderate degree of stiffness of the appendix makes the inversion even easier than otherwise, by keeping the lumen patulous.

The theoretical objection has been suggested to the writer, that by this technique time might be lost by bleeding from the severed and unligatured stump-end. This objection is without basis of fact. The preliminary ligation and division of the mesentery of the appendix cuts off its main blood supply. Should a vessel of the divided end spurt, however, nothing is easier than to control it instantly by torsion.

In a word the plan above detailed will be found applicable in a large majority of cases.

It may prove of interest if we here give a list of methods found, upon reading up, to have been employed and advised by various writers. all, the number is eleven-as follows:

In

1. Division flush with the cæcum; and the hole is left closed with one or more commonly two, rows of Lem

bert sutures.

2. Ligation at junction with cacum; section; disinfection of stump by dissecting or by scraping away the infected mucous membrane. And finally further attempted sterilizing of stump either by Paquelin cautery, or else chemically, as by fuming nitric acid, or rubbing with bichloride of mercury tablet, or applying a drop of pure carbolic acid.

3. This is plan number 2, plus burial of the stump beneath the peritoneum of the cæcum. This may be done either by (a) simply one or two rows of Lembert suturing, hiding the stump at the bottom of a furrow, or

(b) the peritoneum is incised, flaps of it dissected up, and the stump (made of ligated muscular and mucous coats of the appendix) tucked beneath these flaps which are then sewn together.

4. Division, leaving a short stump of appendix, which is then disinfected by being cauterized within, the mucous membrane being seared by a slender Paquelin point. Next the stump is ligated, thereby bringing the burned surfaces in contact.

5. Same as number 4 except that a final step is the closure of the peritoneum over the burned and ligated stump by Lembert sutures, with (a) or (b) of method 3.

6. Same as number 5, except that ligation is omitted. The divided appendix has its stump seared within; and then said very short stump is buried beneath the cæcal peritoneum by one or two rows of Lembert sut

ures.

7. Leaving the divided appendix stump a half-inch long; sewing its mucous membrane together at the divided end, then sewing peritoneal coat. together over this, and finally, sometimes sewing the stump so that its end is brought in contact with adjacent peritoneum, as an added protection-either that of the cæcum, or perhaps that of the divided mesentery of the appendix.

To this last step-concealing the end of the stump beneath mesenteric or adjacent omental peritoneum— several writers refer.

8. Tying and dividing, leaving a half-inch stump. Disinfecting this as heretofore mentioned (in plan 2). Inverting it and sewing the cæcal peritoneum over it by Lembert sut

ures.

9. In cases greatly softened by in flammation, so that stitches would cut out of the cæcum, or a ligature would cut through the appendicular base, we may apply one or more small, light hæmostatic clamps; divide distally to these, and leave them in place a day or two.

10. Inverting the entire and unopened appendix into the cæcum.

11. Doing nothing to the appendix, if this organ is found so placed, or so bound by adhesions that dangerous violence would be needed in order to free and remove it; or that by freeing it a protecting layer of adhesions against peritoneal infection would be opened up.

Of the plans above outlined, method 3 seems to the writer that in most popular use to-day. But it is based on bad surgical principles.

What would be thought of a surgeon who should treat a small wound penetrating a gut by tying a string around it, leaving two foul and infected mucous surfaces tied together?

And yet is not this exactly what this technique contemplates? The disinfection outside that string, by whatever plan, will not reach the ligated surfaces; and these cannot reasonably be expected to grow together. Fortunately, nature commonly protects this botch with a heavy layer of fibrine, thus prevent ing leakage; but once in a long while there occurs a fatal fistula; and the reason is not far to seek.

On the other hand, the writer claims that his technique is not only much shorter and simpler than this, but is based upon the same surgical doctrine which guides us elsewhere in bowel-wounds; namely to invert the edges and bring peritoneal sur

faces, not mucous, in contact. And the longer the inverted surface the greater the protection against leakage, which is one reason why the writer's plan is better than method number 1.

Why, in this region alone, should surgeons violate the rule of procedure followed invariably elsewhere, from stomach to rectum along this canal?

As a further element of danger in the favorite plan, number 3, let us note that here, as also in plan number 8, we will have a hollow space with a ligature at its two ends (for the outer suture is practically a ligature). And if infection proceeds in that hollow-which is entirely possible in spite of attempts to the contrary-the poisonous fluids are as likely to burst outwardly as inwardly. Some surgeons, seeing this danger, ligate the stump with fine catgut, which will soon be absorbed. But, even so, for two or three days this peril remains.

It is in this worse-than-useless ligation of the end of the stump, as well as one or two other points which have been noted, that method number 8 differs from the plan advocated in this paper, which it somewhat resembles. In the method which the writer advocates, it will be noted that drainage is perfect and unopposed into the cæcum, where it ought to go.

Regarding the plan of searing by cautery the interior of the stump, and then ligating (method 4): Here we have two sloughs brought in contact. This may be safer than foul mucous surfaces, but they cannot be expected to grow together, being dead tissue. We are depending

again upon a providential deposit of thick fibrin over a bad job. Of course Providence generally obliges us; but why use a bad principle when a good one and an easier and safer, is at hand?

Regarding Dr. Edebohl's plan of inverting the entire and unopened appendix, the writer can see no sufficient advantage in doing this in healthy appendices; and in a long ap

In

pendix it is extremely difficult. the diseased organ it will generally be found impossible of accomplishment. Severing and stretching the canal for a moment by the plan advocated in this paper are essential, as a rule, in order to invert a stump of more than merely trivial length, because of the plastic and congestive strictures so often present.-The Internal Journal of Surgery.

THE reputed success of antitoxin

in the treatment of diphtheria and tetanus has led to innumerable experiments in the serum treatment of other supposed infectious diseases. One of these experiments, which, if all sources of error could be eliminated, would be most significant in its bearing upon the yet unknown pathogenesis of an important disease, was made by Richet and Hericourt in the treatment of cancer. Two cases were experimented upon and the results were reported to the Academy of Sciences on April 29. On February 9 they took an osteosarcoma of the leg which had just been removed by amputation, triturated it, macerated it in water and then injected the filtered liquid into two dogs and a sheep. There was no reaction following these injections. On the fifth, seventh and fifteenth days blood was drawn from the animals to obtain an anti-cancerous serum.

The first case treated was that of a woman who had been operated upon in October, 1894, for the removal of a fibrosarcoma involving three of the ribs. In February, 1895, there was a return of the growth, which at the

time of the serum experiment, was the size of a small orange. The treatment was begun March 12, injection of 3 c. c. being made each day for forty days into the cellular tissue surrounding the tumor. On March 25 it could be plainly seen that the neoplasm was diminishing in size, and this decrease became more and more rapid until finally the tumor had completely disappeared. At the same time the patient's health was greatly improved and she increased steadily in weight.

An

The second case was one that had been diagnosed as an inoperable cancer of the stomach. An injection of 4 c. c. of serum was made on April 6, and from that date to the 24th a total amount of 60 c. c. was injected. improvement in health was soon apparent, and a diminution in the size of the tumor was evident by the fourth day of the injection. At the time the report was made no real tumor could be made out but merely a sort of boggy feeling, indistinct and difficult to define strictly.

The diagnosis seems to have been fairly certain in the first case, and very probable in the second. Wheth