medicament to the uterine cavity. The application of gauze along with camphorated phenol or any other medicament may be used with beneficial effect. Another point comes in. After you have tamponed the cervical canal with gauze, in a week or ten days, and sometimes three weeks, in cases of sterility, you have a recontraction of the cervical canal. It is in these cases that a drainage-tube, properly constructed, will give free exit to the material in the uterine cavity, and at the same time prevent recontraction of internal os, which will be beneficial in a great many cases of sterility and relieve the patient materially. A great mistake that many physicians make is in dilating the cervical canal at their offices without making proper preliminary preparations. It is such operations that should be condemned.

Dr. C. D. Hurt, Atlanta: I do not care to discuss Dr. Harbin's paper at length, but want to reply to one portion of it in which he speaks of the necessity of producing abortion. I cannot agree with him that we ought to produce frequent abortions in these cases. I am satisfied it has been done many times when it might very well have been avoided, greatly to the relief of the patient. In these constrictions about the cervical canal, whether they be from flexions or narrowing of the channel, there is some disturbance of the nerves which touch this portion of the uterus, and they are calculated to give more trouble in cases of conception than if the cervix was in every respect normal; but if there has been dilatation of the cervical canal it overcomes in a large measure the tension upon these nerves, and if there has not been, the process of gestation so changes the condition of the uterus as to lessen the pressure, and while it may be very irritating in the beginning it gradually grows less. But even in the case of persistent nausea following conception, in those cases of constricted cervix or cervix with flexion, dilatation of the cervix alone without inter

pregnancy

fering with the cavity of the uterus, even after conception, is not at all an objectionable, and becomes a satisfactory, remedy in many cases. I must protest against anything like a frequent production of abortion in cases of with nausea. I have never seen the necessity for it, in as much as 2 per cent. of the cases that have come under my observation. By faithful effort and careful attention to the patient we may be able to steer her through with safety.

Dr. Harbin (closing the discussion): In replying to Dr. Hurt's criticism, he misunderstood me. My remarks applied to the cases that conceive very rapidly, and where we have such obstinate nausea and vomiting that it is necessary to induce abortion, and where oftentimes we are driven to the consideration of ovariotomy to prevent a recurrence of conception. In those cases I would advise dilatation of the uterus as a preventive more than anything else; but the remarks of my paper referred more to mechanical dysmenorrhea and sterility rapidly arising therefrom. According to a recent writer, 23 per cent. of all dysmenorrheas are mechanical, and the greater amount of sterilities are due to the same cause, and in such cases dilatation of the uterus is recommended.

REMARKS ON FISTULA IN ANO.

BY WM. S. GOLDSMITH, M.D., ATLANta, Ga.

The relative frequency of fistula in ano as compared with other rectal affections induces me to a consideration of this interesting, though perhaps well-worn subject. Some differences of opinion exist among authors as to the frequency of fistula. Allingham states that in a collection of 4,000 consecutive rectal cases in the out-patient department of St. Mark's Hospital, 1,057 were fistula in ano, 196 abscesses, 151 of which subsequently became fistula, and that for a period of several years two-thirds of the cases operated on in this hospital were for fistula.

Matthews, on the other hand, states that while the mar gin is small, internal hemorrhoids have occurred more frequently in his practice. Omitting the simpler forms of rectal affections, such as fissure and ulcer, and accepting fistula and internal hemorrhoids as the most common, I am inclined to place the former at the head of the list. This is my experience in private practice, and that also of the cases presented at one of the largest outdoor surgical clinies in the South. Fistula, therefore, occupying such a prominent position among the more common and grave surgical diseases, I ask your indulgence that I may briefly bring out some points underlying the principles of treat

ment.

In common with all other practitioners, I am inclined to a certain degree of partiality in the use of the expression "conservative surgery," but in the discussion of this affection I shall for once endeavor to escape its fascinative eu

phony. Individual experience has amply demonstrated that only the most radical and thorough technique is productive of the permanent results so anxiously sought, and any deviation from this rule is most likely to redound to our discredit. I trust that my attitude in laying such particular stress on this point will not be charged to exaggerated presumption, as I am sure that all of us can recall an instance in our surgical work where a poor result is safely attributed to some negligence in technique or undue trepidation in method.

I feel no hesitancy in declaring that the incision of all fistulous tracts and sinuses, and the complete section of the sphincter muscles, with the knife, is the only method by which we can, with considerable certainty, assure the patient that the operation will result in a rapid and successful cure. The methods of ligation and chemical irritation will not, therefore, enter into the discussion. The fallacious methods advocated by the older writers cannot be other than productive of most unsuccessful and humiliating results. For instance, Hamilton,in his Principles and Practice of Surgery, says: "The probe or somewhat flexible groove director, being now thrust into the rectum and brought out at the anus, the operation is completed by dividing the intermediate tissues. Having cut the sphincter, it only remains to lay a small piece of lint between the margins of the wound and place the patient in bed."

Dr. Matthews, in his book on Diseases of the Rectum, corrects this proposition in the following admirable manner: "To illustrate how erroneous the advice is, allow me to cite a case: If an abscess in the ischio-rectal fossa has left a sinus which runs directly into the bowel,and from this branch a fistula runs out into the perineum, and another diverges from the main channel into the buttock, no such operation as is described by Hamilton would effect a cure. It is the smallest part of the operation to lay open the tissues which lie over the main sinus. How often it is that

the surgeon is disappointed in the wounds refusing to heal after an operation for fistula, and an investigation reveals that it is due to a small sinus or pocket that has been overlooked! I am sure after a long experience in dealing with this operation, that in the majority of cases operated upon, if a single sinus is left, a good result will not be obtained. In other words, the inflammation excited will not be sufficient to eradicate the branch fistula. The flaps or thin edges of the wound alone, if left, would prevent good union."

I have yet to see a wound made in the area usually involved fail to promptly and satisfactorily granulate, provided it has had the benefit of a thorough eradication of all morbid tissues. To further elucidate this point, suppose all branches and pockets have been opened, should the operation be pronounced completed? Decidedly no. And just here my friend Dr. Matthews executes a procedure that is rather tedious, and, I think, quite unnecessary. He advises the excision of the whole bottom of the wound, using pinch forceps and curved scissors, and states that he is not satisfied with simply scraping out the sinuses. I think the careful use of the Volkman spoon, together with the application of peroxide of hydrogen, in the manner to be described, is far preferable. After incising the main tract and all sinuses, satisfying myself that the superior extremity of the original tract is reached, and making a rather prolonged search for pockets and hidden branches, I trim away the overhanging edges of skin along the entire cut area, paying particular attention to the edges and vicinity of the original external apertures.

This is followed by a thorough curettage of the bottom of the sinus, and the removal, as far as possible, of every particle of the so-called pyogenic membrane. The wound is irrigated and sponged as dry as circumstances will permit. I now use peroxide of hydrogen, full strength, ap