the deeper structures, as is the case with the sore throat of the measles patient.

The mucous membrane of the throat and naso-pharynx in scarlet fever is a field where the poison shows its intensity to a marked degree, more markedly than in any of the preceding diseases mentioned.

Sore throat is one of the earliest and most prominent symptoms, and it precedes the cutaneous eruption by from twelve to twenty-four hours. On the third to the fifth day, in some severe cases, a false membrane can be seen very similar in appearance to the membrane of diphtheria. The inflammation of the throat in the early stage of scarlet fever may in no way differ from that of an ordinary catarrhal inflammation. The lining membrane of the follicles and crypts of the tonsils may be involved, as in a case recently under my own observation, and then may in no way differ in appearance from a simple follicular tonsillitis.

Whittaker remarks that no individual symptoms show such variation of intensity as the angina. Therefore, the most severe inflammation may be present with intense redness, swelling, involvement of the glands of the neck with cellulitis, later followed by abscess formation, and in the throat the pseudo-membrane or gangrenous sores may add to the suffering of the patient.

True,

Naso-pharyngeal inflammation, with extension to the middle. ear, is common, and a mild coryza is often present. diphtheria 2 may occur simultaneously, but it is most likely. to occur in the second week, while, as has been mentioned, the pseudo-membrane of scarlet fever which so similates diphtheria appears from the third to the fifth day from the onset of the disease. Two cases have come under my personal notice where were present the two diseases.

The complications of cellulitis with pus formation, gangrenous angina, or of diphtheria are very likely to prove fatal, but there are exceptions to the rule. The sequelæ are similar to those mentioned in measles, though from the fact that the

1 Pepper, American System of Theory and Practice.

2 Keating, Cyclopedia of Diseases of Children.

nasal inflammation is not so severe, atrophic rhinitis and empyema of the accessory sinuses do not occur so frequently as in the last-mentioned disease.

This paper, in so much as it is necessarily a compilation of the observations of well-known authorities, would be of little value to the members of this society did it not endeavor to emphasize certain practical deductions. It has been shown by certain observers that many of the complications of the exanthemata are due, not so much to the direct infection of the disease as to the transmission of micro-organisms from a portion of the throat primarily affected to adjacent structures and cavities, these micro-organisms being the result or the accompaniment of the primary degenerative change. It is believed that many of these secondary effects could be prevented were it the rule to, under all circumstances, examine the upper respiratory tract with a good reflected light and with the proper instrumental diagnostic aids. Were this method systematically carried out, indications for remedial treatment would often be suggested which would escape notice were one to depend upon external appearances and subjective symptoms alone.

It is believed also that cleanly measures could be brought to bear which would prove of great aid to the indicated remedy, and would also directly combat the formation and transference of the micro-organisms above referred to. It is not difficult to use a spray or gargle, or to simply rinse the throat and mouth frequently with a hydrogen dioxide solution made slightly alkaline just before using.

This solution is harmless if swallowed, and it could in no way interfere with the indicated remedy. A mild alkaline antiseptic solution could, with equal benefit, be used as a nasal wash, though the use of hydrogen dioxide here could not be continually used without producing much irritation. Other preparations would, however, readily suggest themselves. I can learn of no reason why measures of cleanliness should be neglected in nasal, naso-pharyngeal, and throat degenerative inflammations more than in the case of external ulcerations or other destructive processes.

A STUDY CONCERNING THE CAUSE OF MANY FAILURES IN RECTAL OPERATIONS.

BY F. W. HALSEY, M.D.

[Read before the Surgical and Gynecological Society.]

That most rectal operations are successful in the main cannot be denied, and that we are thus enabled to restore to health and comfort a class of patients to whom life has often become a burden is certainly a cause for congratulation. That many rectal operations are not attended by such happy results most of us are aware; indeed, until within a very few years have these unfortunate results been so common that a general aversion to an operation has shown itself amongst the laity. Fortunately, with better aseptic methods and more skilful surgical work, these prejudices are passing away, yet even to-day the results are not always ideal in rectal work. There are reasons for these failures undoubtedly; I feel sure I have found some of them, and to call your attention to a few is my purpose to-day.

The unfortunate results frequently attending operative measures for the cure of fistula in ano are well known to all of you. First, the entire failure to cure the fistula, and second, the cure of the fistula accomplished, but at the expense of the destruction of the sphincter ani, a condition in which, while the life of the patient is not imperiled, the living of that life is rendered anything but pleasant. Sometimes these bad results are due to a faulty method of operating, a failure to find the main sinus, through or under the sphincter ani, first dividing this sinus completely, and afterwards attending to the branching sinuses which almost without exception open into this main canal rather than the rectum itself, thus keeping outside of the sphincter muscles, dividing it through into the bowel but once, and by this method avoid complete incontinence. Again, the failure may come from lack of personal attention of the surgeon to the wound. The operation may have been faultless, but from lack of time, interest, or cause unknown, the daily packing

and dressing is left to some one less expert, or to the tender mercies of the nurse, who, however conscientious and faithful she may be, is hardly able to differentiate between healthy and unhealthy granulations, nor able to appreciate the dangers of fresh sinuses forming, or the many other pitfalls which beset the healing process in fistulæ.

Or again, the failure may result from a desire on the part of the surgeon to hurry the matter, and thus save time for his patient. He may decide to dissect away all the diseased tissue, bring the parts together closely by buried or deep and superficial sutures, hoping to get union by first intention. The parts apparently heal rapidly, and the surgeon congratulates himself on thus saving valuable time. But before the patient leaves the hospital, or soon after his return home, the tissues break down at one point or another, and the surgeon finds he has his work to do over. Experience has taught me that abscess cavities or fistulous tracks quite a distance away from the bowel can be cleaned out thoroughly and put together with some hopes for primary union, but that sewing together the tissues near the bowel, and especially if the fistula runs very high in the rectum, is usually attended with failure.

Are operations for hemorrhoids ever attended by failures or bad results? Unfortunately they are. Probably the most common error committed is that of opening with the knife an external, oedematous hemorrhoid, under the supposition that it is of the thrombic variety. This is an unfortunate mistake, and but adds to the suffering of the patient. The causes giving rise to these two forms of hemorrhoids being so entirely different, a treatment which will relieve and cure the simple blood clot of the thrombic variety will but add to the inflammation and pain incident to the oedematous pile. Of the various operations usually done for the cure of internal hemorrhoids, there is not one single operation but from which we get at times, if not exactly bad results, at least not ideal. In England and parts of the Continent the ligature is used almost to the exclusion of any other method. Besides the great amount of pain always following

the employment of this method, unless the operator is very careful, cutting generously into the skin tissue and up well onto the hemorrhoid on its sphincter face, great contraction is sure to follow, and not infrequently stricture, hard to overcome, results.

In this country the slit operation performed with the scissors and the form of operation done with the scissors, clamp, and cautery have obtained most favor. The chief danger in the slit operation lies in the tendency to sacrifice too much tissue, in the effort to make a smooth surface. Unless some loose skin and mucous membrane is left, too great contraction is sure to follow, and no chance is left for the necessary dilatation required for the passage of a wellformed stool; pain, bleeding, fissure, etc., are sure to follow, and future operative measures to relieve are of little avail. The minor difficulties, like pain after the operation, pinching the nerve terminals by the sutures (of which we read so much at times), can all be overcome, and the operative method will always have a place in surgery.

In the operation by clamp and cautery, the trouble generally comes from the failure to take away sufficient tissue, particularly mucous membrane. Many operators wash and rub away the eschar formed by the cautery, a most mischievous custom, and likely to provoke dangerous hemorrhage. A failure also to recognize the large isolated hemorrhoids. particularly suited for this method is another common error; and again, the fact that all anemic and chlorotic patients. should have some other form of operation, owing to the feeble power of coagulation which the blood offers, and the danger of long-continued oozing, and consequent protracted convalescence after using the clamp and cautery.

I have not mentioned that almost diabolical method, known as the Whitehead or the American operation, for the cure of hemorrhoids, which to my mind has nothing to recommend it and everything against it. I have on several occasions given my reasons for disliking it at length, and now should consider myself false to my convictions did I fail to raise my voice in solemn protest against its employment by