PALLIATIVE TREATMENT.—This method of treatment will be required in cases where there is a positive refusal on the part of the patient to submit to an operation, and in persons whose constitutions are broken down by disease and in whom the reparative powers of the body are not equal to the task of restoring it to health. Chronic alcoholism, albuminuria, diabetes, malignant diseases, etc., are conditions in which operative procedures are attended with risk, and in which palliative measures should be tried. Phthisis is not an absolute contra-indication to operative measures. The rule which I observe is to operate in those cases of tubercular subjects in which the disease is quiescent, but to avoid such interference if the lung-mischief is at all active. Incomplete external fistulæ, and even complete fistulæ of somewhat recent origin and not extensively indurated, may be cured by non-operative measures; but such treatment requires constant attention on the part of the practitioner, as well as a willingness on the part of the patient to give sufficient time to the treatment. Even under such circumstances the process of repair is slow, and in many cases the result will not be perfectly satisfactory. It is true that fistulæ sometimes recover spontaneously, or are cured by simple means, such as the mere passage of a probe used in examining the fistulous track, but instances of this kind are rare. In certain selected cases of fistulæ I am in the habit of endeavoring to effect a cure by stimulating the sinus and allowing free drainage of the secretions, so as to avoid the use of the knife. To accomplish satisfactory results with this mode of treatment, the following indications should be borne in mind: 1, that the external orifice be perfectly free; 2, that the sinus be kept clean, so as to prevent putrefactive changes; 3, that an effort be made to excite a healthy action in the fistulous channel; and 4, that the parts be kept as quiet as possible. To meet the first indication, it is necessary to dilate the outer opening of the fistula with sponge or sea-tangle tents: but better still for this purpose are the Lee's Antiseptic Slippery-Elm Tents (Fig. 25).[46] These are made of selected slippery-elm bark, and compressed under high pressure. Owing to their non-irritant and demulcent properties, I find them superior to other tents. [Illustration: Fig. 25—Slippery-Elm Tent (large size).] The second indication (that the sinus be kept clean, so as to prevent putrefactive changes) is best carried out by the use of peroxide of hydrogen. I have cured some cases of fistula in ano by means of injections into the sinus of peroxide of hydrogen alone, being careful to keep the external opening free, and treating the patient daily until healing occurred. I am in the habit of using Marchand's preparation, undiluted. It is injected into the sinus by means of a long, flexible silver canula (Fig. 26) attached to a hypodermatic syringe.