always limited to the sigmoid; it frequently involves the descending colon as well; in addition to the contraction of the gut, it loses also its resilience, which further adds to the difficulty of the passage of fecal débris. The etiologic factor is the absorption of bacteria. and toxic products from the sigmoidal contents. The mesentery is also involved and is thickened and shortened. The whole process is chronic, several years being required to bring on the condition. Surgery offers the only relief; an anastomosis must be effected by any suitable surgical procedure between the unaffected position of the intestinal tract above and below the lesion.

A Report of Two Cases of Sigmoidopexy.

DR. S. T. EARLE, Baltimore, Md. In one of the cases there was the third degree of prolapse of the rectum, the invagination of the upper part into the lower portion of the rectum; in the other case there was a very acute flexure of the sigmoid upon the rectum. Both of the conditions, as is well known, are frequently due to an abnormally long meso-sigmoid. The symptoms in each case were obstinate, and persistent constipation, frequent bearing-down pains in the lower pelvis, a sense of weight, and especially a feeling of unrelief for some hours following a stool, or an attempt at the same; associated with these local symptoms were darting pains in various parts of the body, nausea, anorexia, frequent headaches, and the various neurotic symptoms that go to make up a typical case of neurasthenia. The case of invagination was diagnosed positively by a digital examination while straining at stool, the sulcus being distinctly felt with the finger; the case of acute flexure was diagnosed by means of the proctoscope, the flexure being so acute that it was only possible to enter the sigmoid with the proctoscope by getting the end of the latter around the flexure and pulling it aside. The flexure was so acute that it obliterated the lumen of the bowel at this point. The technique of the operation is such as given in Tuttle and Gant's works on "Diseases of the Rectum and Anus." I met with no special difficulty in performing the operations. The meso-sigmoid was very long in both. I was particular in pulling off the abdominal peritoneum where the sigmoid was to be held in apposition, and also in attaching the sigmoid to the transversalis fascia. Both cases made good recoveries, except that one was retarded by a stitch abscess. The results in both cases were most satisfactory and pronounced, with almost immediate relief of the persistent and obstinate constipation, with the gradual disap

Dp. Lewis H. ADLER, JR., Philadelphia, Pa., in a paper entitled "Fecal Impaction,' called attention to the result of obstipation, or an attack of constipation causing an accumulation of feces in the cecum or in any part of the colon; but the term impaction, the subject of the paper, should be usually employed when such accumulation occurs in the pouch or ampulla of the rectum, or in the sigmoid flexure.

Attention was called to the difference between an ordinary persistent constipation and an impaction, as the latter may follow from a single attack of constipation; whereas, obstinate constipation may never, or only after a long period, cause impaction. The symptoms of the two conditions are also very different, as an impaction is usually marked by a diarrhea, whereas chronic constipation is associated with costiveness. After calling attention to the various causes of the malady under consideration and the symptoms of the same, the treatment was detailed as consisting primarily in the removal of the mass, and, secondarily, in the relief of the inflammation of the mucous membrane occasioned by the irritating presence of the fecal matter, as well as the removal of all causes which contribute to the const pited habit, which is undoubtedly the prime factor in most cases in producing an impaction.

The easiest manner of breaking up the fecal mass is to put the patient under an anesthetic and then to forcibly divulse the sphincters, after which the mass may be disintegrated by means of the finger, a lithotomy scoop or an old-fashioned iron spoon. In women considerable assistance may be rendered by passing a couple of fingers into the vagina, and by this means steadying the mass so that it may be the more readily broken. In some instances the writer was able to break up an impaction without resorting to anesthesia, simply by using the finger and sometimes by the additional use of a bivalve speculum and a rectal scoop or spoon.

Previous to resorting to instrumental aid in

the removal of the impaction, the fecal mass may be softened and its passage facilitated by the use of enemas; especially is this so in cases in which the sigmoid is the part affected, in which situation material assistance cannot be gained by the employment of instruments. For the purpose of administering the injection a douche-bag holding several quarts is to be preferred. The injection substance should be composed of soap and water, to which I have found the addition of glycerine of considerable benefit, a dessertspoonful to a quart. When the impaction is in the sigmoid the injection should be given through a Wales bougie, preferably the one modified by Dr. Dwight H. Murray, of Syracuse, N. Y., which is stiffer than the ordinary article sold, which latter is frequently useless for the purpose intended, as it readily doubles on itself, and a high injection is rendered impossible by its use. When this method is employed the patient should be placed in the knee-chest posture.

A word of caution should be given here as to the danger surrounding the unguarded use of drastic purgative drugs in cases of impaction. By their employment peristalsis is increased and the fecal mass softened, but the bowel in its inflamed and distended condition may be thereby the more easily ruptured, and if, in addition, a stricture is present, the calibre of the gut may be entirely cccluded by forcing into it the hard fecal mass, with the attendant symptoms and consequences of total obstruction of the intestines. So much for the treatment of the actual impaction.

Pruritus Ani: Is it a Disease Per Se or Merely a Symptom?

DR. LOUIS J. KROUSE, Cincinnati, quoted from the works of Bodenhamer, Agnew, Wright, Ball, Crepps, Gant, Matthews, Tuttle and others, their opinions regarding the etiology of this disease and then stated: "Pruritus ani essentially is a disease which is due, nct to a local, but to a constitutional cause, and is due to some trophic changes in the nerves supplying the parts." He further stated that the changes occurring in the skin of the anus and surrounding parts, namely, the hypertrophy, the loss of pliability, and the absence of pigment, can only be explained on the faulty nervous supply of the parts. He showed that an increase of pigment ought to accon pany severe itching, and not a total disappearance, and finishes his article by saying that "the absorption of the normal coloring matter of the affected area does occur, notwithstanding that the epidermis was not destroyed; a similar process of absorption takes

place in leucoderma." He said that all authorities acknowledge that the cause of the latter disease is to be found in the nervous system, and concluded with the statement that "pruritus ani, at least in such cases, is a disease per se and not a symptom."

New Instrument; Case Report.

DR. DWIGHT H. MURRAY, Syracuse, N Y., presented a new hemorrhoidal clamp which had the following qualities, in combination, that make a first-class instrument, viz., scissors-shaped, parallel jaws; can be closed and released instantly without the use of a thumb-screw, thereby saving much time while operating. The Goodell dilator reversed is used as the ground principle for the lock.

Dr. Murray also reported the case of a man, forty-eight years old, who had been troubled with sciatica in the right leg for two years, and had also been a sufferer from hemorrhoids for ten years, having frequent profuse hemorrhages therefrom. The hemorrhoids had not been treated. The sciatic nerve had been stretched and treated by various methods, by a physician at his home town, included in which was the following, completed in three sittings two days apart: At the first sitting, six hypodermic injections, 1-150 gr. of atrophine each, were given into the sheath of the sciatic nerve. At the second sitting seven injections of the same amount, and at the third sitting eight injections were given as before, and one extra into the nerve before it leaves the pelvis. The patient was unconscious for fourteen hours after the last sitting; very little improvement resulted.

In November, 1906, the author was first consulted, and on December 12, 1906, operated on him for internal hemorrhoids. He made the usual recovery up to the nirth day, when there was a sudden profuse secondary hemorrhage. The patient was almost exsanguinated before the author arrived. He immediately examined, found the superior hemorrhoidal artery was throwing a full-sizel stream; this was secured, the patient stimulated and made an uneventful but slow recovery, The patient has had no sciatic pain since the operation.

Dr. Murray concluded that, inasmuch as sciatica is often symptomatic, that no such severe treatment is justified until all possible reflex causes are first removed. The cause of the hemorrhage was probably due to the thrombus or eschar at the end of the vessel being thrown off before thorough healing had taken place, and was influenced largely by his general anemic condition before the operation.

The Treatment of Ischio-Rectal and Pelvi-Rectal Abscesses.

DR. T. CHITTENDEN HILL, Boston, Mass., said that he employed general anesthesia produced with ethyl-chloride for the ischio-rectal abscess and ether anesthesia for the pelvirectal abscess. His experience with infiltration anesthesia has been unsatisfactory. He emphasized the importance of an early incision for peri-rectal abscesses, claiming that when acute symptoms have existed for a day or two, with pain and tenderness, even before there is much edema or discoloration of the skin, long before fluctuation can be detected, an incision may prevent abscess formation by allowing the escape of blood or serous exudate from the engorged blood-vessels. He advised a T-incision and breaking up the existing septa with the finger, after which the sphincters are divulsed. He believed squeezing, scraping or disinfecting an acute abscess to be a great mistake, as it only serves to destroy the new granulation tissue and to spread the infecting bacteria. For the deeper ischio-rectal and in all pelvi-rectal abscesses he recommended rubber drainage-tubes, discarding their use as quickly as possible in the after-treatment. Cryptitis.

DR. J. COLES BRICK, Philadelphia, Pa.: The anal valves and crypts, first pointed out by Morgagni, and called after his name, are found as vestigical remains of the junction of the rectal mucous membrane with the skin. They vary in number and size, but are absent in the anterior and posterior commissures. They have no known functions, but are the cause of obscure symptoms when diseased, and from the fact that the valve or covering part of the crypt may conceal the diseased area, repeated examination will fail to show the lesion, unless each crypt is probed, when tenderness or pain will be felt. A conical fenestrated speculum is the best to use, and when the diagnosis has been made the valve should be removed and the crypt converted into a raw surface, so that healing will obliterate it.

Observations on Certain Points in the Anatomy and Physiology of the Rectum.

DR. A. B. COOKE read a paper with this title. He expressed the view that the usual conception of the external sphincter muscle is erroneous; that under normal conditions it is not in a state of tonic contraction, but, on the other hand, is at rest and passive, the shape of the muscle and the arrangement of its fibres being such that the anal aperture is

It

maintained in a state of passive closure. is not conceivable that a voluntary muscle should require the constant action of nerve force to keep it in a state of rest. The only action of this muscle is to voluntarily oppose or terminate the act of defecation by tonic contraction.

With reference to the internal sphincter, the essayist observed that there is no occasion to credit this muscle with any special action in addition to that of the circular coat of the bowel, of which it is a part. By reason of its location and thickness, it probably exercises some passive sphincter control, but its chief action is undoubtedly that of a detrusor, serving to complete the expulsion of feces and keep the anal canal free of contents.

The levator ani muscles, acting together, constitute the sphincter of the proximal extremity of the anal canal. To understand this it is only necessary to remember (1) that the upper or pelvic surface of these muscles presents a deep, funnel-shaped concavity, the beginning of the anal canal being at the lowest point; (2) the strong bundles of fibres which unite immediately behind the rectum arise in front from the pubis and anterior portion of the fascial line and pass downward and backward in close relation with the lateral walls of the rectum, crossing it obliquely at the upper limit of the anal canal.

The well-known difficulty of voiding urine while a costive stool is being expelled, which is usually attributed to the action of the levatores ani, is due rather to the pressure of the fecal mass upon the prostatic and membranous portions of the urethra, since, at the time of defecation, these muscles, like the sphincters, must be in a state of relaxation.

The part played by the anal canal in defecation is purely passive, except at the completion of the act, when the voluntary muscles which enclose it are strongly contracted, expelling any remnant of feces and bringing its walls again into their normal relation when at rest of close apposition.

The essayist dissented from the commonly accepted teaching that there is an inhibitory centre in the cord which presides over the action of the external sphincter and which is called into action at the time of defecation to inhibit its tonic. The relaxation which occurs at such times seemed to him fully explained by the mechanical pressure of the descending mass upon a structure which only offers passive resistance unless contracted by voluntary effort, and which possesses sufficient resilience, independent of any nerve influence, to regain its normal form and tone as soon as the pressure is removed.

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SATURDAY, AUGUST 10, 1907.

NO ROOM FOR PESSIMISM. Poor, disillusioned Dr. S. A. Mereness, in the New York State State Journal of Medicine, admits that to him "there is nothing more discouraging than the fact that our work, in its last analysis, largely comes to naught. Grant that, by our advice and ministrations, a life has been saved or prolonged. What then? If the life is a valuable one; if without it nature and humanity would have suffered loss, then we have done well, but if that life would have been neutral, or productive of actual harm to society, then you may draw your own conclusions as to the worth of those services."

In the general rush of optimism in which the average American finds himself these days the above is refreshing by contrast. And yet, who has told Dr. Mereness that our work comes to naught? If the great masters in medicine, who did their work so simply that they never realized the great things they were accomplishing, had spoken thusly, would drainage of pool and marsh have prevented the incubation of mosquitoes, or vaccination have robbed variola of its terrors, or antitoxin rendered diphtheria a mere trifling indisposition? Did pessimism banish cholera and yellow fever and puerperal infection? And who is to judge whether a life we have prolonged is "neutral or productive of actual harm to society?" These are relative terms. Our duty is to save life and to relieve suf

we may enable the dormant spark of divinity. in every bosom to kindle and to warm untold thousand? The true physician cannot be a stern judge. Neither can he be a pessimist. He has no time or inclination for either.

IN QUEST OF ELUCIDATION. Prof. John Uri Lloyd, of Cincinnati (Eclectic Review), says: "I want no doctor to treat my family who establishes the value of his remedies by injecting them into healthy dogs. Give me the empiricist who watches disease expression and the action of remedies in disease expression, and who reads after men whose remedies were established in the same way, and I will call him the scientist in medicine, believing that the man who establishes his practice by injecting his remedies into the veins of healthy animals is more of an empiricist, and a visionary empiricist at that."

Considering the eminence which Prof. Lloyd has attained as Lloyd has attained as a chemist, it seems especially to be regretted that he gave utterance to such statements as the above. The wonderful progress which has been achieved in medicine has been the result of careful research. It would have been impossible to experiment on human subjects in a manner necessary to establish an hypothesis. The experimental laboratory was essential to medical progress, and the men who sought verification of their theories were actuated by the noblest motives that ever stirred the human breast. If a lower animal was made the subject of experimentation it was to save more precious human lives. If the great boons which were handed to society by these scientists could be withdrawn, would Prof. Lloyd be willing to have us sink again into medieval ignorance and filth and disease, simply to save a few animals? Would he substitute human beings, since he must grant the necessity for experimentation? Would he permit a physician to experiment on him with an unknown alkaloid, for instance? If he had a mitral lesion and his medical adviser proposed to try some extract

of aconite root, because, forsooth, the hitherto unknown drug might possibly be equal to digitalis-would he permit it? Were he suffering from cerebrospinal meningitis, would he take large doses of strychnine just isolated from strychnos nux-vomica? Suppose some one near and dear to him were indisposed, and before the diagnosis were fully established a friend treated the symptoms empirically with tinctures of unknown strength, because not yet standardized, would he close his eyes and trust to luck that the untried remedy would not kill? There is the su

preme test.

The question naturally arises: How did the followers of his school determine the physiological action of their "specific" medicines? Did they experiment on human beings, since they could not try them on a dog? How did they originally learn what were cardiac sedatives and 'what were cardiac stimulants? How came the knowledge that certain drugs were diaphoretics, eliminants, emetics, emmenagogues, expectorants, hypnotics, mydriatics, oxytoxics, tonics? Did some great soul immolate himself on the altar of science and permit the eclectic empiricist to acquire priceless knowledge from his quivering body? Or did the sick unwillingly and ignorantly furnish the requisite material through the century that an eclectic materia medica was formulated and perfected?

There is no desire in presenting these questions to be supercilious. But when the leading scientist of the eclectic school makes certain surprising statements it is meet and proper for the old-school physician to ask for enlightenment.

WHEREIN POPULAR EDUCATION HAS FAILED.

In an article by Harold Williams, in Annals of Gynecology and Pediatry, the reason wherein. popular education has failed is put succinctly. It has failed, according to Dr. Williams, “because in our leading American universities fifty hours per week are devoted to Greek, while not a single hour per week is devoted to the study of the etiology and prevention of disease." Undue time has been

spent in imparting knowledge of comparatively little importance in life, and none has been spent in inculcating upon the minds of the young the lessons necessary to develop their instinct of self-preservation, which includes the knowledge how to prevent infection of every sort. Classical education leads to refinement and to gentility, and the graces of life must be cultivated. We need no Lord Chesterfield to insist on their importance. And yet, if the over-educated young person ignorantly contracts an infectious disease which may ruin his entire life all his laboriously acquired knowledge of the Greek author and of the theorems of Euclid will not prevent his being miserable and unhappy. The curriculum in our high schools and colleges should be changed. The abrogation of useless studies, the modification of a number not so essential, and the addition of others which twentieth century enlightenment proves to be necessary- these things will render popular education a complete success.

HOW GARRIGUES BANISHED PUERPERAL INFECTION.

Brooks H. Wells, in an address before the American Gynecological Society at Washington, May 8, 1907 (American Journal of Obstetrics), spoke in appreciation of the work of Henry J. Garrigues in the New York Maternity Hospital in 1883. Up to that time the mortatity in lying-in hospitals was frightful. It was explained by a "specific puerperal atmosphere" that caused "puerperal septicemia." septicemia." Few believed that it was a septic infection, and that the obstetrician was responsible for its occurrence. Holmes and Semmelweis gave the first hints as to the real nature of the infection, but it remained for Henry J. Garrigues to deal adequately with the situation. His method was this:

Frequent fumigation with sulphur was practiced, followed by scrubbing with soap and water and by a 1:1,000 bichloride solution. Fresh bedding was furnished at each change. The floors were sprinkled four times daily with the bichloride solution. Visitors were excluded. Doctors and nurses employed in the maternity were not allowed to enter other