sometimes cease its pressure and require the trifling remnant of the structure to be divided or simply nicked to free the ligature.

Now how shall the elastic ligature be introduced in this class of fistula? Allingham has suggested an instrument for this purpose, in cases of fistula in ano. The instrument of Allingham can not be available in recto-labial fistula. It is too large at the extremity, and its size, to be inserted through such narrow fistulous tracks as exist in these fistulæ.

I have given the preference to a small, slight, ductile silver probe instead, and I have not found any difficulty, though it requires a little time to accomplish its task. There are two different ways of passing the ligature:

The first is that which Barton adopted, and which may be considered by some as the best, and to appearance the easiest and most simple. Recognizing the locality of the rectal or internal opening by introducing the silver probe of moderate size and proper length, with the eye of the probe threaded with the elastic ligature, into the labial or vulvar orifice, direct the probe to the internal or rectal orifice of the sinus, then with the left forefinger introduced into the rectum, having felt the probe, bend it and bring it down through the rectum and out of the anus. Withdraw the probe, having left one end of the ligature out of the anus and the other out of the labial orifice, remove the probe, then introduce it again into the labial opening, pass it down along the perinæum till it reaches just outside of the sphincter ani, low down, then cut on the end of the probe and draw the ligature through the new channel with the end of the ligature which was at the labial orifice left after the first introduction in the labia. The ligature is then tied, shotted and clamped, and the ends clipped off, and the patient returned to the bed. (See Fig. 1.)

The second method, and the one I have most usually followed:

The usual surgical silver probe is introduced into the labial orifice, pressed down to the lower part just outside of the sphincter ani, the end is then cut upon, then withdrawn, and a more

slender, ductile one substituted, and passed up to the rectal opening through the sinus, having the eye threaded with the ligature; the finger is introduced into the rectum, recognizes the probe; this is curved, and gradually and gently drawn

FIG. 6.-A, End of anal ligature. B, End of labial ligature. C, Perineal ligature, as passed.

through the rectum and anus. The two ends are then tied, shotted, and clamped, to make it more secure. When the external artificial opening is made, it is apparent that we now have simply an ordinary fistula in ano, with an internal or rectal orifice high up the gut.

The question has often been put to me, What do you do do with the labial orifice, as you now have three openings? The fact must be self-evident: it takes care of itself. In a few days, or at most two weeks, the sinus or fistulous opening will be perfectly closed, for just as soon as the rectal opening is united and the ulceration or sinus gradually healing up, there can no more air or fluid fæces enter and pass through the sinuous tract out of the labial orifice.

Nothing more is requisite to be done after the operation than to have either warm or cool applications, agreeably to the sensations of the patient, made with simple water, several times

during the day. Should the patient require an anodyne, it can be given, but it is not always necessary. In a few days the elastic ligature will have cut its way through the intervening structure involved in the ligature.

Possibly, gentlemen, I have been more prolix than the subject I have invited your attention to called for. I am aware I have entered into more detail on some points than might be deemed necessary. I should not have done so if my experience had not informed me that the recognition of such a clear, comprehensive, and simple idea of Professor Barton, by the conversion of a recto-labial or vulvar fistula into a common fistula in ano, and the success attending the treatment of so rare and unfortunate and loathsome fistula in the female, by the use of the ligature instead of the knife, which would carry with it, a most lamentable and distressing sequence, for many years, if not for a lifetime.

I have presented this important subject afresh to you, since my last paper in 1866. I have done so in justice, as I conceive, and as a tribute of great respect to the memory of one of my first teachers when I entered as a student in the medical profession, though having seen many more cases than he had, as he had had but a single instance of the affection. My experience for over forty years ratifies in my own mind the correctness of his original idea, and confirms the great utility and benefit it creates for the suffering patient. It is due to his memory, for he was one of the most eminent surgeons during his dayconservative in his views respecting his surgical cases-brilliant in his operations, and exceedingly successful in the result of them.

A PRESENTATION AND REMARKS.

DR. TAYLOR: Mr. President, if you will permit me, I have a gift to the Association from Dr. Samuel W. Francis, of Newport. It is quite a unique obstetrical instrument. I call it the obstetrical abstractor. Also this skull, which illustrates very finely the over-lapping of the parietal bones, I give on my account. I suppose the diminution to be at least half an inch. I think both of them, not only the head but the instrument, will be of some interest to all of you. Whose instrument this is I do not know. The head is certainly very valuable, because you may not be able to match such a head out of four or five hundred cases.

DR. FERGUSON: I think, Mr. Chairman, the highest compli ment has been paid to Professor Taylor's paper this afternoon by the fact that there is hesitation in remarks upon it. The subject has been so clearly presented, is so thorough in all its details, and the statements cover the ground so completely, and are so evidently the truth in all particulars, that I do not see that there is any opportunity for discussing it.

So far as the instrument is concerned, it is certainly a novel one, and the question arises at once, Why has not it been thought of before and been more frequently put into use?

I wish to offer a resolution of thanks to Dr. Samuel W. Francis, of Newport, R. I., for the peculiar instrument shown by Dr. Taylor. Also to Dr. Taylor for the skull accompanying the instrument.

The resolution was seconded and carried unanimously.

RECURRING LUXATIONS.

By EDWARD M. MOORE, M. D., of Monroe County.

Read November 17, 1885.

THE recurrence of dislocations is a topic with which in a general sense the profession is familiar, and certain rules of practice have been laid down to prevent immediate as well as subsequent reluxation. For instance, the necessity of quiet, so as to induce a close union of the edges of the rents in the capsule and ligaments, and the adoption of certain positions favorable to this result, have been insisted upon from time immemorial. There are, however, a few procedures that have been somewhat neglected, and some, in my opinion, are erroneous, while the attention of the profession has not been sufficiently, if at all, directed to cases of bad results from the failure to observe proper precautions. The literature is meager, and in some directions, I am inclined to believe, is silent where the importance of the matter is great.

In making some experiments with reference to the pathology of luxations, I became convinced that some causes of recurrence had been overlooked, although the practical direction to prevent it had it been properly devised. In others, I believe the device itself to be at fault. The time allowed this paper necessitates merely a cursory statement of that which I have to say; but perhaps that is all that would be profitable.

That every one knows that luxations are apt to recur, I assume to be true. Also, that they do so not only as the result of the force similar to that which produced the original one at remote intervals of time, but also that they recur at once, the moment after reduction; indeed, they drop out of place as it