Recto-labial. In the treatment of recto-labial cases care should be exercised to avoid the sacrifice of the perineum. Ordinary incision, as practiced on simple fistula? of the rectum, may prove of serious consequence when the perinea body is weakened as a result of carrying out this treatment of these cases. Experience has taught me that when the external opening is near or above the sphincter vaginae, an incision carried parallel with the muscle bands to the center of the perineum and then carried down through that body to the rectal opening will make a triangular opening, with the base toward the rectum, and the apex at the vagina. This incision will preserve the muscular tissue to a fair degree. It has been my good fortune in a few cases to secure a primary union after suturing in that portion of the wound involving the vaginal muscles, intentionally leaving the incision through the perineum open to heal by subsequent granulation When there is more than one external opening, the ingenuity of the operator will be severely taxed, but he should be governed by the effort to avoid destruction of the perineum.

Recto-urethral Fistula are seldom met with by the rectal specialist, and reports of such cases are most frequently made by our Benito-urinary confreres. They occur most frequently at the site of contact with the prostate and just below the pro static urethra.

Treatment. There are many operations suggested for the relief of this condition without success attendant upon them. Sir Henry Thompson recommends that the patient be catheterized whenever there is a desire to empty the bladder and also just prior to movement of the bowels. This serves two purposes, first that it dilates the stricture and secondly it prevents to a certain extent irritation and lateral burrowing. He recommends the use of nitrate of silver, chloride of zinc, iodine and the galvanometer-cattery with the idea of stimulating granulation to close the wound. This treatment seems applicable only to acute cases, as those of long standing and surrounded by hard cicatrice tissue are apt to be made larger, or result in a stricture of the urethra. Where the opening is very large and feces escapes into the urethra, causing great suffering, an artificial anus should be provided for when less radical measures have failed to give relief. It may be possible to cure the fistula after the fecal current has been changed in this manner by an effort at plastic surgery.

Cuttle recommends a most successful plastic operation for this type of fistula, and as his results have proved most satisfactory, it seems well to give his operation in detail.

"The patient was prepared for treatment by clearing out the intestinal canal, sterilization of the urinary tract through the administration of Doric acid and salon and daily irrigation of the urethra and bladder.

"The rectum was then incised in the middle line anterior, the cut being carried through into the urethra and extended from the scrotal junction of the perineum into the fistulous opening, thus dividing the urethral stricture. The cicatrice tissue around the entire fistula was trimmed away with the scissors. The intestinal wall was then dissected from its anterior attachments for three-fourths of an inch above the fistula and one-half an inch to each side, a flap was then dissected from the soft tissues on either side of the urethra large enough to replace that portion of the floor of this organ which had been destroyed. A steel sound No. 30 French was introduced into the bladder and these flaps sutured together over it at a slight tension.

Secondary flaps were taken outside of the first flaps and entirely surrounding them making a sort of cuff to the first area sutured. The edges of the rectal wall were sewed together in all their thickness with chromite catgut down to the external sphincter muscle at which point the mucous membrane was dissected loose for a short distance to each side and drawn together by stitches which did not involve the muscle. The incision into the urethra from just below the site of the fistulous opening was left unstructured A No. 12 soft-rubber catheter introduced through the meats into the bladder was fastened there by adhesive straps attached to the head of the penis. The anterior portion of the perinea incision was loosely packed with absorbent gauze and a large drainage tube introduced into the rectum to facilitate the escape of gas. The catheter seems to cause the patient no inconvenience and it was left in position for eighteen days, the bladder and perinea wound being irrigated daily with Thievery’s solution."