with illustrative cases. With this reasoning all the cases cured by medical treatment should be cured over again by operation at the proper time, as the danger of operating in the interval of attacks is less dangerous than the leaking appendix; a recurring attack ending fatally without operating, or with it, if the same is done in an emergency.

I object to tying off an appendix under any circumstances or leaving any stump of appendix within a ligature, nor would I approve of cutting off a piece of the cecum until the forceps have closed the wound and sterilized it by heat. I clamp the base of the appendix including a portion of the cecum. The forceps should have a very slender jaw, with edges beveled so as to form a groove when they are closed, in which the cautery slides, until their blades are heated to a blue heat. The bevel on the under side prevents cutting the serosa of the cecum where they compress it.

The appendix is then severed with a cautery, while the cecum is being held with forceps, not with fingers. The cautery is rubbed on the forceps jaws until the tissue in their grasp is desiccated (cooked). From five to seven Lembert sutures are carried through the cecum over the forceps jaw into the cecum again.

Then the forceps are unlocked and withdrawn from under the sutures, which draw the cecum together over the (cooked) cicatrix. In this way we have a complete closure without any stump whatever.*

After the appendix has been severed with the cautery the meso-appendix is transfixed and tied so tightly with fine silk as to arrest bleeding from the artery of the meso-appendix. It will be found much more convenient to ligate the meso-appendix after than before the appendix is severed. With this technique, the area about the work can not become infected from cecum or cut appendix, as is sometimes the case when we are working to invert or cover over the stump with peritoneum. I have completely inverted the entire appendix many times and *If there is a portion of the appendix infected, it is all infected, and nearly always a portion of the cecum in and about the cecal orifice of the appendix, is infected or ulcerated. In many instances where I have opened an abdomen the second time, the "button" beyond the constricting ligature on the pedicle is not to be found. Any "button" left beyond the ligature on an appendix must be cast off and infect the serous membrane which has been used to cover the stump. Again, the vitality of the cecum near the appendix is impaired by depriving it of blood, when we ligate the vascular meso-appendix to control hemorrhage from its artery.

tried nearly every technique, but step by step have evolved and used this method with much satisfaction. In every abdominal section I ask after the health of the appendix, and if the blood vessels are prominent on the outside, I conclude there is microbic infection with catarrhal inflammation on the inside and it is removed. Holding the cecum with these forceps obviates the handling of the serous covering of intestines and wound, and the additional operation scarcely adds a danger to our other work.

The following conclusions are warranted by our observation and experience:

First-The unqualified dictum, "operate as soon as the diagnosis of appendicitis is made" is unsound, unsafe and often pernicious.

Second-Appendicitis is a disease demanding surgical treatment at the hands of the expert in abdominal work for the reasons: (a) In no abdominal operation is so thorough mastery of the principles and technique of asepsis necessary. (b) The operator with an experience of hundreds of abdominal sections can give the patient a better chance of life than one who occasionally opens an abdomen. This need not deter any surgeon or physician from operating in an emergency.

Third-After an attack of appendicitis the patient is carrying an open communication between the intestinal lumen and the peritoneal cavity, which if temporarily closed, may open at any time by absorption of the exudate, or adhesions which have temporarily closed the leaking sinus.

Fourth-The cases cured (?) by medicine should, during their convalescence from the cure (?), be submitted to a surgical cure in fact, not in fancy, for the reason that operation in interval of attack is less dangerous than medical cures.

Fifth-All cases in which an appendical abscess has been opened come under the same head as medical cures (?) and demand surgical cure in fact, not waiting for a second explosion of dynamite.

Sixth-Who would think of living in a house with a bursted, leaking sewer, sending out microbic infection and poison, depending on the debris of filth, feces and fungous granulations or accumulations to hermetically seal up the opening. It would be contrary to all the best principles of correct science of good surgery and of sound sense.

Seventh-"Surgery should be as the hand-maid of medicine, not supplanting her mistress nor yet usurping her rights, but rather assisting her to maintain them."

METALORGANIC HEMATOTHERAPY.

By DR. E. C. HILL,

Denver, Colo.

Iron is the life of the blood, as it is of the leaf. It is the ferryman of the miniature boats that carry oxygen to the ever hungering tissues. Though constituting but one-hundredth of one-hundredth of the total weight of the body, it is not outranked in vital importance by any of the other sixteen corporeal elements.

Dried hemoglobin yields .42 per cent. of iron. The hemoglobin content of a given quantity of blood can be estimated directly from the amount of contained iron, but the color tests are commonly employed because of their much greater convenience.

Oligochromemia, or diminished hemoglobin, is observed in a large number of morbid conditions. In chlorosis the decrease is marked both absolutely and relatively to the reduction of the number of red cells-a pathognomonic feature. In the secondary anemias, such as complicate tuberculosis, infectious fevers, gastric ulcer or malignant disease, the diminution of coloring matter is parallel with the oligocythemia. In progressive pernicious anemia, on the contrary, there is relative excess of hemoglobin, or a high color index. Hemoglobin reduction is noticed further in leukemia, pyemia, typhoid fever, obesity, rachitis, hepatic cirrhosis and renal dropsy. The rare state of absolute hemoglobin excess is met with in pulmonary stenosis and at times in diabetes mellitus.

The symptoms pointing to deficiency of iron in the blood are those of chloroanemia, namely, fatigue and breathlessness on slight exertion, cardiac palpitation, vertigo, syncope, continued headache worse on standing than lying, neuralgias, persistent pain in the splenic region, backache, apparently causeless nausea and vomiting, and amenorrhea or dysmenorrhea. Slight fever is a not uncommon accompaniment. The pulse is rapid, full, soft and compressible, but usually regular. There is persistent pallor in all cases, varying from the simple lack

of color of secondary anemias to the greenish yellow tinge of chlorosis, or the smooth, waxy, lemon tint of pernicious anemia. Slight dropsy is not uncommon, beginning almost invariably about the ankles. The hands and feet are often cold and clammy. Soft or loud but distant basic systolic murmurs are frequently observed, and the humming top murmur over the right jugular is highly diagnostic. Hysteria and neurasthenia are familiar complicating affections.

To restore the blood to its pristine normal state we must first of all devote earnest attention to the elimination of causal factors, whether simple malnutrition, intestinal autointoxication or infectious heterotoxemia. The cardinal remedies are fresh air, sunshine, rest and abundant nourishment of the proteid class, particularly eggs, milk, red meats and bone marrow. Cakes and pies and candies are to be eschewed as baneful in the extreme. Make the bowels move if they don't of their own accord, drink at least three pints of water daily, go to bed at 9 o'clock after a cold salt sponge bath and a rough rub-down. And withal take iron.

When we consider the fact that an ordinary beefsteak contains as much iron as is in the human blood current, it would seem a very easy matter to repair any deficiency thereof. Clinical experience, however, demonstrates that it is not altogether what we take into our stomachs that feeds us, but rather what is taken into the blood. While almost every physician uses iron in some form in the treatment of anemias, each is apt to differ somewhat in his preference among the forty-three official and numerous non-official preparations of this metal. An old favorite has been the tincture of ferric chloride, which on account of the free hydrochloric acid it contains, is a valuable stomachic tonic in cases of hypochlorhydria. On account of their acid constituent, the mineral salts of iron are generally astringent and constipating in action; in large doses they are quite irritating and have even proved fatal. The hypophosphite and iodide of iron are useful chiefly as vehicles for the metalloids which they represent. Of the mineral acid salts of iron the pyrophosphate is probably the least irritating and is said to be non-constipative. Metallic compounds are commonly absorbed into the blood as albuminates; hence the advantage of taking them in milk.