and the common habit of diagnosing every rectal ailment as "piles," without an examination, and prescribing a salve therefor, which in the majority of cases proves absolutely useless. Another fruitful source of failure is the fact that serious rectal diseases are often everlooked and neglected until too late, because of false modesty on the part of the patient.

A knowledge of diseases of the rectum, especially the ability to make a correct and complete diagnosis, is of as much importance to the man in general practice as is a knowledge of the eye, ear, nose and throat, of skin and genito urinary diseases, or in fact of any other specialty. A positive and early diagnosis is of the greatest importance to the patient suffering from rectal disease, because in a large majority of benign cases an early and correct diagnosis and proper treatment means a rapid cure, while a haphazard diagnosis and delay may allow a simple condition to become extremely serious and perhaps end disastrously to the patient.

After citing the various methods of examining the rectum, recommending the simplest as being the best, cautioning gentleness always in manipulation of instruments when necessary to use them, mentioning the use of the procto- and sigmoidoscope for examining disease high up in the bowel, he proceeds to a brief review of the anatomy of the rectum, adopting that division of the large bowel now generally regarded as preferable by modern authorities. In this the anal canal is two-thirds to one inch in length, extending from the muco-cutaneous junction to the dentate border of the crypt of morgagni. The rectum comprises that part of the large bowel between the ano-rectal line and the mesenteric attachment opposite the third sacral vertebra and varies in length from four to six inches. Quoting from Tuttle, he says: It gives to the organ definite limits; it separates the mobile from the immobile portions of the gut; it marks the line where the course of blood supply changes; it indicates the point where the three longitudinal muscular bands of the colon spread out and become more or less equally distributed around the gut; and finally it marks a point at which there is always a decided narrowing in caliber, indicating the juncture of the rectum with the pelvic colon. The rectum is further divided into a lower and an upper portion, the former being one and one-half to two inches in length and extending from the anus to the tip of the coccyx or the apex of the prostate. The upper portion extends

from the tip of the coccyx to the third sacral vertebra, and is three to three and one-half inches long.

In discussing ano-rectal ulceration, Hawley points out the necessity of radical treatment saying, "a lesion within the anal canal does not naturally tend to recovery, for the reason that the mucocutaneous lining of this canal has little resisting power and a limited blood supply, and further that it is continuously irritated by the bowel passages, and by the spasmodic contractions of the sphincter muscle." Only in cases wherein the ulceration is not extensive and where there is no induration or hypertrophy is the non-operative treatment successful. In such cases he recom. mends the application every two or three days of pure ichthyol. After describing the most approved methods of opening perirectal abscesses, one statement is made which is open to criticism. "After completing the incision the sphincter should be well stretched." It is difficult to imagine any advantage to be derived from stretching the sphincter muscle after the opening of an abscess. In fact care to preserve the tonicity of the sphincter should be uppermost in the mind of the operator. As frequently happens the attachments and supports of the sphincter for a considerable part of its circumference may be found dissected loose from that muscle by the action of the pus in complicated rectal abscesses, and unless the conditions be recognized and care taken the function of the sphincter may be permanently impaired.

In the treatment of hemorrhoids the clamp and cautery and the ligature methods are recommended. The injection method he believes, should be considered only palliative, and should be used, if at all, only in certain selected cases of interval hemorrhoids.

Malignant Disease of the Rectum.-F. Reder, M. D., (The Proctologist, March, 1908). In this article only operable cases of cancer, i. e., those in which all diseased tissue can be removed, are considered, and in this connection the advisability of doing a preliminary colostomy is argued. The chief advantages being, first the avoidance of interference with the healing of the wound due to direct contact of fecal matter; second, permanently directing the fecal current away from a once diseased bowel, which must necessarily remain tender for a considerable time after healing has taken place, thus lessening the chances of recurrence of the malignant growth.

Ano-rectal Fistula.-Charles B. Kelsey, (Medical Record). An important distinction is made between abscess and fistula, which if observed will prevent mistakes in treatment. An abscess which has opened into the rectum or on the cutaneous surface near the anus, and is discharging from this opening, is only potentially, not actually fistula. A fistula implies chronicity, also induration and canalization, with shrinking of the original abscess cavity to a mere canal. Abscesses often heal spontan

eously after being incised or breaking; fistula almost never. After an abscess has ceased to heal, when in fact it has reached a stage where spontaneous closure and repair are no longer possible, it becomes fistula. The track is hard, cord-like, and can often be felt as such under the skin or mucous membrane. . This view co-incides with the difinition that a fistula is a contracted but unobliterated abscess cavity.

A fistula may have from one to twenty, or more external openings. There may be more than one internal opening, and tracks may run in any and every direction. These cases are, however, all operable, excepting those in which patients are near their end from constitutional disease. The possibility of incontinence following the operation, or resulting from extensive destruction of tissue due to the disease, must be kept in mind. Much may be done by the skilled surgeon to avoid this. Many cases of fistula may be operated on under local anesthesia. One great objection, however, is the difficulty of determining the exact extent of the trouble previous to the time of operation; a frequent experience being to find what seemed beforehand to be very simple fistula, proving to be, as the operation progresses, a very complex one. Tuberculous fistula

are no longer considered incurable. The treatment is the same as in ordinary inflammatory fistula, only rather more radical, and with the added use of the cautery to destroy the tuberculous deposit.

BOOK REVIEWS.

THE DIAGNOSIS AND TREATMENT OF PULMONARY TUBERCU LOSIS.-By Francis M. Pottinger, A. M., M. D., Monrovia, California.. Medical Director of the Pottenger Sanitorium for Diseases of the Lungs and Throat, Monrovia, Cal.; Professor of Clinical Medicine, Medical Department, University of Southern California; Chief of Medical Staff of the Helping Station of the Southern California Anti-Tuberculosis League, Los Cal.; Fellow of the Angeles, American Academy of Medicine; Member of the American Climatological Association; Member of the American Therapeutic Society; Corresponding Member of the International Anti-Tuberculosis Association, etc. New York: William Wood & Co., 1908.

So much has been said and written on the subject of tuberculosis of late that the announcement of a new book on tuberculosis is not calculated to fill us with enthusiasm. Yet we read this book with care, attention, interest and profit, and we unhesitatingly and unqualifiedly recommend it to the medical profession. Dr. Pottenger's experience and reputation warrants him a hearing, and the book does the rest. This complete little book of three hundred and fifty pages is carefully and beautifully written. It is full of meat from cover to cover; the interest never flags from the first to the last chapter; there is much in it that is entirely new to the average general practitioner, and that which is not absolutely new is presented in such a way that new interest attaches to it, and he sees it from an entirely different point of view; the author, in discussing the probable time of infection, brings out the question of the possibilities of latency. In teaching medicine this has always been one of our hobbies. Pottenger has several chapters on the early recognition of tuberculosis. They are superb, and should be read and understood by every doctor. He teaches us how to find the earliest clinical symptoms and physical signs, and goes carefully into the most minute details as regards the value to be placed on these signs when found. He condemns such terms as "weak lungs," "run down,' "bronchial trouble," " catarrh," "colds" and "stomach cough." He places the blame where it belongs-on the doctor-and advises that we shall no longer take refuge behind. such flimsy subterfuges. He says the physician should in every case push his investigations to the farthest possible point, and not wait for tubercle bacilli to appear in the sputum before he makes a diagnosis, for this usually means destruction of tissue -ulceration, with cavity formation.

Dr.

The chapters on treatment form what is probably the most satisfactory and complete part of the book. Here every factor

that might be of the least possible value is taken up in detail and in order, and is considered very exhaustively.

Worthy of especial mention also is the chapter on "The Specific Treatment of Tuberculosis," e. g., tuberculin and allied products. This little chapter or essay contains in condensed and readable form all of the positive and dependable knowledge that we have to-day along these lines. Knowledge that could only be obtained by long and arduous labor on the part of an expert. This excellent book should be in the hands of every general practitioner, as it contains everything that is new and worth while on the subject of tuberculosis.

THE PRACTICE OF OBSTETRICS IN ORIGINAL CONTRIBUTIONS. -By American Authors. Edited by Reuben Peterson, A. B., M. D., Professor of Obstetrics and Gynecology in the University of Michigan, Ann Arbor, Mich.; Obstetrician and Gynecologist-in-Chief to the University of Michigan Hospital. Illustrated with 523 engravings and 30 full-page plates. Lea Bros. & Co., Philadelphia and New York, 1907.

This text is a compilation of contributions by specialists in obstetrics connected with Universities of Chicago, Buffalo, Pennsylvania, Michigan, Detroit, Georgetown and Johns-Hopkins. Each of the nine sections of the text is principally the work of one contributor. The sections are:

1. Physiology and Development of the Ovum.

2. Physiology of Pregnancy.

3. Physiology of Labor.

4. Physiology of the Puerperium.

5. Pathology of Pregnancy.

6. Pathology of Labor.

7. Pathology of Puerperium. 8. Obstetric Operations.

9. The New Born Infant.

From this arrangement the work is one which makes it a ready reference work as well as a series of special treatises. is one of the most copiously, clearly and satisfactorily illustrated works on obstetrics that the writer has seen. Most of the articles are not only reliable from a medical and surgical standpoint, but readable as well.

The greater portion of the book is devoted to the pathology of obstetrics. Taken all in all, it is a useful contribution to the literature on the subject.

MATERIA MEDICA AND THERAPEUTICS.-By Geo. F. Butler, M. D. W. B. Sannders & Co., Publishers, Philadelphia, Pa.

One of the very best text books on materia medica, therapeutics and pharmacology is one written by Professor George F.