5. Rose, Carless, Kümmell, König and other surgeons ligate the appendix near the caput coli and invaginate the stump by means of a few Lembert sutures in the colon. Professor Senn advocates, among other methods, the amputation of the appendix close to cæcum. He then applies two Czerny and three to six Lembert sutures in the stump. Professor Sonnenburg, of Berlin, ligates the appendix near the colon. He does not cauterize the mucosa, but buries the stump by two rows of catgut sutures. The first row of sutures embraces all of the coats of the cæcum contrary to the usual practice. (From Professor Senn's "Surgical Notes.") 6. Dawbarn was the first to practice complete invagination of the stump without the ligature by means of the "purse string" sutures in the colon. This plan is favored by McBurney and others. The appendix is freed from adhesions and "delivered." The caput coli is held by an assistant so as to prevent any fæcal matter escaping, and the appendix is amputated near the bowel. Small forceps are then introduced and the appendiceal opening is dilated so as to allow of complete inversion, that is, the mucous membrane of the appendiceal stump is turned outside in and invaginated into the colon with its mucosa in contact with the mucosa of the bowel. The "purse string" suture previously applied is then tightened and tied and the stump is within the colon without any ligature about it. 7. Ochsner practices practically the Dawbarn method with the addition of Lembert sutures over the " purse string"-a very wise precaution. 8. Other surgeons, again, destroy the mucous membrane of the stump by means of the cautery and ligate "within the cauterized area." 9. Park ligates the appendix near the colon with catgut, ablates with the Paquelin cautery and invaginates the stump into the bowel with sutures in the colon. 10. Doyen was the first to crush the appendix near the colonic opening, thereby simplifying the whole procedure. By means of an angiotribe the mucous, submucous and muscular coats of the appendix are crushed so that only the serous covering remains. This greatly facilitates ligating and invaginating as may be desired. Professor Kocher applies compression forceps at base of appendix; ties over compressed area near colon, ablates and buries the stump by means of continuous serous sutures. These ten methods (with slight modifications) represent the practice of treating the stump in appendectomy in vogue to-day. We have the simple ligature, the "cuff," the Lembert, invagination of the stump into the colon with the Lembert sutures, with the "purse string" sutures, with and without the ligature of the stump, and the angiotribe method with and without the ligature and invagination. My own experience in a goodly number of cases, in which I have tried nearly all methods, inclines me to use by preference the Doyen-Dawbarn method with ligature and invagination of the stump. I proceed as follows: As soon as the appendix is "delivered" or brought out of the abdominal cavity with or without a portion of the caput coli, and freed from adhesions, should there be any, I apply an angiotribe (the blades of which measure one centimeter in width) to the appendix close up to and flush with the colon. The angiotribe compresses the appendiceal tissues so firmly that only the peritoneal tissue remains. By means of an intestinal or cambric needle, threaded with No. "0" catgut, a "purse string" ligature is applied in the walls of the colon one centimeter from the base of the appendix. The next step consists in the introduction of a ligature of the same material through the mesenteriolum midway between the appendix and its free margin. The abdominal wound is now carefully packed with sterile moist gauze to protect the peritoneal cavity from the slightest possible infection. The angiotribe is removed and the ligature tied around the appendix, flush with the bowel where the angiotribe has crushed the tissues. When practicable, as it usually is, the same ligature is retied about and made to include the mesoappendix. Should the latter be too large or contain too much adipose tissue several small ligatures are applied to it. Forceps are now applied to the distal end of the appendix and mesoappendix within two centimeters of the ligature and the appendix and mesenteriolum are amputated between the ligatures and forceps. The ligatures control all the bleeding and oozing and the 10 milimeters of appendiceal stump consist of nothing but peritoneal tissue, the mucosa and muscularis having been crushed. Pure liquid carbolic acid is applied to the stump; this is followed with pure peroxide. The whole is washed with sterile hot normal salt solution and then carefully dried. An assistant now depresses the stump into the caput coli and the "purse string" ligature is tied, thus completely invaginating the ligatured stump. By placing the "purse string" ligatures about one centimeter from the base of the appendix, and by leaving the stump only about 10 milimeters long, the serous surfaces of the invaginated colon and appendiceal stump come in actual contact and rapidly adhere, forming a solid base, which has never, in my hands, left any depression or infundibulum for future trouble. The advantages of treating the stump as above described are: 1. The mucosa is entirely crushed and the stump thoroughly sterilized. 2. The ligature is applied flush with the colon, leaving no infundibulum and no appendiceal tissue to create further trouble. 3. The invagination is complete with sero-serous surfaces in contact, favoring rapid healing. 4. Absorbable ligature (catgut) material is used, from which I never had a fistula. Silk may become infected and is then liable to cause a sinus, which persists until the silk is thrown off or removed by a secondary operation. 5. Intra-abdominal adhesions do not take place as the cut surfaces are invaginated. 6. The ligature about the appendiceal stump is perhaps not necessary, still I feel more secure from a possible fistula which I have known to occur when the stump was not ligatured. 7. This method presents the advantages of simplicity, rapidity of execution and the assurance of aseptic work, from which in the last 100 cases I have not observed the least complication. RESPONSE TO CALLS.-A state license to practice medicine bestowed upon a physician is held in Hurley vs. Eddingfield (Ind.), 53 L. R. A., 135, to impose no obligation to respond to every call, so as to render him liable for arbitrarily refusing to attend a sick person, although no other physician is procurable.-Medico Legal Bulletin. THE MEDICAL PROFESSION IN A CIVILIZED, By B. M. JACKSON, M. D., L. L. B., Omaha, Neb. First of all, I shall beg the reader's pardon for encroaching upon his valuable time, and secondly, crave the editor's pardon for wasting his valuable space. My reason therefor is because this article does not deal with any scientific theory or fact, something which physicians are ever ready to absorb, and for which they generally look in a medical journal. This article deals with matters of fact and common sense; and I believe that physicians ought to be as much interested in matters involving their individual welfare and professional statu quo as with science. One may be ever so scientific, yet if his inalienable right to the pursuit of happiness is taken away by law for the exclusive benefit of a few, of what use is his science? Science alone will not buy even a loaf of bread, let alone butter, if the field for spreading that science is strictly limited, and the individual who spent years of labor to master it finds himself handicapped whenever he wishes to make a step and apply that science for the benefit of mankind. Most physicians regard the profession of medicine as a noble one, and that it should be so regarded is indisputable. But a few of them do not regard it as such, hence they make a living by means of grafting and imposing on their confreres. In this wise they persuade themselves to believe that the rank and file are non compos mentis, therefore they ask the Legislatures to pass laws giving them the right to "manage" the fraternity and regulate its affairs. To do that effectually, and in order not to arouse the suspicions of those who were more or less capable to reason, they formed State societies as adjuncts to a National one and advanced the following reasons (1) that the laws will weed out the "quacks", and the fact is that there are more quacks to-day than ever before-Vide editorial entitled "Cures" on page 537 of this JOURNAL for September, 1903, and please take a look around and you will see signs of all kinds of "healing arts"-and what is more they are constantly increasing; (2) that the laws would keep undesirable men out of the profession, and the fact is that there are more undesirable men turned out to-day than ever before (Vide page 1205, issue of May 7th, of the Journal A. M. A.), and the numbers of desirable and undesirable members are on the increase every year; (3) that the laws will shut down medical colleges, and the fact is that during the last ten years there have been organized and firmly established, good, bau and indifferent ones by the score. Thus, then, the laws have been "tried and found wanting." The highest tribunal in the land also decided not long age that any man has a right to start a "healing profession" based upon some reasonable ground; hence Magnetic Healing is practically a recognized profession, and one who is a "Magnetic Healer" is at liberty to go wherever the Stars and Stripes float and open a Magnetic Healing Parlor or office without paying a fee or submit to a "code." But what about the physician? What about the man who spent years in a medical college, and thousands of dollars before he was allowed to, at least, prescribe for the commonest everyday ailment? He cannot make a move. There are half a dozen physicians in each State who, by means of “law” and by virtue of greed, are imposing and holding up their confreres. In this wise, a man who graduates from a medical school must go before them and pay (what they please to call) a "license fee" and "pass" an examination. What they really want is the fee; because the laws in some States provide that from fees obtained they -Boards of Examiners and Registration-are entitled to so much per diem (usually from $15 to $25) for as many days as they are in session, and in other States all the fees. The examination is merely a pretense and secondary consideration. My reasons for this conclusion are based upon well known facts, to-wit: all medical colleges seek the best professional talent obtainable, and only those physicians become teachers who are more or less known to possess professional qualifications; and if these teachers who have supervision over a man for four years do not know whether or not he is qualified to practice, a Board of Examiners cannot ascertain that fact by means of a few questions within the space of two or three days; secondly, the fact that one passes an examination before a Board of Examiners does not prove whether he has had any preliminary training, and one who has not had such training is a poor addition to the profession; thirdly, medical col |