with the cautery. This, in my experience, is the secret of avoiding hemorrhage in this operation.

It is claimed by those who specially advocate this method, that it is superior to the ligature, because it can be more quickly done, causes less after-pain, and results in earlier healing of the parts. From this opinion I must dissent after having given both methods a thorough trial. It requires but little dexterity to do the operation by ligation as quickly as with the clamp and cautery. The after pain is not less, so far as my observation goes, than after ligation. I am still of the opinion stated in a previous communication (Trans. Vt. State Medical Society, 1893) pain after the operation depends more upon whether or not a portion of the skin has been cut or burned than upon the method employed," provided also in both cases that the sphincter has been thoroughly divulsed.

that

Upon the third point I have made careful comparison in private cases and in hospital work, and I do not find that a cure is effected quicker with one method than with the other. On the other hand, there is no doubt but that the operation by ligation is the safest. This is the opinion of surgeons the world over, and is proven by statistics. Now, safety from hemorrhage is the principal criterion, and constitutes the only necessity for the use of either the ligature or the cautery.

The clamp and cautery operation is not applicable where the patient is weak or anæmic, or where the tumors are large and very vascular. Again, one point which especially commends the ligature operation, for the general practitioner at least, is the fact that it requires no special instruments. The operation completed by any of the methods described, a small piece of gauze is inserted

within the anus, between the stumps of the tumors, and the parts covered with an antiseptic dressing held in place by a snug T bandage.

Whitehead's operation, in my opinion, is seldom indicated, but in case it seems wise to excise the whole pile area, a better operation would seem to be one originated by Dr. Henry O. Marcy of Boston, which consists of excision, prevention of hemorrhage, and closure of the wound by buried tendon sutures.

The time at my disposal will allow of only a brief consideration of the conditions of ulceration, cancer and stricture of the rectum. I have devoted most of my time to the more common rectal troubles, believing that this course would be most profitable.

Ulceration of the Rectum.-Clinically all cases of rectal ulcers will fall within the category of simple, syphilitic, or tubercular ulceration. While the greater number of cases undoubtedly are syphilitic in origin, there is no doubt that many cases are due to the breaking down of tubercular tissue.

The successful surgical treatment of these two forms of rectal ulceration is impossible, without proper constitutional treatment. In syphilitic ulceration we may depend upon mercury and iodide of potassium. In tubercular cases there is of course no specific, and we must not look for repair of the lesion, unless we can improve the constitutional condition.

In cases of simple ulceration, dilatation of the sphicter and application of pure carbolic acid or of a solution of nitrate of silver, thirty or forty grains to the ounce, repeated at intervals of three or four days, will be the proper treatment, and will usually result in a cure in a short time.

The same treatment will apply to tuberculous ulceration, but must often be extended over several months time. It will sometimes be necessary to incise the ulcer and the sphincter as well, for the sake of perfect rest to the parts.

In syphilitic ulceration, in addition to the foregoing, it may be necessary to thoroughly curette the base of the ulcer, and apply lunar caustic or to use the thermo-cautery. In all cases continued rest in bed and a light or liquid diet is a necessity.

Cancer. One of the most serious conditions met with in surgical practice is cancer of the rectum. Many cases are not seen by the surgeon until the disease has made considerable progress, and the question of operative interference is one of vital importance, calling for careful judgment on the part of the operator.

Will the disease recur and in what length of time, will the patient live longer or more comfortably, will the local condition be better, will the operation save life? These are some of the questions which enter into a consideration of the advisability of an operation for cancer of the rectum, and every case must be settled on its own merits.

However, one rule of surgery must not be deviated from, and that is to operate only in those cases in which the entire growth, together with the infected lymphatic glands, can be safely removed. Cases in which the bladder or prostate gland are much encroached upon are not favorable for operation.

Excision of the rectum by the method of Allingham, and the Kraske operation, are the radical methods mostly in vogue at the present time. The latter is to be preferred, where applicable, for it leaves the patient with control of the bowel, as it preserves the sphincter muscles.

Upon the subject of colotomy for rectal cancer, I will say that I do not believe it indicated except in the rarest cases, and as a last resort.

Benign Stricture. In some cases of benign stricture, dilatation by means of bougies gives relief for a time, but is not curative. The stricture contracts gradually in spite of the treatment, resulting finally in obstruction of the bowel. The best method for dealing with this condition is posterior proctotomy, which consists in making a free incision posteriorly through the constriction, and extending it downwards through the sphincters and intervening tissues. This relieves pain and admits of free drainage and the easy discharge of fæces.

After-contraction must be prevented, if possible, by the passage of bougies. When obstruction results, in spite of the above methods, lumbar or inguinal colotomy-my preference being for the latter-promises relief and gives the patient new lease of life.

The indications for colotomy in the conditions of cancer and of benign stricture are not at all parallel. In the former it probably does not prolong life, while in the latter it may do so indefinitely.

Puerperal Fever.

By J. M. Hamilton M. D., Proctor.

Mr. President, and Gentlemen of the Vermont Medical Society: I assure you that it is with many misgivings that I come before you to-day with a paper on any subject. My province is to listen, but since your committee has beguiled me to be so presumptive, I shall present for your consideration a subject that interests us all, puerperal fever. My plea must be that we all strive to avoid it, for nowadays and most properly too one's reputation is not good in proportion to the number of his cases of puerperal sepis that recover but in proportion to the number of cases he prevents.

That puerperal fever-so called-is caused by germ infection is now an axiom and all the old theories of spontaneity and suppression of lochia, one after another of which have prevailed until recent years, are exploded and every one admits puerperal fever to be puerperal infection. Some wound in the genitalia as a rule, has been innoculated with the germs-not of puerperal fever, for such do not exist independently,-but with some of the pyogenic germs. There may be cases in which the particular wound infected cannot be discovered: a small nick in the perineum or cervix, or a slightly abraded vaginal wall, offer good entrance to the germs. The placental site, however, is most common seat of infection.