few months before examination did not know that she was anatomically different from other young women. She was reared by a maiden aunt who, while realizing that her charge was not normal, felt that as long as she was having regular bowel movements, she would put off any operative interference until later in life. The operation in this case consisted in closing the vaginal and orifice after dissecting the rectum free from the vaginal septum. There being present an infantile sphincter muscle at the normal anal site, an incision was made through the center of this, and by blunt dissection the tissues between it and the blind end of the rectum were separated. The rectum was then pulled down, opened and sutured to the integument. The perineum was not split open nor was the sphincter divided. A good functional result followed. His second case was also unmarried, twenty-three years of age. The case was very similar to Case I, except that there was an overdevelopment of the sphincter vaginæ which gave her good fecal control. There was present in this case a small fistula connecting the anus and vulva but not communicating with the rectum. In this case the perineum was split and the fistula dissected out. The vaginal anus was dissected free and brought down to the normal anal site in a manner similar to that pursued in Case I. The perineum was then repaired as in ordinary perineorrhaphy. The functional result in this case was also good. The author concludes from his experience with these two cases, and realizing the very high mortality from operations for imporforate anus, in infants, that when there is some abnormal outlet for the feces present, it is far better to allow patients to continue in their abnormal condition until they grow old and strong enough for surgical interference and the correction of nature's failure.

TUBERCULAR Fistula with eXTENSIVE INFILTRATION, WITH

SPECIMEN EXHIBITED.

SAMUEL T. EARLE, M. D., of Baltimore, reported a case of tubercular ischiorectal fistula, which on the skin surface, resembled an acute inflammatory condition ready to break down, yet when opened, it proved to be a dense mass of fibrous tissue with only a few tracts of necrotic tissue running through it. The patient was a policeman, age forty-five; robust and of a ruddy color, weighing one hundred and eighty pounds; no cough, no history of pulmonary trouble. Patient admitted to hospital, December 29, 1906. The left buttock was very much swollen and inflamed; there were several fistulous openings on its surface, which could not be followed far beneath the skin, and there was one of them that opened just to the right of the anterior commissure, into the anal canal. Upon laying open the buttock between two of the openings, there was exposed a mass of white fibrous tissue that seemed to be encapsulated, except at points which apparently were necrotic, which was adherent to the subcutaneous tissue. Supposing it to be a tumor, which had broken down in places, an incision was made, on either side near each lateral border, for the purpose of removing it, which was done. The mass measured 6x3x2 inches. It ran down to and some went between the muscles of the buttock, and in one or two

instances involved the same. The tract from the inner margin of the mass, to the opening in the anal canal, was then laid open and packed with gauze. The cavity left was so large that sutures were introduced to draw the edges partially together, and to hold in the packing. These were supplemented by adhesive strips. After the mass was removed, it was found to be composed principally of fat, with here and there a sinus which was surrounded by dense fibrous tissue from one-quarter to one-half inch thick, and there were found several large larva, supposedly of flies, deep down in the sinues of the growth. The tapering, tail-like process, that extended over the trochanter major, was composed principally of muscle. Upon miscroscopic examination, the growth proved to be tubercular. The patient made a slow but complete recovery. The large cavity filled in completely. The patient is now perfectly well and robust.

FISTULA IN THE POSTERIOR ANAL COMMISSURE.

J. COLES BRICK, M. D., of Philadelphia, stated that the anatomy of the posterior anal commissure is of such peculiar arrangement that ulcers or fistulæ, in this region frequently do not granulate in a proper manner. The greater part of the external sphincter muscle arises from the coccyx, and after forming the anococcygeal body of Symington, passes around the anus, forming a Y-shaped or triangular culdesac at the posterior anal commissure, making this the weeakest part of the anal circumference. The levator ani muscle is separated from the coccygeus muscle by a cellular interspace, rendering possible an easy extension of pyogenic organisms. In ulcerations or small fistulæ in the posterior anal commissure, it is the writer's custom to make a triangular incision with the apex toward the anus, rather than an anteroposterior cut. In cases of fissure in this commissure, two incisions, one-eighth of an inch deep are made down into the sphincter muscle on each side of the fissure, all fibrous tissue being removed from the fissure itself. The physiologic action is, that during defecation, the lateral fibres of the sphincter forming the triangular space are at rest, due to their division; thus saving distension of this space, and consequently no interference with healing.

MODIFIED TECHNIC IN RESECTION OF the rectum.

J. RAWSON PENNINGTON, M. D., of Chicago, showed numerous illustrations intended to serve as demonstrations designed and employed by himself and Doctor Gronnerud in resection of the rectum in a special case. The growth for which the method was employed extended upward from the upward border of the levator ani muscle for about two and one-half inches. A perineorrthaphy was first done, splitting the rectovaginal sepum back to Douglas' culdesac. The rectum was then dissected from its lateral and posterior connections upward until it could be pulled downward far enough to effect an end-to-end anastomosis, when the section, including the growth was removed. The incision was closed with buried catgut sutures, and silkworm-gut for the skin. The posterior vaginal flap covering up, as it did, the operating field, prevents the urine, vaginal and uterine secretions, from coming in contact with the wound.

ABDOMINAL MASSAGE IN THE TREATMENT OF CHRONIC
CONSTIPATION, ET CETERA.

T. L. HAZZARD, M. D., of Pittsburgh, Pennsylvania, referred to the fact that general massage had been practiced from very ancient times until the present for the relief of fatigue and for the purpose of increasing the flow of fluids in the blood-vessels, the lymph spaces and juice canals, by which more perfect elimination of waste is obtained and better assimilation brought about. Two conditions which, in his opinion, the relief of will do away with two-thirds of the slight ailments as well as of some of the more serious ones. He began massage for the relief of chronic constipation and was much surprised to find the far-reaching, adventitious effects produced. Among others, for example, that the chalky deposit in the joints in articular rheumatism, under careful, patient, persistent manual therapeutics as applied to the bowels, will entirely disappear more often than not. He mentioned no particular method, saying that any good textbook would give the technic sufficiently well. This manipulation is recommended not only for chronic constipation, but also for the relief of coprostasis, for which operation it is very frequently done. After indicating more of the benefits and some of the dangers of the method, the writer said that if this treatment called for more time than the physician or surgeon could spare, it had better be left off altogether, although the patient would surely lose a very great benefit. The paper closed with the remark that doubters as to the very great advantages which will accrue to the sick, in many, many ailments, has but to practice careful and intelligent massage to be convinced. INTESTINAL AUTOINTOXICATION: ITS TREATMENT BY IRRIGATION.

WILLIAM L. DICKINSON, M. D., of Saginaw, Michigan, said that during normal digestion, there are present in the intestine peptones, crystalline bodies, aromatic substances and ptomains, which are toxic, but changed into less toxic bodies and eliminated by the stools. Whenever their number is very great, relief is obtained by a profuse intercurrent diarrhea, while the remaining toxic bodies, having been acted upon partially by the digestive mucosa, are changed in the liver, then enter the circulation, and being further changed by the antitoxic glands, finally are eliminated through the skin, kidneys and lungs. Many patients have suffered for years, and, perhaps the greater part of their lives, from constipation, and the condition has been aggravated as they have grown older and more sedentary in their habits. There are well-marked symptoms in the autointoxicated. Among the prominent are: a drawn expression; sunken eyes; frequently the so-called lived spots; often the patient is pot-bellied and the skin is dry and harsh; it is quite common to have the bowels greatly distended by gases, shortly after meals, necessitating the loosening of the clothing; the breath is frequently very offensive; the odor of the stools is sickening, while the stools are constipated, hard, lumpy, and of small caliber or semiliquid and mushy, and upon examination mucus and membranes are found. Patients are often unable to concentrate their thoughts,

and there is loss of memory. There is great fatigue, and depression of spirits. Pruritus, urticaria, eczema, or furunculosis caused by intestinal autointoxication may be present. These are not all the symptoms that may arise from intestinal autointoxication but they are sufficient to emphasize the importance of the subject, and the necessity of having the intestinal discharges examined by a competent person before and during the treatment of the patient. An examination of the urine to determine the amount of indican present in cases of itestinal autointoxication can be made by any physician, but there are times when a laboratory examination must be made by an expert. The treatment must of necessity begin with careful attention to the kind and amount of food taken. Vegetables should largely replace meats, and in fact the patient will gain faster if meat is not partaken of at all. There should be a liberal use of water internally, drinking between meals two to three quarts of water daily. The treatment is not simple and is one that requires attention and generally a long time. The routine method is the administration of one-tenth grain of calomel and one twenty-fourth grain of podophyllin repeated every hour for eight or ten doses, followed with rochelle salt one-half ounce in six ounces of hot water every two hours until the stools are watery. The colon should be distended with warm water containing half an ounce of soda sulphate to the quart. The patient should be in the knee-chest position. The water should flow slowly, fully distending the bowels, but not causing pain. This washing out of the bowels should be done daily for about one week and the urine should be examined again for indican, and if it is found present, the indication is that there is need of another course of the calomel and podophyllin. The bowels should be made aseptic by the use of ten grains of sulphocarbolate of zinc to one quart of water used by enemata, retaining as much of it as possible. The treatment is to keep the intestine as clean as possible.

PERIRECTAL ABSCESS.

JAMES A. MACMILLAN, M. D., of Detroit, called attention to the fact that in a large proportion of cases of perirectal abscesses, the bacillus tuberculosis is present, and that next in importance as an etiologic factor, is the gonococcus. A diagnosis is most difficult when the abscess is located above the levator ani. In this location it is frequently found to be complicated with some disease of one or more of the pelvic organs. In this condition it is sometimes necessary to make an abdominal incision both for exploratory purposes and to rectify the condition. In the treatment of the perirectal abscess, however, the drainage should always be from below.

DISEASE OF THE COLON DUE TO EXTRAINTESTINAL CAUSES, WITH SPECIAL REFERENCE TO MEMBRANOUS COLITIS :— ILLUSTRATIVE CASES.

A. BENNETT COOKE, M. D., Nashville, Tennessee, pointed out the intimate functional relations existing between the several viscera of digestion, which is recognized by all, and stated that the anatomic relations of the alimentary tube and the frequency with which they are to be looked to for

the explanation of many of its pathologic conditions, have not received the serious consideration their importance demands. He also called special attention to certain familiar diseases of the colon, which are often found to exist primarily because of these relations, and the mechanical irritation. growing out of them. Perhaps, the most conspicuous of which, was cited membranous colitis. The writer recalled the great divergence of opinion that has always prevailed as to the true nature and pathology of this malady, and notwithstanding the conclusions of such authorities as Osler, Tyson, Hemmeter and others, that the disease is a secretion neurosis; he takes the contrary view held by many other equally careful and competent clinicians, who hold that there are always pathologic lesions that bear directly. upon the colon, either from without, as by pressure from other misplaced organs, or by adhesions, or by some local irritant from within to account for these cases. For present purposes the term membranous colitis is limited to that peculiar affection, which is characterized by the periodic discharge of mucus with membranes or casts from the bowel, and of which fecal stasis is always a prominent feature. With reference to this type of colitis, Doctor Cooke stated unequivocally that he had never seen a case in which he failed to find some gross pathologic condition of one, or more abdominal organs as well as of the mucosa itself; and furthermore, that the etiologic relation between the two has been clearly established in a number of cases by the prompt and permanent disappearance of the bowel trouble upon correction of the extraintestinal condition, after all other methods of treatment had failed. From this experience he had been led to conclude that the primary causes of this particular variety of colitis belongs in the main, if not exclusively, to a special class, namely, those which act mechanically. Most noteworthy in the list of such causes are enteroptosis, right movable kidney, peritoneal adhesions and extraintestinal growths which occasion continuous pressure upon some portion of the colon. He then discussed each of these causes in detail and supported his argument by the enumeration of well-illustrated cases.

NECESSITY FOR ROUTINE EXAMINATION OF THE RECTUM IN

INTESTINAL DISEASES:-ILLUSTRATIVE CASES.

DWIGHT H. MURRAY, M. D., of Syracuse, read a paper that was of special interest to the general practitioner and emphasized the necessity for rectal and colonic examinations in all cases of protracted diseases of the digestive tract, whether special symptoms are directed to the rectum and colon or not. In many cases of grastrointestinal disturbances the real cause may be found in the rectum or colon, if sought, though the patient gives no symptoms of such rectal trouble. These are amenable to local treatment. A thorough examination, including rectal and bacteriologic examination of the stools, should be made in every chronic intestinal case before beginning treatment. He advised that physicians should not treat patients who refuse to allow the necessary examination. He reported illustrative cases including so-called intestinal indigestion and dyspepsia, chronic diarrhea,