adhesions exist, the rectum may easily Diverticulitis of the sigmoid may cause symptoms very like pelvic cellulitis and acute salpingitis. Because of the mobility of the sigmoid, the inflammatory mass in which the diverticulum is included may be on either side of the median line and be so deep that it cannot be distinguished digitally from an enlarged ovary or tube. Pelvic cellulitis often goes on to abscess formation with sometimes rectal stricture resulting. Appendicular abscesses also sometimes rupture into the sigmoid colon. Retro uterine abscess invading the - pouch of Douglas is associated with pain high up in the rectum occurring on defecation and this pain continues long after the abscess has been relieved because of the scar. Pelvic abscesses of gonorrheal or tubercular nature are made much more virulent by the mixed infection caused by adhesions to the rectum which permit the migration of intestinal micro-organisms into the abscess cavity. Hemorrhoids-A form of vicarious menstrual loss is the increased tendency of hemorrhoidal veins to bleed at this time when no actual hemorrhoids may exist. As extrarectal causes of hemorrhoids we must remember diseases of the heart, liver, lungs and atheroma of the vessels. Valvular insufficiency of the right side of the heart, through the venous back pressure and hepatic engorgement which it causes, induces hemorrhoids because the hemorrhoidal vessels cannot empty themselves. Cirrhosis of the liver acts similarly and causes piles. The female reproductive organs are particularly prone to reflex disturbances due to rectal pain. The close anatomical and physiological relation of the bladder and rectum often gives rise to disturbed functioning in either organ, probably by way of short circuit spinal impulses. The operation for hemorrhoids is frequently fol No case of dysmenorrhoea or other pelvic phenomena can be thoroughly examined or treated intelligently without first having examined the colon, rectum and anal canal even more thoroughly than the genito-urinary tract. Why pathologists have so failed to recognize this viscious circle in the pelvis and the fact that most cases of pelvic diseases in women have their real origin in the colon, rectum or anal canal is due perhaps to the fact that those of us who specialize in the treatment of one particular organ or system of organs are too prone to forget there are other organs or tissues in the body that are also of importance in the making up of our diagnosis. The Far-Reaching Effects of Rectal Dis eases Upon the General Health. In an interesting study of this subject, Dr. A. L. Douglas in Colorado Medicine (Nov., 1920) writes as follows: The common diseases affecting the rectum are hemorrhoids, fissure, fistula, papillitis, cryptitis, fibroid growths and proctitis. Any of these diseases except possibly fistula may go on for years with out any great amount of distress as long as the pathological process remains above Hilton's white line. It is only when the disease reaches below this line that the patients are aware, through subjetive symptoms, that they have any rectal trouble, and for that reason they neglect to mention the rectum when consulting their physician, thus allowing a possible simple condition to develop into a cancer, stricture or some other serious disease. In the meantime, while these conditions are developing, the patient will be taking treatment for constipation, headaches, spinal trouble, rheumatism or other group of symptoms without relief, when a thorough examination of the rectum and anus would reveal to the attending physician the underlying cause. some The sigmoid corresponds to a trap under a sink, with this exception, however, that when the sigmoid becomes filled it will automatically empty itself into the rectum, and this is when we have our first warning that there is something to be evacuated. The disarrangement of this beautiful automatic action brings about a general stasis of the whole colon, and more or less accumulation of waste material remains permanently in the rectum, sigmoid, transverse colon and cecum. Keeping this in mind, one can readily see how rectal diseases may be responsible for at least fifty per cent of the cases of acute or chronic appendicitis. Any little growth just within the rectum, such as an elongated papilla, small ulceration near the crypts, a small fissure or a foreign body will develop some of the most distressing symptoms in other parts of the body, such as headaches, bladder irritation, rheumatic pains in the back and lower limbs, profound depression of spirits or extreme irritability, due to the resultant disturbance of the sympathetic nerves and absorption of toxins. Much Worse. Local Anaesthesia in the Treatment of The use of local anaesthesia, in the treatment of ano-rectal diseases, is not a new practice, says Dr. L. E. Moon in Medical Herald (April, 1921) but it is one that should receive more attention by the general medical profession than it does. He states that: We are neglecting our patients by allowing, in some cases unintentionally persuading them, to go to the quack, by trying to force them to submit to a general anaesthetic for some minor ailment which requires but a few minutes' work with a local anaesthetic. By doing the minor operations in the office, or the home, the patient is saved both time and the hospital expense and the convalescent period is generally shortened. Among the anaesthetic solutions which have been and are being used at present are sterile water, ethyl chloride, quinine and urea hydrochloride, apothesine, beta eucaine hydro-chlorate, and the lactate, alypin, stovaine, novocaine or procaine, and chloretone, as well as several others. In my work I prefer to use procaine as I have found that it does give a quicker and more complete anaesthesia, with less pain during injection, and I have had no serious complications following its use. With the procaine solution I always combine the adrenalin solution as it then gives you a bloodless field while operating. The preparation for operation in these cases is not unlike that for any rectal operation excepting the fact that the patient is allowed to take a light diet. I always advise giving morphine and atropine one hour previous to the time of the operation as the patient will be less apprehensive and will have less pain after the procaine ceases to act. One must always keep in mind the fact that the anaesthetic dulls only the sense of pain and that the touch sense "Have you a little fairy in your and hearing and sight are unaffected. home?" So all handling of tissues should be done "No, but I have a little miss in my gently and there should be no rattling and display of instruments. engine." It is quite generally conceded among American surgeons that the clamp and cautery operation is the most satisfactory for internal hemorrhoids, but it is not done very frequently with local anaesthesia. I have found this operation to be the one which gives me the most satisfactory results and am now doing it under local anaesthesia. In my work I use a small electro-cautery knife which the patient does not see. It is heated without noise, and by placing moist sponges beneath the blades of the pile clamp, after it has been placed in position, you eliminate the conduction of heat to the buttock. Many good operations are made a failure by lack of attention following the operation. It is not enough to remove a bunch of piles, stick a rubber tube in the rectum and leave nature to do the rest. Instead of using a Pennington Tube, which acts as an instrument of torture, I fill the rectum with an ointment with an anodyne incorporated. On each succeeding day until the wound is healed I apply Unguentun Zinc Oxide or some.similar non-irritating ointment. The patient is then instructed to return at intervals, according to the operation, for inspection, dressings and treatments. I fthe patient leaves the city, instructions are sent to his home physician, or he is instructed how to care for himself. The Incidence of Kidney Infections in Acute Appendicitis. Dr. R. M. Harbin in Southern Medical Journal (Feb., 1921) asserts: In a series of nine hundred complete examinations by our associates during the present year, there were one hundred and twenty-five consecutive laparotomies for intraperitoneal diseases in which there were thirty-two cases of acute appendicitis, while there were fourteen abscess cases, the diagnosis of which was not called in question. In this series there were four cases associated with active kidney infections, and it is very common to find that a case of suspected appendicitis turns out. to be a kidney infection. In the absence of routine methods, this discovery may be made after operation, especially in cases of pregnancy. But this phase of the question does not concern the present discussion. Right-sided symptoms of infection of the renal pelvis and ureter interfering with drainage very closely resemble those of acute appendicitis, and the difficulty we have experienced in differentiating these uncommonly coexisting conditions justifies the attempt of a detailed report of same. We frequently have the one or the other of these two pathologies to eliminate in diagnosis, and in their coexistence a failure to recognze the presence of actual appendicitis constitutes a serious danger. We are prone to discard the diagnosis of appendicitis upon the discovery of characteristic findings of renal infec tion. In dealing with a case of acute appendicitis, it is of utmost importance to make an early diagnosis. At first this is easier to do, since duration of the disease only increases the difficulty of diagnosis. Of course, it is easier to establish the presence of a kidney infection than it is to diagnose appendicitis. It should be borne in mind that there may be pronounced history of bladder symptoms with an entire absence of evidences of kidney pathology. The association of these two pathologies leads us to believe that they are of common origin, and that they have proceeded from infected tonsils, abscessed teeth, colds, etc. The infection semes to have a selective action. In chronic diseased conditions of the kidneys and appendix, the problem of diagnosis is not urgent and is more easily worked out. By the use of ureteral catheterization and the x-ray, renal pathology can be excluded. Yet failure to carry out these details is reflected in statistics by Judd (Annals of Surgery, February, 1920) who reports fifty-four cases out of four hundred operations for ureteral stones, or 13 per cent, who had been appendectomized elsewhere. He concludes as follows: 1. While mechanical conditions of the appendix may be at times a causative factor, these observations warrant the belief that there are metastatic infections of the appendix and kidneys that seem to have a selective action and point to the existence of some common focus. 2. A greater danger lies in assuming that the actual symptoms of appendicitis are of kidney origin and in suspicious cases extreme caution should be practiced before excluding the diagnosis of appendicitis in the presence of evidence of renal pathology. 3. The characteristic first day's clinical data of an increasing leucocytosis with moderate temperature in the presence of albumin, blood and casts in the urine would tend to prove the existence of an acute appendicitis. In order to avoid contamination it is important that specimens of urine should be obtained by catheter. 4. In the absence of violent symptoms of appendicitis, there may be cases. of doubt in which it is prudent to deliberate for twelve to tweny-four hours for additional leucocyte readings, which are usually progressively higher in appendicitis. The Prophylaxis and Treatment of Gallstone Disease. Surgery has a distinct place in the treatment of gallstones, but the treatment of gallstone disease may with truth be said to be entirely medical. According to Dr. Samuel Weiss in Medical Record (May 22, 1920), the general medical treatment of gallstones, and the various manifectations of the same, may be considered under the following heads: The prevention of stagnation of bile; the prevention of the occurrence of catarrhal inflammation of the gall-bladder and bile ducts; the removal of catarrhal inflammation when it has appeared; the attempts to remove calculi from the gall-bladder and the ducts; diet, spa treatment, vaccines and local therapy. Stagnation favors infection, cholecys titis, and hence the production of gallstones, or if these are already present, an immediate attack of colic. It is therefore important that stagnation should be prevented as far as possible and for this object the following methods. may be adopted: 1. Exercise leads to increased movements of the diaphragm and liver and so to an increased flow of bile to the duodenum. Horseback riding is perhaps the best, but cycling, climbing, rowing and tennis are excellent. Deep respirations should be practiced, so as to induce vigorous movements of the diaphragm and the liver. After pregnancy, the lax condition of the abdominal wall which favors enteroptosis, hepatoptosis, and stagnation of bile may be met by massage of the abdominal muscles, care being taken not to bear directly on the gall-bladder, since cholecystitis may thus be set up. 2. Attention should be paid to the dress; the corset, tight waist bands, and heavy skirts should be avoided. 3. Meals at short intervals are more effective than large meals at long intervals. In addition some supper should be eaten before going to bed. When food passes into the duodenum, bile is driven out of the gall-bladder into the duode num. 4. Vichy, Carlsbad, or hot water containing sulphate or phosphate of soda may have a good effect and act as a cholagogue. In order to get the maximum effect from the water, it should be taken before meals when the stomach is empty. The water should not be taken in excessive quantities or too hot, otherwise dilatation of the stomach may occur. 5. Although a number of drugs have been credited with the power of increasing the secretion of bile, it is now generally agreed that salycilate of soda and bile salts are the only drugs. Salicylate of soda also acts as an intestinal antiseptic tending to diminish intestinal catarrh. In the prevention of catarrhal inflammation it should be remembered that indigestion and gastritis, by leading to gastroduodenal catarrh, might set up catarrhal inflammation of the bile ducts, which must be treated by careful diet ing, drugs, and the prevention of constipation. For this purpose my usual prescription is an old formula of the late Dr. William Hanna Thompson, consisting of phosphate of soda, 2 oz., salicylate of soda, 3 drams, and benzoate of lithia, 1 dram, divided into twelve powders, one powder to be taken in a glass of hot water and sipped slowly on rising every morning. A half tumbler of natural Carlsbad water with a little hot water before breakfast or one or two drams of Carlsbad salts dissolved in hot water are useful. The Carlsbad salts are better borne by the stomach if a little infusion of quassia or cinchona is added to the draught. After taking the salts, the patient should walk about, or better, practice systematic exercises with deep inspiratory movements to favor the descent of the diaphragm, and should not have any food until an hour after the draught has been taken. Worry and anxiety are frequent causes of dyspepsia, and in this way may be instrumental in favoring infection of the ducts and gall-bladder. Focal infections such as pyorrhea, sinusitis or a chronic appendix may be the starting point of a cholecystitis, and this way predispose to the formation of calculi. It is important to remove catarrhal inflammation of the biliary and intestinal tracts, because calculi are formed as a result of catarrhal cholecystitis and are likely to keep up the irritation and predispose to attacks. The methods already referred to by which the flow of bile is increased and the bile passages washed down are of use in removing catarrhal inflammation of the gall-bladder and bile ducts. The abdomen should be kept warm to avoid chills, and in cases where there is tenderness over the gall-bladder, poultices, hot packs or fomentations, or heat by means of the thermophore may be applied over the right hypochondrium. The treatment of gallstones consists in treatment for relief of the painful acute attack and treatment of the patient between attacks. In acute biliary colic the pain is so agonizing that it often needs the hypodermic administration of morphine for its relief, or the patient may be kept lightly under the influence of chloroform inhalations. I personally have discarded morphine as a dangerous and habit forming drug, and in its stead employ a tablet of 1/150 grain of atropine dissolved under the tongue, or a suppository of extract of belladonna, 1 grain. Amyl valerate in 15 grain capsules repeated every 4 or 5 hours may prove effective and should, if possible, always be given in preference to any opium derivative. Antipyrin given early in the paroxysm may prove useful, and hot applications, unless contraindicated by cholecystitis, may be tried over the hepatic region. In less severe cases, the patient may be put in a hot bath and given tincture of belladonna, eight minims in about a teaspoonful of spirit of chloroform. The vomiting accompanying the attack hardly requires any special treatment. Bismuth, soda, or dilute hydrocyanic acid may be given. I employ hot water containing bicarbonate of soda, which relieves purposeless retching by giving the stomach something to bring up. If retching persists, and the patient is in a state of collapse, iced champagne may be given. Within the past year a new remedy made its appearance which has given me quite some satisfaction in relieving, and sometimes preventing, attacks of biliary colic. This drug is benzyl benzoate, which has been extensively described by D. I. Macht of Baltimore. Treatment Between Attacks.-According to the surgeon, an operation will be the best way to relieve or cure the patient. The surgical treatment, as previously asserted, should be confined to those instances of the disease in which mechanical removal of the foreign body is necessary, the procedure in each case being adapted to the patient in hand. It is difficult to see how operation can do more than relieve the condition present at the time of the undertaking, for even removal of the gall-bladder can hardly prevent the further formation of calculi in the bile ducts. It is within the medical man's power to advise a change in the patient's mode of life which will tend to prevent or diminish the liability to catarrhal inflammation of the gall-bladder and bile ducts. The points to be borne in mind are to pre |