IRcctal Conbtttous EtTGENE P. HOYT, M, D. LONDON m^M^^!^w:^M ACsr>'<3 Columbia (Hnitiewttj) mtljeCttpoflmitork CoUege of l^f^v^itiana mh burgeons! I IRectal Conbitions EUGENE E. HOYT, M. D NKW YORK A.ND LONDON f?C2i^ r o m en preface. ^U have come to the conclusion that nobody abuses another, unless he fears him or envies him,'" When I have completed my thirty -sixth year in this specialty^ and that wont take long now — / am going to retire. I am sending out a few farewell lines, not for the purpose of self-exploitation, as I passed that neces- sity many years ago — hut to offer a suggestion and in- ducement that may lead many younger men to adopt this line of practice. There are about one hundred bright physicians in this city to-day that are just thirty years old that could not do better than to follow this outlook. With one hundred in the fields all well equipped and honest, the subject would be so popularised that it could not fail to command the patronage of that 2ofo of all the people that are suffering from something of this kind. No one reputation can compass but a small portion of this in- valid class, but a united array of masterful talent could so impress its stamp of superiority upon this invalid world, that a general and popular support could not fail to be the outcome. Of course no one can be infallible, but ap- proximations express the relative difference between dif- ferent individuals. The compensations both as to money and gratitude are greater than in any other form of practice, because more can be done to quicken that sense of appreciation which always speaks the language of true equivalents. Digitized by tine Internet Arciiive in 2010 witii funding from Open Knowledge Commons http://www.archive.org/details/rectalconditionsOOhoyt IRectal Conbitions WITHOUT in the least indulging in the luxury of conjecture, I shall endeavor to outline a measure of intuition, because intuition is the refinement of practical knowledge. In the absolute this is quite impossible, for the full fruition of an expert experience can never be translated into a con- cise exposition of any subject, as every student and every philosopher must build their own watchwords. To a certain extent this is dangerous business. Any one having traveled on a synthetic train for over thirty years, catalogued every danger signal, eliminated every possible disaster, it is hardly reasonable to expect that a man of incoherent qualifications can fly in the face of such an equipment without becoming more or less confused as to his comprehension of such specified conditions. Consequently, there ensues adverse opin- ions and disappointments, because of the want of parity between the man and the undertaking. Frequently there goes floating on the ocean of peri- odical literature a sharp criticism, condemning some surgical proposition — sitting in judgment upon an idea because of the insufficiency of an individual. As ex- perience is the only safe standard of judgment, it is surely unwise to embrace an opinion gathered from an array of head-lines that denote the doings of those devoid of experience. This may seem a little emo- tional, but it arises from a lurid conviction that this subject has been greatly neglected by the general phy- sician, thereby overlooking a world of disturbing influ- ences that send such wicked messages all along the many highw^ays of human feeling. It is a well-knozvn fact that there are a greater num- ber of years stolen from human lives by the persistent robbery of Rectal disea^ses than by any other influence. This explains why so many pernicious preparations are Hooding the market, alleging to cover these conditions, because the general public has not found satisfaction in the legitimate medical world. I have operated upon hundreds and hundreds of Fistula cases, by every known method, all the time sifting and thinking and eliminating and qualifying, hoping to arrive at some reliable standard by which this dreaded condition could be rescued from the bondage of so many painful and enervating details. The fact that there are so many ways of accomplishing the same purpose proves that the subject does not carry any harmony of thought, any perfect and uniform prospect that can lend a sense of comfort and peace to the unfortunate sufferers, in view of which there naturally arises. What is the answer? As an expression of simplicity and success, the an- swer is as follows : To divide the wall over the sinus is imperative — any suggestion at variance with this idea is trifling with a sacred responsibility. Inject co- caine so as to get its effect for about one inch parallel to the outer extremity of the fistula; then introduce the grooved director, after which divide the tissue so affected ; then with a double bulbed atomizer, filled with electrozone, throw a continued spray into the wound for one minute, holding the nozzle about four inches away so as to reduce the force of impact. There is something peculiar and very satisfactory in the action of this antiseptic, as it renders the parts free from that sensitive soreness that naturally would be expected, allowing the patient to continue his daily avocation without inconvenience. The first dressing after incision consists of packing firmly with iodoform gauze covered with antiseptic cotton and held in posi- tion by a T bandage. In about every three to ten days an inch can be divided, and so on until the inner end is reached. // there are any branches they always show themselves, as their point of departure from the central track refuses to heal with the general result; so it is impossible to overlook any diverging issue. It is interesting to note how about three minutes' daily attention can secure such prompt resolution in these cases, the patient being lifted out of a depressed relation in a manner that gives prompt buoyancy to their feelings, simply because all septicemic poisoning has been discontinued. There is always a gain in weight from the beginning. In hospital methods, which have the sanction of the entire surgical world, these cases are frequently operated upon several times, each event repeating the usual details of anesthetics and confinement. The reason of this is found in the eccentric and complex windings of numerous tracks with only a central one presenting an objective exist- ence. Collateral to this main issue there may slumber several connecting branches, either circling the entire rectum or extending in any direction, a veritable con- flux of pathological surprises. / defy any man to diagnose in full completeness the entire compass of one of these cases before or at time of operation. Some- times there are several distinct tracks, having all their internal and external terminations at a common junc- ture with all the evidence of existence resting with the one closest to the surface. Through this one the surgeon goes with every reason for a favorable prognosis ; but in a brief time one of these other companions, having inherited the responsibility that heretofore fell upon its destroyed associate, now awakens into activity and de- mands recognition. By treating these cases in sections as intimated, nothing of this kind can occur, as the whole combination falls within easy range of the central idea, and when once the result has been attained it remains a permanent reality, barring only those inci- dents that relate to every human being. When a man's whole kingdom consists in what he does, he is always anxious to do it well. Even the purblind charaltan would bow to the most exacting penalty if he could only do as well a^ he pretends, I do not know of higher flights of feeling as a reward of doing well, than that vortex of gratitude and apprecia- tion that comes from the individual who has been bodily lifted out of a fistulous bondage in a manner that has obviated all those experiences usual in such cases; besides, it is a very agreeable emotion to throw an olive branch to that strain of tragedy that runs through the temperament of every human being. It is probably true that cocaine has never been sug- gested as a means of healing those anatomical breaks that thrive upon the mobility of the sphincter muscle. All incipient fissures and allied conditions that refuse granulation can be brought to a prompt and successful issue by injecting once daily a few drops of the 4 per cent, solution at right angles just through the floor of the difficulty. This holds the parts to a passive career until the next movement, when it should be repeated, and in a few days only the resolution will be complete, saving the necessity of dilatation, which is the standard method of treating these affairs. It will also remedy those old organic fissures, controlling the pain at once ; but in such cases the muscles have become hypertrophied, creating mechanical constipation and a wonderful wilderness of reflex symptoms that demand divulsion. STRETCHING THE SPHINCTER MUSCLE ! How I wish I possessed sufficient command of lan- guage to paint in graphic colors all that is true regard- ing the beneficence of this apparently simple device. When this muscle loses its ordination, what a field of wickedness does it create ! I have seen thousands of people locked in the grasp of its misbehavior, every moment seemingly the last one that could be endured, just because a slight rupture of continuity created a reflex activity and threw the entire rectum into a spasm. There are a multitude of distributed discords that picture a more passive expression of reflex actions, playing facsimile to the entire pathogenesis of every known remedy, completely stranding the pure symp- tomatologist who finds that this complex a/rray of indications refuse to abdicate at the instance of his medicine, while the patient becomes demoralized in disposition, and yields to a paralysis of hope — so de- pressing are these migratory influences. And yet, just a little skill in the direction of a peripheral inquiry would promptly solve the subtle mystery. Divulsion for constipation exclusively is very seldom indicated; but when the conditions correspond to a well-defined adaptability, then the result is most beau- tiful. These cases usually are women of high nervous tension, whose original moulds of temperament were seemingly decoyed from destiny by some adventitious circumstance, whose dispositions play the entire range upon the keyboard of fluctuating humor, — either very happy or very mad, but supremely emphatic at either extreme. Upon examination there will be found a slim spasmodic sphincter muscle, with its correlative con- dition of general engorgement, obstinate constipation attended with great exhaustion after each movement, owing to the excessive nervous combustion, referable both to the type of woman and the discord discovered. The slightest effort to exercise any extrusive energy- will cause the muscle to spasmodically contract, com- pletely locking the function. In one minute these cases can be restored by stretching the sphincter. It must be thoroughly realized, that because this idea is so successful in given instances, it does not follow that every case of this complaint can be similarly overcome. Differentiation is the religion of this specialty, and no surgical theory can become a surgical fact without an infinity of successful repetitions. It is an almost inevitable sequence — a fistula follow- ing an abscess — because of the everlasting mobility of the parts, both from the function and the compound action of the sphincter muscles. Whenever the genesis of one of these events comes under consideration, it is quite easy to close the affair without the fistulous consequence, allowing the physician to round out the experience with a vast amount of mutual satisfaction. Coincident with the opening of the abscess dilate the muscle thoroughly, and the region becomes a passive location amenable to all those repairing influences referable to rest and local stimulations. The only trouble with these cases is, the physician is not usually consulted until that specific sinus has become a living issue. Strangulated hemorrhoids mean ten days in bed under influences that tend to allay pain and absorb the effusion, unless they can be promptly returned. When they have become fixed in an external relation and refuse to be conciliated, — locked out, as it were, by the agency of a spasmodic grasp, — then under an anesthetic push the entire mass back into place, dilate the rectum to insure a quiet behavior, support with a firm compress, and in twenty-four hours the patient can go his way unmindful of recent events, saving a week in time both as to pain and business. This refers strictly and exclusively to a protrusion of hemorrhoidal growths and not to that marginal circular effusion into cellular tissue that is so often mistaken for inflamed hemorrhoids. There are a great many people suffering from a peripheral poverty, even to the extent of finger nails wasting from inanition, just because the circulation fails to reach the capillary frontier, being held in in- sufficiency by a Rectal obstruction of some specific nature. When the blockade has been overcome then the cutaneous nourishment becomes re-established with all of its auxiliary details, giving longer life and im- proved personality to the individual. These particular instances are profusely provocative of mistakes by the general practitioner, because he only considers the objective outcome, letting the central storm centre go on undisturbed, daily lowering the vitality and leading to premature dissolution. In the above brief examples can be found the range of adaptability suited to rectal dilatation, and hov/ swiftly the comprehension can measure the benefits of this wonderful service. There is nothing left to contingency, no fluctuating quotations of hope, no unsolved puzzle that has to be gone over the second time — it is all in the grasp of one word, compatibility — and quicker than arithmetic arrives the satisfactory result. A large portion of my reputation has been built upon the prompt and material benefits resulting from the correct application of divulsion, so deep and lasting is the spirit of appreciation that springs into activity out of the responsive senses of every patient so quickly restored. Yet there has been a vast amount of harm engendered by the wholesale and haphazard use of this idea by those who seem to forget that judg- ment must be exercised in every individual instance and not let one conclusion stand sponsor for the multi- tude. There are also those, in the spirit of fanaticism, that pronounce nearly every phase of pathology as the reflex result of some orificial disturbance, teaching that nearly all diseases can be overcome through the agency of some local repair ; but most every one prefers a well- balanced mind that deals in reason to one that evolves such lurid imaginations — for imagination when given unbridled liberty becomes a most dangerous adventurer. In dilating the rectum, place the patient on left side close to edge of the bed, with limbs flexed firmly upon the abdomen. An assistant gives the anesthetic — nitrous oxide is the best, easiest and quickest, one min- ute being time enough, including the operation. With ether it is different. Then introducing the thumb of the right hand very slowly — if it is not done slowly an unconscious mobility is aroused that extends the limbs and interrupts the proceeding. Follow this with the index finger of the left hand, and the entire situation is under complete command. Begin with slight traction, so as to measure the resistance, as no two cases are alike — a certain force necessary in one would be ruin in another. Continue until the entire muscle has lost all its power of competition, alternating the applied force several times with complete cessation, so as to give a kneading conciliating motion to the entire event. Never use a speculum, as a machine does not have any intelligence, and so many people have been fastened to a lifelong calamity by the incompetence of this idea. With a little experience any one can get an educated touch that will become automatic, insuring a perfect result in every instance. Rectal apoplexy yields an opportunity for making great and favorable impressions — away beyond the measure of importance the condition implies. By some mechanical circumstance a small vessel becomes rup- tured, pouring its contents out into the adjacent tissue, and coagulates. To the touch comes the indication of a small, hard foreign substance. Inject cocaine, open the pocket and out comes the clot, to the great delight 10 of the patient, because he always has a sudden fear of dangerous complications, as the whole affair may develop in an hour. In 1874 I accidentally encountered the original idea of destroying hemorrhoidal tissue by an interstitial diffusion of carbolic acid. At once I began the prose- cution of the problem, always conservative, always persistent, and always flushed with great confidence as to the ultimate outcome of the fascinating proposition. Little by little the units of merit were unfolded and classified, expanding here and restricting there, making permanent such factors as stood endless repetitions of success. / never vaulted into wayward conclusions on the impulse of insuificient evidence, hut charged every fracture of expectation to the personal account of un- developed skill, and proceeded to build in by practical thought and practical execution good solid material in the place of such laggard fragments as refused to round out info a harmony of perfect result. When confronted with any one that says he has a hemorrhoidal condition, in nine cases out of ten he does not have anything of the kind, because there seems to be an organized understanding to call every Rectal condition by this one name. When he tells you of a prolapsus at every action it may be one of several different affairs, and it is imperative that the diagnosis be correctly made at once. I always inject an anti- septic saline solution and allow the patient to force it all away, when the prolapsus brings into view the true character of the case. Carbolic acid is such a chaste remedy, truly typical of all the virtues, and stands seemingly foreordained as an agent thoroughly qualified to answer for the perfect annihilation of all those hemorrhoidal growths that represent an anastomosis of blood vessels. All other types are outside the range of this treatment, 11 and right at this point emanates the battle cry of dis- appointment, simply because an undeveloped judgment wanders beyond the boundary lines of its own jurisdic- tion. A 10 per cent, solution, thrown very slowly and very sparingly into the living hemorrhoidal tissue, becomes at once thoroughly distributed, entering into an intimate relation with every unit of the structure, coagulating just enough albumen to interrupt nutrition, practically choking the tumor out of existence. This may have to be repeated once or twice, but the rectal surfaces are always restored to their normal condition without leaving any indication of a pathological his- tory. When the recovery has advanced, so there is no more protrusion under any circumstances, it is not safe to discontinue, for a considerable portion remains that is never observed from the outside. By means of a slide speculum, the entire field should be cleared of all remnants, dealing with the tissue while insinuated in the fenestrum. This all looks very easy, but it is not, because the intellect has to experience the most com- plex activities in order to give expression to this masterly simplicity. I can say with absolute confidence, regarding this system, that admiration will always wait upon acquaintance with perfect compatibility, though great stress must be placed upon the fact that the word ''acquaintance" is wonderfully relative. The war cry of danger, coming from undefined directions, has found some currency along the lines of monthly literature, but it does not rise to the dignity of authority, because it is the outcome of collected quotations either from nondescript practitioners or those that have only made a desultory investigation of the subject. What I have to offer is founded upon thirty thousand successful cases covering the entire half of a long lifetime, which proves that what is chimerical in the eyes of opinion may become a well- defined reality through the medium of experience. 12 One writer exclaims that his investigation consisted in throwing five drops of a 50 per cent, solution into the center of the tumor, then waiting for the commotion. He was wise to abandon the idea. He makes me think of a man playing billiards without skill, just hitting the object ball with all his force, then watching the result. Sometimes he really makes a count, but never becomes an authority in billiards. A judgment founded upon the alphabet stages of any investigation is always worthless. The man that is contented with things as they are forgets that the world is not yet completed, but is always completing, and only the elect ride on the latest wave, because perpetual modernness is the measure of merit. SOME COMPARATIVE ADVANTAGES. Two hundred cases can be kept under way all the time, thereby catching the rhythm of that sweet old legend, "the greatest good to the greater number." A large number of people adopt these ideas, that would never subject themselves to other methods. As the surface of a hemorrhoidal tumor is never broken there is no such thing as post-operative hem- orrhage. A skillful application of this system leaves pain out of the experience and patients can attend to their usual affairs. A case thoroughly restored is permanent; but if it had to be treated every year, the advantages would still exist. Any substance injected into animal tissue travels in the direction of the least resistance; hence, in these matters, it does not invade deeper relations to their detriment. The general health improves from the first day. There is only one disadvantage, under this head, and that is, it takes so much experience to become skillful ; 13 whereas, in other systems there are no complex ideas. Every case is simply a case, and awakens nothing different. The greatest advantage of this interstitial invasion, as a means of destroying hemorrhoids, is that there are no disadvantages. Prolapsus, involving the mucous membrane and sub- mucous tissue, is a condition that is quite versatile in disturbing the general health and disposition. At every movement all the inner coatings seemingly slip from their normal relations, traveling out into the outer world, where they are grasped by the sphincter muscle, engendering a vast amount of sickening anguish and irritable humor. Whenever the muscle has lost its usual degree of integrity then the entire affair comes down at any time, irrespective of place or occasion, when the patient becomes burdened with a busy experi- ence, that lends everything but joy to the complexity of his feelings. Coincident with this experience the sympathetic nervous system is lashed into greater activity, the excess of combustion causing a rapidity of existence to the extent of about a dozen days for every week, hence that perennial enervation. Gather up — in sections — into the fenestrum of a speculum, all of that relaxed tissue, and inject a 5 per cent, solution of carbolic acid, just enough to get a gentle distribution, without commotion, and a general atrophy will result, tighten- ing the entire rectum to such an extent that the func- tion will be restored to original behavior. Perhaps there is nothing in the range of this specialty that will command more gratitude than to take a relaxed rectum and return it to perfection, unloading a cata- logue of burdens that have weighed heavily upon every nerve center in the economy of all such sufferers. Pruritus is one of the most rebellious conditions we meet, and no one can say just what the outcome is U going to be in any given case. I never promise any- thing, but find the most satisfactory results from the following application, used in connection with a 20 per cent, solution of fluid hydrastis injected into the rectum twice daily and allowed to remain : Acid carbolic grs. xxx. Calomel dr. i. Tar dr. iss. Menthol gr. xx. Zinc oxide dr. ii. Lanoline oz. ii. Rub actively into the skin twice daily after bathing with hot water. I always detested the idea of flashing any personal lime-light, but it is orthodox to battle facts against fancy; so I am constrained to say that I have a repu- tation, ever stretching in its radius, that has been de- veloped on account of the above apparently simple ideas, being moulded into correct affinities and cor- rectly applied. There is a minute minority of the medical profession permanently sold to unbelief, that I fain would incite to some interest in this question; so if they will come with me out into the open of my accumulated occurrences I will try and unpack reason with deeds, showing them the living evidence from which we have drawn this abbreviated farrago. MAKING AN EGOTISM OF IGNORANCE. A distinguished member of the Academy of Medi- cine recently read a very interesting paper, describing the various methods of destroying hemorrhoids. After discoursing most learnedly as to the many devices re- lating to this condition, he reached the highest fervor of his effort by saying " he did not know anything about the interstitial invasion, and did not want to." Even if this gentleman does confess he is devoid of 15 all knowledge regarding the beneficial quality of this particular practice, I happen to be in a position to tell him, from information that comes to me guarded by the most conservative judgment, that there are about thirty thousand people in this city that do know all about it, and are eloquently recommending this plan every day, people that have their reasons from personal experiences, and form the texture of a reputation that expresses such a volume of appreciation that it would be quite difficult to duplicate it. A man's reputation is always measured by the humor of those with whom he has done business, and not by the compliments of his competitors. About thirty years ago the Western Union Tele- graph Company used these very same words : "We don't know anything about it and don't want to." This occurred when the new-born telephone knocked at its threshold, pleading for recognition and opportunity. Every one knows the subsequent history. Within a much smaller magnitude, but involving a more vital question — the conservation of human life, the very same kind of experience has been duplicated for those able gentlemen that thrive upon the practice of this specialty, have been omitted by hundreds and hundreds of afflicted people, just because they did not open their minds wide enough and long enough to grasp the full meaning that embellishes the simplicity of this im- portant subject. "Success requires not something new To win applause and recognition; But doing that which others do Beyond their range of competition.' What could be more scientific, more in harmony with practical uncommon sense, more happy as a response to the solicitations of a suffering people, than to meet 16 every case that brings an array of hemorrhoidal tumors as a burden of complaint, with an easy application of this idea, by sending a lo per cent, solution of carbolic acid all through the structural tissue of each growth, but only one at a time. The chaste affinity that this medicine has for such vascular creations, simply neu- tralizes their nourishment, and as an inevitable conse- quence the whole volume affected is carried away within a reasonable time, leaving a thoroughfare free of every indication as to what had gone before. Behind this brief outline, there must exist of course, a master of detail, trained by long experience to execute all those delicate and necessary manoeuvres, in order to attain the full fruition of this proceeding, for discord was never known to lead up to harmony, though all adverse criticisms that have been written or spoken upon this subject can be traced to discord in execution. In the further employment of this system there is that enervating condition where the mucous membrane and some sub-mucous tissue is always so willing to travel along with the slightest extrusive energy, seemingly lost as to all organic anchorage, even sliding out into the open world, frequently requiring forcible readjust- ment, much to the mental and physical disturbance of the individual. Every physician knows what a burden this is upon the general health, how every vital function is apt to be extensively involved, just because the law of reflex action finds here such a rich opportunity for its versa- tile and pernicious activity. Unless the greatest care is exercised this symptomatic picture may be easily mistaken for the true details of a well defined reality, so vivid and so graphic are the simulating messages that are constantly being distributed from the active warfare at the peripheries. By introducing a tubular speculum, this relaxed tissue can be profusely strained into the fenestrum, showing a billowy roll of irresolute 17 mucous membrane apparently without any avocation, or any other means of support. Into this mass inject the solution above mentioned, until there is a general diffusion all through the entire volume, holding the speculum in position for about one minute, so as its constriction will retain the medicine within the mass involved until it becomes fixed by virtue of its natural affinity. By repeating this every several days, until the entire territory at fault comes under this specific influence, there will ensue a general atrophy of the entire rectum, tightening it up as it were, and bringing the wayward function back to a normal behavior. Then there is that condition of recurrent hemorrhage that appears without any other symptom or complica- tion, losing a sufficient amount of blood to diminish the entire vitality very much, according to the tem- perament of the individual affected. By drawing back the slide after the speculum has been thoroughly intro- duced, the hemorrhagic surface comes into easy view, showing an uncovered area that allows the blood to escape, as the daily function comes along with its volume of unresisting pressure. Just let some of the same solution flow into this insinuated tissue by means of a hypodermic machine, when the circulation there becomes coagulated at once, sealing up forever the open door of depletion, locked by the skillful gesture of a simple practical thought. To perform the White- head operation for such an affair — as is being fre- quently done — would be like using a sledge hammer to break a butterfly. These little catches from a life work along this line are only hints as to what has been done, and can be done, and are given as something tangible, in answer to the nothingness of an open con- fession that admits an absolute lack of information on this subject. I have myself seen a great many thou- sands restored to health by this method, and they can be found close together all through this city, as well 18 as in every city in the country, including every city in Europe, all coming here in response to a reputation that lives up to the better v^ay. To neutralize this growing influence by the play of just one negative sentence, would be as impossible as going out to Wilkesbarre for the purpose of destroying one of the greatest industries in existence by waving a little flag of hostility against the boundless commerce in coal. The eminent practitioner whose peculiar laconism gave creation to these meagre and modest lines, can not surely object to a few analytical sentences of criticism, inasmuch as he has openly endeavored to deprecate the character of a well established and fascinating fact. It has been estimated with a considerable show of accuracy, that about twenty people out of every hun- dred are suffering from this malady, all looking for release, but very few willing to adopt any personal attention. Having been intimately related to the temperamental experiences that find such an expansive currency in this matter, it may not seem unreasonable to offer a relative diagram, approximating the disposi- tion of this specialty, when considered in the light of such influences as the caption of this message would seem to imply. Acting upon an intuition that has grown from personal observations extending over thirty years, I feel I am quite safe in estimating that just one person out of the twenty above mentioned is willing to adopt any measure of relief suggested by those who have him under jurisdiction, but that two people out of the same quotation, hesitate before going to such extremes, and begin to ask questions about more reasonable and attractive means, shrinking from occupying the centre of the stage in that great popular tragedy, known as the necromancy of knives. The remaining seventeen refuse to have anything done by anybody, depending upon such adventitious things as come to them from the chaos of promiscuous sugges- tions. Q It Is not very difficult to estimate the injury resulting from a man of high degree standing up in his pulpit of self-sufficiency and announcing by innuendo, that what he does not know is not worth knowing, even going so far as to denominate his favorite brand of ignorance. When such a statement goes out to the medical world it travels very fast indeed, being propelled by the breath of prejudice, while old-fashioned truth, married to time, journeys along very slowly in pursuit, but ultimately it always prevails. The general profession is not usually equipped to furnish the refinement of surgical means for this i per cent, class of sufferers, and having been influenced by such messages as I have already repeated, consequently the entire 3 per cent, are left helpless and neglected, when so many of them could be rescued, as they will be when thoughts divorced from antiquity are generally distributed and adopted. Like a little wave of retribution, there is a humorous bit of history that contributes quite an argument against the feasibility of these antagonisms, showing how unequal is the equation when only a personal feeling is thrown in the balance against end- less object lessons of a living and expanding reality. Over and over again has it occurred that the family physician — that blessed oracle and Court of Appeals in so many domestic consultations, has weighted his great influence in opposition to modern means when- ever a rectal malady required immediate and specific attention. I have been made aware in several hundred instances, that the conflict has run so high, the family has taken the question out of dispute, following their own judgment, breaking forever the bonds of mutual- ity, then making arrangements for a successor of their medical advisor. An established truth made so by public appreciation and support, can never be driven back by prejudice that has been withering for over thirty years, until 30 now only a remnant remains, while many physicians are not only personal patients, but are swinging all their available influence in the building up of a system, I am doubly assured by those in a position to know, that prolongs more lives in this city by dealing with more cases than all the other plans combined. To that remaining minority whose feelings find friction in dissolving views — I would request an audience, for the purpose of suggesting that they place a modern candle power behind every window of their souls, thereby yielding an exhibition of bright new light and genial warmth, in place of that perennial darkness, which so easily spreads thick shadows all over their careworn faces, whenever a beloved patron has the temerity to whisper thoughts of innovation. When a self-appointed censor climbs so high in an atmosphere of theory, that the rarefied air begets an incoherency of reasoning compelling him to improvise a hypotheti- cal basis in the place of mental equivalents, he is wav- ing the colors of the negative factor in the great progressive duel between ignorance and knowledge. When he breathes bitterness against a proposition that he says he don't know anything about, he is enacting a behavior parallel to condemning reputable citizens without listening to any disapproving testimony. When he so narrows the range of professional lib- erty, that every departure in thought or action that does not bear his courteous stamp of approval, must be considered as unpardonable heresy, then he is fos- tering a disposition that would just revel in the disaster of one case gone wrong, and draw the dusty curtain of silence across the picture of ten thousand brilliant successes. When he closes the avenue that might lead to valuable acquisitions of information, and in the spirit of being well satisfied with himself says he don't want to know anything more upon a given subject, knowing enough already, he may be thriving as a 31 temporary attraction of frenzied popularity, but such conduct never builds tablets in the everlasting Hall of Fame. The man that does things, and swings his entire life in the circle of honest endeavor, insisting upon know- ing all the possibilities that pertain to his personal world, and never condemns except upon the basis of being qualified by investigation, is the man who lives close down to ancestral earth, that reliable incubator of all our existing values. "You don't know how much I appreciate what you have done for me. I had been treated about six years and by thirty-one different surgeons. Your generosity and big-heartedness is incomparable. You make small of your wonderful work and your liberal and honest treatment of your patients, but I think you are so far ahead of all the men I have seen that I find it impossi- ble to make your work appear anything but great. I enclose the check for sum you intimated when I first saw you. It is so small for the service rendered that I can not help but feel ashamed ; but, as you say, there are many things better than money. I realize you made me special terms out of the greatness of your generous nature and I appreciate it more than you can know." I print the above personal letter without apology, not for the purpose of expanding my own reputation • — which I don't need — ^but to show how the average surgeon overestimates the requisite necessities as to rescuing a man from such a condition. Here was an army officer that had contracted chronic diarrhoea in the Philippines, and when I saw him first found the entire rectum one entire mass of ulceration, looking like an old garment that had been riddled by the activi- ties of a million moths. About six inches above the sphincter muscle was a stricture that would not admit a bougie only of the smallest size. Down from this 22 constriction burrowed an incomplete internal fistula that traveled back into the lumbar region, the entire picture being hung in an enervating frame of constant pain and tenesmus. It is not my humor to tell what had been done for him or proposed as a last resort. I only want to describe the simple simplicity that made him well, as simplicity is the only broad and popular religion of this specialty. With a long, thin, small dilator, made for the case, I opened the rectum daily to the very margin of dis- comfort and held it there for one minute, first flushing the entire capacity with an antiseptic neutralizing solu- tion. This left the function in a purified state and robbed of a large portion of its involuntary mobility — and there is nothing like rest to restore such cases. Before withdrawing the machine, a good-sized tampon of dry cotton was introduced to the upper extremity of the dilator, so as to dam up in measure the secretions that journey downward, thus insuring an approxi- mated dryness and passivity of the involvement for nearly twenty hours. It was gladness to watch those confluent ulcerations fill in with new and normal tissue. And within sixty days the entire fault was gone — including the posterior fistula, which had been divided upon the installment plan clear out to its lumbar extremity. During all this attention, not one day did he lose from his business, which is a most valuable consideration. The eccentricities of fistulous tracks forms one of the surprises of this specialty. I am going to relate the features of a couple cases that would never be met in a general practice. For twenty-five years a well- developed man had been suffering with pains involving the whole rectal neighborhood, especially in lumbar region and along the urethra up to the left inguinal gland. Nothing was visible except the landmarks of many hospital operations, but by the closest scrutiny 23 I found a small pinhole in the small of the back, which would admit a slender probe for about one inch. I injected cocaine into this tissue and opened the track. Then I found the sinus continued in a circle of three inches in diameter. Following this course until it had toured its circular extent, the journey was continued in a straight line for eight inches, opening into the posterior wall of the rectum. From this location it circled around the right side to the perineum, then following close to the urethra up to base of scrotum, when it turned to the left and ended in the left inguinal gland. This entire tunnel was opened by dividing a portion at a time, and dressing daily with antiseptic attention. In fifty days the entire course was changed into healthy tissue ; he not losing one day from business, being a city official. For about three inches of the track opened the urethra was exposed, showing it had laid in a cesspool of indolent ulceration for many years. Being a man of large stature, afforded ample chances for extensive lengths, and the sinus measured just twenty-five inches in its complete circuitous extent. Another man that weighed 350 pounds, furnishing great possibilities for these involvements, had an open- ing out over the right hip joint, connecting with the rectum by way of a large excavation in the centre of its course, where a good-sized orange could have been sequestered. Having been abandoned by every one that should have given him relief, I was glad to battle with him for his life. By opening the deep central excavation an elastic ligature was adjusted to the outer half, which divided that portion quite promptly, and the entire condition was made antiseptic from the first day the awful chills caused by absorbing the poison were discontinued. In about three weeks this section was sufficiently healed so the remaining half could be also divided by ligature. The centre of the fistula was just four inches below the surface. In just fifty-two days this case was fully restored. 24 "A ROLLING STONE GATHERS NO MOSS.' E. F. HOYT^ M.D. I hate moss ! and with all my soul I hate the stone that will not roll; But in its bed of slothful ease It gathers there by slow degrees This useless garb of idle years. No thoughts, no strifes, no hopes, no fears, Unfold a life of crisp conceits, That yield a lustre, and completes A round of beneficial deeds. Responsive to ambition's needs. As the unwinding wheel of time Pays out the centuries sublime. And each successive one reveals The grander lesson it conceals. So onward goes a mighty world. The God of nature has unfurled The banner of progressive thought. The subtle laws that He has wrought Evolving to the human mind In currents measured, and combined With comprehensive methods rare. The race that live to-day declare Achievements to the past unknown, But still this mossy, carping stone Ignores the grandeur of the scene Contrasting with its heedless mien, And chants that aphoristic wail, By countless ages rendered stale, Which pleads for favor and for fame Upon that weak and foolish claim Of having clogged its years with dross, By ever hoarding worthless moss. I sing the stone that dares to roll. That superstition can't control. That braves tradition's haughty creed, And journeys on with rapid speed, Upsetting all dogmatic whims. Whose stolid shadow ever dims The mental vision of the age 25 With that peculiar quoting rage Adopted by the weary host That ever flaunt some lingual ghost Into the light of present needs, To garnish thus their feeble deeds. The rolling stone encounters then, Every shade and class of men; Observes the spirit of their lives, And ever watchful, it contrives To glean the substance, and regale Its bright career with such detail Of enterprising thoughts, that lead To broader aims, and supercede The withered yearnings of the stone That only pleads to be alone. To catalogue the human race, And designate by trait and place, The current attributes of life Outflowered by aggressive strife. Commands attention to the grade Attained by human nature's trade, When moulding on that narrow plan The form and semblance of a man. Whose meagre soul is ever prone To t3^ify the idle stone. The highway of his true domain, Where walk the pigmies of his brain, Lead not among the fragrant fields Of cultured minds and grand ideals, But circles in a smaller sphere The confines of his whole career. Enclosed within this petty realm. He vainly thinks he holds the helm That sets the course of mighty deeds And guides the judgment that succeeds. His shriveled nature is replete With all the forms of mean conceit. And when his little mind is sought To harmonize with broader thought, He shrinks away from easy view. Abhorring all things that are new. Unless they bear the stamp and creed Of a sluggish heart and selfish greed. 20 No softening showers of heavenly grace Can melt the hardness from his face; The nectar that the gods do quaff Could ne'er subdue his vulgar laugh; No magic minds could e'er impart A single impulse to his heart; No joyous scenes, with gladness fraught, Can kindle there a warmer thought; No soothing words, however choice. Can take the harshness from his voice; His little life's-enacting role Echoes the dryness of his soul; But when the sun's outpouring light Redeems a day from gloomy night, And brings to view the silent force Oppressing manhood's only source, 'Tis then we know the conscious loss Of being clogged with skeptic moss. 27 COLUMBIA UNIVERSITY LIBRARIES This book is due on the date indicated below, or at the expiration of a definite period after the date of borrowing, as provided by the rules of the Library or by special arrange- ment with the Librarian in charge. DATE BORROWED DATE DUE DATE BORROWED DATE DUE C2e(l14l)M100 I ^ I H86 iip^coiiditions Rc^t>4 n^ h