COLLEGE OF OSTEOPATHIC PHYSICIANS AND SURGEONS LOS ANGELES, CALIFORNIA UNIVERSITY OF CALIFORNIA "VJFORPIIA COLLEGE OF MEClC APR 2 7 19T3 CAUFCRNIA 92667 ^^ ORIFICIAL L_ UERFY OF E OF ITS Philosophy Application am/ Technique ^ Compiled and Edited by B. E. DAWSON, M. D. Kansas City, Mo. Assisted by ELIZABETH H. MUNCIE, M. D., A. B. GRANT, M. D M and H. E. BEEBE, M. D. Authorized by The American Association of Orificial Surgeons Published by the PHYSICIANS DRUG NEWS CO. NEWARK, N. J. 1(2- COPYRIGHT 1912 By PHYSICIANS DRUG NEWS CO. NEWARK, N. J. Preface. "Instead of condemning me to death the city (Athens) should grant me a pension." Socrates. A word of explanation is due the reader as to the origin of this book. For several years I have been an enthusiastic disciple of Dr. E. H. Pratt, and have written numerous articles for various medical journals and read papers before medical societies on the subject of Orificial Surgery. About one year since I was solicited by a number of individuals, some I had never seen, to write a book on this subject as there is none extant. I strongly demurred until these requests became so urgent that I consented to compile a small book and solicited the assistance of other orificialists. At the request of Dr. Elizabeth H. Muneie, of Brooklyn, I held in abeyance my plans until the next meeting of the American Association of Orificial Surgeons. At that meeting Dr. Pratt, Dr. Muneie and I held a conference and agreed on the plan that produced this book. Dr. Muneie, who was then president of the Association, recommended it in her "presi- dent's address," and the Association authorized it by unani- mous vote. The plan was to compile the book from material to be selected from The Journal of Orificial Surgery, edited by Dr. Pratt several years ago, and also from the year books, reporting Dr. Pratt 's clinics. I was appointed editor, and Drs. Elizabeth H. Muneie, A. B. Grant and H. E. Beebe were ap- pointed on a committee to assist in selecting the material. This material was gleaned from a vast amount of litera- ture and amply covers the field for the purpose of this volume. Much that is most excellent had to be left out for want of space. There are some repetitions, but of such importance as to need this emphasis. o iv PREFACE. The reader will bear in mind that some chapters were written several years since, and may require a retrospective interpretation of chronological statements, though I have taken the liberty of revising most of these statements. I have also taken the liberty to eliminate portions of articles not germane in book form. Many reports of cases were forced out to give room to matter more directly setting forth the Orifieial Thought. The classifying of this material was often perplex- ing; not being written for book form, some articles dealt with more than one subject but could not be divided. Much space is given to the Philosophy of Orifieial Surgery and also to the Rectum. This is for two reasons: first, on ac- count of their value and prominence in the inventory ; second, because there was so large an amount of material on these subjects that was so excellently practical as to forbid curtail- ment. The medication prescribed might have been cut out, and in many cases was, but some times left as helpful to those who wish it. As editor I have had but little to write as the field is so well covered. I have eliminated and made some changes, and here and there sandwiched in a few lines, designated to show the responsibility. I wish to heartily thank our beloved Dr. Pratt, for his help and encouragement, also my assistants and all others who have encouraged me in the work. It has been a labor of love as well as helpfulness to me in a reflex way. It affords me much pleasure to launch this volume freighted with a cargo of commjodities to bless humanity. May it be received and utilized with the same earnest desire that prompted its launch- ing: that of doing good in helping others. B. E. Dawson, M. D., 3220 Oak Street. E. H. PRATT, M. D. Orificial surgery no longer needs individual indorsement. Its principles are indelibly etched into medical history, and its establishment has now become extensively accomplished and will unquestionably mark an era in medical practice. It no longer needs individual support or indorsement, as its growth, appreciation, and prominence are already assured. There is no longer the slightest danger that orificial surgery will be either ignored, forgotten, or neglected by the medical world or its patrons. Much progress has been made in its meth- ods and there is still room for more ; but the foundation prin- ciples have never changed since their first enunciation ; nor can they ever change, because they are so consistent with what is already known of the structure and vital processes of every human being. Slowly, by degrees, the profession are awakening to the all-important fact that there is but one central idea in medical practice, and that is the circulation of the blood. By this single process has all growth been accomplished, and by this same process must all repairs be made. Consequently, remedial measures are valuable only as they act upon the circulation, either locally or generally. Just in proportion as this con- ception has secured recognition, to a corresponding degree has the profession been liberalized, so that it now contains large numbers of ardent truth-seekers, who are earnestly making the acquaintance of every available means by which the blood-stream can be fluctuated and controlled. Prejudice is melting away, hostilities to innovations are becoming en- feebled, all hindrances to progress are being torn down, the tyranny of ignorance and conceit is being rapidly overcome, and never before in its history has there been such a whole- some and widespread awakening and friendliness in the hearts vi INTRODUCTION. of medical men to every new idea that can demonstrate its ability to flush or pale bodily tissues. Drugs and knives and local applications no longer constitute a complete medical armamentarium. The part which mental and emotional forces play, not only in the functional activity of all bodily organs, but also in pathological formations, is at last being recognized by medical leaders, and also to a considerable extent by the rank and file of the profession ; and a knowledge of suggestive therapeutics will soon become a necessary part of a complete medical education. The value of osteopathy as a remedial agent will in due time be recognized, and no doubt many other forces as yet unheralded are to be recognized and secure a recognition as legitimate means of cure in the new book of progressive medicine which the first end of the twentieth century is rapidly compiling. The reason why orificial surgery has gained so rapid and complete a victory against the bigotry and intolerance of the ignorance which first opposed it, is because- it speedily dem- onstrated its ability to stimulate the nutrition, and thereby influence the functions and conditions of the entire body and all its parts. Its growth has been phenomenal, and an ig- norance of its principles of operation and neglect of their employment in proper cases is rapidly becoming a medical disgrace. Orificial surgery is not hostile to any other remedial measure in medicine, but the doctor's quiver is by no means too full of arrows. His armanentarium is not any too well stocked with remedial measures. We are striving to add another arrow, another remedy, and we present it to the fraternity with an abiding faith in its reliability and truth- fulness. The good which can be accomplished by all remedial measures familiar to doctors is little enough, and if orificial surgery shall be the means of lessening the amount of suf- fering in the world to only a slight degree, our enterprise will have served a worthy purpose. The philisophy of orificial surgery is so thoroughly grounded in anatomical and physio- INTRODUCTION. vii logical facts and principles that we feel confident that it must in time become recognized universally as sound and practical and a well-taken step of pronounced progress in the history of medicine. The methods, however, which we have at pres- ent to present, are oftentimes severe and objectionable in many ways, and therefore may be shortlived, being superseded by kindlier and more effective ones. We are wedded to no practices that we would not willingly abandon for better ones and will be grateful for suggestions of improvements. It is wonderful that you can take a person with asthma and in fifteen minutes stop it; take a case of chronic rheuma- tism, with the joints all swollen and full of pain and have the pain stop and the patient immediately get better before the sun goes down. The physical accomplishment of orificial work is simply beyond our appreciation. As I stop to think of things I have seen done by that work I stand dumfounded. I am surprised that it is not appreciated more, but it is because it is so big. If it were only a cure for rheumatism, it would be widely known; if it were good to cure only dyspepsia, if it were only to cure paralysis there would be a great move among paralytics for the work. If it would cure only the insane it would be used in insane asylums, but when you claim that a measure is a measure that is needed in all cases, it is so big it knocks other big things down. It asks other measures to step aside and let it in to lay the foundation. It is such a conceited proposition that it is denied a hearing but it is going to be heard, and its wonderful work. Contents. Chapter Page I. The Birth of Orificial Surgery 17 II. A Brief Chapter in the History of Orificial Surgery. . 26 HI. Orificial Surgery: What is it Fact, Fad or Fancy?. . 39 IV. A Plea for Orificial Surgery 46 V. Orificial Surgery 55 VI. Orificial Surgery 61 VII. A Synopsis of Orificial Surgery and What It Has Achieved, with a Eeport of Cases 72 VIII. Orificial Surgery and the General Practitioner 82 IXs The Composite Physiological Man 87 X. The Mutual Relations and Separate Functions of the Two Nervous Systems 92 XI. Some Points in the Manner of Nerve Distribution, Some Characteristics of the Sympathetic Nerve and the Meaning of the Term Orificial 101 XII. The Philosophy of "Nutrition" and the Relation of its Disturbances to Affections of the Nervous System, and the Value of Orificial Treatment Therein 110 XIII. The Orificial Philosophy and Its 'Methods 114 XIV. Science of Orificopathy or Orificial Methods of Cure.. 120 XV. Orificial Philosophy 122 XVI. Vasomotor Centres 129 XVII. The Sympathetic Nervous System or why Orificial Sur- gery Should Cure or Affect Most Chronic Diseases, Explained from an Anatomical and Physological Basis 133 x CONTENTS. Chapter Page XVIII. Reflexes 141 XIX. Reflex Neuroses 153 XX. Orifieial Reflexes Clinically Illustrated 1.1.1 XXI. Necessity of Considering the Reflexes in Making Diag- noses 160 XXII. The Technique of Crificial Surgery 165 XXI1L Surgical Judgment 171 XXIV. Orifieial Surgery Its Dangers and Possibilities A Preventive Measure 173 XXV. A Consideration of Orifieial Methods and Operations. .181 XXVI. Orifieial Suggestions 106 XXVII. The Confirmation of Experience 202 XXVIIL Surgical Duties of the General Practitioner 211 XXIX. Nerve Impingement in Operative Surgery 216 XXX. Abdominal Section in the Light of Orifieial Philosophy 229 XXXI. Neuroses of the Rectum and Anus 237 XXXII. Rectal Surgery Considered in Its Relation to General Surgery 242 XXXIII. The Toilet of the Rectum 247 XXXIV. A Few Points on the Anatomy and Physiology of the Rectum Pockets and Papillae 250 XXXV. Rectal Surgery from an Orifieial Standpoint 281 XXXVI. Hemorrhoids 293 XXXVII. The Slit Operation 306 XXXVIII. The Slit Operation Under Cocaine 311 XXXIX. The Treatment of Hemorrhoids 312 XL. The American Operation in Hemorrhoids 318 XLI. The American Operation 320 XL1I. Rectal Diseases Pistulae . ..328 CONTENTS. xi Chapter Page XLIII. Strictures and Ulcers of the Rectum 33t> XLIV. Fistulae-in-Ano 345 XLV. Rectal Fissures 361 XLVI. Diseases of the Rectum and Sigmoid 365 XL VII. Sigmoid Catarrh in Women 369 XL VIII. The Sigmoid 372 XLIX. Non-Malignant Diseases of the Upper Rectal Pouch and Sigmoid Flexure, and an Improved Method of Treatment 380 L. Some Points Concerning the Anatomy and Physiology of the Male Sexual Organs 387 LI. Circumcision 392 LIT. Circumcision 401 LIII. Lesions Arising from Contracted Prepuce Twenty Con- secutive Illustrative Cases 404 LIV. The Male Meatus and Urethra 407 LV. The Use of Male Sounds 412 LVI. Diseases of the Prostate 418 LVLT. Some Points Concerning the Anatomy and Physiology of the Female Organs 431 LVI1I. Terminal Nerves of the Sympathetic and their Troubles as a Factor in Pelvic Inflammations and Other Dis- orders of Women 444 LIX. Dilatation of the Vulva, Vagina and Uterus 454 LX. The Cervix Uteri 461 LXI. Improved Technique in Vaginal Hysterectomy 466 LXII. Vaginal Hysterectomy 474 LXIII. Circumcision of Girls . ..482 xii CONTENTS. Chapter Page LXIV. Preputial Adhesions in Little Girls 491 LXV. Gynaecological Keflexes 495 LXVL Improved Method for the Bepair of Complete Lacera- tion of the Perineum 499 LXVII. The Psychic Factor 505 LXVI1I. Mental Healing 529 LXIX. Suggestive Therapeutics ir, the Treatment of Chronic Cases; or as an Aide to Orificial Surgery 543 LXX. Lowered Vitality 551 LXXI. Functional (Disturbances and Mental Conditions In Chronic Diseases 555 LXX1I. Insomnia Its Relief by Orificial Methods 566 LXXIII. Functional Insanity 568 LXXIV. Neurasthenia 575 LXXV. Chronic Constipation 578 LXXVI. Constipation and Diarrhea as a Neurosis Treatment from an Orificial Standpoint 581 LXXVH. Constipation 584 LXXVIII. Epilepsy Treated Officially 586 LXXIX. Acne Simplex in Young Men 591 LXXX. Sympathetic Vomiting 593 LXXXI. Hiccough Cured 595 LXXXIL Sexual Habits and Necessities 601 LXXXI1I. Tissue Reading from an Orificial Standpoint 612 LXXXIV. Prostates and Wombs 619 LXXXV. Importance of After-treatment in Orificial Surgery. . .625 LXXXVI. After-Care 627 LXXXV1I. After-treatment in Orifieial Surgery 629 LXXXVIII. Some After-thoughts, Warnings and Helpful Hints 645 Contributors. Appleton, T. J 247 Beebe, Curtis M 171 Beebe, H. E 551 Bessey, AV. E n Bliem, M. J 82 Brown, S. G. A 155 Chancy, E. N 361 Cogswell, G. E 372 Cole, E. Z 280, 627 Costain, T. E 328, 401, 578 Dawson, Benj. E 46, 548, 574, 584, 631, 640, 645 Eaton, Cora Smith 306, 311, 369 Eldridge, C. S 165 Green, W. E 499 Grosvenor, L. C 466 Holbrook, Francis D 474, 629 Hood, C. T 543 Hubbell, Eug 120, 318, 586 Hurt, W. H 593 Means, J. W 129, 404, 581 Morley, F. W 619 Muncie, Elizabeth H 39, 72, 491 Notrebe, E. P 135, 555 Pauly, C. A 312, 365 Pratt, Leonard 46 Pratt, E. H 17, 26, 87, 92, 101, 114, 173, 181, 196, 211, 216, 229, 242, 250, 281, 293, 320, 335, 345, 387, 392, 407, 412, 418, 431, 444, 454, 461, 466, 482, 505, 529, 595, 601, 612 Reddish, A. W 153 Eeplogle, P. S 160 Runnels, A. M 61 Runnels, M. T 495 Sawyer, C. E 122, 202, 575 Sherwood, H. A 625 Skiles, H. P 568 Townsend, H. L 237 Weirick, C. A . .141 SECTION I. General View of the Orificial Thought. CHAPTER I. THE BIRTH OF ORIFICIAL SURGERY. E. H. PRATT, M. D. The occasion of its delivery was marked by a peculiar combination of circumstances. It was in February, near the close of the winter term, in the Chicago Homeopathic Medical College in the year 1886. The class had had a hard winter and were much fatigued and many of them ill. The surgical clinic had been a heavy one and was replete with illustrations of the connection between orificial irritation and chronic general conditions, and at the close of the clinic just preceding the delivery of the lecture we are about to publish, the nature and scope of the orificial philosophy, which before had been but fragmentary in its manifestation, dawned upon the writer in such intensity and fullness of conception as to leave the class at the close of the clinic with the impression that some- thing had happened. It was announced that the next lecture would be "A Surgical Talk upon the Orifices of the Body." The circumstance had been noised about to some extent, so that when the lecturer arrived the audience chamber was crowded to its capacity. Fortunately he had been solicited as a member of the faculty to contribute an article to the Medical Era, and as he was not at that time in the habit of writing and consequently had delayed complying with the request, and as the subject to be presented was an entirely new one, he concluded to employ a stenographer to chronicle the truths he was about to present, and in this way accom- plish two purposes, fulfilling his promise to the Medical Era to furnish it an article, and at the same time preserve a record of his first expression of the orificial thought, which he imme- diately conceived was destined to occupy a prominent position in medical knowledge and literature. To that end Dr. W. S. 18 OEIFICIAL SURGERY. Moffatt, at that time of Wheaton, who was a professional stenographer, was engaged to attend the lecture and report it. But for the promise of an article to the Medical Era, in all probability no published record would now exist of this birth of a new medical idea. We believe that neither ourselves nor any person present at that hour will ever forget the occasion. As for ourselves, our feeling of depression was extreme, and if the stenographer had not been engaged to be present and the announcement made that something unusual was to take place, we would have invented some excuse to escape that talk at the college. But duty and a sense of honor whipped us into the rostrum and ushered us into the most remarkable hour's experience which our lives had thus far known. Our talk for the first ten minutes was heavy, laborious, every word of it forced. The extreme position we were placed in had already begun to dawn upon us, for if what we were about to say were true it was such an innovation in the practice of medicine as to completely ostracize us from the medical profession, and would necessitate our demonstrating speedily the correctness of our position, or demand our withdrawal from the institution with which we were connected, and probably from the State So- ciety, the American Institute, and in all probability from the practice of medicine. So the issue as it presented itself to our mind in that moment of exalted preception was a question of professional life or death. Under some circumstances one could be forced to the edge of a precipice by some extreme danger, where the only safety lay in a superhuman leap to some secure resting ground beyond. This first ten minutes was like the poise on such a brink. "We had gone too far to recede, and we had such faith in the vision that we determined to stand by the courage of our convictions. We realized fully the peril of the position we were taking, and how revolu- tionary were the prospects that it involved. But what we had seen had been based upon a knowledge of anatomy which had been acquired in a ten year's experience in teaching, and upon such a mass of confirmatory experience, surgical and medical, as to be overwhelmingly convincing if it could only OEIFICIAL SURGERY. 19 be massed and presented in consecutive form, especially if the profession were only fair-minded enough to want the truth and recognize it when they had the opportunity. Hesitation prevailed but for a short time. It was decided to demonstrate the courage of our convictions, and the following lecture was delivered. The original copy can be found in the Medical Era for March, 1886. A SURGICAL TALK UPON THE ORIFICES OF THE BODY. The subject upon which I shall speak today is the one I briefly referred to at last Tuesday's clinic. It is intended as a resume of some of the clinical work which you have witnes- sed during the present session. There is but one thought in this talk of today, but as I deem it of more importance than any other of the present course, I am anxious to present it to you plainly and concisely, that you may, in case of neces- sity, safely rely upon your notes for future reference. It is a comprehensive, far-reaching idea more so, perhaps than you now appreciate. It is not a hasty conclusion, born on the spur of the occasion, but a thoroughly tested theory. Let us call it a surgical talk upon the orifices of the human body. In this talk we shall have to recall just a little anatomy, refer slightly to physiology, tread gently on the toes of theory and practice, and trespass somewhat upon the chair of gyne- cology. We shall wander from surgery proper, however, as little as is consistent with a fair presentation of the subject as a purely surgical thought. The cerebro-spinal nervous system is the grand con- necting link between body and soul. It receives a steady influx of life, and by it makes the entire organism dance to whatever music it wishes. The rest of the body is its faithful servant, its slave; but even slaves get sick and are at times unfit for their master's bidding, and what I shall say today concerns the health and prosperity of the body as it is acted upon by other influences than those which come through the cerebro-spinal system. When a bolus of food descends below the pharynx it is 20 ORIFICIAL SURGERY. carried to the intestinal tract, digested, assimilated, carried by the thoracic duct into the left subclavian vein except what is taken up by the mesenteric veins themselves passed into the heart, and circulated first through the lungs for the breath of life, and thence throughout the entire body by a nervous system, entirely distinct from the cerebro-spinal, ex- cept as its branches seek out the cerebro-spinal nerves for the purpose of a mutual exchange of ideas in matters of common interest. The brains of this system, which you at once recog- nize as the sympathetic, are small knots of gray matter, con- nected by nerve cords as beads are held together by strings, and lying in two parallel rows in front of the spinal column, extending from the base of the cranium to the coccyx. From these knots of brain substance fine tendrils reach out and, seeking the branches of the arterial tree, climb by their aid to every nook and corner of the human anatomy. This sympa- thetic nerve is the great nerve of animal existence ; on its tonicity and uninterrupted action hangs our very life. The peristaltic action of the bowels, of the glands, of the blood- vessels and of the excretory organs is dependent upon its in- fluence ; when it is strong and vigorous all the processes of waste and repair are carried on with a vigor that laughs at the excesses and irregularities with which the erratic cerebro- spinal system taxes it, and it keeps under subjection inherited and acquired tendencies of every description. Who ever heard of consumption or scrofula or syphilis consuming its prey when plenty of wholesome nourishment reaches the capillaries ? If colds and bruises and miasms overcome a body, it is because that body is too enfeebled to resist their influence. Let us regard, then, this point as established : that a vigorous sympathetic nervous system means health and long life. What surgical interest have we in this fact? It can be told in just one sentence. The weakness and the power of the sympathetic nerve lies at the orifices of the body. Surgery must keep these orifices properly smoothed and di- lated. You will have to chase that sympathetic nerve from one end of the body to the other, peering in at every crack and crevice where mucous membrane touches skin, if you wish OBIPIC'IAL SURGERY. 21 satisfactorily to comprehend the pathological basis for the great majority of disorders which take advantage of an ener- vated sympathetic nerve. If the anterior nares is fissured, incise it or cauterize it. Your patient will thank you the next time you see him. Operate at an earlier stage upon labial irritations and tumors than upon similar conditions on either mucous membrane or skin away from the orifice of the mouth. If a palate is chronically elongated and causing an irritating throat cough, do not hesi- tate to shorten it with a pair of scissors. If tonsils are hyper- trophied and yielding an abundant product of mucous or calcareous matter, and thickening the voice and congesting the fauces and pharynx, use your tonsillotome. When a new- born boy presents a pin-hole opening in the foreskin, what is the use of postponing an operation until some slight irritation, as from teething or cold, precipitates him into convulsions ? Or, if he escapes this calamity until approaching puberty starts an irritation which induces masturbation, and ushers him into an era of enervating sensuality which will surround him with a moral and physical depression which, if he ever escapes, will entail years of trouble and suffering, not to mention the ground which such a condition lays for venereal vaccination. Circum- cise early and often. Men have no menstrual period. Nocturnal emissions, com- ing at any time or in any case, are unnatural and depleting, and the doctor who claims to regard them as a normal physio- logical process, in my humble estimation, is simply apoligizing for his inability to cure them. They are always a product of an irritation which you can and should remove. Urethral dila- tation with cold steel sounds, practiced weekly, will soon re- store to its proper tone the sexual system. In the few cases which do not promptly respond to this treatment, you will find other sources of irritation which you must seek out and remove. If you wish to reduce an enlarged prostate, pass sounds. Their tonic action, by touching the orifices of the prostatic ducts, will invigorate and reduce to healthy condition the en- tire gland. If you wish to benefit a chronic orchitis or epididy- mitis, pass sounds. They come into contact with the orifices 22 ORtPIClAL SURGERY. of the ejaculatory ducts, and as soon as these are relieved of congestion or subacute inflammation, the circulation will be restored throughout the entire testicle and its vas deferens. The gynecologist will tell you that an irritable hymen may induce vaginismus, uterine congestion and pruritus vulva. I will assure you, if he does not, that its baneful influence does not stop here. Aside from the nervous irritability and sexual disorders from it, its influence is sometimes reflected to the digestive tract, and how much farther I will not say. I have cured two cases of chronic diarrhea by the simple practice of removing an irritable hymen. So, if the os vaginae is rough, render it smooth. The reputation of the uterus as a centre of all sorts of reflex disorders and affections which are not felt at their start- ing-point, is too well established to require further considera- tion in this connection. Let me simply call your attention to one essential point in an examination to determine a uterine condition, when you are searching for the origin of reflex troubles; look at the internal and at the external os. Cold steel will aid you here as it does in troubles of the male sexual system. It will tone up and strengthen when the uterus is atrophied and too weak to support itself so that it topples over into the various misplacements; it will restore capillary circu- lation and reduce hypertrophy when congestion and subacute inflammation have distorted its shape and disturbed its position. But of all openings of the body, the one most neglected, most abused, yet most influential in its action upon the general health and tonicity of the human organism, is the lower open- ing of the bowels. I refer to the last inch of the rectum, from the upper border of the internal sphincter to the lower border of the external sphincter. When you stop to think of the anatomical situation of this part at the very base of the body and that its return circulation passes into the portal system, and hence affects and is affected by the condition of the vari- ous digestive organs in general, and the liver in particular; when you think also how the largest part of the rectum is sud- denly puckered down to the narrow limits of this small open- ing; when you think, too, of the almost universal carelessness OBIFICIAL SUBGEBY. 23 of mankind in attending regularly to the demands of nature, that this part shall be kept empty and free from the irritation of prolonged distention; and when, last of all, but not least, you recall the great variety of harsh and scraping debris, from the rough and clinging stones of small fruits, such as straw- berries, raspberries, blackberries, etc., to the pricking oatmeal husk, you will no longer wonder that the lower rectum should frequently become disordered, but, rather, be surprised that the care of this part has so long been entrusted to the unskilled hands of incompetent specialists, and that it has escaped the notice of regularly educated practitioners of medicine and sur- gery. Of course, when a patient is so badly afflicted as to be con- scious of local trouble, and comes to you with his case already diagnosed, perhaps you would be compelled to treat his piles, or cauterize his fissure or ulcer, or operate on his fistula about the only conditions that would speak for themselves loudly enough to diagnose his own case and compel him to apply to you for relief. But a uterus can express its wail of complaint by dyspepsia, by headache, by heartache, or func- tional derangements almost anywhere in the body. So can a hymen, so can a prostate, so can a testicle, so can a glans penis. Why should the part that is more exposed to incidents and ac- cidents than all the others put together, be less potent to tele- phone its distress to sympathizing relatives or friends ? If you think so you are mistaken, for a rectum has a sphere of influ- ence in the human economy as much wider than the other openings as its usefulness is greater. The particular disorders to which this part is liable, is not for us to discuss today. That topic will receive attention next Thursday. Today's talk treats but of the general outline and background of a picture whose individual figures will be drawn hereafter. I have seen surgical treatment of the rec- tum clear a tongue that was chronically coated, in six hours after the operation. I have seen it cure rapidly and perman- ently an acne of the lips and tip of the nose. I have seen it take pallor from the mouth and restore an even color to the face. I have seen it cure inveterate catarrh, relieve obstinate 24 ORIFICIlAL SURGERY. constipation, cure headache, spasmodic urethral stricture, cough, uterine congestion, leucorrhea, and other troubles too numerous to mention. I know, and so can anyone know, who will investigate for himself, that rectal conditions influence waste and repair more than any other one point of the system, and that no chronic case is thoroughly examined without rectal exploration, and it is my duty to make you all surgeons to the extent of teaching you what to look for. There is no time today for a detail of cases in illustration. The discussion of this subject has been purposely postponed until the close of the term, that you might watch the extensive surgical clinic and see for yourselves. As I stand here today, your fixed attention and complimentary bearing tell me of your hearty and intelligent endorsement of every word spoken. I thank you heartily for your patient waiting, as we have cut and trimmed and pruned the various orifices of the body in your presence. The results of this work you have witnessed from time to time. Nothing has been concealed or kept back from you. We have studied together, and let this summary put a meaning to the work let it give a "method to the madness" that otherwise might seem eccentric. In conclusion, let me sum up the entire subject in a single sentence. Bring me an individual with clean lips and nostrils ; a palate of proper length and unobtruding tonsils; a rectum that presents neither piles, prolapsus, fissure, ulcer, pockets nor papillae an individual whose sexual orifices are smooth and free from all irritation; if it be a man, his foreskin shall be free, the frenum of sufficient length, the urethral passage smooth and normal in size, especially in its prostatic portion ; if a woman, her hymen must be pale and atrophied, her urethra devoid of caruncles and ulcerations, her internal and external os uteri reasonably patulous, and without undue sensitiveness ; bring such an individual, and I will point to the same person and show you a human being whose digestion is good, whose sleep is sweet and restful, whose capillary circulation is superb, whose very existence is a constant source of uninterrupted de- lights. Such men and women maintain a steady poise of mind and body they live to the fullness of time, and, unless removed ORIFICIAL SURGERY. 25 by accident, their dissolution takes place on the principle of the "one-boss shay" they settle slowly and peacefully into their last sleep, just because their life's time-piece has run down. On the other hand, introduce to me a mortal suffering with passive congestion in various parts, whose blood finds its lazy way back to the heart by slow stages because the peristalic action of the arteries is tired out a person whose vitality is low, and whose poor, enfeebled body begins to be the prey of inherited or acquired tendencies consumption, scrofula, syph- ilis, organic derangements, or whatever form they may take show me such an individual, and they are as numerous as with- ered leaves in autumn, and I will stake the reputation of this idea that I shall be able, without straining a point, to find legi- timate fault with the condition of some one or more of the various orifices of the body. This lecture was delivered with such intensity of expres- sion, with such earnestness and force, that it produced a most remarkable effect upon the class. The applause following the lecture was deafening and lingering and followed by hand- Shaking, which, of course, might result from any lecture de- livered with a sufficient degree of warmth. But the most re- markable effect of the lecture was in the fact that in the fol- lowing three weeks which remained before the term closed, notwithstanding the fatigue of the class and their nearness to examinations, sixteen members of the class itself presented themselves for examination and operation upon the new prin- ciple. Some were troubled with chronic headaches, some with dyspepsia, some with constipation, some with insomnia, some with lack of memory, and others with other troubles which have long since been forgotton except by those who possessed them. These sixteen were all operated upon, and the thought was thus put to an immediate test by those who had observed its workings in the clinic during the entire term. The results of this crucial test were so brilliant and satisfactory that from that time its popularity with the class became thoroughly es- tablished and has never since flagged. As the years go by, every class which has graduated from the college has mani- fested its profound interest, respect and firm belief in the teach- 26 ORIFICIAL SURGERY. ing of the philosophy. They have seen its successes and fail- ures from year to year, have heard it expounded and heard it criticized, have been in a perfectly impartial attitude in every particular, but their yearly indorsement and adoption of the teachings of the orificial department has been a great source of encouragement and cheer to the founder of the philosophy. Many of the class experiences with the work have been com- paratively uneventful, but the class of '85- '86 witnessed the gestation and birth of the thought and listened to its first full expression in the lecture which is here published, and it offered so many of its numbers as examples for the demonstration of the new thought that it will forever rank as a class of remark- able courage and fidelity to its convictions of what it was satis- fied was a great truth, and its various members by their actions became pioneers in its acceptation so far as the medical pro- fession is concerned. CHAPTER II. A BRIEF CHAPTER IX THE HISTORY OF ORIFICIAL SURGERY. K, H. PRATT, M. D. The orificial thought, as it now exists, was born a part at a time, like any other baby, and was not delivered into the hands of the medical profession, for its adoption or rejection, until February, 1886, although portions of the thought had found expression at earlier dates. The order in which the various pelvic organs established themselves, in an appreciation which gradually extended until they were all included in what is known as orificial considera- tion, was as follows : First, laceration of the cervix uteri ; later on periodical uterine dilatation with graded sounds. Soon afterward the male foreskin aroused reflection, and the male urethra, meatus and frenum soon followed. Then came the hymen, after which soon followed the clitoris and its hood and the female urethra, and, later on, rectal conditions. ORIFICIAL SURGERY. 27 It was a summing up of years of experience with these various parts and the influence they had been found to ex- ercise over the bodily economy that suddenly took place in a most unexpected manner at the surgical clinic in the Chicago Homeopathic College on a Tuesday morning in the early part of February, 1886, when the startling announcement was made by the author that at the next surgical hour students would be invited to listen to a lecture upon a surgical cure for chronic diseases. The effect of the lecture was so profound that, although it was within three weeks of the close of the winter term and the students were busy preparing for examination, the principles enunciated were so clearly understood by the students and so practically indorsed, that during that three weeks sixteen of its members applied for orificial treatment and received it. One was troubled with headaches, one with insomnia, two or three suffered from dyspepsia, several had seminal losses, and the whole sixteen were one by one placed under an anesthetic and given the benefit of orificial work, and without exception, there was ample excuse for the treatment. Reports of the stu- dents upon the effects of the work in their individual cases were of the most flattering and satisfactory nature, so much so that, in order to put the new idea to the greatest possible test, the author's weekly surgical clinic of the college was run upon orificial principles during the entire year, winter and summer, without interruption, and the amphitheater of the institution bcame a weekly debating room, where objections were raised and answered, where the orificial thought was re- peatedly put to the severest possible tests as to its reliability and efficiency, and where doubts and skepticisms were as wel- come as commendations and indorsements. One of the first effects of pelvic work accomplished under the effects of an anesthetic noticed, was the immediate influence of rectal dilatation upon the respiration in cases where the sym- pathetic nerve was in a normal condition. At that time rectal surgery was more or less in disrepute among doctors generally. People were so sensitive about rectal examinations, and doctors were so shy about making them, that only in severe cases of 28 ORIFICIAL SURGERY. self-conscious rectal troubles were examinations of this part deemed necessary either by patient or physician, as both were apparently anxious to avoid the subject as much as possible, and only in extreme cases was this diffidence overcome and a local inspection made. Rectal diseases were, as a general rule, in the hands of itinerants who were looked down upon as medi- cal scavengers, and reputable medical men were in the habit of ignoring, as far as possible, even the existence of the rec- tum itself. There were no satisfactory rectal instruments in the shops, and a good, practical rectal speculum was unobtain- able either in the United States or on the Continent, to say nothing of other instruments necessary for the practice of rectal surgery or other rectal treatments. The dilatation which at this time was practiced was universally accomplished with- out instruments. A few incidents which occurred in the first series of ori- ficial clinics will serve to illustrate the nature of what was constantly recurring. The professor of anatomy of the college was a personal friend of the author, but skeptical as to the utility of orificial work, and upon one occasion, soon after the close of the term, visited the clinic just to see what was going on, being attracted by the stir which the operations upon the students had made in the college. An anesthetized patient lay upon the operating table when the professor entered, and the question of the effect of rectal dilitation upon the respiration was under discussion. The clinician had just called the atten- tion of the visiting doctors and students in attendance to the existence of two nervous systems of the body, the cerebro- spinal and the sympathetic, the one registering conscious sen- sations and acts of conscious volition, the other performing the involuntary and unconscious service of bodily function and nutrition. Attention was called to the fact that the cerebro- spinal system was sometimes abnormally sensitive or hyperes thetic, and sometimes abnormally insensitive or anesthetic, and the statement was made that the sympathetic nervous system enjoyed the same privileges, that is, it sometimes would be ab- normally sensitive and be immediately startled into undue activity on the slightest irritation of any of the mucous sur- OKIFICIAL SURGERY. 29 faces which it supplied, and at other times it would be so dor- mant or anesthetic as to refuse to respond even to severe forms of irritation. Where the sympathtic nerve, however, was in normal condition, it was held that rectal dilatation would in- duce such spasmodic action of the diaphragm or glottis or both, while it was being practiced, as to more or less completely sus- pend respiration, after which a deep inspiration would follow, this in turn to be succeeded by universal flushing of the capil- laries throughout the entire body, for the heart's action, al- though somewhat inhibited by the dilatation, would be more than counterbalanced by the temporary paralysis of the vaso- motor system of the nerves, thus opening arteries and favoring a more thorough rushing of the blood to the tissues universally. In this way, it was explained that cold extremities were almost immediately warmed, local congestions and inflammations were immediately relieved, and the capillary circulation throughout the system equalized. As all organic activity, including growth and repair, is accomplished by the blood stream, the effect of rectal dilatation upon chronic diseases generally was thus ex- plained. In order to impress the visiting professor with the first point of the chain of argument, viz. : that rectal dilatation, where the sympathetic nerve was in a normal condition, would for the time being suspend the respiration, the sleeping patient was placed upon the side, and the professor himself invited to practice the dilatation, while the company was requested to maintain silence in order to note the effect of his manipula- tions. Inserting his thumbs back to back in the anus, he care- fully and thoroughly performed the act of dilatation without producing the slightest disturbance of the respiration of the patient. As he turned away a smile of apparent satisfaction at the failure of the experiment spread over his countenance. When he was accused of merriment, he frankly confessed to being amused at the incident. As the clinician, however, was not satisfied with the test, the professor was requested to sus- pend his judgment for a moment and witness a repetition of the experiment. The operator then inserted the middle and index fingers of his two hands, back to back, completely within the anus so as the secure a substantial grip upon the internal 30 OEIFICIAL SUKGERY. sphincter. Upon then practicing thorough dilatation, the ex- pected phenomenon of suspended respiration was conspicuous- ly produced, much to the amazement of the witnessing profes- sor and the audience, not to mention the satisfaction of the sur- geon, who then remarked that smiles were now in order, and that the professor also deserved the thanks of the audience for aiding in the demonstration upon a living subject of a bit of important anatomy and physiology. With his thumbs the pro- fessor had seized merely the external sphincter which is sup- plied by the cerebro-spinal nervous system, and although he practiced dilatation of this muscle honestly, it produced no ap- parent effect upon the respiration or circulation. The surgeon, however, by securing with his fingers a higher impingement of the anus and practicing dilatation upon the internal sphincter, was able to suspend the respiration, because the internal sphinc- ter is a muscle of the involuntary type and supplied by the sympathetic nerve, thus establishing two important facts, one that the function of respiration is dominated by the sympa- thetic nerve, at least during anesthesia, and that in conse- quence of this, forms of rectal irritation which induce spas- modic contraction of the internal sphincter are more disas- trous from the standpoint of bodily waste and repair than those which, although they may cause more pain and self-consciousness on the part of the patient, appeal merely to muscles and surfaces supplied by the cerebro-spinal system. The professor fully appreciated the object lesson, and later on in his private practice took advantage of the sug- gestion. Not long after this, however, another member of the facul- ty, by no means so kindly disposed, presented himself at the clinic for the purpose of entering protest against the promin- ence which was being given to the orificial thought. When he entered the clinic room a patient was on the operating table, for the purpose of removing the lower jaw for necrosis of that bone. Before the operation was begun the attention of those in attendance was attracted to the effect of rectal dilatation over respiration, as on the occasion, just mentioned. No sooner had the statement been made that rectal dilatation for the time OEIFICIAL SURGERY. 31 being, would suspend respiration, and by its secondary action deepen it, thus producing a universal flushing of the capillaries, than the self-constituted disturber of the peace immediately disclosed the hostility of his attitude by scoffing at the state- ment and asserting that a like effect could be produced by pinching the skin of the patient or by hurting her anywhere. The author immediately accepted the challenge and ordered the patient to be put in a position for rectal dilatation. The case happened to be one unusually susceptible to rectal dila- tation, and could easily have been choked to death had the dila- tation been sufficiently prolonged. As soon, however, as the blood had become well blackened by the lack of oxygen, the dilatation was stopped and air was ushered into the lungs with a deep, gasping inspiration which soon restored the complexion of the sleeping patient to a bright, red, wholesome color. To exclude accident, the process was repeated, but with the same result. The patient was then placed at the disposal of the pro- fessor who came to protest against the idea, and his first im- pulse was to forcibly flex the toes, but after partly removing one of her 'shoes, he changed his mind and seized her in the right groin by a powerful clutch of both hands, but the ex- ercise of all the force at his command was unavailing. The patient being thoroughly anesthetized, no amount of injury to the parts supplied by the cerebro-spinal nervous system, or even to those supplied by the sympathetic nerve, except the pelvic outlets, could be so cut or squeezed or injured in any way as in the slightest degree to influence the rhythm of re- spiration, for there is no clinic in the world upon which the effect upon the respiration as described is ever produced, ex- cept a clinic involving the impingement of terminal nerve fib- ers of the pelvic organs. The professor was reminded that per- haps she was asleep or had gone on a journey, and was urged to pinch her harder, much to his own irritation and the amuse- ment of those who were witnessing the experiment. The pur- pose of the professor in visiting the clinic was too deeply malicious, however, to be thus easily balked. He then gave vent to his opinion in most emphatic terms, that the whole pro- ceeding was most thoroughly unscientific ; that to account for 32 ORIPICIAL SURGERY. J chronic diseases by universal existence of pelvic irritation was simply ridiculous, and that to attempt their cure by any type of pelvic attention, thus placing orificial work in the light of a panacea for human ills, was misleading and detrimental to the best interests of the college, the profession and the community, and he had come to call a halt upon all such teaching. The professor was thanked for his honest, fearless and frank ex- pression of opinion and was asked to employ his "scientific" knowledge for a better interpretation of a large number of clinical facts which were then presented to him for consider- ation. Case after case was then brought in which had been cured by orificial methods. One, a chronic abscess of the groin in a girl ten years of age, cured in three days' time by loosen- ing the hood of the clitoris and removing a few pockets and papillae from the rectum. A man with syphilitic enlargement of the glands of the neck, axilla and groins, accompanied by extreme emaciation, suffering for six months and defying all other forms of treatment, had been restored to a normal con- dition of the glands and to an increase of twenty pounds in weight by the removal of some small hemorrhoids and by cir- cumcision. This was accomplished in three weeks' time. A tumor of the breast, which otherwise would have required ex- cision, was completely absorbed in a few weeks' time after much needed pelvic work, and so on. Indeed, for three consecutive hours a procession of cases of various kinds that had been cured by orificial methods was presented before the professor for his consideration, and he was asked to explain upon an anatomical and physiological basis the extended application of the work and its phenomenal effects upon general nutrition. The complete discomfiture of the disturbing member of the faculty was accomplished, and his apology both for his ignorance and for his audacity was later on secured. Throughout the year there was, perhaps, no more marked exhibition of the power of the work than occurred in a case of secondary syphilis, which presented itself at the clinic for re- lief one summer's day. He gave a perfect syphilitic history, so far as the primary sore and the subsequent symptoms were OEIFICIAL SURGERY. 33 concerned, and when he came before the class was a pitiful sight to behold. Sores varying from the size of a small pea to a silver dollar completely bespattered his skin surface. He was stripped and photographed. The largest sores were upon his body, but his face and head were thoroughly sprinkled with them, as were also the palms of his hands and the soles of his feet. He had applied to neighboring clinics without relief, and was so offensive in his appearance as be an unwelcome guest wherever he went. No examination of his pelvic condition was made at the time the case was under inspection, as the influ- ence of orificial work upon the nutrition had long since been demonstrated to be reliable regardless of whatever type of pelvic pathology might be encountered. His consent to oper- ative procedure was obtained, and after being placed under an anesthetic, he was circumcised, his urethra dilated with steel sounds up to No. 18, English scale, and the rectum trimmed and dilated. The rectum, although tightly contracted, pre- sented no graver pathology than two small rectal pockets and one or two diminutive papillae, the membrane covering the en- tire last inch being atrophied. The local pathology encountered was so diminutive as to make it seem unreasonable to hope for the cure of the case by its correction. Nevertheless, the thought was put to an honest test, the work was done, and strict instruc- tions given that the man should receive no medicine whatever and should not be permitted even to take a bath. "When brought before the class at the next clinic the change wrought in his appearance was pronounced. While many of the larger sores remained in statu quo, a number of these and multitudes of the smaller ones had entirely healed and the scabs from them had dropped off, disclosing the characteristic color of syphilitic cicatrization. At the second clinic he was once more stripped, and not a sore remained unhealed. He was kept at the hospital for one more week for observation, but no more sores appear- ing, and the man having regained to a considerable extent his vigor and comeliness of appearance, was discharged as con- valescent. It may be well right here to briefly describe some of the remarkable cases, the study and explanation of which ultimate- 34 OBIFICIAL SURGERY. ly led to the establishment of the orificial philosophy. They will be presented in the order in which they occurred, so as to accurately illustrate the mental process by which an orificial explanation was arrived at as the only scientific and rational theory by which their cure could be accounted for. Case 1. Was simply a nervous, dyspeptic, hysterical woman, who, as a result of childbirth, presented locally what would now be described as a lacerated hyperplastic and eroded cervix. Although Dr. Emmet, of New York, had but a short time previously recognized the importance of cervical repairs and had dwelt upon the removal of cicatricial plugs from women who had been torn in childbirth, and who had become neurotics, this case was not at the time recognized by the auth- or as a case for Emmet's operation, and was subjected merely to internal medication and local treatments by means of medi- cated tampons. As the treatments were a failure, the case fell into the hands of another doctor, who placed her under an anesthetic and performed some kind of surgical operation. Years afterward the author ascertained that his successor in the case had amputated the cervix, but at the time he was led to suppose that the case was cured by Emmet 's operation. One lesson of this kind was enough for the author, and soon afterward followed Case 2. This was a case of what was known at that time as galloping consumption. The tubercular bacillus had not yet been discovered, so an examination of the sputum was not made, but she had the rapidly increasing emaciation, the night sweats and hectic fever, the quick pulse and profuse expector- ation ; also the chest rales and percussion sounds characteristic of broken-down lung tissue. In addition to this she was suffer- ing with chronic diarrhea and extreme prostration. Her con- dition supervened upon a miscarriage three months previous, followed by what was supposed at the time to be a severe cold. Local examination disclosed a uterine condition similar to that just described in Case 1. She was a small, delicate woman, weighing not over eighty-five pounds, and although fears were entertained as to the safety of employing an anesthetic, the case was so desperate that it seemed necessary that what re- OBIFICIAL SUEGEEY. 35 lief was attempted should be undertaken at once in order to have even the slightest ground to hope for a favorable issue. She was placed under an anesthetic. Sim's speculum at that time had not been invented, neither had the plug forceps, nor was the use of guy ropes known. Through the blades of a bi- valve speculum, by the aid of a pair of tenacula, sharp pointed scissors and a needle threaded with silver wire, the two cica- tricial plugs were removed, one from either side, the lower united portions of the cervix were denuded and the parts were brought together. Xo dilatation of the uterus or curettement was made use of, and the perineum, although lacerated, was not interfered with. Neither the clitoris nor rectum was touched nor thought of. The immediate effect upon the pa- tient was as startling as it was alarming. In the afternoon of the day of the operation she was taken with a chill, her pulse ran up to 1-40 beats per minute and her temperatue reached 104 degrees Fahrenheit. Her cough became dry, slightly streaked with blood, and expectoration ceased. Her chest was immediately encased in a flaxseed jacked, which was changed three times every twenty-four hours. Internal medication was employed, and the case at the end of three days enjoyed a complete convalescence. The cough entirely disappeared, fever, night sweats and diarrhea were gone, and the recovery from that time on was uneventful. As a result of the experience with this case, lacerations of the cervix in the practice of the author were not overlooked, especially when the healing had been but partial and erosions and hyperplasia were encountered. In the course of a few months the third case came under observation. Case 3. Was a case of paralysis, thirty-two years of age, but completely bedridden, being unable to move either of her lower limbs and having but slight use of her arms. She was unable to feed herself and could not even pick up a pin. As she presented no record of pelvic troubles, her local condition was not even examined, and for three months her treatment consisted in the administration of internal remedies and the employment of a Faradic battery. As there was not even the 36 ORIFICIAL SURGERY. slightest improvement after three months' faithful attention, a local examination was requested and obtained. The uterus was found to be atrophied and presented what seemed like a very slight laceration upon either side. This had resulted from a miscarriage a few years previous, as she had never given birth to a child at full term. Under an anesthetic, the small cicatrical plugs were removed and the wounds closed by silver sutures. To prevent the ends of the twisted wires from prick- ing the vagina they were cut long and curled. Two stitches were taken on either side. The remarkable part of this case was that before these stitches were removed from the uterus, which was nine days after the operation, the patient could move her toes, and her paralysis gradually but steadily disap- peared until her convalescence was complete, and she is at the present writing a strong, healthy woman, fifty-two years of age, having never since the operation suffered any severe illness. These cases furnished food for thought upon married women who had borne children or sustained miscarriages, but threw no light upon female neurasthenics who had never con- ceived. The influence of the uterus in chronic ailments of women, however, such as malnutrition, chlorosis, lung and spinal cord troubles began to be appreciated by the author, who felt the need of some form of uterine stimulant that could be made use of in cases not subjects for the operation for lacer- ation of the cervix. Spooner's uterine tips were placed on the market, and uterine stenosis, cervical or corporeal endometri- tis and anteflexion were soon found to be greatly benefited by their use, and the correction of these local troubles was in- variably beneficial to the general health of most of those who were subjected to the employment. This treatment was also tried upon a few cases of laceration of the cervix in hopes of avoiding that operation by practice of uterine dilatation, but instead of being beneficial, it was found to be harmful, so that the practice of operating for laceration of the cervix was again resumed, and that of dilating lacerated uteri was aban- doned. ORIFICIAL SUKGERY. 37 Case 4. Was a married woman having chronic diarrhoea of five years' standing, which had resisted the efforts of several celebrated prescribers and which the author was equ- ally unsuccessful in relieving by the employment of internal remedies. The patient, aside from the diarrhea, seemed to enjoy perfect health. Close questioning finally disclosed the fact that the diarrhea was always worse after sexual inter- course. This fact led to a local examination, when nothing abnormal could be observed except that the base of the hy- men was excoriated. As the hope of being able to relieve the case by the exhibition of drugs had grown faint indeed, she was placed under an anesthetic and the hymen carefully trimmed away, with the satisfactory result of immediately and permanently curing the diarrhea. Case 5. Was an exact repetition of Case 4. Case 6. Was a male child, nine months of age, suffering from marasmus, dyspepsia and insomnia. It was a bottle- baby, but no food could be found that the child ivould retain on its stomach. It had never slept well and was so emaciated that at nine months of age it was one pound lighter than it was when three months old. Three months' prescribing, al- though the child's vomiting was stopped, failed to help it to an appetite or a good night's rest, and the puny, fretful little boy was sent to its grandmother in Des Moines, Iowa, for a change of climate. Several months' absence failed to afford any relief, and as soon as it returned home the author was again asked to resume his care of the child. No teeth had as yet appeared and its condition was so unpromising that counsel was summoned. As the gums over the incisors were somewhat hardened, the consulting physician advised cutting them, as the only treatment which he had to suggest in the case. No relief followed, and shortly the baby's lower limbs began to swell. In desperation, the author had the child stripped and put through a careful examination from head to foot. No physical defects were observed, except that the opening of the foreskin was very small. The author ex- plained to the parents that it was important to loosen and retract the foreskin on general principles, as in case the 38 OKIFICIAL SURGERY. child lived to boyhood it would probably help him to escape from masturbation and its evil effects, no expectation being entertained, however, of securing any immediate relief for the child's dropsical condition, malnutrition and fretfulness. As there seemed nothing else to do in the case, however, with the consent of the parents, by means of a grooved director, the foreskin was loosened from the glans and a small amount of smegma removed. As upon retraction the opening was found to be too small, by means of a pair of scissors, it was clipped along its dorsum from the margin of the foreskin as far up as the edge of the corona, and the mother was instruct- ed to retract the foreskin daily, so as to prevent its readhering to the glans. The surprise of the author may well be imagined when, upon visiting the child on the following morning, the mother reported that the baby had enjoyed the first night's sleep of its life, and had manifested an appetite for its breakfast, a thing heretofore unknown in its brief history. The dropsy in the lower extremities was also perceptibly reduced. Medica- tion was stopped and the case kept under observation for a week, at the end of which time, as it was sleeping and eating well and all dropsical symptoms had entirely disappeared, it was dismissed as cured. Two weeks later, while the author was still pondering upon the marvelous influence which the condition of the foreskin seemed to exercise upon the nutrition of this little patient, the mother of the child summoned the author in great haste for the relief of a new trouble which had set in. The woman was beside herself. She said she knew the child would die; that nothing could be done for its relief and she only wanted a doctor as a means of consolation. Xo intelligent account of the child's condition could be obtained from the mother, and when the author entered the sick-room he was still wondering what possible turn the case could have taken in so short a time. Imagine his consternation when he beheld the little boy lying upon the pillow with a head grown to such extravagant proportions as to distort the little fellow's appearance beyond the possibility of recognition by any one who had previously known him. The dropsy had evidently ORIFICIAL SURGERY. 39 returned, and instead of appearing in the lower half of the body, had taken the form of hydrocephalus. Everywhere else he was emaciated, but his head was enormous. All the sutures of the skull had been pressed apart so far that a finger could be laid in any of them without coming in contact with the margins of the bones entering into its formation. The fore- head protruded to such an extent that the eyes seemed deeply buried under its projection. The child had no power even to raise its head, and simply tossed it from side to side, moaning pitifully. The mother was at once questioned as to the condi- tion of the foreskin. She said it was all right and refused even an examination. Seeing, however, that she was so beside her- self as to be entirely devoid of judgment, the author requested her to leave the room and to send in the nurse. Upon exami- nation the fact at once became apparent that the mother had failed to keep the foreskin retracted and that it had healed up tighter than ever. Once more it was loosened from the glans, again it was slit along the dorsum, and this time cir- cumcision was practiced, and the parts prevented from healing together by a careful stitching of the mucous membrane to the skin around the entire margin of the wound. The benefi- cial effects of the proceeding speedily began to be noticeable. Absorption of the cerebral spinal fluid began at once, and continued until at the end of two weeks' time all suggestion of hydrocephalus had passed away and the child was once more dismissed as cured. This time the recovery was per- manent. The baby became a boy, and the boy a man, and from that time to this he has never been seriously ill. CHAPTER III. ORIFICIAL SURGERY: WHAT IS IT FACT, FAD OR FANCYf LIBBIE HAMILTON MUNCIE, M. D., PH. M. As the years go by the progress of medical and surgical science is brought about by discoveries which, when perfected, revolutionize the healing art; when, however, departures are 40 ORIFICIAL SURGERY. made from accepted dogmas of schools, and a healer finds a new way, which practice proves most wonderfully efficacious, this healer is indeed an exception to the rule is he establishes his results without unjust criticism from those who should have been his most earnest supporters. Dr. E. H. Pratt, after months of satisfactory practical application of his philosophy, first publicly demonstrated the principle and theory of the orificial thought in the senior lecture-room of the Chicago Homoeopathic Medical College, in the presence of the students. The effect of the presentation of the thought was so energetic that in the three weeks of the term that yet remained, sixteen of the class presented them- selves for the application of orificial methods to their con- ditions. Some were suffering from headaches, some from dyspepsia, some from insomnia, some from spermatorrhea, some from constipation and some from general malnutrition. The success of the work upon these test cases was such as to win forever the good will of the undergraduates. From then until now the surgical clinic of the college has been conducted as far as possible upon orificial principles. The experience here acquired, with that at the largest hospital in Chicago (Cook County), as well as in other institutions, but confirms in every particular the foundation principles of the philosophy; and had not our experience of years, coupled with that of fellow workers, been a parallel one, had not the practical workings of the philosophy been so marvelously effective in the treat- ment of chronic diseases, I would not feel justified in asking your attention to that which would but fascinate with theories, and flatter your intelligence. I therefore feel it an honor to have the privilege of presenting to you that help for chronic diseases which has for its corner-stone orificial philosophy; that which is not antagonistic to, or in place of, but a great addition to, all other resources of the medical profession. The facts which merit attention in this connection are based upon anatomy, physiology and pathology. It is well known that we have two nervous systems, the cerebro-spinal and the sympathetic. OEIFICIAL SURGERY. 41 The cerebro-spinal system furnishes the sensations of which we are conscious, and is the directing power of the voluntary muscles. The sympathetic nervous system is that force which is called into activity from the moment of conception until death calls the mortal to his long home. It is the faithful monitor that never sleeps. It keeps the machinery of life going in our sleeping as well as during our waking hours. Its activities extend to the most remote and minute parts of the body. As has been truthfully said, "We live by tubes." The peristaltic action of these tubes is carried on under the stimulus of this wonderful sympathetic system, and the result is digestion, circulation, assimilation and nutrition. Perfect nutrition is acknowledged to be essential to perfect vitality of a part or a whole, therefore there must be an unhampered, sympathetic force for the maintaining of this nutrition and this brings us to the fact that "the problem of health is the problem of sympathetic nerve force, and the problem of disease is the problem of sympathetic nerve waste;" therefore the greatest economy in the unnecessary expenditure of this nerve force is the all-important theme for the consideration of the medical profession. Dalton in his "Physiology" states the following: "In experimenting upon the sympathetic nerves, evidences of sensibility are much less acute than that manifest by the cerebro-spinal nerves, and show themselves only after pro- longed application of the exciting cause." This statement demonstrates that these are intelligent nerves, though of a low order of intelligence, and that con- tinud irritation upon any mucous membrane will inevitably, sooner or later, induce a strictured condition of the tube in- volved. Any prolonged muscular action, even though involun- tary, means a waste of strength or nerve force, and enervates the entire sympathetic nervous system, and through it the cerebro-spinal, reducing the vigor of circulation, which is the beginning of all pathological conditions. It has been shown that the most common points of irrita- tion are found where the sympathetic nerve supply is most 42 ORIFICIAL SURGERY. abundant ; that is, at the orifices of the body, and especially the lower orifice. The cause for this is explained when we think of the universal gateways, not only for the exit of effete matter, but the gateways of new life as well, as points of greatest friction, and that the circumstances of one's life may greatly impair these parts. Orificial surgery means the surgery of the lower orifices of the body. It is a fact that dilatation of the upper orifices will not influence respiration or the capillary circulation of an entire body; it will not resuscitate after drowning, or from the effect of an anesthetic or shock. On the other hand, most profound results are obtained in these cases from the dilatation of the lower orifices and especially the rectum ; this fact proves conclusively the important relation these orifices bear to the important functions of respiration and circulation, and through these upon all organic functions and conditions of nutrition. Some have been so short-sighted as to suppose that orificial surgery begins and ends with dilatation of the sphincter mus- cles; to the contrary, it is necessary to keep in mind that this procedure alone may in some cases produce more irritation of mucous membrance, and more contraction of sphincters and more pinched nerves and tissues, instead of less. Orificial philosophy teaches, further, the removal of all points of iritation from the lower orifices of the body by meth- ods that produce little shock, immediately arousing a bettered nutrition to every part by flushing the capillaries, avoiding the clamping and ligating of masses of tissues, removing of all diseased parts, not only tying but encapsulating all the bleeding points in surrounding healthy tissue, leaving no de- nuded surfaces to granulate, and no tissues to slough. That the advantage of these principles applies not alone to cases requiring attention at or through the lower orifices, but in all cases requiring abdominal section, is a fact which has now become established beyond the possibility of successful controversy. That Professor Pratt is the most original and progressive surgeon of our day is acknowledged by physicians of both schools at home and abroad. If he had done no more than to OKIFICIAL SURGERY. 43 teach how a clampless, ligatureless and comparatively blood- less vaginal hysterectomy can be done, how abdominal surgery can be done without leaving pinched tissues, it would make the greatest revolution in the art of surgery next to the aseptic methods. Scattered through a number of text-books can be found records of different surgeons who have enucleated the uterus through the vagina. These accounts date as far back as the first century of the Christian era. But to Dr. Pratt belongs the first public record of extirpating the uterus with a view to the avoiding of shock incidental to the use of clamps or of tying blood vessels en masse. This entirely new and original method has met with success to the extent that places him in the foremost ranks as a benefactor to mankind. In this country there was comparatively little known of vaginal hysterectomy until Dr. Pratt introduced it, after which the medical journals, for a season, were teeming with various phases of denunciation of the operation ; it nevertheless proved to be the power that started the ball rolling, and now we find many surgeons who have added to their list of operations vaginal hysterectomy, although many of them follow the French and German systems, using clamps or ligatures or, in other words, placing the entire broad ligament in a relentless grasp, for the object of preventing a hemorrhage from one main artery which may easily be pushed aside without sever- ing or, if necessary, can be ligated in its entirety without injury to surrounding tissues. If the sympathetic nerves could resist as can the cerebro- spinal when irritated on the surface of the body, the surgeon would not dare to clamp these involuntary tissues. There is now a better way shown than to take advantage of that part of the system which simply bears uncomplainingly for a time. It is not long since pain has been traced from nerve to nerve until it is finally located at the starting point of irrita- tion. Progressive oculists, thoracic specialists and dermatolo- gists are learning that they can not expect desired results until all sympathetic disturbances have been relieved. Neuro- logists here and there are acknowledging that reason does not 44 ORIFICIAL SURGERY. easily become dethroned without a former disturbance of the very citadel of life the sexual sphere. It has been stated by one of large experience that "a lunatic without a morbid rectum or genitals is an anomaly." This should be sufficient to lead to an examination of the pelvic organs of every case of insanity, and that by an expert in this branch. It is not consistent or thorough to diagnose and prognose a case as insanity, and thus to consign the unfortunate to the madhouse. I venture to state that there can be hardly a case of insanity produced but what gives a history of orificial irritation, either objective or subjective. Experience teaches that the pudic nerve from its five principal terminals in the lower orifices of the body is the bearer of more messages of discord than all the other nerves combined.-" There is not only a disposition to have their own family grievances, but to get the neighborhood, if not the whole community, in an uproar. This acknowledged phy- siological conclusion explains why Emmet's operation for lacerated cervix has proved in some cases beneficial, and so useless in others. He had not discovered that an irritated, sympathetic nerve terminal in one part of the system could be as much of a disturber of the systemic harmony as would an irritated terminal in another part. That the same pencil of sympathetic as well as cerebro-spinal nerves which sup- plies the cervix is also distributed to the rectum and external sexual organs, and consequently susceptible to irritation, has not been long considered. Thus may be explained how orifi- cial surgery has carried to ripe development the work that Addison Emmet began fifty years ago. It was the disappointing results in several cases operated upon for lacerated cervix, where diseased rectums were left unattended, that led us to the investigation of the orificial methods, and later to their application so gratifying. So much beyond our most sanguine expectations have the results proven, that it requires no stretch of the imagination to state that orificial surgery, scientifically applied, points the way to reach and cure multitudes hitherto beyond help. OBIFICIAL SURGERY. 45 The advocates of orificial surgery do not claim that there- in is offered a panacea for every ill, or that it can cure under all circumstances. Failures to cure always have been and always will be recorded, but under consistent pursuing of reflexes from periphery to center and center to pheriphery, and eradication of irritations of sympathetic terminals, failures will be less frequent than under any method heretofore em- ployed ; and it will be more fully realized that chronic diseases, from skin troubles to insanity, and every phase of malnutri- tion or neurasthenia, are amenable to the procedure of orificial surgery. Many, however, will be found whose poor tenements are too far degenerated to be reclaimed, and the tenant-must seek that home from whence none return. This brings us to a realization of physical decay or organic disease, and since long-continued functional disturbance leads to organic changes, and irritation leads to functional disturbance, the awake physician will be on the alert to eradicate all points of irritation at their earliest appearance, instead of waiting until the body cries out in distress for deliverance. Therefore the time to make an examination and operation is not when organic disease has been established, but while they are simply in the earlier stages of functional disturbances. Every organic disease (barring congenital) is of slow development, is an evidence of innervated vitality or lessened resistance-power against disease, and must first exist as a functional disease. It does not come in a minute; the sympathetic makes a strong and dilligent fight against it until it can hold out no longer and is marked by defeat ; therefore the best way to prevent organic disease is to prevent functional disease, and the way to prevent func- tional trouble is to keep the sympathetic unburdened and un- hampered by the everlasting naggings that are produced by the lesser or greater irritation at the orifices of the body the gateways to the centers of life. Still there may be found prac- titioners who will object to the removal of rectal papillae and the relieving of preputial adhesions in the young woman who, he knows, is rapidly passing into incurable conditions. By nature these methods are unpleasant to both patient and physician, and are not altogether painless. There seems 46 ORIFICIAL SURGERY. to be nothing to recommend it to popular favor but the results. "With the laity it has won a reputation to the extent that pa- ients and friends often become so enthusiastic in its recommen- dation as to insist upon their friends receiving its benefits. Judging from the number of orificial surgeons that convene each year in Chicago, and the enthusiasm they manifest, there seems to be an ever-increasing demand for this line of treat- ment from the people in almost every part of the United States. Orificial surgery is a gift from God to suffering humanity ; it cannot, therefore, be a mere fancy, it cannot be a useless fad ; is is a veritable fact. CHAPTER IV. A PLEA FOR ORIFICIAL SURGERY. LEONARD PRATT, M. D. It is with a firm conviction of the value and importance of this special surgical work in the true physician's legitimate sphere of action that I am pleased with this opportunity of urging it upon your attention. The incurable cases of chronic diseases are known to be numerous. Failures to permanently cure are in the experience of each one of us. They are common to all physicians. Each one of you just think over the list of such in your own circle of professional acquaintances and notice how many you can call to mind. Probably a large number of these are relieved by intelligent prescriptions, adapting the remedies as nearly as possible to indications in accordance with our natural law of cure. Failures to cure permanently are still so numer- ous that each physician can count in his own practice a score of such. There are not far from twelve thousand practitioners of our school in the United States, and if each one has but a few such cases what a vast army presents itself. ORIFICIAL SURGERY. 47 Add to this list the millions resorting to nostrums and quack remedies, and the vast number who are under the con- stant treatment of our professional brethren of the other school without being cured, and we have a phalanx of invalids which should enlist the honest, earnest and best efforts of all good physicians to devise other means of cure where our present skill proves a partial or entire failure. Oriflcial surgery provides a happy means to that important object. Its claims are based upon results well established by oft repeated experiences. Properly applied, by its means at least three-fourths of this vast army of invalids are curable. Still many physicians and medical organizations turn from its just claims to investigation and close their eyes to its merits, plodding on in the old beaten paths. It is the duty of every true physician to cure the sick and afflicted. This should be the exclusive object of his life's work. He is morally obligated to familiarize himself with the most effectual means of accomplishing that noble object. Otherwise it is inconsistent for him to claim to be a phy- sician in the true sense of the word. The evidences of the truth and value of the orificial philosophy and the happy re- sults of its judicious application are now so prominent that the profession is remiss in its duty and obligations when it passes by its just claims without investigating its merits and testing its curative powers. It is no longer mere experiment. Its philosophy is based upon facts pertaining to pathology, phy- siology and anatomy. Let us consider it briefly. After food is introduced into the aesophagus we all know that it is conveyed into the digestive organs, digested, absorbed into the circulation, conveyed to the capillary vessels of each organ of the body from which the organ receives and appro- priates the elements necessary to perpetually rebuild the waste caused by effete cells whose duty is done ; and this is done in- dependently of any exercise of volition or even perception on our part. This is accomplished, as every physician knows, by the force and functional power of the sympathetic nervous system. The circulation of the blood, the secretion and excretion, waste 48 ORIPICIAL SURGERY. and repair of all the organs of the body are carried on by means of peristalic movements through tubular structures. "We know that these structures "are supplied with a muscular coat whose fibres are arranged longitudinally and circularly so that by their alternate contraction and relaxation a vermicu- lar motion is kept up by means of which solids and fluids are propelled along their various channels." These functional activities of the organism are presided over by the sympathetic nervous system, which is constant in its work whether we sleep or wake, rest or labor, in sickness and health. The cerebro-spinal system sleeps when we sleep, and var- ious causes may contribute to arrest the functional power of this system as shocks, faintings, anaesthetics, sleep, etc. but when the functional power of the sympathetic nervous system is arrested immediate death is the result. Now, inasmuch as the latter system controls respiration, circulation, nutrition and all the functions of waste and repair constantly going on, it follows that any cause which weakens the nervous force thus supplied will so far make the various organs and tissues sus- ceptible to morbific changes. The power of reacting against the various causes of disease is in so far destroyed as this force is diminished. You see, then, the question of health is really one of nerve force. This force holds in harmonious activity and union all the physical structures which it supplies, and when organic disease is developed it is because that force is so weakened that it cannot control the capillary circulation of the organ. We all know that physical health is entirely de- pendent upon the proper circulation of the blood. No matter what means are used to restore health to diseased organs, they all have one grand object in view, viz. : to restore to a normal condition the circulation of the blood. When that is accom- plished and maintained and the current is full and free, health is assured. When the general circulation is poor or local congestions occur morbific changes at once set in. Blood stasis is the be- ginning of all pathological changes, and the great problem for us to solve is how to restore a normal circulation of the blood and perpetuate it. To solve this question it becomes necessary OEIFICIAL SURGERY. 49 for us to inquire and determine where the causes of nerve waste exist. Orificial philosophy says, "in the lower orifices of the body." Let us now consider how this is. In the first place the proposition laid down by the author of the orificial philosophy is found to be true, viz. : " In all pathological con- ditions, surgical or medical, which linger persistently in spite of all efforts at removal, from the delicate derangements of brain substance that induce insanity, and the various forms of neur asthenia, to the great variety of morbid changes repeatedly found in the coarser structures of the body, there will invar- iably be found more or less irritation at the rectum, or the ori- fices of the sexual system, or both. In other words, there is one predisposing cause for all forms of chronic disease, and that is, a sympathetic nerve waste occasioned by orificial irri- tation at the lower openings of the body." This has been con- firmed by close observation by thousands of physicians since its promulgation. The testimony is unanimous that whenever a case of chronic disease exists, persistent in its nature, resist- ing all common means adopted for its cure, there is always found irritation at some one of these orifices. It is legitimate and appropriate to ask, how is it that irritation there wastes and exhausts the force and power of the sympathetic nerve, the integrity of which is so necessary for good health? The limits of the present paper will not permit a considera- tion of all the lower orifices, and so we will take simply the rectum for purposes of illustration. "We find two distinct sphincter muscles external and internal. They are situated one to one and a half inches apart. The upper one, being an involuntary muscle, is supplied with nerves from the sympathe- tic nervous system. This is true in relation to the fibres of all involuntary muscles. The external sphincter, being more or less under the con- trol of the will, takes its supply of nerves from the cerebro- spinal system. Irritation of these muscles or between them causes an involuntary contraction of the fibres, especially of the internal one, and constant spasmodic contraction is what wastes the functional power of the sympathetic nerve in such a manner as to permit organic disease to develop without suffi- 50 ORIFICIAL SUBGERY. cient nerve force to throw it off. It is well known that spasm of any muscle, either voluntary or involuntary, is very prodi- gal of nerve force. If you steadily contract any voluntary muscle the evidence of this will soon manifest itself. This is easily demonstrated by experiment. Hence it is that the constant contraction of muscles composed of involun- tary fibres caused by morbid conditions of the rectum rapidly exhausts the nerve force which supplies them. Now, as men- tioned, it is this sympathetic nerve force which controls nu- trition and the capillary circulation of the entire organism; we see at once that the health of the various organs and their harmonious activity depend entirely upon the integrity of this sympathetic nerve force. Normal power and activity of this force mean a healthy organism. Weaken this force and the whole physical machinery is liable to get out of repair. It takes away the reactive power of the system to ward off active causes of disease. The power of the "vis medicatrix naturae" is thus diminished, making restoration to health more difficult. Response to the action of appropriate remedies is more tardy and many times it fails utterly. Clonic spasms of involuntary muscular fibres are very disastrous in their effects upon the organism, and the feeble- ness of nerve exhaustion thus induced shows itself chiefly in functional disorders, and they are the voices liable to be misun- derstood. They do not call directly to the cause which secretly does its effective work. Long continued contraction of volun- tary muscular fibres talks in direct and unmistakable lan- guage. It points directly to the cause of suffering thus induced. But many cases of serious functional disease are caused by the weakening effect upon the sympathetic nerve of spasms of the involuntary muscular fibres of the sphincter muscles when the local irritation has not been sufficient to annoy the patient. Hence, often a suggestion that a secret cause may exist there is treated as very improbable and even an examination not allowed on account of such a conviction. In most of such cases subsequent investigation and treatment have confirmed the suspicion of local irritation, and removal of its cause has been the means of a permanent cure of functional disorders. OEIPICIAL SUEGERY. 51 These functional disorders at times are marked and violent while the orificial irritation may be so slight as not to be no- ticed by the patient. Such cases are often relieved at once by simply stretching the sphincter ani. A typical illustration of cases of this nature is mentioned by Dr. "Win. T. Helmuth, of New York, in the dis- cussion of an article on orificial surgery presented by Dr. E. H. Pratt, at the meeting of the International Congress held in Atlantic City, N. J., last June. His experience in orificial surgery has been very limited and he professes to know but little about it.- He says, "the little that I do know about this method has been extremely satisfactory to me. I cannot say, for I do not know, that by means of orificial surgery almost every disease, including insanity, may be cured, nor do I know from personal experience how extensively these reflexes affect other diseases mentioned by Dr. Pratt, but when any member of this Intsitute stands in his place and details his experience we are bound to investigate and believe him, or those who know to the contrary should arise and contradict him. For myself I can only say that a case of the most persistent vomit- ing in a young lady came under my care. She had been under both systems of practice, and I had tried all the remedies which I knew. It was doubtless a case of hysterical emesis. In desperation I suggested that the sphincter ani be stretched ; it was thoroughly done, and she has not vomited from that time to this. I had another patient upon whom I operated after- ward for a nephrotomy, opening the kidney and allowing large quantities of pus to drain off. This gentleman was well known in the west, and suffered such terrible spasmodic action of his bladder, that every hour and a half, all night and all day, he would be troubled with such a severe urinary tenesmus that his life was a burden. The introduction of the catheter, opium suppositories, belladonna, hyoscyamus, pichi, canthar- ides, and even the introduction of the rectal tube for a time was tried without avail. Then I stretched his sphincters with immediate and permanent relief of these distressing symp- toms. I state these things simply to uphold Dr. Pratt on one portion of his paper. 52 OBIPICIAL SURGERY. ' ' Of the rationale of these nervous reflexes as yet we know very little, but the facts remain that the practice of orificial surgery as applied to the rectum and lower orifices of the body is often followed by the most remarkable results. We know when we relieve phimosis how many different nervous conditions are instantly removed." Dr. Storke at the same congress observes that although he is not a surgeon of any special school, he claims to have had opportunities to observe the effects of ^orificial surgery. He mentions one patient, "an old time-worn minister, who had suffered from very severe mental symptoms, nervous depres- sion, exhaustion, poor digestion and rectal troubles until his life was unbearable to him. He had passed through the hands of many physicians without any benefit. I was able to afford him but little relief, and simply prescribed for him from day to day with slight pallation. He passed into the hands of one of Dr. Pratt 's pupils, who found that there was an irritable condition of the sphincters, some slight inflammation of the rectal mucous membrane and a little discharge of pure white mucus. The sphincters ani were thoroughly stretched, and with that one operation disappeared every vestige of the old man's sickness. T had an opportunity of observing him for some months after that operation, and to my certain know- ledge he was as well as any man of sixty-five years of age could expect to be. After the stretching this patient took no medicine." Dr. Skiles, at the same meeting after this work had been referred to during the discussion as curative in almost every conceivable nervous trouble sympathetic nervous trouble said: "It doesn't seem to make any difference what kind of a nervous trouble, whether it is paralysis, whether it is neu- ralgia or insanity. Now this seems like a very broad statement to us, and when I first heard of this method of Dr. Pratt 's I didn't believe a word of it; in fact I fought it as best I knew how. I can best illustrate this by telling you how I came to believe it. I had a patient, a consumptive, a lady whom I expected to die in from ten days to two weeks. The most ORIFICIAL SURGERY. 53 tormenting thing she had was a diarrhoea. As you all know, this is very tormenting in the last stages of consumption. A young physician who was then watching Dr. Pratt 's experi- ments, five years ago last winter, told me one day that I could cure that diarrhoea if I would. I said at once, 'do you think that thing of Pratt 's would cure that trouble?' He said he did. I said to him, 'here is ten dollars. Go down-town and get the necessary instruments and we will operate.' Next morning we gave the patient some chloroform, snipped out two or three papillae and some pockets, and within three days the diarrhoea stopped, and my patient lived several weeks in comfort. Since that time I have been a thorough believer in orificial surgery. I can assure you, too, that I have relieved paralysis, complete hemiplegia, running twelve months. I can also assure you that I have relieved insanity quite a num- ber of times; one case particularly would be of interest. This case was of a lady twenty-eight years of age who had pro- found melancholia. Of course you all know that is the hardest kind to treat. These violent cases of insanity in a great many cases get well spontaneously, but never the melancholias. In this class of cases it is my custom to put them under chloroform and see if there is not some cause for the trouble beside the organic trouble of the brain. She could not utter one single sentence. A word or two she could utter, but with great difficulty. I found that the rectum was ulcerated; that the uterus was ulcerated, retro verted and lacerated; that the urethra was carnucled. I though any one of these was enough to produce her mania. I treated this lady every ten days, under chloroform, for three months; at the end of that three months I had the rectum in healthy condition, the uterus in a normal position, the ulceration was gone and the bladder was in a healthy condition. Still she could not talk nor could she utter one single clear thought. We still had the lacera- tions. I told the husband there was one thing to do, namely, repair the laceration, believing that this was enough to pro- duce the congestion of the brain so that she could not talk. The following day I repaired it under chloroform, and to my 54 ORIPICIAL SURGERY. profound delight when she came out from under the chloro- form she was in her normal right mind, and she has remained so ever since. And this was fourteen months ago." There are members of this society who could relate many remarkable results in their practice. Your humble servant could write a volume of his experiences in the past five or six years showing results of this work marvelous and in some cases almost incredible. In many of the eastern and some of the southern and western states there are now thousands of able physicians whose testimony confirms the value and importance of orificial surgery. It is not a substitute for other treatment. It simply supplies a foundation for skillful treatment to cure many cases otherwise, so far as we know, incurable. This method is not advised except in cases where other means fail to cure. Of this class of cases fully three-fourths can be brought into a state of reasonably good health by its methods. Does not this furnish good ground for a plea in its favor? It is known to some of our members that in September, 1888, a Society of Orificial Surgeons was organized in the city of Chicago. This society now numbers several hundred phy- sicians from all over the United States. Its reports confirm the position taken in this paper of the inestimable value of its methods. The Sanitarium at Chicago, now having one hundred and forty rooms which are filled most of the time, has been running about two years successfully, and its reports are very flattering as to the results of orificial surgery. Pre- vious to the erection of this building patients were accom- modated at hotels, private boarding-houses and two buildings fitted up which were soon too limited to accommodate all the patients. Nine medical colleges teach its philosophy in their curriculums. Our college here should not hesitate to teach and test its utility. It should be introduced into our hospitals. I firmly be- lieve that more than half of the cases of insanity in our asylums can be cured by skillful orificial surgery used as a foundation for judicious treatment afterward. Experience ORIFICIAL SURGERY. 55 and reports of many reliable physicians supply a good basis for this confidence. In all earnestness I ask each physician of all schools to give this method his deliberate consideration. Submit it to the only true test of any method of practice. Learn its methods thoroughly and apply them skillfully. You will then realize astonishingly happy results. Why not do this? Take the cases you fail to cure otherwise. No harmful results follow the work when properly done. The testimony in its favor is overwhelming. Can you be justified in withholding your attention from a method which, with good grounds, promises to do so much where other means fail ? It will have its failures. Is this surprising when you view the class of cases submitted to this surgical work, viz., the incurables, and yet more than half of these are restored to a reasonable degree of good health and of course made happy in the enjoyment of home and society ? The list of chronic diseases to which this work is applic- able is a long one. I mention a few of them. Diseases of women, bronchitis, derangements of the stomach and bowels, dyspepsia, asthma, spinal irritation, nervous prostration, eczema, kidney and liver diseases, dropsy, neuralgia, paralysis in short all chronic maladies which resist other skillful treatment. Even cancer is much benefited by the work because it equalizes nervous force and the capillary circulation. It is the invalid 's firm friend and should be used skillfully as the physician's chief reliance when other means of cure fail. Again my plea is that you investigate and test its merits. CHAPTER V. ORIFICIAL SURGERY. W. E. BLOYER, M. D. We will not attempt in this paper to give an exposition of the orificial philosophy. It has too much breadth, too much depth, too much general scope, to bring it within the confines 56 ORIFICIAL SURGERY. of a society paper. It has, however, been'thus briefly stated: "All chronic diseases, surgical or medical in character, are due to irritation at the lower orifices, causing nerve waste." To many, no doubt, such a declaration may seem too broad, too sweeping, too comprehensive; it may seem illogical, unreasonable, or to border upon presumption. Certainly we are not now all prepared to accept such a statement in its totality or as being literally true. It favors too much the expression of the ordinary "cure-all." But as liberal-minded men, and as physicians, ready and willing to learn to get good from any and all sources the whole phi- losophy should not be condemned because we cannot encompass or comprehend this brief expression of it. Some of us have gradually learned to appreciate the fact that there is much truth in the orificial philosophy, and we have been brought to a realization of this fact by accepting in an unbiased way the results of so-called orificial surgery. The further fact that such surgical attention paid to the lower orifices of the body in correcting and smoothing them does not, in every case, remove (or has not removed) every vestige of disease from the person so operated upon, should not lead to the condemnation of the whole idea, because the operation may have been imperfectly done, the cause may not have been reached, or many other vital conditions may have been vio- lated, or the orificial principles may not have been given proper consideration. For instance, one would hardly expect to cure a chronic headache due to eye-strain by orificial procedures, nor would it be within ordinary reason to expect to cure a bronchitis, or a pneumonia, or an influenza, at once, by a trach- elorrhaphy or a removal of the prepuce, or a dilatation of the sphincters. Within our own individual experience results have cer- tainly been very satisfactory, although we feel that we have not pressed the work to its limit by any means. The orificial surgeon should be a general surgeon. He should fully under- stand and appreciate the principles of surgery. More than this : He should be a physician, and combine with his orificial methods the means and armamentarium at the command of ORIFICIAL SURGERY. 57 the observing practitioner of medicine. We would not make of orificial surgery a special surgery, but rather an adjunct to both medicine and surgery. It is hardly necessary to call the attention of the members of this society to the ease and certainty with which the very centers of life can be touched through the lower orifices of the body. No matter how profoundly your patient be under the influence of an anaesthetic; he may be so unconscious that a knife-thrust at any point upon body or limb will not in the least disturb the eerebro-spinal nervous system into the slightest expression of pain. In fact, the abdomen, chest, or cranium can be opened, the most vital parts and organs touched, cut, or excised, and there will not be the least mani- festation of consciousness. The patient, as far as consciousness is concerned, seems absolutely dead. Yet, while he is in this condition, if a rectal speculum be introduced into the anal outlet, and its blades separated, there are immediately not only expressions of pain; but an evident serious disturbance, if not a sudden cessation in the action of the heart and the respira- tion. The operator, armed with this knowledge, has always at his command the means to revive the patient that is about to succumb to the depression due to anesthesia. Chloroform narcosis has been robbed of many victims by the immediate and thorough dilatation of the sphincters surrounding the end of the bowel. No demonstration could be clearer or more conclusive. Through these points the great sympathetic nerv- ous system the the vegetative system of nerves the nerves of the body that never sleep, day or night the nerves that attend to the breathing, the circulation of the blood, the diges- tion of the contents of the alimentary tract the nerves that tear down and build up the tissues of the body in conformity to the unfathomable laws of life, and are always at work, even while conscious man sleeps the nerves that anesthesia itself does not anesthetize can be impressed through their exposed orperipheral terminations at the lower outlets of the body. We are positive of this; nothing is more certainly proven. Thus the first step towards the orificial philosophy has been made. 58 ORIFICIAL SURGERY. We must next necessarily know when these nerves need to be impressed their expressions of pathology how they should be impressed whether there is excess, defect, or per- version of their actions, and how or by what means or man- ipulations surgical procedures, if you please the existing wrongs can be righted. The absolute truths now known or recognized by physi cians and surgeons relative to the orificial idea, are of recent discovery. The whole philosophy is not yet knownnot yet developed and years, perhaps decades, may pass before ori- ficial surgery will have been fitted, as it were, for the niche in the wall of human knowledge, of which it is undoubtedly a part. Observation and trial, and time, will eventually de- velop it. But no matter how much truth and science there is in the orificial philosophy, it is at all times, like so many other things in close relation to medicine and surgery, subject to the ever- varying complications and conditions of the patient to his physical inheritance, to his circumstances, and to his environ- ment. However, from our observations, based upon our own experience and that of others, the results of orificial treatment are many times astonishingly favorable, and we may say al- ways satisfactory, when the work has been properly done. A few cases coming under our own observation may help bring to the orificial idea the favorable opinion that may lead to its thorough investigation that we so much desire. The. sooner it rises to the height, or falls to the depth, to which its merits consign it, as is determined by the physician in active practice, the better will it be for the profession and humanity. Mrs. A., married five years, had been pregnant once within the last year, but aborted about the end of the second month. Her menstrual periods, though fairly regular, were fraught with the most intense pains and nervousness. For a week or ten days in each calendar month she was unable to be out of bed. The remainder of the month her stomach was a disturber; her tongue was always covered with a white fur, and the relish of food was wholly unknown to her. She ate ORIFICIAL SURGERY. 59 her meals in a sort of mechanical way simply because she thought she should eat them, and not because she enjoyed them in the least. In consequence of these troubles, she was thin in flesh, sallow if not yellow, constipated, weak, peevish, nervous a burden to herself and her friends. She had suf- fered many things of many physicians. Pills, powders, po- tions of all kinds, had been tried and always without favorable results. With the assistance of two of my colleagues respected members of this Association but not until the ordinary medi- cal measures had been exhausted, orificial methods were used upon her. The clitoris was "unhooded, " and smegma, that had perhaps been secreted and prevented from escaping, from the time of her birth, in abundance was turned out. Her ure- thra was small, irritable, and ragged, and a small caruncle pre- sented. It was trimmed smoothly and dilated. The external os uteri was "pin hole." The cervical canal small, sinuous. The endometrium was tender and covered by granular excre- scences. The os and canal were dilated. The cavity carefully but thoroughly curetted and then mopped, so that neither debris nor clotted blood remained in it to become a nidus for septic troubles. The sphincter ani was close and extremely strong. The rectal speculum revealed some pockets and papil- lae. They were all removed, and the sphincters thoroughly dilated, if not divulsed. After twenty-four hours, when the chloroform sickness had been overcome, she expressed herself as feeling somewhat sore locally, but mentally she was calm, serene, easy upon an altogether different nervous plane. The tension had been taken off, and she was let down to her natural self. I need hardly tell you that the dysmenorrhea is no more. The stom- ach and digestive tract act as a good stomach and digestive tract should. The constipation is gone, her sallowness is gone. She hardly seems the same woman ; in fact, she is not the same woman. Her predecessor was nervous, high strung, half wild, hysterical, both day and night. This woman is cool, quiet, and unconcerned. 60 OBIFICIAL SURGERY. Had not the change been wrought, Doctor, aould you tell where her nervousness would have carried her? Do not our asylums contain many whose troubles began as hers? Would medicine alone have wrought the change? "Was called to see a scrawny, milk-and-water looking boy. His father said, "Doctor, take Joe, and look him over. He sleeps badly, is restless, uneasy, dreamy. He eats poorly his appetite is vicarious and morbid or many times he eats noth- ing. He looks bad, he complains of vague pains, and he ivets the bed nearly every night." Everything in his make-up pointed to a lack or waste of sympathetic nerve force. 1 at once said. "Let me see that foreskin." Here it was, a half or three- quarters of an inch too long, with a very, very small opening, so small that when an effort was made to retract it, only a small red point on the glans penis could be made to peep through. Said I, "Here is the trouble. Get rid of this, and your boy will be better, if not well. ' ' We not only amputated that fore- skin, but we dissected strong adhesions where it was attached to the glans penis. When loose, rolls of smegma, like pencils of butter, were set free. The sphincters were stretched, and the result was like magic. The orificial treatment was to this boy the "open sesame" from a poor life to a new life. Today he is becoming red-faced, chubby the picture of health. The bed-wetting, the restlessness, the vague pains, the poor diges- tion and appetite are gone, and gone forever. Another Mrs. R., married, though a woman of good flesh and appetite, was restless, nervous, and barren. She had had many physicians, but she received little aid. An examination revealed a tightly-hooded clitoris, a caruncle of no mean size in the urethra, and a "pin-hole" os. All of these were at- tended to and the result was magical. She was transformed. The cold, lifeless, unfeeling sexual embrace gave way to a feel- ing that we fear salix nigra would not suppress. The tantaliz- ing urinary disturbances are no more. Menstruation is free, easy, regular, and there is hope that the much-desired and long- sought-for pregnancy will come. In short, she is now a well woman, and enjoys life to the fullest extent of the word. OEIFICIAL SURGEKY. 61 Scores of cases could be reported in which, the attention to these minor matters was to the patient, as it were, a new creation, if not a new birth. "We ask the members of this society to give this orificial idea some attention. It will not cure everybody of every dis- ease ; but help humanity by helping the profession to find out and to know exactly what it will do, and to place it in the sphere in which it belongs. CHAPTER VI. ORIFICIAL SURGERY. O. S. RUNNELS, A. M., M. D. I desire to consider today the general subject of orificial surgery. I wish to do so, not as a partisan, but as a scientific physician, intent only upon the recognition of truth. In science all personal equations are ruled out ; all parties and cliques are lost sight of. "What mankind is concerned about is the revela- tion of truth. It is more than twenty-five years since the discovery of the great principle that underlies the practice of orificial sur- gery. Many isolated facts have been known, and the knowl- edge had been turned to account in the physical betterment of mankind; but there had been no recognition of the rela- tivity of these truths; there had been no systematic arrange- ment of the knowledge acquired; there had not been the co- ordination necessary to the requirement of science. Prior to the time in question there was no correlation of the knowledge possessed upon the subject. One fact did not mean anything in particular when placed in juxtaposition with another fact. Facts now known to be closely related at that time shed no particular light upon each other. Each stood by itself, and had solitary significance. For instance, the oldest voluntary surgical operation was circumcision. The prehistoric observer had learned that it was better to relieve every male child of his foreskin, and it 62 OBIFICIAL SURGERY. was done. This finally was adopted as a religious rite, and be- came eventually, except with the Jews, Mohammedans and a few semi-barbarous tribes, practically obsolete. It had, how- ever, no particular luminosity and suggestiveness in the broad settlement of pathological questions, and was employed only upon individual demand, or in conformity to the church or- dinance. Fifty years ago T. Addis Emmet discovered that certain incurable erosions and epithelial vegetations of the cervix uteri were due to the presence of cicatricial tissue, the result of laceration in child birth; that much derangement of the sexual functions could be directly chargeable to the same con- dition, and that many neuroses of distant organs were indirect- ly dependent also upon this cicatricial cervical plug. The com- prehension of this fact was one of the most potent means for the quickening of gynecological advancement ; and, next to the invention of the Sims speculum, did more for the betterment of women than all that had preceded. But this discovery, pro- lific as it was of good results, did not have any meaning in common with circumcision and the recorded effects of pre- putial irritation. Quack specialists for ages had plied their vocation in the treatment of piles, but the work was regarded as a dirty busi- ness, and below the level of a learned profession. Finally some reputable physicians reached the conclusion that painful nem- orrhoids demanded attention, and that it was legitimate for professional dignity to unbend in certain cases long enough to essay relief. But in every instance the end sought was the alleviation of local discomfort and suffering. There was little or no reasoning about the systemic effects of such a condition, and absolutely no regard paid to non-painful cases to mor- bid rectal conditions that gave no anal discomfort. That rec- tal morbidity had much to do in the provocation of distant or- ganic disturbances was entertained feebly, if at all, by but few; that it was present in almost all forms of chronic dis- ease, and was a most potent factor, either in their causation or maintenance, was believed by none. So far as kinship be- tween morbid rectum, morbid cervix uteri and appendages, and ORIFICIAL SUEGEEY. 63 morbid prepuce or clitoris, in the etilogy of disease, was con- cerned, there was no consensus of opinion, and as a matter of fact no individual belief. Much evidence had been taken and many facts accumulated along the different lines, but there was no orderly arrangement of the knowledge possessed, and it had no common significance when taken as a whole. It was a heap of building stones, an agglomeration of material which had not found its rightful place in the walls of the temple of knowedge. What was known, therefore, was more or less chaotic and unsystematized. In the year 1885, however, it dawned upon E. H. Pratt that there was a great principle underlying all these phe- nomena; that the observations recorded were of closest kin, and when understood in their true meaning had vaster sig- nificance than had been accorded hitherto ; and that the dis- orders of the prepuce, the clitoris, the uterus, the prostate, the bladder, and the rectum had intimate and especial relation- ship when irritated, not only with each other as the sex per- mitted, but with all other parts of the body as well. He re- alized and emphasized as none had done before that an irri- tated sympathetic nerve-terminal in one part of the system could be as much of a disturber of the organic peace as could an irritated sympathetic nerve-terminal in another part of the system; that the richest and most accessible distribution of sympathetic nerve filaments was to be found in the orifices of the body, but chiefly in the lower orifices, and that the welfare of the body, the maintenance of its health and its reclamation from disease, particularly chronic disease, was dependent in a most remarkable degree upon the entire freedom of these orifices from persistent irritations. This bought into more prominent discussion than ever before the part played by the sympathetic nervous system in the function called life. It made a sharper contrast between the anatomical and physio- logical relationship of the cerebro-spinal or consciously sensi- tive nervous system, and led us to the clearer realization of the fact that the chief office of the former was to preside over the volitional functions of life while the chief office of the latter was to preside over those functions of the body that must be 84 ORIFICIAL SURGERY. performed whether the mind or will rules or not, i. e., the organic functions. From this became more apparent the fact that all pathogenesis has to deal primarily with the sympa- thetic nervous system; that all life manifestation from the germination of the embryo through all the vicissitudes of ges- tation and unconscious development, through all the experi- ences of the intellectual man, his wakings and sleepings, his deliriums and narcoses, till death supersedes all, are governed by the activities of the sympathetic nervous system; that the ultimate residence of vitality its holiest of holies is found in that center and distribution of brain substance which embraces and dominates the ganglia of the ^ sympathetic nervous sys- tem, and that consequently the study of pathogenesis is but the study of the morbid manifestations of this basal expres- sion of life. The accentuation of this groat fact led to a deeper and more methodical study of the function of the sympathetic ner- vous system in health; to its physiology before its pathology. This was the beginning of the etiological renaissance. The study of causation was paramount. The quest of knowledge in this regard was quickened as never before. With this em- bracing thought men have delved to greater depths in the search for life-secrets, and deeper insights into the modus operandi of life have been gained. Knowledge previously at- tained upon the subject, like loose sand upon a vibrating plate, has fallen into place, giving shape and symmetry as well as vast indication to the thought. Men have felt with this deeper view into life process a consciousness of greater nearness to the fount of being ; a sense as if the great secret was within possi- ble grasp, and that with yet more and more persistent explor- ation it might be attained. But while this north pole of knowl- edge shall never be gained in this world, the fact remains that these recent years have brought us nearer to it by several de- grees and that the knowledge thus acquired enables us to ameliorate to a greater extent than ever before the ills to which mankind is subject. Coming now from the abstract to the concrete, let us con- sider this subject somewhat more in detail ; let us understand OEIFICIAL SUBGEBY. 65 more clearly what it all means. I have said above that the primary fixation and establishment of the human soul in visible matter is evidenced in the ultimate by the manifestations of the sympathetic system of nerves; that as far back in organi- zation as we are permitted, in the individual case, to go, i.e., to the time of the coalescence of the two germs in the matrix, the life expression is served and voiced by this medium. I will say further that observation and inference prove the same to be true of the life manifestation in all the stages and grada- tions of animal evolution back even to the amoeboid protoplasm of the great primal ooze, or to the period of impossible differ- entiation between sensitive animal and sensitive plant; that from that ancient creation-day through all animate existence, including the human family and the units thereof, to the final day of individual death, the sympathetic nervous system, sim- ple or complex, has subserved the ends of existence and been its conservator. Nothing can go further toward the establishment of faith in an All-Wise Father and Universal Providence than the sweep of this mighty thought. When one but faintly realizes the in- telligent provision and protection that has been exercised over all the feeble folk of the world through all the vista of time, that while millions of the different families in the chain of de- velopment never awoke to consciousness during the period of their earthly lives but were yet endowed with an organic in- telligence that continued to perform the life functions and evolve to higher conditions; when one senses the fact that in the specific instance of the man's own life, through all that dark night of existence in utero and babbling childhood, pre- ceding his awakening to the sense of existence, and through all subsequent periods of darkness occasioned by natural sleep or morbid obscurations from whatever cause also during his waking but careless and forgetful moments as well his faith- ful servant the sympathetic nervous system has been attending strictly to its assigned task of life-supervision, I say when one realizes all this, he can but feel that he has been kept as in the hollow of a Mighty Hand, that Life from God preceded all or- ganization and that man is but a passenger on the great train 66 OBIPICIAL SURGERY. of being. But while the human mind is thus brought into a realization of this fact of subserviency to the "power not our- selves" that works for the Tightness of our physical lives, it is led still further into the contemplation of this mechanism that God uses primarily to accomplish human life. The great study of the present and all future time must be the study of this connecting link, or chain of links between the soul and the body, or mind and matter. This is the great interrogation that shall fascinate men while time lasts but the ultimate answer to which shall ever recede before them as one acquisition of knowledge after another is made. Certainly no greater question can exercise the minds of men than how they may touch and influence the generator and liberator of life- force and thus be enabled to work together with this great and silent power in the banishment of physical ills. Having realized that the life-force is resident in the depths of the nervous system and that the very citadel and reservoir of this force is that portion of it known as the sympathetic, observation must center itself upon the phenomena of the sym- pathetic. How, then, may we reach and impress the sympa- thetic ? The chapter concerning the "reflexes" has now grown to be a very long one and it would be tautological for me to go into any lengthy dissertation upon them. It will be enough for me to cite them as instances of sympathetc irritation ; and to remind you that all nerves are made to report contact, es- pecially inimical contact. Sensation, whether conscious or not, always comes from the periphery, the terminals of distribution. So far as the cere- bro-spinal, or the markedly sensitive nerves are concerned it must come from contact surfaces, chiefly from the integumen- tary portions of the body and from regions of special sense. There is a notable difference of sensitivity even among nerves of this class dependent upon their use and education, the nerves of the index finger for instance attaining a proficiency in intelligence almost beyond the boundaries of belief. So far as the sympathetic or markedly insensitive nerves are con- cerned impressions must come also from their peripheral dis- OEIFICIAL SUEGBBY. 67 tributions. Being the nerves of the organs of the body they are restricted in their external expansions to the orifices of the body. The periphery of distribution of the sympathetic nerve- terminals has been found to be almost wholly in the body 's ori- fices. Their language, however, is not primarily, pain to the ego ; but discord among the life harmonies. It requires trans- lation into terms of sensorial understanding before the inter- pretation is complete. One must become a reader of the facies sympathetica if he would know the significance of the mes- sage conveyed; he must be trained to look through symptoms to causation. The patient who does not bear ample facial evi- dence of his illness; who does not get credit from his fellows for his bad feelings ; who has given expression in his long con- tinued complaints to a variety of neuralgic or secondary man- ifestations in different localities; who recognizes that his phy- sical abilities have a short limit and that he can do no more than so much without inducing prostration or some familiar "spell," and who shows in measurable ways a progressive waste of that substance which we call vitality that patient I say bears the insignia of an embarrassed sympathetic and is under orificial indictment. So far as we can see there is a notable difference of im- pressionability also among sympathetic nerves the nerves of one orifice giving more marked expression in certain ways than another. Rhinologists and laryngologists have been led to believe that the chief and most important sources of reflex irritability are to be found in the nose and throat; while their antipodal co-workers, the pelvic specialists, are impressed with the belief that the greatest reactions of the sympathetic are resultant from the irritations of the urethra, the uterus, and the rectum particularly the rectum and the extensions and relations of these respective tubes. But this division of opinion is but superficial, and is dependent upon the restriction of vision to a given locality. Taken together the observations of all orificial co-workers are complimentary, and round to the full the truth that the nerve-wastes due to persistent irritations 68 OBIFICIAL SURGERY. of one or more of the body's orifices have largely to do with the impairment of vitality and are the origin and dependency of most cases of pathogenesis. The evidence is cumulative that all disease manifestation is but proof of impairment of vitality ; that when the Leyden- jar of life is full and the electric discharge if you may so call it vigorous and repellant, there can be no morbidity; and that the measure of health is correlative always with the volume of vitality. Search far and wide and you will find that it is only the vulnerable who succumb; that it is only the susceptible who are affected; that those fortified by their due allotment of reserve force go through unharmed, and that never can regainment of lost life or health be made until the waste of vital force be stopped and be reversed into an in- crement. This is especially true of chronic diseases and has relevancy also to zymotic diseases and many diseases of the accidental type. Convalescence implies increment of vital force ; it implies the cessation of inimical influences ; it implies peace and harmony in the sympathetc nervous system. Men may sneer at and speak derogatively of your propo- sition when you explain the common causation of extensive and apparently non-related diseases, and when you insist upon the discovery of what to them appears to be a wholly inade- quate irritation; but this is evidence only of their slow rate of travel; it is proof only that they are still copyists of obselete formulas. They have not learned the lesson of Sinai, that the Lord was not in the thunder and tempest, but in the still small voice, and that the greatest physical revulsions witnessed by pathologists may be due to a seemingly inconsequential dis- turber of the organic peace. Up-to-date oculists are no longer doubting that the strum- ous diseases with which they have to contend are due to some causation of vital poverty, and that their results, even to the rectification of accommodative and other nerve difficulties, are dependent upon the restoration of that lost vitality. Thoracic specialists are realizing that the asthma and incipient phthisis encountered by them has been induced, and may be OBIFICIAL SURGEEY. 6d fostered by some hypertrophy of nose or throat, by some dist- ant pelvic irritation, by some reducer of vitality in some near or remote part of the economy. Dermatologists are learning that their herculean task of diagnosis and reconciliation of variant nomenclatures is superficial, and unsatisfactory if the deeper search for causation is not prosecuted to the ultimate. They will learn, if they have not, that the exhibitions upon the plane of the integument are, the most of them, but reflexes and that the most brilliant cures cannot be made till all sympathetic disturbances have been quieted. They will rec- ognize that even parasitic dermatoses are dependent upon the ease with which a nidus is made, and that this too is largely a question of susceptibility. Alienists and neurologists are awakening to the fact that the sweet bells of the mind never go jangling and out of tune while harmony prevails in that substructure of the economy upon which all life interpretation is posited; that such a thing as insanity without an embar- rassed sympathetic is rare, and that if the history of each case had been carefully written, it would show that the in- ception of the mental alienation of most of the unfortunate persons incarcerated in the mad-houses of the world was made through the devastating influences of orificial irritation. Cases of cranial depression aside, and the lunatic without morbid rectum or morbid genitals, is an anomaly. This is but another way of saying that the most of the mad people of the world ought to be, and can be, pacified and returned to their avenues of useful occupation in an incredibly short space of time. Specialists of all sorts, in short, are finding out that they are addressing but parts of a great whole; that the part of the body which is claiming their especial attention is con- nected most intimately with the central organism, and that it is dependent for its welfare upon the welfare and normal function of that central. Every specialist deserving the name has learned that he must be a generalist also if he would determine with any degree of credibility the peculiar sig- nificance of local phenomena and to what extent the local 70 ORIFICIAL SURGERY. is controlled or influenced by the general. For this reason it is that the recent discoveries touching the universal in- fluences of sympathetic irritation are germane to all remedial effort; that no specialist can attain reasonable success without the restoration of the equilibrium of the sympathetic nervous system, and that this can not be done till all orificial irrita- tion has been abated. Organic diseases there are. Yes, but every organic disease is a thing of slow development; it is an index of crippled vitality and existed for a longer or shorter time as a func- tional. It did not come full-formed without a moment 's notice. The sympathetic in every instance fought a good fight, and, when the odds were finally too much for it, the effects of the discord became crystallized into organic defect. The best way to cure organic diseases is to prevent them ; and the best way to prevent them is to relieve the sympathetic nerv- ous system of all persistent irritation and nagging; and the best way to prevent irritation and nagging, nerve waste and vital loss, is to attend to the orifices of the body. So long as poverty is the characteristic of the life capital, so long shall the individual be haunted by a thousand physical fears ; so long shall he give expression to manifold and widely variant inabilities; so long shall he be the unfortunate candi date for ultimate organic disease. The most appropriate time to make a life-examination is not when some corporation is willing to make a money wager upon the life in question; but primarily when the life is first ushered into the world. If close inspection were then made, much subsequent misfortune would be averted. If the orifices of the new-born were known to be normal; particularly if every prepuce or clitoris were proven to be free from ad- hesions, and every imprisoned cake of smegma behind such adhesions were liberated, how much outcry might not be pre- vented how many cases of convulsions and nutritional diseases might not be thus hedged against? If it were a law that in the progress of life an all-over examination of the body should be made by an expert at stated intervals, say ORIFICIAL SURGERY. 71 every three or five years, whether symptoms were recognized or not, it would be a great advancement. And if, in addition, every individual could be possessed with the knowledge of the necessity for the immediate removal of the irritant, how- ever trivial, and a willingness to follow the indication to whatever extent, how much functional disease might not be evaded, and how, almost wholly, might not organic diseases be ruled out ? This is all the more necessary since it is known that sympathetic irritations can go on without the recogni tion of the patient ; since the fact has been revealed that the sympathetic nerves have conscious sensation to a very feeble extent, if at all, and that they usually reflect their disturb- ances for the most part to distant nerves and organs for report, and since it is indisputably proven that all disease is preceded by progressive waste of vital force. The advancement in this knowledge of the causation of disease and the great strides made through its exercise in the amelioration and banishment of human ills, is the great- est contribution to medical science during the nineteenth century. Whatever in the future may be the modification of the technique of this or that orifieial surgical procedure, the great truths of the orifieial philosophy will hold their places upon the scroll of science and be amplified more and more into fuller meaning as the perfect day of knowledge shall come. But while it is true on the one hand that orifieial exami- nation and restoration is a prerequisite to cure in almost every instance of physical malady, and that every physician, whether general or special, must avail himself of the assist- ance afforded by the teaching and practice of orifieial surgery if he would effect the speediest and most permanent cure of his cases, especially of all chronic cases, it is no less true on the other hand that the knowledge of the physiology and pathology of the orifices, is expert knowledge of the highest order, and that tyros, however well skilled in other branches of healing, are in no sense qualified to put into practice its major operations. It requires the finest discrimination often 72 ORIFICIAL SURGERY. to make an orificial diagnosis, and no branch of surgical practice demands to a greater degree an established technique. Inexperience has been the basis of most of the deplorable results in all branches of surgery. Until methods have been perfected through trial, much failure and disappointment must be realized. The history of surgery abundantly attests the accuracy of this statement. No medical man, therefore, and no surgeon even, is qualified to practice orificial surgery until he has acquired the technique especially called for and demanded by the surgery pertaining to the sphincter muscles. While all can detect the more patent forms of preputial and rectal irritations and rectify them to some extent, none but an expert should essay the major orificial procedures. Let no one suppose that orificial surgery is trivial surgery and that any first-course student is capable of performing it. I affirm that no surgeon requires higher skill than the orificial surgeon, and that the operations which he may be called upon to perform take rank in their difficulties and dangers with coeliotomy or any capital operation. When these truths shall have been realized to the full, there will be fewer practi- tioners of orificial surgery and a far higher grade of orificial work. When that day shall have arrived much of the criti- cism now in some measure just, will have disappeared, and orificial surgery stripped of its burdens and embarrassments will be fully equipped for its usefulness, and will continue to bless mankind while that kind continues to exist. CHAPTER VII. A SYNOPSIS OP ORIFICIAL SURGERY AND WHAT IT HAS ACHIEVED, WITH A REPORT OF CASES. LIBBIE HAMILTON MUNCIE, M. D., PH. M. When an earnest advocate of any system endeavors to make plain its virtues, he is an exception to the rule, if he escapes the criticism of being incapable of seeing any good outside of his specialty, and of making claims for that sys- OEIFICIAL SUKGBRY. 73 tern far beyond its true worth. So much does each one live within himself that, as deplorable as it may be, this criticism is too often just. There are many useful measures in this age of science for the relief of the sick, but all are applied for the one great purpose of equalizing capillary circulation. How to best reach that neurotic influence which controls cir- culation is the great aim, and is perfectly or imperfectly accomplished in many ways. All must act through this chan- nel, and every panacea that ever has or ever will exist has its place, and will be so acknowledged by the true physician. The orificialist is forced to believe that the majority of chronic diseases have their origin in pathological conditions at the lower openings of the body, because he has seen the most excruciating chronic suffering promptly relieved and perm- anently cured by the removal of these lesions; he, therefore, must conclude that these methods stand first in rank, and although the philosophy is correct, judgment and technique may be faulty. Also, there will be found cases which have passed over the boundary line where reactive power is so far destroyed that only death itself can emancipate them from their suffering. This fact should urge the surgeon to a more expert judgment in selecting his cases. It must be remem- bered that the cases presented to the orificialist are usually those which are nearing this boundary line, and that the orificial work is not the agent which cures the patient, but that which removes the barrier from the way, thus equalizing circulation and enabling nature to recall her discordant forces into harmonious action. This process is often slow, because nature seems to make no account of time; therefore, it is not uncommon to meet with those cases where recovery is tardy, but nevertheless sure. There is a disposition in all the walks of life, with a large proportion of individuals, to investigate no system, however well founded, until it has won by its true merit a large following. There are others who, like Peter of old, rush eagerly in advance of his incredulous companions; thus he 74 OBIPICIAL SURGERY. more quickly receives the good, and rejects the bad. His more conservative brother sooner or later reaps the benefit from his investigation, though he resists most bitterly for a season, thereby not only hampering the progress of his en- thusiastic friend, but belittling the influence that he himself might otherwise have enjoyed. The time has arrived when tivery honest, though most conservative, physician and surgeon, must acknowledge that the so-called orificial surgery has achieved great results, since there are now scattered through- out the United States many most successful private sanatori- ums which are an outgrowth from the practical application of orificial methods. The equipment of these private hospitals and the prosperity they enjoy is second to none; therefore, it may be said that orificial surgery has achieved the erec- tion of institutions. It has established chairs in many medical colleges in this country. It has enlarged the field of useful- ness for every physician who has practiced its teachings; and better than all else, it has relieved the sufferings of thous- ands who have turned to its methods as a last resort. It has been demonstrated by a large number of the medical profession, that when dealing with the lower orifices of the body, because of the rich commingling of the branches from the pudic nerve, and those from the hypogastric plexus, there is aroused that neurotic influence which flushes the capillaries thus controlling nutrition, which is essential to the vitality of every part. The human body is inflicted with all forms of pathological lesions at the terminal portion of the sympathetic system, from the preputial adhesions and rectal papillae, to the various large tumors of the pelvic cavity. It is not only a theory, but it has been thoroughly proven, from practical experience in thousands of cases, that even the smallest of these pathological irritations will in many cases, so hamper the activities of the sympathetic nerv- ous system, as to cause, at some remote point, the most pro- found functional disturbances; we, therefore, find all forms of chronic diseases, from neurasthenia to insanity, from hyper- trophy to atrophy, coming within the scope of its practice. ORIFICIAL SURGERY. 75 Orificial surgery, then, is that agent which seeks to remove all points of irritation from the accessible portion of the sympathetic terminals, whereby she is enabled to perform all her functions, unhampered from her regulating power over the greater involuntary activities of existence, to the most remote infinitesimal and homogeneous functions of life. A careful study of the physiology and anatomy of the great sympathetic system, in combination with the voluntary com- manding forces, or the cerebro-spinal, enables one to under- stand easily why any chronic disease is but an evidence of enervated nerve force or a lessening of the natural resistance power against its ravages. It is said that we are frequently confronted with organic diseases, yet all these organic dis- eases, barring the congenital, are preceded by functional disturbances which are actuated by nervous influences. Nerv- ous influences outside of mental shock and worry are usually due to pathological conditions at the orifices; therefore, there cannot be a chronic sufferer produced, who upon experienced investigation will not present pathology at the lower open- ings of the body. The irritation may be so slight as to be ignored by those physicians who have not learned that a tightened frenum, or a slight preputial adhesion, or a rectal papilla, will produce upon certain sensitive individuals a more profound systemic disturbance than in another case may be produced by pathology so pronounced as to be easily recog- nized by any first-year medical student. Inasmuch, then, as the repair of a lacerated cervix, and other orificial pathology, so often results in the alleviation and cure of many reflex neuroses, does it not speak relief for millions of chronic suf- ferers heretofore beyond help? If the lower orifices of the body could be kept free from all pathological conditions from infancy to old age, then the surgical profession would be re- lieved of the painful necessity of performing capital operations except in cases of accident or inherited tendencies, and the latter would be long deferred, instead of siezing the victim at the first unfavorable circumstances of life. 76 ORIFICIAL SURGERY. It should be borne in mind that physical conditions are not unlike moral states. The nervous system takes upon itself habits which it is not easy to immediately overcome; therefore, in the long-continued habits of chronic sufferers, there will often be found not only the primary lesion to over- come, but other effects which in turn become causes, and so on through an almost endless chain, which may be illustrated in the following lines: "Fleas have fleas on 'em that bite 'em; These fleas have fleas ad infinitum." It will be observed that agencies which before the surgi- cal work was performed were absolutely inert will afterward become effective should other agents be needed. In dealing with these chronic diseases, a patient should be under observation for at least one year after the operation, and during that year it may be advisable to anesthetize him once or twice for the removal of any smaller pathology which it may have been unadvisable to remove at the time of the major operation; although in most cases, where immediate operation is not imperative (as in septicemia or pyemia), it is better to perform a preparatory operation, consisting of a clearing of all pathological conditions from the external geni- tals and rectum. This work will equalize the circulation, thereby strength- ening the weak, fluttering heart, often bringing it down from one hundred beats to seventy for each consecutive minute. From one to two weeks after this minor surgery, there may be performed the major operation, with little shock to the patient, and a happy lessening of anxiety to the surgeon. Be- cause of most astounding and gratifying results in many cases, one naturally becomes impatient over the slow recov- eries in other cases. These, however, frequently present the most satisfactory results in the long run. It is not uncommon to have patients who were operated upon three or four years ago make the statement that they feel that they are still gaining strength from month to month, and year to year. For that class which requires careful accessory treatment for some ORIFICIAL SUEGERY. 77 months following an operation, there are many measures which will prove of benefit; such as electricity, massage, baths, ice- packs, drugs, etc. These agencies, however, in many cases are of less importance than is the attention to the maintaining of the pelvic organs in a normal position. Too much cannot be said in this direction. These results may often be accom- plished after a proper all-around operation has been performed where it was out of the question before, without causing ex- cruciating pain, and small fibroids and complications of the ovaries and tubes will often disappear. As to the use of pessaries, they have their virtues. It is often important that they be used in the proper cases, and for the proper length of time, and that they are perfectly fitted to the case in question. "When judiciously used, they hasten the patient's restoration to health, making it possible for her to enjoy activities with the healthy from which she would otherwise be deprived. The occasional dilatation with the graded sound, of the internal os, followed by the use of the intra-uterine stem pessary, will give great relief in many cases. Although un- warrantable injury has often been observed from the injudi- cious use of pessaries, they should not be cast aside as valueless, for in proper hands they hold a very important place in gynecological treatment. The Thomas intra-uterine electrode stem pessary deserves special mention. They come in several sizes, and are just what their name indicates. They are especially useful in those cases presenting atonic uterine walls with flexion, and in the undeveloped states. The glass stems are considered better adapted to the hyperesthetic cases, where the patient may have to be kept under the influence of an anodyne for perhaps a day, until the uterus ceases to rebel; this it may not do at the first attempt, when it becomes advisable to allow the patient to wait a week before replacing. It must be asserted, that no physician should make use of stem pes- saries until he has become sufficiently experienced in pelvic 78 ORIFICIAL SURGERY. examinations to diagnose with some degree of certainty con- ditions above the cul-de-sac. The most telling presentation of what the methods under consideration have achieved in the relief of chronic condi- tions can best be given in a report of cases. We will therefore select from the clinic book only those cases which had re- ceived professional attention from physicians in high standing, and had turned to these methods when all else had failed. Those persons only will be mentioned with whom we are now in direct communication, enabling us to speak positively of their present condition. "While all cases have not been so satisfactory as these which shall be given, it can honestly be said that the disappointments, or failures as some would term them, have been so few that were they mentioned here, there would be a very small space occupied. Case 1. One year ago there came to our care a man who had been insane for four years. His history was as follows: Mr. C., age 48, married. A man of excellent habits and social standing, having for twenty years occupied a very responsible business position. In disposition he had always been one to see the bright, and withal the ridiculous side of circumstances, and had enjoyed exemption from dis- ease during his life, save for occasional attacks of indigestion. In 1892 he was seized with la grippe of a very severe type, which left him a raving maniac. In about six months he became more quiet. After many consultations with expert mental specialists, the case was abandoned as hopeless. It was in April, 1896, the writer first saw the patient, who was in the most profund distress because he "had committed the unpardonable gin." He conversed with great reluctance, showing an inability to produce the word expressing his meaning, whereupon he would throw up his hands in an atti- tude of despair, with a broken ejaculation of hopelessness. The next day, when anesthetized, we discovered a pale Brians penis with an irritable pouting urethral orifice, and a very tight frenum. Upon dilatation of the rectum (which lay par- tially open before dilating), there appeared a zone of grisley OBIFICIAL SUBGERY. 79 papillae, ranging in size from one eighth of an inch to an inch and a half long, pointing upward and overhanging a mass of old hemorrhoidal tissue, the blood-clots having under- gone hardening and partial organization. The operation consisted in the passing of graded steel urethral sounds to the extent of perfect relaxation, clipping the frenum, and a thorough slit-operation upon the rectum, bringing the slits well outward to the integument and inward above the internal sphincter, leaving but a few almost hair-lines of mucous membrane to proliferate. After completing the operation a good-sized rectal plug, wrapped in the fluid extract of ham- amelis, hypericum and calendula, was inserted in the rectum and left there for about six hours. The patient meantime was kept quiet by morphia. The next morning he smiled and said "the clouds are passing away." The wife and daughter declared that he had not appeared so much like himself in all the four years, for during that time a smile had not once marked his countenance. Every day the improvement be- came more marked, until five weeks later he was returned to his home "like his old self," with the exception of slowness of speech, which, however, was entirely overcome in three weeks more. He soon assumed a responsible position in the Auditor's office, giving perfect satisfaction. He remains a perfectly cured man, even though he has had many difficulties to encounter, through illness in his family. Case 2. Mrs. P., age 58, had been suffering with melan- cholia for eight years, during which time there had never been a perfectly lucid moment. She had been under treat- ment in three of the best institutions in the East, and at times in her own home under the best neurologists of her city, but to no avail. She was presented to us in the fall of 1894. Her condition was then rapidly passing on to that of dementia. Her husband stated that he had spent a fortune seeking her restoration, and he now brought her here as the last resort, inasmuch as each physician who had attended her case had given an unfavorable prognosis. He hoped that we would find something to account for her condition, although he had 80 OBIFICIAL SURGERY. been told there was not sufficient pathology within the pelvis to so affect her mind. Her history gave a picture of a hem- orrhagic tendency of the uterus since the birth of her first child (which was still-born, twenty years prior to this inter- view). There had been nine pregnancies, each aborting from no apparent cause. Examination revealed laceration at in- ternal os, a slight degree of anteflexion, chronic meteritis, and the boggy feel so characteristic of malignancy, also a sus- picion of a cystic tumor. The patient was suffering from a valvular heart-lesion. Because of the suspicion of malignancy, vaginal hysterectomy was the only operation that could be con- sistently advised. After explaining to her husband the dangers of such a procedure, he decided that death was preferable to hopeless insanity, and he would take this one chance for restoration. The operation was therefore ventured. The fundus proved to be carcinomatous, the ovaries and tubes which were massed by inflammatory exudate were totally removed, as was a cyst. The entire operation was done with- out clamp or ligature, according to the Pratt method. All denuded surfaces were perfectly coapted, and the border of the broad ligament sutured with No. 1 catgut. The root of the vagina was tightly pressed against the base of the broad ligament and held in position by silk, against which was placed sterilized gauze of sufficient quantity to produce an even pressure. The patient bore the operation remarkably well, suffering no shock thereafter. For the next three days the temperature registered 100, pulse 90 to 100. In the afternoon of the third day, the temperature arose to 103. Abdominal tenderness and tympanitis developed. The fol- lowing week was one of great anxiety, although the symptoms did not become positively critical. A few days later the pulse and temperature became normal. During the week of the peritonitis, and for two weeks following, the mental symp- toms passed into a typhoid condition, with occasional periods during each day of perfect mental clearness, when she would laugh and make witty remarks, which her husband said was characteristic of her in her younger days. These seasons of OKIFICIAL SURGERY. 81 improvement became longer, until her mind was perfectly restored. She was discharged in seven weeks after her opera- tion, a cured woman, and so she remains to the present time. Case 3. Mrs. M., age 34. Had puerperal mania after the birth of her first and only child, five years previous to her entrance for treatment. Frequent attacks of illusions and hallucinations occurred during the five years. When she was brought for consultation, she was indeed a candidate for confinement, having been pronounced by a specialist in mental diseases "a hopeless case"; and when he was con- sulted as to the advisability of attention to the pelvic disorder, he replied, "It will be money thrown away." However, the patient, who possessed a badly lacerated and retroflexed uterus, was placed in our care and we repaired the cervix, at the same time removing all lesser points of irritation about the orifices. She was quiet and rational for three days, when an aggravation of her mental condition developed until she' became unmanageable, and at the same time a profuse hem- orrhage occurred from the uterus. The nurse in attendance very wisely packed and repacked the vagina until the doctors arrived, when it was found necessary to tie the uterine arte- ries, as sloughing had taken place about the cervical stitches, extending directly into these arteries. The diseased tissue was at the same time scraped away. All this demonstrated that the organ was doomed to extirpation, but we hoped to have a few days after this procedure to make up for loss of blood before the more critical operation should be under- taken. The mania, however, intensified, and the hemorrhage again commenced, bringing us face to face, about midnight, with a patient who in a very few hours of acute mania would die from exhaustion unless something was done. No sooner was the position appreciated than orders were given,' and with three good nurses and two doctors it was not long before our little patient was asleep, and soon the offensive organ was removed and the patient's life still preserved. She was quiet for a few days, but this was not to continue, and in the three week's struggle which followed it seemed that two 82 OBIP1CIAL SUBGEKY. spirits, one commanding, the other opposing, possessed her, each fighting for supremacy. During this time it was nec- essary to feed her with a nasal tube. At the end of three weeks, when failure seemed to be inevitable, her reason began to dawn, appetite became natural, sleep refreshing, and a general quietness bespoke victory. Two weeks later she was delivered to happy parents in her right mind; they tell us that she has been perfectly well in mind and body ever since. CHAPTER VIII. ORIFICIAL SURGERY AND THE GENERAL PRACTI- TIONER. MILTON J. BLIEM, M. D. There are specialists and specialists and yet it is safe to say that seven-eighths of the whole profession do still and must ever cover the whole ground of practice in general. While the surgeon has in the development of the orificial philosophy and methods found an extension of his previous work, the general practitioner has been made even a greater gainer. Much, of course, of orificial surgery is called for by local orificial conditions, well recognized both by patient and surgeon. Such conditions were clearly defined long before the origin of such a phrase as "orificial surgery." To my mind the chief and all -important benefit of orificial work has come more especiajJy from the general practitioner and his patients. It has made the physician more vividly con- scious of the existence of the sympathetic nervous system and has opened his eyes wide to the wondrous host of reflexes. It has placed in his puzzled hands a new key by which he has be- come able to unlock and explore new labyrinths of aetiology and which has presently led him to the happy solution of the problem. It is in the general practice of the physician that the meth- ods of orificial surgery are most often called for. May I not OEIFICIAL SUKGERY. 83 say that fully one-half of our prescribing is for functional diseases, many of them chronic? What a weary round of doc- tors and pills do the victims of headaches and nervousness, dyspepsia, neuralgia and constipation, travel! The most thor- oughly physical examinations fail to reveal the slightest or- ganic lesion; the most careful prescribing falls short of giving permanent relief. Patient and doctor are at their wit's end. How many physicians would (before so much noise was made about it) have thought of examining the rectum, the anus, the introitus, the os, the cervix, the clitoris, the meatus, or the urethra in such cases ? And how many, even if led to examine, would have known enough to recognize what they did see and to attribute these obscure but real troubles to such trivial things as pockets and papillae or inflamed carunculae? How changed all this. If in these days a patient with obscure symptoms resists the best efforts of the physician in prescrib- ing, he soon directs his attention to possible orificial irritation as a cause. In many cases, to say the least, he finds what he is looking for, removes it and cures his case. Thus orificial sur- gery, at least in its simpler forms, has become a sine qua non to the general practitioner. Some of the orificial lesions occasionally found by physi- cians require severe surgical operations, demanding the high- est surgical skill. I protest against ordinary practitioners with ordinary surgical skill and experience undertaking such operations. I believe it is a great mistake for men who have never done any general surgery to rush into orificial surgery and attempt to run the whole gamut of operations. By no means should the general practitioner, unless he be an ex- perienced surgeon also, undertake such an operation for in- stance as either the Whitehead or the Pratt method of remov- hi -reflecting upon this ease the writer speedily realized ing the haemorrhoidal area ; nor should many practitioners at- tempt even perineorraphy or trachelorraphy. I have seen these operations done by surgical novices with most disastrous re- sults. While only men are at fault, the system suffers the blame. 84 OBIFICIAL SURGERY. However, many of the simpler orificial operations can be done by any general practitioner who is capable of handling the lancet and the scissors and has good common sense. Hap- pily the great mass of orificial cases demands nothing more. In this lies another great advantage to the general physician, in that he is able to operate upon the majority of his cases him- self and needs not refer them to a surgeon specialist. He thus not only acquires greater surgical skill in a safe way, but also adds to his reputation for curing his patients and constantly widens his sphere of usefulness. All this he can do in the nat- ural course of his practice without going one inch out of his way as a general physician. In conclusion, orificial surgery bears such an intimate re- lation to the therapeutic art in medical diseases that no gen- eral practitioner can afford to remain ignorant of its princi- ples nor fail to accomplish himself in, at least, the simpler operations. SECTION II. Philosophy of Orificial Surgery ORIFICIAL SURGERY. CHAPTER IX. THE COMPOSITE PHYSIOLOGICAL MAN. E. H. PRATT, M. D. [This chapter is rather a synopsis of Dr. Pratt 's book, "The Composite Man," which is a most charming and in- structive work. I would advise every one interested in Ori- ficial Surgery to procure this book and read it. Published by the IT. H. Publishing House, Chicago. Price $2.00. Editor.] The human form consists of an intricate and delicate in- terweaving of several human forms, the blending together of which constitutes the individual which is to be the object of our study. The bones which form the framework of the body have a head, a trunk, a spine, arms and lower limbs, hands and feet, and when properly adjusted in their natural position, so perfectly take on the human shape as to merit the recog- nition of the fact that there is a veritable bony man in every human being. Muscles, too, are everywhere present, the invol- untary type forming one of the coats of all the tubular struc- tures of the interior of the body, and those of the voluntary type covering the head, neck, trunk and extremities in such symmetrical manner that if all the other tissues were disen- tangled from the muscular structures the muscles would con- stitute, when placed in their proper relation, a veritable mus- cular man. The great central artery which starts at the heart and the veins which return to it, visit, by their branches, ev- ery part of the human economy. There are vascular eyes, ears, nose, throat, lungs, intestines, spine and extremities in 88 OBIFICIAL SURGERY. each human being. Were all the other tissues carefully dissect- ed from the vascular system without disturbing the proper anatomical location of the blood-vessels, the shape of the vascu- lar man would be found to be a very perfect one. In the same manner there exists two nervous men cerebro-spinal and sympathetic, a lymphatic man, a skin man, and yet another and still more perfect man than any of these mentioned. There is a tissue in the human body so representative as tc form the frame work of all the other men and also to act as a bond of union between them, amalgamating all these differ- ent structures into one perfect human shape. It is the funda- mental element of the skin man and furnishes a covering for the bony man. It forms the framework of all the interior or- gans of the body and enters into the formations of every one of the other men, besides welding them all together, thus com- pleting the structure of the human form. The name of this most perfect physical man is the areolar man. These various men are all thoroughly dissected and studied by anatomists by the aid of the scalpel and microscope until every nook and corner of the human body has come under repeated and accu- rate observation, and the various facts with relation to this human house are thoroughly classified and arranged for the guidance of students in medicine and surgery. Why is it that the study of man by doctors should stop here, however, has always been a question with the writer, for it leaves unconsidered the most important of all the men whose delicate blending with the other men is essential to the knowl- edge and practice of the healing art. I refer to a man still finer than the areolar man. The composite man as already de- scribed constitutes nothing but a corpse, which is not a proper object for consideration for practitioners of medicine. The presence of still another human form is absolutely essential to the necessities of medical practice, and our enumeration of the elements of the composite man called the human being will not be complete without adding the spiritual man to the list. The areolar man is a fine one, forming as it does the basis of all the other physical men, but the spiritual man is still finer for it adds the element of life to the areolar man itself. ORIFICIAL SUEGEBY. 89 Without the presence of the spiritual man the human form would be simply anatomy. The presence of the spiritual man changes anatomy to physiology and adds the element of re- action which makes the healing of the sick and the mainte- nance of all the bodily activities possible. The dead cannot respond to remedial measures, cannot inflame, cannot undergo pathological changes, cannot indulge in any physiological pro- cesses whatsoever. It is only as the cells of these various men are living that they can become sick and need a doctor. When a part of the human body becomes disordered in its functions the confusion of the part in question involves all of the va- rious men whose blending constitutes the part. In a felon, for instance, the distress of the affliction is visited upon the bony finger, the vascular finger, the lymphatic finger, the skin fin- ger, the nervous finger, the areolar finger and upon the spir- itual finger, and why the medical profession should consider the morbid states of the material finger, and entirely ignore the affliction of the most perfect finger in the composite member is a question which must present itself to every thinking doctor. The consideration of the orificial philosophy and its meth- ods involves a study of reflexes, which are limited only by the limitations of the human organization. A reflex of irritation, congestion and their pathological sequences in all their varie- ties may occur from any point of irritation to any part of any one of the various men enumerated as elements of the com- posite man. Any bone of the human skeleton can suffer from metastic irritation. Any muscle of the muscular man, any company of lymphatic glands of the lymphatic man, any patch of surface of the skin man, any cluster of capillaries of the vascular man, any bundle of fibers of either nervous men, any nest of meshes of the areolar man, and any combination of thoughts and feelings which are characteristic solely of the spiritual man can suffer disorder, disintegration and even death from causes remotely distant. Just as the members of any human family can be prostrated and disorganized by un- welcome news from an absent member of the household, when, perchance, the occasion for the disturbance was wholly out of 90 ORIFICIAL SURGERY. proportion to the disastrous consequences. In the practice of orificial surgery so many licentious individuals have been made virtuous, so many irritable natures have been rendered amiable, so many disordered imaginations have been correct- ed, so many aberrations of mind and heart have been rectified that to ignore the presence of the spiritual man in an ex- haustive series of articles upon the orificial philosophy would be an unpardonable omission. Soul and body are so closely knit together, so inseparably intertwined that it is impossible to fairly consider the earthly habitation of a man without taking into consideration the man himself. Kemember that we are doctoring the living and not the dead, and any force which affects the capillary circulation of the body has an in- fluence upon all the elements of the composite man and must be taken into consideration in our efforts at repair. Material influences are proper objects of our study, but not less than these are those wonderful pulsations of thought and feeling that blush faces and pale them, that start sweat glands and dry them, that accelerate the heart's action and slow it, that affect excretions and secretions, and that by their constant play either induce pathology or tend to re-establish physi- ology. The living, composite, physiological man, therefore, is our first study and our last one. It requires a thorough acquaint- ance with it in all its characteristics in order to furnish us a standard of excellence in our struggles with pathology. In its physiological condition it is continually suffering molecular disentegration in every part by the incessant death of its cel- lular elements. It is also experiencing in an equal degree a perpetual succession of molecular births for the daily renewal of its forms and functions. This succession of changes in structure necessitates a constant supply of new material, whose object is the birth of new cells and perpetual funeral trains for the burial of the dead. Food, drink and air supply our hopes for the future. The alvine canal, urinary tracts, the sweat glands and our expirations relieve us of what has been. These bodily activities are all accomplished by the blood stream, which contains in solution the food for the complete ORIFICIAL SUEGEEY. 91 composite man, and which brings away in its return current its debris. The health of the body, therefore, depends solely on the perfection of its system of supplies and removals. In other words, capillary circulation. A normal circulation means a proper digestion, assimilation and appropriation of food and a complete, thorough and continuous renovation of the body; and therefore the beginning of all pathology is an obstructed or insufficient capillary circulation. To possess a universally good capillary circulation is then, to be in a physiological condition. To present enfeebled or deficient capillary circulation is to institute pathology. The capillaries are, consequently, the battle ground between health and dis- ease, between life and death, and all remedial measures in cases of disease accomplish their purpose by restoring a normal capillary activity. The history of medicine is a record of bat- tles. In its early stages will be found three great remedial agents which were almost the sole reliance upon which our ancestral doctors depended for establishing capillary circu- lation and securing a restoration to health, whether the disease to be overcome was a local or a general one. These measures were attacks upon the alimentary canal by means of emetics or purgatives, blisters and other forms of counter irritants and the lancet. Every additional measure which has been sug- gested to the fraternity for the relief of human suffering, since that early morning of medicine, has met with such violent op- position and criticism that its final adoption by the profession has been compulsory, its battle being won by a series of con- quests against prejudice, bigotry, intolerance, and all the other bad elements that go to make up the professional weapons of defensive warfare. Every new idea in medicine, like other births, has "leaped with a wail into being," and its initiation into full recognition in the profession as a legitimate means of cure has been a severe one. If the proposition which has just been laid down be once universally understood and recognized, medical evolution will speedily become an easier process and the ailments of the hu- man race will be alleviated with corresponding increase in ra- pidity. Truth is mighty and will prevail, even though learned 92 ORIFICIAL SURGERY. doctors foolishly essay to oppose its progress. Successful con- quests have been waged against professional conservatism un til there is now quite a number of measures which have won their way to good standing in the profession as a legitimate means of healing the sick. Massage, baths, electricity, plasters, ointments, heat and cold, dieting, artificial and natural wa- ters, change in relations and surroundings, mental thera- peutics and numerous other valuable adjuvants now bear the stamp of professional sanction, although the introduction of each measure has been a campaign in itself. The introduction of the orificial philosophy to the consideration of the medical profession furnishes another illustration of the truth of this statement. It was treated by the profession as an unwelcome child; it was assailed in its cradle, scoffed at in its childhood and ridiculed in its youth; but its manhood has come and it is all the stronger for the conquests it has been compelled to make against contending forces; and has now attained such widespread recognition and appreciation that it feels at home in the list of accepted remedial measures for the relief of hu- man suffering. The presentation of its basic principles and their method of application becomes a matter of extreme pleasure and con- solation. As all the influences which play upon the circula- tion and consequently have to do with the health and repair of all the elements of the composite man reach their destina^ tion in the capillary system, whether they issue from mind or matter, by means of nerves, our next article will be a consid- eration of the two nervous systems, in their mutual relations and separate functions. CHAPTER X. THE MUTUAL RELATIONS AND SEPARATE FUNCTIONS OF THE TWO NERVOUS SYSTEMS. E. H. PRATT, M. D. Agreeable to our promise we shall discuss in the present number the telegraph and telephone wires of the human body. The agencies by which mind speaks to matter and matter re- OEIFICIAL SURGERY. 93 plies to mind. The wonderful entanglement of life- wires whose communications thrill the whole being with delight, or plunge it into the depths of misery. All the happiness of the com- posite man and all its pains, all its health and all its sickness, all its harmony and all its discord, are merely messages which traverse the life- wires, one extremity of which reaches upward to the inexhaustible sources of being, and the other extremity of which is grounded in every part and particle of the ma- terial organism. As these remarkable structures are the means by which all influences from within and from without are enabled to play upon the various tissues of the body, a general consideration of their structure and functions will furnish an interesting and profitable review of many subjects we are too prone to forget. The universal principle of duality which appears to exist in all created things finds an illustration in the construction of the human nervous system. The two general parts of which it consists have been named by anatomists the cerebro-spinal and sympathetic, respectively, and while each of these parts has separate functions, they whisper together in every morning of their intention, and also in every evening of their accom- plishment. The study of their construction and mutual rela- tions is not only necessary to a proper understanding of all bodily functions and activities, but is also of thrilling interest to every student of life. Let us for a moment give our attention to the cerebro- spinal part of our nervous system. Its gray matter consists of a mass of cell elements so numerous and closely huddled together as to form by their association a considerable portion of the structures known as the brain and spinal cord. The gray matter of the brain surrounds it and lines it it is its bark and its heart. Scattered over the surface of its convolutions and sulci in several layers of varying thickness, its appearance has induced some imaginative anatomist to give it the name of cineraceous or ashlike substance. In the interior of the brain, its cells are crowded together in ashy heaps called ganglia, whose names are mostly fanciful and unimportant in the present connection. . 94 ORIFICIAL SURGERY. In the spinal cord the gray matter assumes the form of two lateral crescents, connected by a short commissure which extends along the center of the cord for its entire length. The white matter of the eerebro-spinal system is simply a mass of telegraph wires connecting different parts of the brain matter, and also uniting the gray matter with every part of the human body over which it pre- sides. The gray matter is therefore the headquarters, the central office, of the cerebro-spinal organization, and the white matter consists of a mass of telegraph wires which carry its messages. If the cerebro-spinal structure be likened to a tree, its gray substance will correspond to the roots of the tree, dripping down deep into the sources of being from which all life draws its inspiration; and its white substance, which trans- mits the vital forces to the ultimate tisues of the body, will correspond to the trunk and branches of the tree, which carry sustenance to its leaves and fruit. But the cerebro- spinal arrangement is not equal to all the requirements of the body. It wakes in the morning, lays its plans for the campaign of the day; walks the body; sits the body; laughs the body; cries the body; sweats the body; dries the body; manipulates the body to its purposes as long as it will endure its sovereignty and obey its commands ; but when endurance ceases to be a virtue, and bodily languor and fa- tigue demand a respite from the labors of the day, the cerebro- spinal ruler throws its wearied slave upon its nightly couch CEREBRO-SPINAL SYSTEM. OEIFICIAL SURGERY. 95 and suspends its activity until the recuperative processes of nature which it disdains to superintend have repaired the bod- ily damage it has wrought, and furnishes it a re-invigorated instrument of service for another day's employment. The ce- rebro-spinal part of the nervous system is scarcely to be re- lied upon for purposes of nutrition and repair. Its influence may at times be invigorating, but this is merely incidental to its steady and deliberate intention. In hours of sleep under the influence of anaesthetics and narcotics, in the hot pursuit of the day's purposes, the bodily wants of renewal and burial essential to its continued exist- ence would be sadly neglected were they not more faithfully sustained by another and more reliable supply of nerve in- fluences. The so-called sympathetic part of the nervous system seems to be a complete organization in itself, although it is possibly merely a storage battery of nerve force, arranged for the steady and uninterrupted supply of nerve power for pur- poses of nutrition. The appearances are that it has an indi- viduality of its own has its own purposes in life, its own brains and means of accomplishment of those purposes. Its brains consist of two chains of ganglia lying parallel in front of the spinal column and extending from the base of the crani- um to the coccyx. There are four ganglia on each side at the base of the skull, associated with different branches of the fifth nerve. There are three in the cervical region and for the rest of the way down there is but one ganglia on each side for a vertebra. In front of the coccyx the last ganglia of each chain have joined hands to make one good-sized ganglion, called the ganglion impar. These ganglia are connected with each other by nerve trunks and also communicate with the cerebro-spinal nerves as they issue from the intervertebral and sacrum foramina, while yet other nerve cords wander out into the* body, forming complicated plexuses about the heart, and a little lower down, just back of the stomach, congregating to form the great solar plexus, whose rays, following the arterial trunks, extend to the remotest corners of the body, illuminat- ing their dark recesses with glad tidings of food and drink for their daily sustenance. 96 ORIFICIAL SURGERY. The adjoining cut presents a side view and consequently one-half of the great sympathetic nerve. Like the cerebro- spinal system it has effer- ent and afferent nerves, the former of which bring to the headquarters or ganglia the oft-repeated story of the various wants of the bodily organs; and the later of which are distributed to the peculiar muscular structures whose office it is to supply those wants. "We have two kinds of muscular structure, one for the outside of the body and the other for its inter- ior framework. The outer muscles pad the face, neck, trunk and extremities. The fibrillse have a striated ^ap- pearance under the micro- scope and their action is dominated by the cerebro- spinal system and conse- quently is under the con- trol of the human will. Through their agency we can stand, sit or re- cline; we can smile or frown; we can run or walk: we- can transport ourselves from one point to another; avoid dangers or hasten to meet tlim. In other words, can urge the body along the path- SYMPATHETIC SYSTEM. WRy Q jjf e through its cycles of years. OEIFICIAL SURGERY. 97 The interior muscles form one of the coatings of all the tubular structures by means of which the processes of life are carried on. The intestinal tract, the bronchial tubes, the blood vessels, the lymphatics, all the glandular structures, with the exception of the spleen and thyroid and the sexual and urinary tracts, are supplied with a muscular coating by whose action peristalsis is secured and bodily activities progress. By these tubes we live. Supplies are brought, waste materials are carted away, secretions and excretions, air and blood all reach their destination and are propelled on their way by these minute muscular structures. The muscular coats of these tubes are arranged in layers so that the fibers run in two directions, longitudinally and cir- cularly. The longitudinal fibers, when they contract, shorten the tube which they cover, while the circular ones, when they contract, constrict it so that by the combined action of these two sets of muscles, vermicular motion is secured and solid, liquid and gaseous substances are kept in motion. Under the microscope, the fibers of these interior muscles are found to be non-striated and are called involuntary muscles because they are not under the control of the will. They are supplied solely by the sympathetic nerve. When the afferent nerves report to the ganglia the needs of the various tissues, a response comes steadily through the efferent or motor nerves and the wheels of life are set in mo- tion to feed the hungry, furnish drink to the thirsty, and re- move the crumbs after the feast is over. It is wonderful ma- chinery. So harmonious does its clockwork operate that the slightest disorder of one part affects in sympathy every other part of the organization. It is not equally active at all times, but it is our veritable clock of time. It is wound up for one hundred years or more. Our poor knowledge of how to care for it and the recklessness of our selfishness have lowered the average of its running to thirty odd years; but whether the time be long or short, the perpetual motion of these parts of the machinery of our life, these tubular structures with their peristaltic actions, stimu- lated to operation under the inspiration of the sympathetic 98 OBIPICIAL SURGERY. nerve, are the means by which we run our brief career. They hold the various parts of the body in such close communication that all the organs enjoy together and likewise suffer together. I wonder if the inspired brain that named the nervous system which presides over peristaltic actions appreciated the beauty of his naming when he called it the "sympathetic" nerve, from "syn," together, and "pathos," suffering; crys- tallizing in anatomical naming the fact that when one organ is sick all others are conscious of the fact and feel more or less completely the depressing influence of the trouble. In re- capitulation, then, the cerebro-spinal system furnishes us with all conscious sensations, our special senses and the common one of touch and places our physical organizations at our com- mand for the purposes of life as they prompt us to action. The sympathetic nerve furnishes the sensations of hunger and thirst and orders funeral trains for the removal of debris, and prepares our food and drink, digests them, circulates them and provides in every way for our bodily necessities. One point should be a little farther emphasized. The' two parts of the nervous system, the cerebro-spinal and the sym- pathetic, are closely associated at their roots and distal ex- tremeties. The first branches from the sympathetic ganglia, wherever located, can be traced wending their way to some cerebro-spinal nerve trunk with which they blend. So that every ganglion of the sympathetic nerve is associated with some part of the cerebro-spinal system. In this way the de- fenseless sympathetic is supplied with a Court of Appeals. If its machinery is hopelessly entangled or if it is harmonious ; if it is taxed for nervous power beyond its ability to supply or if it bounds with the spontaneity of health, whatever the condi- tion of its work or play, any time it desires to do so it can whisper its confidences to the lordly cerebro-spinal system and receive its sympathy and co-operation or be hushed into sub- mission and a still farther endurance as that structure may elect. It constitutes itself a sort of bodily conscience which like any other conscience is a sure guide to prosperity and happi- ness if its admonitions are only heeded. In orderly beings. OBIFICIAL SURGERY. 99 where the cerebro-spinal system respects the messages from the sympathetic and shapes its course of conduct accordingly, the system is never overtaxed, is always repaired when out of order, rests when tired, is active when rested and demon- strates its possibilities as a creature of divine origin. But when the cerebro-spinal system is arrogant, self-willed and incon- siderate, like a man smothering his conscience for the sake of his appetites, and refuses to listen to the pleadings and re- quests of the sympathetic system, its lawless and bulldozing conduct sooner or later brings disorder and confusion upon the machinery of life. The body is unduly prodded to action in the pursuits of gain or pleasure, is not permitted proper remedies for its illness or proper time for its repairs, and con- sequently, slowly by degrees, or more suddenly in some unex- pected disaster, succumbs to the unnecessary friction of ex- travagant and unfair demands of service. If the sympathetic organization, thus unduly taxed, turns like a worm and causes the cerebro-spinal to suffer disaster, strikes it blind or deaf or dumb, makes it writhe in pain or stiffen in sclerosis, it is sim- ply following the universal laws of action and reaction and is but to be expected. While nutrition is therefore provided for by the sympa- thetic system, it can either be helped or interfered with ac- cording to the behavior of the cerebro-spinal. This possibility is achieved by the mingling of the roots of the two nervous or- ganizations. But their leaves also touch. Once more out in the duties of their separate lives, they mingle in common ac- tion. The cerebro-spinal system furnishes the special sensa- tions, and the skin with the common sensation of touch. It furnishes all the voluntary muscles of the body with motor in- fluence. The sympathetic nerves are distributed to all the mu- cous membranes of the body, furnishing them with their sen- sations, recognized by the sympathetic nerve itself, but not ap- pealing to the cerebro-spinal system. The motor nerves of the sympathetic go to the involun- tary muscular fibers and these preside over peristaltic actions. But beside these separate functions, the two nervous systems intertwine their terminal branches in plexuses of nerves which 100 OBIFICIAL SURGERY. wrap around the arterial and venous trees as vines cling to an oak, following the great trees of life from their roots at the body or starve them by constriction. An equal privilege by this arrangement is furnished to the cerebro-spinal system. It can dilate arteries and contract them, can hasten or retard their pulsations, can flush the capillaries in every part of the heart to their terminal branches in the capillaries, so that the vermicular motion in the arteries and veins is provided for by the entire force of the nervous system. The plexuses thus formed are called the vaso-motor nerves. Sympathetic force can start the heart's action or stop it; can blush the face or pale it; can sweat the body or dry it; every thought and emo- tion which it entertains clutches the coats of the arteries in some form of self-love or widens them at the command of gen- erous impulses as it may elect. It can warm the extremities with the pulsations of love or freeze them with the constrained action of hate ; it can gladden them with throbs of good-will to fellow-man or depress them with communications of jealousy and greed. On the banks of this arterial stream of life are found the boundary lines be- tween mind and matter, and the animal and the spiritual, im- personated in the sympathetic and cerebro-spinal nerves, hold- ing councils of peace or war and fluctuating the quotations of the commerce of the body according to the decrees of their councils. The decisions of the vaso-motor system prescribe the blood supply perpetually. It is well for us that the cerebro- spinal system retires at night from these councils and leaves the management of the vaso-motor nerves entirely to the sym- pathetic, because its tendencies are too wayward, too reckless, too unreasonable, too selfish to exercise an unremitting influ- ence upon the distribution of the blood. So much for the separate and combined spheres of action of the two parts of the great nervous system which keeps the machinery of our life in motion. The next article in the present series will present some points as to the manner of nerve distribution, call attention to some of the characteristics of the sympathetic nerve and ex- plain why, in using the term "orificial surgery," we limit its meaning to the lower openings of the body. ORIFICIAL SURGERY. 101 CHAPTER XI. SOME POINTS IN THE MANNER OF NERVE DISTRIBU- TION, SOME CHARACTERISTICS OF THE SYM- PATHETIC NERVE AND THE MEANING OF THE TERM ORIFICIAL. E. H. PRATT, M. D. Hilton's work on "Rest and Pain" is one of the most practical as well as scientific productions in medical literature. If it were more generally studied and appreciated, and the suggestive thoughts with which it abounds were carried still further, practical anatomists would be more numerous, suc- cessful surgeons greatly multiplied and the human race cor- respondingly benefited. A few of the thoughts in the present article are thoroughly elaborated in this work, and the physi- cian who aspires to a thorough knowledge of the human body, to an accurate interpretation of its aches and pains and to a rational application of remedial measures, will do well to be- come familiar with every page of the work. To properly understand the orificial philosophy and its application one must have a basis in anatomical and physio- logical facts; and the failures in orificial work will come mostly from the ignorant and unscientific practitioners of the philosophy. In the narrow limits of a magazine article it is impossible to present with any degree of thoroughness even the foundation principles of the philosophy, for this involves whole treatises upon the structure and functions of the house we live in. More or less of a thorough medical education on the part of the readers is presumed and their attention attracted merely to new associations and interpretations of facts already well known, although oftentimes forgotten. If, by the present se- ries, an appreciation for Hilton's valuable volume, Ranney's "Applied Anatomy of the Nervous System," Mitchell's "In- 102 OEIFICIAL SURGERY. juries of Nerves" and the whole list of works upon anatomy and its application in disease, is stimulated to increased ac- tivity, at least one worthy purpose will be served. The fact of it is, that it is not surgeons but nature that cures people. Nature, in fact, often performs surgical operations upon her- self wholly unaided in her work. Many a time she amputates the hemorrhoidal inch as neatly and nicely as could be accom- plished by the American Operation. If a foreign body in any part irritates her, she ostracizes it from her tissues by a zone of inflammatory productions which imprisons it out of harm's way, or else she gradually opens her tissues by disintegration until she completely extrudes it from her temple. In this way she exfoliates necrosed bone, draws the line of demarkation in gangrene, expels biliary and urinary calculi, removes slivers from her fingers and repels hostile attacks of all kinds with more or less success. In fact, a surgeon is but nature's handmaid, whose hand and head are employed to aid nature in her efforts at recovery when otherwise she would cease her struggles with opposing forces and succumb to dis- ease. Consequently every part of nature's domain is intelli- gently organized for offensive or defensive warfare with time 's destructive forces. The limbs could not walk were not the various muscles, membranes, bones, joints, skin and other structures intelli- gently associated so as to work in harmonious action. The hands could not successfully accomplish their mission in life were they not constructed upon the same intelligent plan. The voice could not speak, the eyes could not see, the ears could not hear, the whole being in general and in particular could not adapt itself with any success to the uses and possibilities of its life work, without an intricate and complete under- standing existing between all its parts. This is accomplished by means of the nervous system men- tioned in the last number. There is a common principle of nerve distribution to which attention is now invited. It is a principle by which organs associated for a common purpose are supplied by pencils of nerves emanating from a common nerve center so that they may be intelligently associated in ORIFICIAL SURGERY. 103 their action. In the cerebro-spinal system, for instance, where a nerve is distributed to a joint surface, another branch of the same nerve passes to the muscles which move the joint, while still another branch of the same nerve is distributed to the skin surfaces covering both the muscles and the joint. Take, for example, the anterior curval nerve. It is one of the nerves of locomotion and sensation of the lower extremi- ties. The muscles which it supplies are the quadriceps ex- tensor, the psoas magnus, the iliacus, the adductors of the thigh, etc., and as these muscles in their action move the hip and knee joints, you will find branches of the anterior curval nerve supplying both of these joints and you will also find the skin surfaces covering the whole anterior and inner surface of the thigh and on the inner side of the leg as far as the ankle, furnished with sensation by another branch of the same nerve. An inflammation of the hip joint would therefore produce a spasmodic action of the psoas and iliacus muscles, flexing the thigh upon the abdomen and producing a hyperaesthesia of the skin in the region of the groin, thus protecting the part from injury, furnishing nature with an intuitive withdrawal from harm's way. In irritations of the knee joint, the quadriceps extensor by its nerve connection is made sufficiently tense to interfere materially with motions of the joints, struggling to the best of its ability to secure for the joint physiological rest, while a hyperaesthesia of the whole anterior surface of the thigh and the inner part of the leg as far as the ankle, warns all intruders that the parts which it covers are ill and must not be disturbed. Illustrations of this same principle occur in all parts of the body. In the face, for instance, the fifth nerve sends a nerve filament to the glenoid cavity, supplies with motor in- fluence the muscles of mastication and with sensory influence the entire skin and mucous surfaces covering and lining the face and jaws. An accurate knowledge of the distribution of the filaments of these nerves is often indispensable to a cor- rect diagnosis of pathological conditions about the head or face. Is the pain in the upper or back part of the ear? The teeth and other organs of mastication have nothing to do with 104 OBIFICIAL SURGERY. it. Is it in the lower and front part of the ear? It may be caused by a decayed tooth. Is an apparently sound tooth in trouble? It may be induced by an inflammatory process in the lower part of the ear. Is trismus present? It may be caused by the effort of a growing tooth to pierce its envelop- ing membranes. The birth of wisdom teeth is very often ac- companied by lock-jaw, thus illustrating the nervous connec- tion between the joint, the muscles which move it and the skin or mucous surface covering it, made possible by the law of nerve distribution which we are illustrating. These illustrations of the intelligent nerve distribution in the cerebro-spinal system by which the various organs of a part are enabled to act in harmony, are but illustrations of a plan which is equally true of the sympathetic. The male sexual organs, for instance, are supplied, not by a single nerve trunk, but by a pencil of nerves coming from a common ganglionic center and passing on to their distribution in the various parts of the apparatus they are to dominate. While some of the fila- ments supply the foreskin, others of the same brotherhood of fibres are distributed to the corpora cavernosa, others to the corpus spongiosum, others to the muscles of the urethra, oth- ers to the prostate gland, and yet others to the testes and scrotum; thus enabling the sexual apparatus to erect or sub- side, to perform the functions of sexuality or the mere utility of urination with precision and intelligent purpose. It is just as essential, however, to a proper interpretation of sexual pathology to appreciate the mutual influence which one set of terminal nerve fibres exercises upon another in these parts, as it is to be familiar with the nerve distribution of the face in order to correctly interpret its aches and pains. The same statement will apply to the female sexual sys- tem. The breasts, the clitoris, the meatus urinarius, the vulva, the vagina, the uterus, the Fallopian tubes and ovaries are sup- plied by a sisterhood of nerve cords that hold these separate parts in such close bonds of sympathetic connection that one part can not suffer or act without disturbing the whole pencil of nerves; and the terminal nerve fibre complaining the most is not a true index to the starting point of irritation. Tumors ORIFICIAL SUEGERY. 105 of the breast, for instance, are repeatedly removed by sur- geons when the cause (which is usually in the cervix or en- dometrium) is left wholly untouched. Many a poor mother suffers untold agonies at the nursing of her babe from her cracked nipples which refuse to heal under any form of local treatment, while the cleansing of the uterine cavity, which is the source of irritation, perchance would restore the nipples to their normal condition in a few days' time without visiting upon the nipples any treatment whatsoever. In the same way abnormalities of the uterine cervix can express themselves in urethral irritations and so on through- out the long list of reflex irritations so little appreciated, so poorly understood and to which it is the pleasant duty of this Journal to repeatedly call attention until a better philosophy and a more successful practice of the healing art be universally inaugurated. The pencil of nerves which supplies the sexual system of either sex and the one which supplies the rectum are so closely associated that it is impossible to cure rectal troubles when unconnected sexual disorders prevail and vice versa. Gynaecologists must respect and take into consideration rectal conditions. The time has gone by when they will be permitted to confine their attention without censure to the sexual organs alone. A large percentage of these troubles are merely reflex from rectal conditions, and to doctor them per- petually, persistently and unsuccessfully without even examin- ing the rectum or hunting elsewhere for possible causes of the obstinancy of the case, is not only unskillful and unscientific, but deserves such stronger condemnation as is implied in the words dishonest, dishonorable and in every way censurable. Rectal specialists are open to a similar charge. To per- petually prod a poor rectum when its congestion and irrita- bility is but voicing sexual disorder, is an equally grave mis- take. Has not the time come when what we know of the in- terlacings and intercommunications of the nervous systems, separately and collectively, must play a more prominent part in our diagnosis and treatment of disease? Have we not ar- rived at a stage in our professional development where we can 106 ORIFICIAL SURGERY. be more positive that we are working at causes and not sim- ply struggling with the effects of disordered functions? There is one characteristic of the sympathetic nervous system which deserves especial consideration in the present ar- ticle, and that is its stupidity. It supplies the muscular coats of the various tubes of the body and in order to stimulate them to the peristaltic actions for which they are intended, it is necessary that the sympathetic nerve should be aroused to activity when a tube of the body is distended by a substance forced into it. It seems perfectly reasonable that a bolus of food should be swallowed and carried along the entire twenty- six feet of intestines by peristaltic action under the stimulus of the sympathetic nerve. It seems equally reasonable that when the heart throb expands the great aorta by a large wave of arterial blood, its contracting coats should carry the im- pulse as far as the ocean of the capillaries. When saliva or pancreatic juice, or bile or urine distends the canal along which it is to pass, it seems a very satisfactory and intelligent provision of nature by which the sympathetic nerve stimulates the muscular structures involved to propel the liquids on their way. But how stupid it seems for this delicate nervous system not to discriminate between the distention caused by a sub- stance which it can dispose of and one produced by a swollen state of a membrane lining one of these tubes which it sup- plies. The purging of dysentery, the frequent micturition in urethritis, the perpetual swallowing in oesophagitis, the in- cessant coughing in laryngitis are but examples of either in- nate stupidity or an extreme lack of education on the part of the sympathetic nerve, evidently mistaking the swollen mem- brane for a substance which it can propel along the tube in question. Owing to this unfortunate characteristic of the sym- pathetic nerve an irritable spot in any tube of the body can induce a strictured and shortened condition of the tube caused by prolonged contraction of the circular and longi- tudinal fibres of the muscular coat guarding the point. Were wounds, ulcerations or undue frictions liable to oc- cur indiscriminately in any part of the various tubular struc- ORIFICIAL SURGERY. 107 tures of the body, annoying strictures and a dangerous clog- ging of the machinery of our organism would be of more fre- quent occurrence than it really is. But, fortunately there is a principle of physics that lim- its our danger from this source of disaster to a few and for- tunately accessible portions of our anatomy. The principle is that the irritation of an organ starts at its mouth. It is at the doorways of exit, at the outlets of reservoirs of all kinds, at the portals of departure where the wear and tear of passing streams write the story of the crowding at their egress. The exits of the human body are, therefore, the places where the tubular linings are most subject to attrition and consequently present the hypertrophy or atrophy, the hyperaesthesia or the anaesthesia, the extremes of pathology in either direction, oc- casioned by excessive and unremitting friction. These, then, are the places to search not only for pathology of the areolar tissue, of the blood vessels, of the glandular structures and of the terminal nerve fibres and of mucous membranes ; but also for undue spasmodic action of involuntary muscular fibres, thereby disclosing an extravagant waste of sympathetic nerve force, for it costs nerve force to hold muscles in a state of un- due contraction perpetually. Standing for an hour fatigues one more than walking for half a day ; holding an arm in a horizontal position for fif- teen minutes tires one more than any alternating form of arm exercise followed for many hours; gazing at a fixed point for any length of time is painful and well night impossible for eyes that are capable of intermitten employment so long as day lasts. But these are illustrations of cerebro-spinal fatigue. The same is true, however, of the muscular structures supplied by the sympathetic nerve. When an anus is sufficiently at re- pose to alternately relax and contract with the rhythm of the breath, to safely guard against the escape of alvine contents during extreme bodily exertion as in the act of sneezing and coughing, but at all other times to relax to a proper degree its undue tension ; when a uterus fluctuates the tension of its gate- way to the accommodation of a menstrual flow or other func- tions of its existence, when a sphincter vesicae and constrictor 108 OBIFICIAL SUEGEKY. urethrae can exercise just enough tension to accomplish their purposes without a prodigal expenditure of nerve force, when the terminal nerve fibres that entangle themselves about the lower openings of the body have no demands to make upon the general reservoir of the nervous system except for the normal performance of their duties, the human body is well poised, its peristaltic actions are all normal, its reactive powers superb, the happy individual, who is its possessor, is a perfect speci- .men of human kind and, if these conditions continue, will run to the natural terminus of a well rounded life. He will live until his life's time-piece runs down by the natural law of limitations, unless he is removed by accident. He is wound up for one hundred or more years and is an example of perfect physique, seldom witnessed in our degenerate times. But when pathological states of the friction-exposed linings of the lower openings of the body induce an undue contraction of the muscular fibres surrounding them, the expenditure of sympa- thetic nerve force is extreme, for it is unremitting and per- petual and the nervous drain thus occasioned soon manifests itself in poorly performed functions of the rest of the body. These lower openings are openings not merely for the or- gans of which they are the exit, but are openings for the en- tire body. The waste from every part of the human body that is extracted by the kidneys from the eyes, ears, nose, throat, lungs, etc., finds its exit through the one urethra. The solid debris of the arms, limbs, trunk, head and every part of the human anatomy that takes the form of foecal matter is lodged in the colon and finds its exit at the anus. The sexual force that gives quality to every organ of the body is spent or conserved at the gateways where sexual com- merce is carried on. These lower openings of the body, there- fore, are not merely openings for the individual organs which terminate in them, but are universal gateways in which every organ in the body is most thoroughly interested. For this rea- son their influence is as wide-spread as the body itself and their condition but an index of the whole being. No wonder then that a morbid state of the mucous membranes lining the lower openings of the body, with its accompanying tension of OEIFICIAL SURGERY. 109 sphincter muscles, implies a weakened peristaltic action in all the tubes of the body, a more or less impairment of all the functions of the body, a lowering of its vitality and implied inability to repel invading forces be they microbes or tempta- tions. Under an anaesthetic the inlets of the body can be dilated or manipulated at will, the various cavities can be opened for curious gaze, the limbs can be amputated and joints resected without disturbing the rhythmic flow of life in the sleeping subject, if the operative procedures stop short of destruction. But at the lower openings of the body and only here can dilata- tion and various forms of operative procedure suspend or arouse the breath, empty or flush the capillaries, in short hold as in a balance the vital spark itself. The majority of deaths from anaesthetics occur in opera- tions upon the rectum because surgeons pinch these tissues, suspend respiration and do not know enough to stop the pinch- ing and permit the patient to live. Nearly all of the deaths from anaesthetics occur because doctors do not know the re- suscitating power of the rectal speculum skillfully handled. Similar effects can be produced by dilatation and manipula- tion of the sexual orifices although not so certainly. In hand- ling these lower openings of the body, therefore, the surgeon is not merely doing local work, but is tampering with the capillaries of the entire system. These openings are the mouths of the entire body and whereas the principles of the orificial philosophy are applicable on a smaller scale to any organ in the entire body, these openings are essentially universal in their sphere of influence and are consequently the only ones referred to when mention is made in general terms of the orificial phil- osophy and of orificial surgery. 110 ORIFICIA.L SURGERY. CHAPTER XII. THE PHILOSOPHY OF ''NUTRITION" AND THE RELA- TION OF ITS DISTURBANCES TO AFFECTIONS OF THE NERVOUS SYSTEM, AND THE VALUE OF ORIFICIAL TREATMENT THEREIN. W. E. BESSEY, M. D. There are certain expressions to be found scattered through the medical literature of the past, which by reason of the crystallized terseness of statement of great truths con- cerning the function of nutrition may be accepted as axioms. A citation of a few of these will enable us to outline the accepted thought of the profession and the biological science on this subject at the present period. The first one of these expressions I wish to quote is: "Nutrition is the physical basis of life." What a seed thought this furnishes us, and what a world of meaning it conveys. If this be so, then the condition of the nutrition in any organism must be the true standard of its physical health, and the disturbance of this function such as are expressed in the words ' ' mal-nutrition " and "mal-as- similation, " must of necessity be regarded as potent factors in the long line of physical ailments. This inference has found expression in the annals of medi- cal lore ir the following form : ' ' The state of nutrition in any organism, whether it be plant, animal or man, determines the physical condition of that organism." This at once places the function of nutrition first in the order of importance, and it should be so regarded, and studied by all who are responsible for the health, happiness and physi- cal condition of the race. If this position were assailed, I might quote the Greek philosopher (Aristotle) who wrote: "Nutrition is the fundamental condition (basis) of all vital action, all living manifestation, all organizations, all growth and development, all activity, all successful human action in a word, all life be it vegetable, animal or human." OBIFICIAL SURGERY. Ill Acting upon this philosophy, the gardener or farmer care- fully prepares the soil, thoughtfully (and with more or less scientific knowledge) manures it, and furnishes it with the best kind of plant food, from vegetable decomposition or min- eral salts, as phosphates, etc., possible to obtain. And likewise the stock breeder resorts to "feeding" to improve the nu- trition, and thus perfect the physical condition of his animals. And so the wild animals instinctively select their food, and this faculty still lingers in the domestic. But man, ever at variance with natural law, violates every principle of common sense in his indulgences in eating, and suffers in exact proportion to the extent of his violation of natural law, where he has not invoked the assistance of his fellow-man belonging to the noble profession of medicine (which man's hygienic sins have called into exist- ence) in which case he becomes the victim of a thousand ill- considered and maladroit efforts to restore normal action by the ingesta of more or less potent drugs which add their own deleterious and injurious effects to his previous derangements and leave him a physical wreck for the disciples of orificial principles, a wiser and more rational philosophy, to deal with. When the normal condition of the digestive, assimilative and circulatory organs is interfered with in any way, defective nutrition is found to be the result, and this defect may be par- tial, affecting certain tissues or organs only; or general, af- fecting the entire organism. As every effect has a cause, so every organ must have a source, of energy, enabling it to perform its functions. Trac- ing this to its source, we find it to be the ganglionic or great sympathetic system of nerves (until recently but little studied or understood) and impaired function to be due to defective enervation, similarly induced. And when the nutritive organs suffer or the trophic nerve influence is disturbed, it results in a condition of impaired or mal-nutrition. Thus we find that anything which interferes with the healthy action or normal condition of the sympethetic (called also the nerve of organic or vegetative life) disturbs at once 112 OBIFICTAL SURGERY. the various functions of the body and nutrition, including di- gestion, assimilation, circulation and excretion, most of any. It may be accepted as an axiom, that while a liberal blood supply is the basis of nutrition, yet without a governing nerve influence there could be no trophic action, no nutrition, no growth. Consequently, the twin elements which cause nu- trition are blood and nerve supply; these being liberal assimi- lation will be rapid and extensive ; but if these be deficient, as- similation will be correspondingly defective, or if disturbed, it will be faulty ; and, moreover, should the blood supply be am- ple and the nerve supply defective or disturbed, then will be observed the various trophic disturbances to which nutrition is subject; namely, atrophy, hypertrophy, dystrophy, etc. The only conclusion then that can be reached is that nerve influ- ence is the most important element in nutrition and all cases of defective, or mal-nutrition, have their cause in defective or perverted nerve force. In this connection it is well to observe also that it is upon this ' ' corner-stone ' ' that our orifi cial philosophy is based. Any interference with this source of automatic, organic, vital energy results at once in disturbances of organic func- tions and impairment of nutrition of the various tissues of which the physical organism is composed. It cannot, there- fore, be denied that mal-nutrition and mal-assimilation play important parts in the phenomena of disease. This subject leads up to the study of perverted nutrition of the body, or its parts, brought about, or apparently brought about, by the agency of the nervous system. These may be termed neurotic dystrophies, and include conditions of over-nutrition, and conditions of under-nutrition (when the variation is in quantity rather than kind). Then there are conditions of misdirected nutrition, or eccentric nu- trition, (where the variation is of kind as well as quantity), and this may be best illustrated by turning the attention to neurotic dystrophies of joints and muscles, which all may study for themselves. The study of joint lesions and their ef- fects upon the nervous system in producing wasting diseases ORIFIC1AL SUEGEEY. 113 is one of the very greatest importance as affecting nutrition, but it is impossible to consider them in this paper. Deranged nerve influence, due to a local irritation, I be- lieve, will account for all the dystrophies which exist, through their disturbing influence over the sympathetic. Irritation of a nerve filament undoubtedly results in ner- vous impairment of the nerve centre to which it belongs. Then again, irritation causes muscular tetanic contractions of the sphincters, muscular walls of the urethra, sexual organs, in- testines or rectum and veins. This produces in turn compres- sion of the nerve filaments, with all its train of evil conse- quences. And as in spinal paralysis, in which the injury to the branches of the nerves issuing from the spinal cord (nerve- communicates) , and uniting with the vertebral ganglia of the sympathetic, affects the circulation, favoring bed-sores on the supposition of a loss of not only direct trophic nerve influence, but also a loss of the regulating action upon the blood ves- sels, affecting the blood pressure in the part. These, and many other arguments might be marshalled to show that although the tissue cells nourish themselves by im- bibation of nutritive pabulum supplied to them through the agency of the capillaries, or blood distributors yet those meta- bolic changes in the tissues can only be carried on under the trophic influence of the nervous system and, the blood supply with its nutritive elements can only be carried to the parts while the rhythm or tone of the capillary vessels is kept in a vigorous condition, through a healthy action of the vaso-motor constrictors or tonic nerve supply to their walls, and that this in turn, can only be secured by securing a relaxed condition of the rectal sphincters, and freedom of the lower openings of the body from every form of local irritation. And therefore in this manner, and in this way only, is the key to nutrition of the human body held in the hands of the operator, when he takes up a Pratt 's speculum or other form of rectal dilator. 114 ORIFICIAL SURGERY. CHAPTER XIII. THE OBIFICIAL PHILOSOPHY AND ITS METHODS. E. H. PRATT, M. D. In the years that have gone by since the promulgation of the orificial philosophy and its presentation to the medical profession for their consideration and employment if found of practical service in healing the sick, there has been no attack worthy of mention made upon it. For a time it was ridiculed by some and ignored by others, but its opponents were in- variably entirely ignorant of what they were opposing and con- sequently were unworthy of attention, as active ignorance in the course of time becomes self-conscious and is shamed first into silence and then repentance for its manifold mistakes. The orificial principles are based upon well-known and universally recognized facts of anatomy and physiology. But anatomy and physiology are merely their basis, and to under- stand the orificial philosophy requires the exercise of the rea- soning faculties, which, as a rule, are so poorly developed in medical men. Doctors are close observers, but very few of them are philosophers. They are frequently well posted, but as a rule they are poor thinkers. Their memories are abund- antly stored with medical facts, but most of them are slaves to tradition and are too timid to think. This leaves them a prey to superstition and prejudice, which will impede their progress until a more liberal general education, involving the development of their logical powers, shall be required as a necessary preparation for the study of medicine. Ours is the age of emancipation and freedom is in the air. Physical slav- ery is ended, but the battle against mental bondage is still on, and until it is ended the orificial philosophy, like every other great truth arrived at only by the exercise of the reasoning faculties, will have to struggle for its rightful recognition. But there is not the slightest question as to the nature of the final verdict. The orificial philosophy is already so firmly es- OEIFIC1AL SURGERY. 115 tablished in the knowledge and active practice of doctors; it is so perfectly invulnerable as a philosophy; it is so valuable, indeed, so indispensable to the cure and prevention of all forms of human suffering; it is such an absolute necessity for the successful practice of medicine that no prejudice can stay its progress ; what few mistakes may be made in its applica- tion cannot spoil its reputation, but simply reflect discredit upon the skill of the incompetent agent ; no greater thought in medicine can become established and relegate it to an insig- nificant position, for it is so broad in its application that no truth can be broader; it is so serviceable that none can be more serviceable ; it is so emancipating in its action that no measure can be made more so; and beyond all question it is destined to sweep the entire civilized world like a cyclone un- til the lustful propensities induced by sexual irritation which are so prodigal of sympathetic nerve force and irritability and fear, which find their incipiency in rectal troubles, shall be swept from the race and universal health, which is the natural condition of mankind, shall become everywhere permanent. The hygiene of all the pelvic organs will in time receive its due meed of attention when the wonderful cures made by orificial methods have aroused the medical profession and the people to a realization of the fact that what can be cured can be prevented. The act of respiration is the central expression of physical life. The vacuum which invites the air to the lungs also acts as a force pump upon the fluids of the body and draws them from their peripheries to their centres. And anything which acts upon the depths of inspiration exercises a profound in- fluence upon the circulation of the blood and other fluids. There is only one region of the human body where respiration can be in the slightest degree affected by manipulation, and that is in the region of the pelvis. You can dilate the mouth to its utmost capacity, distend the nostrils until they are torn, stretch apart the lips until they give way, open the auditory canal to its extreme capacity, trephine the skull, open the thorax, invade the abdomen, amputate the limbs, grasp ar- teries, or nerves, or muscles, or arms with artery forceps and 116 OEIPIC1AL SURGERY. squeeze them to their destruction, and none of these processes will have the slightest effect upon the respiration so long as life remains in the body. Whoever heard of a spasm of the glottis, or diaphragm, or both, produced by any surgical pro- cedure except an orificial one? This power to influence the depth of inspirations and thereby control the circulation of the entire body is peculiar to the floor of the pelvis, and can always be illustrated by dilatation of the lower openings of the body, especially the rectum, except where the sympathetic nerve itself from an undue nerve exhaustion has passed from a normal to an anesthetic state. The orificial philosophy is so true, so effective, so helpful to mankind, that a knowledge of its basic principles and meth- ods of application must of necessity pass on in the course of time to universal recognition by all healers of the sick. It may be in our time and it may be later. The evolution of any great truth is necessarily a slow process, but it is none the less sure, and it matters little to us whether orificial surgery receives its due recognition in our time or after we are passed away. Nothing can prevent its ultimate triumph, and thank God that this is so, for certainly the world is badly in need of it. The superficial, patchwork practice of medicine of the past, and in too many instances of the present, has had its day, and although what good there is in it will still be em- ployed as found serviceable for purposes of temporary relief a deeper healing, born of a broader and more comprehensive conception of the unity of the human body and the mutual interplay of one part upon another, must be universally de- manded. A thought that has such a deep grip upon the fountains of life as to be capable of equalizing the entire cir- culation of the blood cannot fail to affect the activity of every individual particle of the entire body, relieving congestion and correcting anemias, enriching supply currents and clear- ing away debris, melting pathology back into anatomy, and re-establishing normal activities universally. Such a thought is the orificial philosophy, and the rapid progress it has already made toward universal accomplish- ment. ORIFIG1AL SURGERY. 117 As to orificial methods, so far there has been but little change in them except as the several operations have under- gone improvement from time to time. The method of circum- cision, or repairing the cervix and perineum, of removing the female sexual organs, of performing the American and slit operations, have all been more or less improved within the last few years until all the objectionable features of each opera- tion have now well nighf disappeared. But no single method that has ever become well established for carrying out the orificial thought has as yet been abandoned. The American operation has been poorly done in a great many instances, and in all probability has also been as a general rule over- done. In consequence this particular operation has been con- sidered a vulnerable point of attack by those who are ignorant of and consequently prejudiced against orificial practices gen- erally and are anxious to get some basis for assaulting the thought as a whole. The American operation has been vio- lently attacked, slandered, abused, railed against, and ever- lastingly condemned in the most violent terms by an army of professional mossbacks who thought that if they could only annihilate the American operation they would accomplish the extermination of the entire orificial thought, just as though the value of a thought were dependent upon an imperfect means of carrying it out. The result of this crusade has been to diminish the number of American operations performed, which was to be desired, for this operation should never be employed except as a last resort and when every other method proves to be unavailing. But nevertheless there are cases in which the American operation is not only desirable but indis- pensable to the healing of the sick. Some of them are cases of merely local trouble, and some of them are sufferers from malnutrition in distant parts of the body. To all such the American operation has been, is, and always will be a Godsend, and there are already an enormous army of enthusiastic pa- tients whose lives have been prolonged, and whose physical miseries have been ended by a skillfully performed American 118 ORIFIC1AL SURGERY. operation. As a result of this severe criticism which it has sustained, although it will never be abandoned it will be more judiciously employed in the future than it has been in the past, and its critics have done a kindly service to orificialists themselves as well as to humanity. The question as to whether pockets and papillae are ana- tomical or pathological formations, and consequently whether they had better be left unmolested or removed has long since been settled, and the ignorant pretenders to a knowledge of this subject who still claim that they are important physiological organs are now merely laughed at and their false assertions fail even to attract attention. No one has ever been injured by the removal of pockets and papillae, and the thousands who have now submitted to this procedure have been so universally and so wonderfully benefited that the practice of searching for them and removing them when present is becoming very general, even with those who do not appreciate the deep mean- ing and wonderful scope of the orificial philosophy as a whole. Pockets and papillae, as we all know, are by no means uni- versally possessed by human beings. Many have from one to a dozen pockets, some have from one to six or eight papillae, while large numbers have none at all. But whenever they are found their removal is always attended by benefit to the pa- tient. The elaborate discussion of this subject, published in the Journal of Orificial Surgery for December, 1892, covers the entire ground, and subsequent observation has neither add- ed to nor detracted from the positions taken in the article. The hysterectomy which the orificialist has presented to the world was also critically scanned and misrepresented and misunderstood by the non-progressive element of the medical profession, but its techniquqe was too perfect, its reasonable- ness too apparent, and its results too satisfactory to afford any substantial basis for criticism, and there is no longer any doubt as to its superiority over all other methods for the ex- tirpation of the female sexual organs where such serious work is demanded, or of its being ultimately received into universal favor by all practicing gynecologists. It is more scientific, more surgical, more effective, less dangerous, and in every ORIFIC1AI, SURGERY. 119 way more satisfactory than any other method of removing the uterus, ovaries and tubes in vogue, and in a very short time it must completely supersede all other methods by those who are ambitious to excel in gynecological surgery and give their patients the benefit of the best the world has to offer for their relief. The importance of securing a proper condition of the fore- skin for the boys is now commonly recognized not only by doctors but by the laity. And in the last two or three years there has occurred a great awakening to the fact that a corre- sponding benefit can be secured to the girl children by proper attention to the hood of the clitoris. Sub-cutaneous and sub-mucous stitching has grown equal- ly in favor and is now quite commonly practiced by orificial- ists generally wherever it is practicable. In another respect there has been considerable of a change inaugurated. There is a stronger tendency than formerly to avoid surgical interference in orificial practice and to rely more upon so-called orificial treatments, deferring operative interference as long as possible. This is a wholesome tendency and should be encouraged. Surgery is destructive and should always be a last resort. It is a mere apology for better work. The conservative course is ever the true one to follow, and operations should be resorted to only after all other means have failed and they are demonstrated to be a positive neces- sity. Too much has been expected on the part of the optimistic and impulsive natures from the operation itself in orificial work, and much of the disappointment and failure in orificial work has been due to this fact. Experience soon teaches an orificialist that the surgical work to be successful must be fol- lowed by systematic after attention until the ideal orifices are attained, namely, those which are dilatable and free from all forms of irritation. The majority of cases had better remain untouched than to be merely operated upon and abandoned to their fate, as the lower openings of the body are frequently left in a worse condition than before by operative procedures unless careful and intelligent subsequent local attention is em- ployed to secure the ideal condition sought for. 120 OEIFIG1AL SURGERY. There are two specialties that should surrender their titles to that of orificial surgery, namely, the rectal and the gynecological. Rectal surgery is incomplete and ineffective in most cases without proper respect being had to the condition of the sex- ual organs. And on the other hand gynecology is equally lame and abortive if the condition of the rectum be ignored. Orificial surgery unites these two specialties into one, and at the same time goes beyond both of them in its one great thought, that it is found to be efficacious not only in correct- ing mere local conditions of the pelvis of which the patient has become conscious, but at the same time is more ambitious in its scope of application, for it enters with a dominating power the general bodily element. It is good not only for pelvic pathology but as a basis of cure for all forms of chronic disease. CHAPTER XIV. SCIENCE OF ORIFICOPATHY; OR, ORIFICIAL METHODS OF CURE. EUG. HUBBELL, M. D. Life is the manifestation of vital force, call it by what- ever term you please, and is pre-eminently manifest in the the cerebro-spinal must rest from its activity. Hence the vital force must be resident in the sympathetic. The sympathetic is distributed to all parts of the body, and is intimately con- nected with the cerebro-spinal (hence the well-known law of reflexes) . It sends numerous branches that end in the orifices, especially the lower. Peripheral nerve-irritations or impressions are trans- mitted to the centers, or through communicating branches to other nerves, trunks, and centers. Hence, any morbid condi- tion of the orifices must irritate the peripheral terminal fibers of the sympathetic. Continued irritation produces nerve-waste. ORIFK/IAL SUEGEBY. 121 Sympathetic nerve-waste induces functional and organic de- rangement, especially imperfect circulation and respiration; hence assimilation, nutrition, absorption, secretion, and ex- cretion become defective. Irritation of the orificial nerves causes contraction of sphincters, which induces local congestions and inflammation, while the extremities are usually cold and anemic. The ap- pearance of the orifice of a tube is an indication of the con- dition of the other end of the same. Example: a coated tongue indicates a catarrhal condition of the stomach, and red, pouting lips of meatus urinarius indicate inflammation of prostate. Having thus set forth these well-known principles, what can orificial methods do toward restoring health again? It has for its object (as one would naturally infer) the removal of the morbid condition of orifices, allaying the irritation, put ting at rest sphincters, thus stopping nerve-waste, thereby increasing general circulation, restoring assimilation, nutrition, absorption, excretion, etc., by permitting the vital force free sway through its thoroughfares, the nerves. The dilatation of the sphincters, especially of the rectum, exerts a powerful stimulant to the vital force in inducing greater activity in the circulation and flushing the capillaries. Good circulation means good nutrition. Where atrophy of the orifices exists the slumbering nerve-filaments are aroused to activity by proper use of orificial methods. Drugs act through the nerves upon the vital force, stimulating or depressing it, as the case may be ; so with heat and cold, electricity, massage, osteopathy, mental suggestion, etc., all sensitize or disensitize the nerves, thus influencing the vital force. When used to resuscitate the drowning, asphyxiated, or narcotized patient, orificial methods are marvelous. brificopathy is the most potential method we possess of awakening the dormant forces to activity, or quieting turbu- lent manifestations into peace. While orificial surgery will cure thousands, it will maim some, if not carefully used. While it restores many to their right minds, its abuse will send some to the madhouse. While 122 ORTFICIAL SURGERY. it lifts some from the verge of the grave, it also kills. Thus we see how potential a means it is. If some of you say : "If it occasionally kills, we do not want orificopathy," let me refer to the thousands of children and infants that are annually slaughtered by drugs, yet no cry is raised, and we go on in the same way. What we need is more care and painstaking in the use of all methods of cure ; I care not whether it be surgery, medicine, or Christian Science. To sum up, orificopathy may be defined as a method of removing irritation and quieting excitability, or arousing to activity slumbering sympathetic terminal nerve-fibres located in the orifices of the body, overcoming nerve-waste and estab- lishing free action of the vital force and bringing about res- toration of health. CHAPTER XV. ORIFICIAL PHILOSOPHY. C. E. SAWYER, M. D. Philosophy is the science of principles. Principles are the fundamental elements upon which all superstructures rest. The scientific application of orificial principles is therefore the key to whatever in success or failure comes to us as orifioial surgeons. While the practice of orificial surgery is comparatively new, the philosophy upon which it is based is as old as man; and although its principles have been obscured until recently by the mist of inexperience and ignorance, observation teaches that they have ever existed and because of their relation to life itself they are everlasting. From these propositions may be gleaned not only the importance of orificial philosophy, but as well the relation the principles bear to the cure of dis- ease and the security of the foundation upon which orificial surgery is built. ORIFICIAL SURGERY. 123 No matter the vocation in life, the laws which govern are but the evolutions of time, a working over as it were of basic principles, improvement upon former plans rather than the introduction of new ones. Generation after generation de- velops its own searchlights, and as each grows in power the shadows of obscurity become less marked. Things which yes- terday were unrecognized and unknown are clearly perceptible today ; the theories of the past are the realizations of the pres- ent and the progress made evolutionizes all. The river Clyde, in Scotland, has for many generations been the home of ship-builders, and everything from a hollow log hewn out with a stone axe to the present "ocean grey- hound" has found its origin there. In comparison along this line we note the prodigious, almost inconceivable, development which has been made, and yet we are at once struck with the fact that the Campania, with its thirty thousand horse-power, and the Deutschland, with all its magnificence and speed, are but the evolution of experience, the working over of the same principles which were embodied in the tree-trunk. Every epoch in the history of the world has had some one to introduce anew and to reapply the principles of the past. To Dr. Pratt was given the privilege of disclosing to the medi- cal profession orificial philosophy and the means of operation upon these principles successfully. The philosophy he evolved was not an invention, but rather the development of principles so great as to affect life in all its complexities, both in health and disease; an awakening, as it were, of principles and poli- cies which had remained unrecognized until his genius and foresight revealed their power and force to the waiting world. A glance at the development and widespread recognition of orificial philosophy demonstrates the greatness of its basic principles, for without a solid foundation the immense super- structure which has been the outgrowth of persistent effort and painstaking care would not be possible. That we may not forget the grounds upon which orificial surgery is based, I think it well, even at the expense of repetition, to pass in re- view a few of the cardinal principles of orificial philosophy, in order that we may again satisfy ourselves of the stability 124 OEIFICIAL SURGERY. of our position and the certainty of the continuance of orificial surgery. Health and life itself depend upon, first, the quality of the blood and its proper circulation. Second, normal peri- staltic action. Third, regulated sympathetic nerve supply. These are the principles which must be admitted by all to be the fundamental ones underlying whatever in health or disease comes to man. If they are operating properly and in conformity to the requirements of nature, health is their product. If, on the other hand, they are operating out of line, disease is the consequence. With such principles as these to guide in the administra- tion of orificial surgery there is no question as to its efficacy, and with such elements to substantiate there is no doubt as to results. Fortified with these principles well inground we need have no fear of failure, and if our cases are dealt with on these basic principles, success is sure to follow. Experience teaches that orificial methods control these three elements of life perfectly; as to the certainty of this we have had many demonstrations, for year after year at these clinics we have had proof upon proof. And the multiplied ex- perience of each of us individually has grounded us more firm- ly in the power of the means and the effect they have in the readjustment of disturbed body function. The following cases are cited to demonstrate the effect- iveness of orifieial methods applied according to orificial phil- osophy in my own field of work, and they are only a few of many of a like kind which could be given : A year ago a boy sixteen years old presented for con- sultation. A more distressed, cadaverous-looking object I have never met. In height he was that of the average youth of his age. In appearance he was old as a centenarian. His drawn expression and staring look haunt me yet. He weighed 47 pounds. His pulse was beating at the rate of 140 beats per minute. His breathing was rapid and superficial. He had a profuse watery diarrhea, most offensive in character. The flesh on the toes of one foot had sloughed away, while the ORIFIC1AL SUEGERY. 125 other was swollen to twice its normal proportion and was ul- cerated in several places. The skin was dry and scaly. His hair had nearly all fallen out and everything about him bore evidence of malnutrition in a most aggravated form. Physical examination of the blood revealed 2,000,000 red corpuscles to the cubic millimeter, with almost as many white ones. The specific gravity was 1036, the percentage of hemoglobin being 42 per cent., about as poor a condition, it seems, as could pos- sibly exist. His appetite was gone and there seemed to be no means of replenishing his vital store. An adherent foreskin and a tightened sphincter were the only cue to orificial requirements. As anesthesia was out of the question, the means of treatment had to be limited to the simplest form, and consisted of careful retraction of the fore- skin with frequent dilatation of the sphincters ani. With a line of after-treatment consisting of oil rubs and such joint move- ments and massage as could be borne, the tide of affairs slowly began to turn, and with a daily repetition of these means for three months there came out of this woebegone specimen of suffering humanity a youth of average weight and form. It is unnecessary to say that numerous doctors had been em- ployed, that drugs and tonics of every description had been used, that dietetic regimen of various kinds had been em- ployed, and still the chain which held him prisoner had not been loosened until the adherent foreskin and the tightened sphincter had been relaxed. Words are inadequate to express either the transformation of the child, the gratitude of the parents and friends, or my own surprise and satisfaction. Here was a case which had defied all ordinary means. One in which the blood-making processes were so interfered with as to stop all growth and repair. In consequence of which the operation of every organ of the body was more or less dis- arranged, and yet this simple attention was sufficient to start anew proper physiological function. Regular blood tests showed a constant improvement of the quality and relation of the different constituents of the blood. A steady slowing-down of the circulation and respiration demonstrated the effect up- on heart and lungs, and the case with its final results proved 126 ORiFIG'IAL SURGERY. the efficacy of orificial methods, based upon the philosophic principle of blood supply. A case demonstrating the effect of orificial surgery upon peristaltic action is the following: Mr. G. C., an active and prominent business man, had for five years been the subject of what was diagnosed recurring attacks of la grippe. These spells were usually ushered in by a hard chill, fever, profuse sweat and extreme exhaustion. Such had been their severity and the frequence of their repe- tition that the patient was wholly incapacitated for any kind of business, often being confined to his room and bed for weeks at a time. He was obstinately constipated, his appetite poor, his temperature usually subnormal, extremities cold and ev- erything about his appearance indicating the extreme pros- tration from which he was suffering. Like most cases that have been a long time sick, almost every means had been em- ployed for his relief. He was brought to the sanitarium on a cot, and, as his family physician afterward told me, none of his friends expected to see him return home alive. Physical examination revealed a nodulated condition of the entire colon, which I at once diagnosed as retained fecal matter. The sphincters ani were much relaxed and the pile-bearing inch was one mass of hemorrhoidal growths. When he attempted to have an evacuation of the bowels this large mass of tumors and prolapsed gut would come down and become strangulated. From the intense pain thus produced, bowel movement be- came next to impossible. With a temperature at 97, a pulse rate at 120, with extremities cold to the knees, the face pinched and hippocratic, I put him under an anesthetic and proceeded at once to relieve the condition which I felt sure was sapping his vitality. Ordinarily the slit method in such cases is pref- erable, but in this case I decided that nothing but the Ameri- can would do. No sooner had the flap been fairly begun than the bad symptoms began to clear up, and by the time the op- eration was completed the temperature had risen to normal and the pulse dropped twenty beats per minute. The storm, however, was not over, for the following day the symptoms of collapse returned and for the next seventv- ORIFK/IAL SURGERY. 127 two hours his life hung by the narrowest thread. So great was the shock that it seemed impossible that he would survive the storm. Looking over the site of operation, I found a re- tained blood clot which was causing a great deal of pressure and tension. Believing this to be the cause of the complica- tion, I removed two or three stitches and curetted the clot away. From this time on everything was more favorable, and in less than a month this man was back at his desk and at work. I omitted to state that for ten years before the operation he had never had a natural bowel movement. From the time of the operation (now three years ago) up to the present he has never had to use any assistance to bring about a favorable movement of the bowels and his attacks of la grippe have never returned. This was unquestionably a case of autoinfec- tion from a lack of proper peristaltic action of the intestinal tract, and the results, which have been so highly satisfactory, surely warrant the conclusion that the methods employed, based upon the second law of our philosophy, are equal to the most trying emergencies. As a case illustrative of the influence of orificial methods on sympathetic nerve force, I would cite the following: Mrs. L., aged thirty-six years, had become a nervous wreck. She was a highly educated and intellectual woman. Forcible and determined, but withal congenial and agreeable. A leader in society. Within the year preceding her coming under ob- servation she became morose, petulant, fault-finding, worrying about things which did not exist, and complaining without cause. Wakeful by night and restless by day, she was in a constant condition of nervous disquietude. She was pale, anemic, appetite poor, bowels constipated, urination frequent and painful, menstruation irregular, all of these conditions having grown gradually worse until she had become a bed- ridden invalid. Physical examination revealed an atrophied uterus with a very irritable and congested os. As local treatments had be'ii employed without effect, and all-round orificial work in the hands of a good operator having proved useless, I decided 128 ORIFIC1AL SURGERY. upon a hysterectomy. During the operation the bladder was accidentally opened, which served as a very serious compli- cation, and a secondary operation was necessary to overcome the trouble with the bladder. For weeks and even months this woman vacillated between an ordinary degree of health and the lowest degree of physical existence. For days and even weeks together it seemed that her condition had only been aggravated by the operation. Every organ in the body took its turn in becoming disturbed, the stomach absolutely refusing anything in the way of nourishment for days to- gether. The cystic spasms which followed were the most in- tense I have ever witnessed, and the rectum joined in the gen- eral disturbance by spasmodic contractions which would con- tinue for hours at a time, only abating when tired nature failed completely to respond. The urine became suppressed, a distressing bronchitis developed, abscesses in various parts of the body formed, an exhaustive diarrhea supervened, and everything indicated a most unfavorable termination. Past experience told me that I should again do dilatation. By insisting upon its doing, consent was gained, the patient was placed under an anesthetic and thorough dilatation of the rectum, vagina and urethra was performed. For ten days no perceptible change followed; in fact, she seemed to go lower in the scale. At the end of the time usually given to the real convalescence of such cases, she suddenly grew better and continued to improve rapidly to a complete recovery. This I record as one of my most trying experiences and still as one of my greatest successes. The lessons this case taught me were to not hesitate or demur in repeating the work if there was any indication for so doing, and to never give up until every orificial force had been expended, especially where the indicated means have been employed according to the laws of either of the three cardinal principles of orificial philosophy. I realize how tiresome becomes the history of cases, but as it is by the practical application of laws that we determine their value, I have selected these cases. First, because of their gravity; second, because of the lessons they each bring. ORIPIG1AL SURGERY. 129 In the first one, but for the persistent daily attention the results which were brought about could not have been. In the second one, the case would have undoubtedly been lost had not the blood clot been removed and the pinched nerve fibers released. In the third one, nothing would have served to save this woman but the repetition of orificial methods which ordi- narily would seem to have been long since exhausted. CHAPTER XVI. THE VASOMOTOR CENTRES. J. W. MEANS, M. D. The arteries, veins and capillaries constitute what is called the circulatory system. Every organ of the body is supplied with life-giving fluid through a delicately constructed system of tubing, just as every house in our great cities is supplied with water through pipes beneath the surface. The magnificently constructed pumping station of the human system, located among the organs needing the supply of vital fluid most, is a marvel of mechanism and the acme of perfection itself. It has not only the vis a tergo action, but the vis a fronte. This great system provides for the waste and supply also. The impurities and effete matter, when the machine is working normally, pass away through lungs, kid- neys, and skin, while the loss is supplied by the lacteals along the digestive track. The beautiful and elaborately devised channels which carry the blood through the body form a closed system of elastic tubes, whose walls are made up of three coats, viz., ex- ternal, middle, and internal, each differing from the other, but united in a way that adds strength and elasticity to the whole. Here, again, is furnished an example to the artisan who, by following nature's example, discovers that a three- ply hose is more durable and will stand a greater pressure than 130 ORIFICTAL SUEGEEY. a one-ply hose, whose thickness is equal to the combined thickness of the three. From the heart to the capillaries, and from thence to the heart again, the blood is forced every twen- ty-eight seconds; every tissue of the body is replenished from this ever-flowing fountain. The countless streamlets that penetrate the remotest parts of the human frame, not only supply the necessary nutriment, but carry off the effete mat- ter where it is consumed and cast to the elements, as the chaff is divided from the wheat. Having briefly pointed out the perfect system of tubing which has been so artistically arranged through the bodies of all animated beings, what good are these, were it not for that unseen, incomprehensible power generated by the nerve cells Without some central station akin to an electric-light plant, where the electrical current is generated and sent hither and thither over the wires to the various parts of the city, to illuminate the streets, business houses, and residences of the people, there would be absolute inaction. It has been discovered that on the floor of the fourth ventricle, in the medulla oblongata, lie the nerve cells known as the vaso-motor centers, which govern the entire circulatory system, and from this point emanates the power that sustains life and rules the universe. It controls as by automatic sim- plicity the dilatation and contraction of every blood-vessel in the body. This czar of the kingdom over which his scepter extends, rules with an iron hand and holds the key to the pro- gressive and retrogressive development of every organ in the human body. Inflammation, congestion and anemia are all dependent upon the degree of stimulation furnished the organs affected by the central power in the fourth ventricle. The delicate blush of the maiden, localized as it were to the cheeks, has its origin in the intelligent center of the fourth ventricle. Localized disease of any organ is due to the interference of the nutrition of either the nerve-cells or the nerve-fibers at the particular place; either congestion or anemia exists. The cutting of the sympathetic nerve in -the neck is followed by an increase in temperature of that side of the head, and great OREFICIAL SUEGEBY. 131 dilatation of the arteries. It was also observed that stimula- tion of the superior ganglion of the sympathetic, caused a fall in temperature and contraction of the vessels in the side to which the stimulus was applied. Hence we find that con- gestion is controlled by the stimulus furnished, indirectly, to the constrictor fibres of the blood-vessels, from the cells or ganglia, connected with the central power in the fourth ven- tricle. Most of the brain can be removed without diminishing the arterial tone so long as the fibers leading from the floor of the fourth ventricle, or the central station itself is not im- paired, the blood-vessels will maintain their vital contractility which regulates the amount of blood flowing to a given part. The normality or abnormality of an organ depends upon the amount of nutrition furnished by the blood-vessels. Disease is defined as "that condition of the body in which one or more of its functions are not properly performed." Why are the various functions of the organs disturbed? Is it because of microbic action, or disturbed circulation Every disease has its specific germ, according to the up-to-date bacteriologist. Horse serum, scientifically called antitoxine, has become as common as the equine itself and it is advocated today by a large element of medical practitioners as a specific for the cure of diphtheria. All the modern physician has to do is to find the patients, the bacteriologists and the chemist will do the rest. Confidence is the basis of health as well as business, and when the whole economy is acting harmoniously, all parts of the body are supplied with the requisite amount of blood, health is the result. When one section of the country is block- aded business is disturbed, the normal channels of trade are interfered with, stagnation follows, bankruptcy and general loss supervene. So it is with the human body. The vast net- work of arteries, veins and nerves are so intertwined with each other that when one branch of the great system fails to perform its duty, the equilibrium is disturbed, the venal or arterial system is over-distended, effete matter accumulates in the capillaries, the vasomotor nervous system is whipped up to furnish vital fluid to the wcarv muscles of the blood-vessels. 132 OBIFIC'IAL SURGERY. until by sheer exhaustion the parts wherein the battle of life has been waged, become congested; stagnation and disease is the result. No intelligent individual will deny the existence of microbes, but whether they are the cause or result of disease has not been settled beyond cavil. Why is it that diarrheal diseases, and marasmus in chil- dren, and a host of microbic affections are cured by circum- cision and rectal dilatation? Does removal of the prepuce destroy the germ, or does the normal condition following said operation result from the disentanglement of the nerve fibers ? Why does urethral stricture cause gleet, with its characteristic microbes, and the removal of the stricture cure it? It can be accomplished by electricity, dilatation, or urethrotomy, neither of which can be termed germicides, but the germ disappears. We find that the great central motive power, located in the fourth ventricle, has sub-stations known as ganglia, scat- tered throughout the whole system. They are collections of nerve cells, and are joined by delicate bundles of nerve fibers, from which branches lead to the blood-vessels and viscera. They act as transformers, reducing the intensity of the current, changing the voltage and so modifying it, that the circulation is under perfect control. They also act as storage batteries, having afferent and efferent nerves leading to and from the ganglia. They (the ganglia) can be excited, the tone of the vessels increased, and pressure raised, either by direct or in- direct irritation fear will blanch the countenance, joy will flush the capillaries. There is no fear without the central ganglia are irritated by a certain kind of wave impression. There is no joy without central irritation due to a specific cause. In the study of these wonderful nerve centers we learn that stasis means death, not alone in the vasomotor system, but in every department of life. Stagnation means decay. The restless ocean purifies itself by that ceaseless ebb and flow. The great river system of the world would become a stench and a menace to health if it were not for that onward flow through gorge and valley, until lost in the mother ocean. SUBGERY. 133 CHAPTER XVII. THE SYMPATHETIC NERVOUS SYSTEM; OR WHY ORI- FICIAL SURGERY SHOULD CURE OR AFFECT MOST CHRONIC DISEASES, EXPLAINED FROM AN ANA- TOMICAL AND PHYSIOLOGICAL BASIS. E. P. NOTREBE, M. D. When discussing orificial surgery we mention rectal and genital orifices and their appendages, not to the total exclu- sion of other orifices, but because the sympathetic nervous system, the much neglected but the great and important part of the nervous system, is more accessible by lower orifices and their appendages than by any other parts of the body, as will be seen from the great supply and connection of those parts with the sympathetic system. We should treat the lower ori- fices and appendages together and completely connect them in searching for cause of disease, because they are inseparably connected by both sympathetic and cerebro-spinal nervous systems. The pudic nerve, which is of cerebro-spinal origin but which is connected with the sympathetic system in the sacral region, gives off five branches, one to each of the fol- lowing organs and parts : The largest branch ends in the blad- der, the next in size goes to the rectum, the others go to penis or clitoris; the labia and perineum, and the uterus and its appendages. These parts are abundantly supplied with sympa- thetic nerve cords, which originate in the hypogastric plexus. From this connection an irritation of any one of these parts may cause irritation of any one or all of the others. To explain the sympathetic connection of these parts will require a brief anatomical description of the sympathetic ner- vous system. First, there is a chain of ganglia on either side of the vertebras from skull to coccyx, called the lateral chain of the sympathetic. This lateral chain is strongly connected with the cranial, the spinal and the sacral nerves. The second 134 OKIFICTAL SURGERY part of the sympathetic consists of nerve cells or ganglia aris- ing from or connected with the lateral chain, and from these cells or centers actual nerve cords go to all the viscera, to all blood vessels, and to all glands. There are three main plexuses or centers: cervical, solar and hypogastric. The cervical plex- us includes the superior, middle and inferior cervical ganglion. The superior ganglion has communication with the four upper cervical nerves, with petrosal ganglion, with root and trunk of pneumogastric nerve, with carotid, cavernous and pharyn- geal plexuses, with about all cranial nerves, internal carotid artery and superior cardiac nerves. The middle cervical has connection with communicating branches of four, five and six cervical nerves, the middle car- diac and recurrent laryngeal. The inferior cervical, with com- municating branches of seven and eight cervical nerves, in- ferior cardiac, and right and left pulmonary plexuses. The solar plexus, coeliac axis or the abdominal brain or center is connected with the lateral chain by the three to four splanch- nics and phrenic nerve above and with lateral chain and hypo- gastric plexus below. This center sends numerous cords to the ganglia in stomach, liver, spleen, kidneys, pancreas and whole intestinal tract. The course of these nerve strands is along blood vessels to the organs and tissues. The hypogastric plex- us is connected with the lateral chain and sends cord to gang- lia in bladder, uterus and terminal nerves of clitoris, penis, testicles and rectum. The physiology of the sympathetic nervous system is re- flex action. It controls the forces necessary to the life of the body; it presides over nutrition; controls the circulation and glandular secretion, and presides over the organs of genera- tion; it is the governor of emotion or rhythm, of all the tho- racic, abdominal and pelvic viscera, and of all blood vessels and glands wherever located. For a complete nerve reflex action, we must have a center, a conducting cord and a peri- pheral ganglion. The centers of the sympathetic are: The solar plexus or abdominal brain and cervical ganglion. The numerous con- ORrFICTAL SURGERY. 135 ducting cords are sent out from centers to all the viscera, and there end in the peripheral ganglia or plexus of those organs or parts. The centers have the brain power of reorganizing forces, and they manage nourishment and control secretion; they in- itiate, sustain and prohibit rhythm, that is, the centers affect the peripheral ganglia of a viscus, and the rhythm of that vis- cus depends on the action of its ganglia; hence the nutrition and function of an organ are under the control of its terminal ganglion cells. The rhythm of the heart, stomach, intestines, lungs, liver, uterus, bladder and other vital organs, is due to influences act- ing on their special visceral ganglia. We know of the effects of the automatic heart ganglia. These ganglia cause the perfect rhythm of heart, for when separated from the cerebrum it still has this peculiar motion or cycle which we call rhythm. We are familiar, too, with this rhythm in the digestive tract; the peristaltic or vermicular action of the intestines is due to the ganglia situated between the longitudinal and circular mus- cular fibers known as Auerbach's plexus. Auerbach's plexus is the peripheral cells which control the muscular movements or rhythm of the gastro-intestinal tract. Meissner's ganglia have control of the gastro-intestinal secretion, and are located just under the delicate mucous membrane of the gastro-in- testinal tract. So, special ganglia are located in all the vital organs, and these ganglia are almost wholly under the control of the sympathetic nervous system or centers. The disease of a viscus then is usually caused by abnormal stimulation or ir- ritation of its visceral plexus. Irritation may be direct or re- flex; it may be transient or continuous. When transient, the organ may sustain its function, but when continuous it must become irregular in motion, nutrition and secretion, and ab- normal in function. It is the continuous irritation that we as physicians and surgeons have most to deal with, and when we take away that irritation which has been constantly impair- ing the motion, the secretion and nutrition of a part, we free it from its fetters and starvation, and it will soon regain what it has lost, for nature will repair damages if we only give it a 136 ORIPIGTAL SURGERY. natural chance. We are warned of and directed to irritation of the cerebro-spinal nerve by special pain; but the sympa- thetic may be strongly irritated, and we may know nothing of its presence unless it be by symptoms of disturbed nerve force or disturbed nutrition. The patient is not cognizant of pain, but seeks the advice of a physician on account of functional disturbances, such as palpitation of the heart, so-called dys- pepsia, constipation, liver troubles, skin discoloration and erup- tions, cold hands and feet, and various neuroses all from terminal irritation. To trace the effects of irritation and reflex action, we will commence with the endometrium of the uterus or with a dis- eased uterus. The uterine irritation affects the woman's heart, stomach and intestinal tract, also her nervous equilibrium. It affects her heart because the peripheral ganglia or terminal nerves in uterus are irritated and the impression travels along the sympathetic conducting cords to the hypogastric plexus; from thence, by two routes: 1st, by lateral chain directly to cervical ganglia, and 2nd, by cords to abdominal brain and thus to cervical ganglia. In cervical ganglia the forces are reorganized and sent down to heart ganglia by the three car- dio-accelerator nerves, which make the heart go too fast or ir- regularly. The stomach is disturbed because the irritation goes from uterus to hypogastric plexus, and from hypogastric plexus to abdominal brain. The forces are reorganized and sent out by cords along the gastric artery to Auerbach's plexus between muscular layers and cause contraction or cramp of stomach or vomiting. The irritation also affects Meissner's plexus, just under mucous membrane of gastro-intestinal tract, and causes too much secretion, too little secretion, or dispro- portionate secretion or indigestion. The woman has intestinal indigestion because the irritation goes to hypogastric plexus, then to abdominal brain, and forces are reorganized and sent out on superior mesenteric artery to Auerbach's plexus, and cause too much contraction or diarrhoea, or too little contrac- tion or constipation, and affects also Meissner's plexus and causes too much secretion or diarrhoea, to little or constipa- tion, or disproportionate secretion or fermentation and colic. ORIFIC1AL SURGERY. 137 The same irritant may be traced to liver by going from uterus to abdominal brain, from abdominal brain along he- patic artery to hepatic ganglia, which affects the rhythm ot liver and causes it to make too much bile, glycogen and urea ; too little bile, glycogen and urea ; or disproportionate bile, glycogen and urea, in which the function of the liver is dis- turbed and it may become turgescent or hypertrophied or de- generated. The excessive or disproportionate secretions are absorbed partly by blood and show in discoloration or blotches of skin. Irritation of terminal sympathetic nerves, if con- tinued, will carry the patient through five different stages ; the first is simple irritation, by its reflex effects on the blood sup- ply and digestive tract. She has indigestion ; from indigestion comes mal-nutrition ; from mal-nutrition comes anemia ; and from anemia comes neurosis or hysterics. Then the case comes to the physician and probably not before, as it has had no special pain. I take the uterus for an example, simply because its re- flexes from disease or irritation are acknowledged; but the same effects can be caused by irritation of any of the follow- ing parts : Clitoris, urethra, bladder, testicles, labia and rec- tum. Clinical experience teaches that the sympathetic centers can be shocked or stimulated more by the rectum than by any other part. The most satisfactory, reliable and effectual means of resuscitation is by stimulating the centers per rectum!, as the irritant begins in terminal nerves or ganglia of the rec- tum and goes to hypogastric plexus, then by two routes to cervical plexus, one by lateral chain and the other through abdominal brain to cervical ganglia, and the forces are there reorganized and sent to the pneumogastric nerve, also by cords from cervical ganglia to right and left pulmonary plex- uses, which stimulate cell action. The uterus and rectum re- ceive more conducting cords than the others, but all these parts are connected with hypogastric plexus, and as anatomy has so strongly connected these parts with the central brain of the sympathetic system, it is through this connection that orificial philosophy is applied. By affecting the central cells we affect the rhythm and secretion of the viscera; we control 138 ORIFICTAL SUEGERY. the circulation and manage the nutrition of every organ and tissue of the body. By managing these fundamental principles of physiology, orificialists expect to wake up dormant cells and rebuild healthy tissue. This grand philosophy was conceived, developed, proven and demonstrated by one great mind, and made a free gift to the medical profession from noble principles. This mind and these principles are in one man and he should have the honor due such combination ; and that honor is to have the thoughts and feelings of his profession that rightly belong to such a progressive wonder as E. H. Pratt, the hero of the medical profession. In preparing this article I made use freely not only of ordinary text books upon anatomy, but of special discussions, demonstrations and descriptions furnished by Dr. F. Byron Robinson, of Chicago, and have culled freely from articles of Dr. E. H. Pratt, the founder of the orificial philosophy. SECTION III. Reflexes. OR1F1C1AL SUEGEBY. 141 CHAPTER XVIII. REFLEXES. C. A. WEIRICK, M. D. Two forces are continuously exercised in the human or- gan, viz. : Reproductive and destructive. The former is car- ried on by all the great functions of the body, digestion, res- piration, absorption, circulation and secretion, each an im- portant and essential factor in the one great act, nutrition, which not only creates the anatomical elements of a new be- ing and continuously repairs or strives to repair those of an existing organism, but also, at the same time, stores within these elements a potential energy that is invariably liberated and set in action to reproduce and to destroy. If the power which liberates, renders active and controls this energy or force be neither too great nor too small, just sufficient to main- tain a proper co-ordinate organic action, then in the body will production be equal to or in excess of destruction, thereby resulting in health and physical development ; but if an insuf- ficient amount of this latent energy be changed to active force or work and heat, then a slow, insidious degeneration of one or more tissue elements occurs, often, however, preceded by diminution of functional activity. If an amount in excess of the maximum permissible in constructive metabolism be changed into kinetic energy, then the physiological acts and anatomical structure of the tissues are rapidly modified and altered. Health, then, is the production of potential or re- serve energy, and the proper expenditure of the same ; disease is a failure either to develop this force or to expend it in the harmonious activity of all the elements, tissues, organs and functions of the body. Disease is chronic or acute, either as an insufficient or an excessive amount of energy at rest is changed to activity. The development of this force and the regulation of its expenditure therefore come within the prov- 142 ORIFICIAL SURGERY. ince of the physician. Those forces which liberate other forces are known as stimuli. They may be either chemical, electrical, mechanical, physical, or that negatively defined force known as vital, which last, in children at least, depends upon heredity. Because of their anatomical connection by means of the ner- vous system, no organ, or at least no visceral organ, is inde- pendent of any other; hence, a natural stimulus applied to one directly or reflexly influences the normal action of another, providing one or more of the factors essential to a reflex move- ment be not destroyed, even though they may be impaired. It is, therefore, a logical deduction that if the liberating force and the center of reflexion, the centripetal and centrifugal fi- bers, the three factors of a reflex act, be normal the body will be in a state of health. Reflex phenomena depend upon the condition of the re- flex arc and the character of the stimuli, most frequently upon the transferring center of the arc, located either in the sympa- thetic ganglia or in the cerebro-spinal centers. If the center, the cause of action or inaction is central ; if the stimuli, peri- pheral. In a crude manner the reflexes, especially those of the patellar-tendon and next the ankle clonus, have been used as a means of diagnosis to determine well-developed abnormal conditions. I believe the time is not far distant when it will be pos- sible to determine probably by the aid of electricity and suit- able apparatus, the minimum and maximum amount of energy necessary in the transferring centers to maintain the proper degree of harmony in organic action. Then will it be possible, by an earlier diagnosis than it is now possible to make, to pre- vent the development of some of the incurable neurotic and reflex diseases. Perhaps in no other form of acute disease, especially in children, is the energy of the reflexion center reduced below the minimum of health or even exhausted as in catarrhal pneu- monia, one of the very serious diseases of early life. The cough often ceases though there be no improvement in the pathological condition, and there may even be an extension to and an involvement of other lobules of the lungs. The in- ORIFIC1AL SUEGEBY. 143 flammation produces the stimulus, the energy which, trans- mitted by the superior and inferior branches of the vagus, in this case the efferent fibers, to the cough center, liberates a force that is conveyed by the efferent fibres in the nerves of expiration to their periphery, resulting in cough. Then, if the inflammation is the stimulus and it is not abated, why does not the patient continue to cough, and by that means pre- vent an occlusion of the smaller bronchi by an accumulation of mucous? The potential energy of the transferring center has become exhausted, hence there is no power for the stimu- lus to discharge through the efferent fibres of the reflex arc to the contractile tissue involved in the production of cough. This condition is critical and often followed by death. The practical lesson to be drawn from this experience and the results of its development is to sustain the vigor of the ce- rebro-spinal axis, in which is found the cough center, by reme- dies acting upon it, and thereby prevent its exhaustion which is so frequently followed by fatal results. The statement that this may be done is corroborated by clinical experience. No drugs will be mentioned, as it would doubtless lead to a dis- cussion of the general treatment of this form of pneumonia which is not within the scope of the paper. It will occur to all that in many cases of this disease the cough does not suddenly cease, but gradually subsides with the abatement of the pathological condition ; it is so because the potential energy of the reflex cough center has not become ex- hausted, either by the involvement of a large area of lung tis- sue or by constitutional dyscrasia. Because the organs are interdependent ( ?) in action, their reflex influence should be considered in the treatment of any one of them, not only in chronic, but in acute diseases. While improper food is doubtless the most frequent eti- ological factor in the production of diarrho?a of children, yet there are not a few cases of this disease that are caused, not by direct irritation of the digestive tract, but by reflex influ- ences. The power of intense mental conditions to produce greatly exaggerated peristalsis and involuntary defecation has been frequently noticed, especially from fright or any other 144 ORIFIG1AL SURGERY. sudden abnormal mental action. Diarrhoea is also caused in infants by changing the material composing the garments worn next to the skin. This is frequently observed when, even in the hot temperature of July and August, the clothing worn next the skin is changed from woolen to cotton goods. I have often seen cases originating from this cause rapidly cured by replacing the cotton by the woolen garment. It is a well attested fact that sudden atmospheric changes are pro- ductive of increased sickness, and frequently increase the in- tensity, especially in this latitude, of gastro-enteric disorders during the month of September. Unseasonable weather that is, a cold summer and warm winter is accompanied with an increased amount of sickness. This is not brought about by any direct local atmospherical effect, either mechanical or chemical, upon the tissues involved, but by a change of stim- uli, acting on the peripheral nerve terminations, probably of the integument, thereby either diminishing or increasing the power of the inhibitory and motor centers, and therefore changing their reflex energy, resulting in functional and or- ganic changes of organs subject to their influence. It is not an uncommon experience in the treatment of gastro-enteric diseases of infancy to be annoyed and chagrined by frequent recurrence of the attack in the same cases, notwithstanding the diet and remedies have been selected with the greatst care and skill. As impaired glanders secretion, both in quality and quantity, and hypera?mia and inflammations may be caused by the reflex influence of a cold draught acting on some por- tions of the skin, it is logical to conclude, especially as clinical results verify the deduction, that intelligent care of the sur- face of the body will prevent its undue stimulation, and there- fore protect from deleterious reflex influences the already weakened digestive organs, and prevent frequent relapses of diarrhoea in children. Diarrhoea, again, may be produced, not by direct irritation of the intestinal canal by the presence of indigestible food, but by reflex mental influences. The power of intense mental conditions to cause greatly exaggerated peristalsis and involuntary stools has been frequently ob- served, especially from fright. Cases of constipation also OBIFIC1AL SUKGEEY. 145 may result from the same mental influences that in others, by reflex action, are followed by diarrhoea. Why the same ex- citing cause is followed by an overaction in one person, an in- sufficient action in another, and a normal action in a third, is doubtless due to the different conditions of the reflex arc and the influence of the stimuli, not only upon the motor but the inhibitory centers. If the resistance of the former were de- creased and the latter unchanged, then diarrhoea would fol- low ; if vice versa, constipation ; but if they were both active and no relative change in their resisting power, the stimuli would produce neither constipation nor diarrhoea. The delicacy of the mechanism of the reflex structures, and the many changes their action may produce in the charac- ter of a disease, especially in diarrhoea, teach the necessity of careful discrimination in the selection of remedies which are very similar in their action. The many fine points of differ- ence between drugs are therefore not to be ignored, especially in the treatment of diarrhoea. Again in diarrhoea it will be noticed that the indigestible food in the intestinal tract, the pathological condition of the same or whatever other cause may constitute the stimuli, there will be in addition to the altered contents of the intestines only increased peristalsis ; sometimes, however, this increased ac- tion does not occur even though the stools be diarrhoeic in character. This abnormal action represents only a simple re- flex response on the part of the muscular coat of the intestine, but when the discharging stimulus is very strong or there is an excessive degree of excitability of the transferring center, then will incoordinate reflex manifestations exhibit themselves in the form of spasms. It has been noted by Henry Harts- home, M. D., that more males than females die from cholera infantum. Now, as the former is not, as in adult life, more exposed to the unclemency of the weather than the latter, and as the food and clothing are the same for both sexes during infancy, it will be a reasonable deduction to make that the cause of greater mortality in the one sex must be due to some abnormal condition of the genital organs. These parts should be examined. This is not stereotyped advice given in con- 146 ORIFICIAL SURGERY. nection with the care of cholera infantura as all well know, but, because the rate of mortality is so uniformly reported high, the physician is warranted in getting out of the well worn path of treatment which too often leads to death of the child. Of course, it is far better to ascertain before any acute condition manifests itself that not only are the genital but all other organs free from conditions that will impair the normal bodily resistance. If such conditions exist, cure them if pos. sible before they weaken the organism by their reflex influ- ence, and thereby act as a predisposing cause of disease. I think, as a rule, doctors are inclined to ignore the small abnormal conditions of the body which act as stimuli for the reason that they do not produce acute disease or because they forget that a weak stimulus existing for a short time may not cause a reflex act; but if it be continued may produce this act. Had nature intended to protect the body only against large sources of irritation, it would have made the nerves large like the muscular system ; but many of them are microscopical and ramify every part of the body, being especially numerous in the more exposed parts of the body. They are so very suscept- ible to stimuli that one of their functions, no doubt, is to early give warning of an assault, no matter how trivial, on the vital force. A small source of irritation continuously exerted de- creases its power of resistance. For example, a very small foreign substance in the eye may, if not removed, cause de- struction of its fellow; the presence of some indigestible sub- stance in the intestinal tract may produce convulsions and sometimes death. Still another familiar example may be given, viz. : A small piece of secundines will produce hemor- rhage, not because it is large enough to prevent contraction but because of reflex influence. Then, if such a weak stimuli will produce serious functional derangements in adult life, it is not strange that it will have a deleterious influence in child life; and while the harm may not be manifested at once, still the loss of recuperative power so often given as a reason for not curing patients of acute disease may be due to the long continued action of a stimuli so weak that were it continued but a short time it would make no perceptible influence on the ORIFICTAL SURGERY. 147 patient's health. It is to lessen the severity of acute diseases and prevent the development of those that are chronic in character, that the child should be examined for abnormal conditions at birth. Probably the most common of these in male children is the adherent and redundant foreskin. The following cases are given to show some of the different reflex conditions pro- duced by it. The first case showed symptoms of an imperfect gastric digestion during the first few months after its birth, which continued until cured at the age of six years. During the sec- ond summer of its existence it had frequent acute attacks of gastro-intestinal catarrh. These attacks recurred so frequently that the child was taken on a boat to northern Michigan. Some little improvement was wrought by the change of climate, but it was late in the fall before it became fairly out of danger of these serious acute manifestations of the disease. The stom- ach remained weak, imperfectly doing its work, aggravated by a diet not very carefully regulated, both in regard to quality and quantity. It was also influenced by changes of temper- ature. Several physicians, myself among the number, treated the patient without producing any marked improvement. He was for a time under the professional charge of a specialist for diseases of the digestive organs, without benefit. Of course acute exacerbations subsided with or without medicine. When he was six years old I was asked to prescribe for enuresis, that troubled him day as well as night. Thinking there might be some local cause of this annoying trouble, I examined the geni- tal organ, and found the foreskin adherent to one side of the glans penis. This was corrected in less than five minutes with my fingers. He had no further trouble in retaining the urine, and he made marked improvement from that time. One year after his mother reported no more trouble with the digestive organs. It is not claimed, of course, that every case of enuresis, any more than every case of indigestion, is caused by the con- dition described in the above case. 148 ORIFIC1AL SUBGEEY. I was asked to examine a male child eighteen months old, an idiot. The parents were very intelligent. It had been de- livered by the aid of instruments. No evidence of injury could be found. The mother, wiser than some doctors, in this case at least, made a comparative examination between her child and the male child of a friend. The foreskins were different. The mother reasoned that as her child was ill and the friend's well, if either foreskin was wrong it must be that of her boy. The child was circumcised and the adhesion between the glans penis and the foreskin broken up. The child was well in two months. There was marked mental improvement during the first week following the operation. The following are cases cured by operation on the fore- skin, reported by Sayre: Child five years old, knees flexed at angle of 45 degrees, paralysis of extensors, pulse weak. Ten- otomy had been advised, but not performed. Two weeks after the operation the child walked without aid, and finally made a complete recovery. Double talipes equinovarus paralytica in child aged three years. Had been under treatment between two and three years in a public institution of New York. Greatly improved in two weeks after operation. Paralysis of lower extremities, prolapsus of rectum and constipation. Operation June 1, could stand alone June 4, and complete recovery at the end of twelve days. Partial atrophy of optic nerve in man aged 34 years, eye trouble of eight years' duration, can only read large print and then but few minutes together. Operation restored general health in one month and enabled the patient to read a page of small print without any unpleasant results. Dr. Sayre also reports cases benefited by correcting trou- bles of the clitoris. One child whom he treated was eight years old and had never been able to walk. Two months after operation she walked unaided across three rooms. These cases are given to call attention to the fact that an irritation in the same part of the body may produce various reflex diseases in different individuals. It should also be re- membered that the stimuli that results in great functional dis- OREPIC'IAL SURGERY. 149 turbances in a single organ in each case, may in others diffuse its force to many organs, thereby slightly, in a short time, im- pairing them all, with no very clear manifestations of disease in any one ; but by undermining the recuperative power the in- dividual is rendered especially susceptible to any exciting cause of disease and ultimately some chronic ailment is in- sidiously developed. I will give an example to corroborate the last statement. A young lady about eighteen years of age, had for many years of her life been subject to severe attacks of headache, the at- tacks gradually increasing in frequency. She was pale, list- less and tired, with a poor appetite. The menses were regular and normal. She had had several acute diseases, one of which was typhoid fever. She had not since a child been considered a very strong girl by her parents. Of course, she had sought relief from physicians and taken much medicine without any apparent benefit. I was no more successful with drugs than those who had previously prescribed for her. Finally I did what should have been done when she was a child, examined the clitoris, and found the hood adherent. The adhesions were loosened and the patient gradually gained strength and re- covered from the headaches. No drug, no matter how care- fully selected, would cure such a case and it was unwise, un- scientific to administer drugs to her. And yet I have no doubt that many chronic cases called nervous prostration, general debility or some other of the indefinite terms that physicians have taught the laity to expect as expressing something sci- entific, are due to a reflex irritation perhaps no greater than the one in the case just described, and which may be pro- duced by congenital deformities. These cases have been given to show not only that an ab- normal stimulus may cause reflex disease, but also that the same stimulus produces different diseases in different individ- uals. Notice in these cases that the irritation caused by the foreskin resulted in chronic impairment of the stomach di- gestion in one subject; idiocy in another; in a third paralysis of the extensors of the leg; a fourth, talipes equinus; a fifth, paralysis of the lower extremities, constipation and protrusion 150 ORIFICIAL of the rectum; and in the sixth, after many years, serious im- pairment of vision. In other cases with a less degree of irri- tation, or a greater amount of constitutional strength pos- sessed by the patient, there will be produced less marked symptoms of disease, but none the less surely will the various functions of the child organism be impaired and predisposed to disease conditions, which are entirely too common and fatal in childhood. Often nature corrects the trouble ;if it does not the adult is invariably an invalid; but even when nature re- moves the cause of irritation serious harm has been done to the child. It is not creditable to medicine and surgery that there are thousands of people in all countries where medicine is taught suffering from chronic disease. These very often may be traced back to childhood, and to causes that were re- movable at that age. Dr. Pratt has discovered and taught, and his teaching has been corroborated by all who have made clinical use of it, that the lower part of the rectum is abund- antly supplied with nerves, which act as afferent fibers to a reflex arc, and that abnormal conditions of this part of the bowel are productive of many reflex disorders. He has found that dilatation of the sphincter ani is a powerful means of re- suscitation, and that it is the most reliable method known for starting respiration in still-born children. Since the originator of this method introduced it to the profession it has come into general use as a means of resus- citation. A regular physician writes as follows: "The methods of resuscitation usually employed are open to various objections. They all require time which is the all-important element in these cases. Some of them compel the use of unseemly and dis- agreeable measures, others of more or less cumbersome and inconvenient means, and all distract the physician's attention from the mother, who at this time peculiarly and by every right is entitled to that care and consideraton which only the closest and most constant attention can secure to her. These are the general objections not to specify the many inhuman and grotesque impositions, such as spanking the baby, alter- nate boiling and freezing with hot and cold baths, mouth to ORIFICIAL SURGERY. 151 mouth insufflation, artificial respiration, and the various other scientific indignities which are daily being perpetrated upon helpless innocence." Of course dilatation of these sphincters must affect the respiration by means of reflex influence. If relaxing the anal muscles to an extreme degree assists respiration, then their abnormal contraction which may be caused by the presence of a local irritant, will reflexingly hin- der respiration or compel the respiratory centers to expend an undue amount of energy to regulate these processes. In either case disease must result, the vital force be diminished and a chronic disease slowly developed or an acute one rendered less amenable to treatment. It is not my purpose to discuss rectal pathology in con- nection with reflexes, but I do wish to assert that it is the causfc of many functional derangements which are frequently fol- lowed by organic changes. Patients do not understand why a slight irritation of the glans penis, the clitoris, the rectum or the nares will produce trouble remote from its direct action, nor why the ill effects are more pronounced than if a greater stimulus were applied to the nerve nearer its central termina- tion. The first is understood by a knowledge of the fact that a stimulus may be so weak and of such short duration that there will be no discharge of a reflex act, but if it be continued it will produce the act. The second because stimulation of the peripheral end of the efferent nerve more readily and thor- oughly causes the discharge of a reflex act than stimulation in its course. For example, a slight continued tickling of the skin over the knee will in many individuals cause incon- trollable and hysterical laughter, while stimulus applied to the main nerve from which this region is supplied causes local pain only. One of the common derangements of early childhood is constipation. The laxatives of the regular school, the home- opathic remedies and a diet carefully selected from the many foods at the command of the physician all fail too often to cure this condition. Very frequently after other means have been faithfully tried the trouble has been overcome by dilata- i- 152' ORIFIC1AL SURGERY. tion of the anal sphincters. The same cause that will in one subject produce constipation will in another cause diarrhoea. I have seen the former cured by curing an anal fissure; in an- other case the latter cured by removing the same cause. Re- cently a case came under observation who had had diarrhoea for a year. The patient had from two to a dozen loose stools in twenty-four hours. Colicky pains preceded defecation with rumbling of gas in the abdomen. There were no sharp nor se- vere pains in the anus, only a slight smarting or burning sen- sation nothing that resembled the usual description of the pains incident to a fissure. But nevertheless a large one ex- isted. Local anaesthesia was produced by a solution of cocaine, then 95 per cent, carbolic acid applied to the fissure ; the stools became normal in one week after the treatment. It should not seem strange to the members of our school of medicine that dif- ferent conditions, or rather opposite manifestations of the same conditions, respond to the same remedy. It may be explained by the difference in the discharging power of the center of the reflex arc. While calling attention in a general way to the important influence that stimuli may exert in a reflex manner on remote organs of the body, it is in nowise intended that other causes of disease should be ignored, for it would be foolish to treat a disease due to central conditions alone as a reflex disorder. I believe, however, that many chronic pathological conditions which seem to be primary are due to long continued impair- ment of important processes of the body due to reflex influ- ences that permit the development of these diseases which be- come independent and do not disappear after the exciting cause is removed. The importance of a thorough examination of a child can not be overestimated. All abnormal stimuli should be corrected if the danger incident to child life be re- duced to a minimum and the increase in the great army of chronic sufferers be stopped. ORIFICIAL SURGERY. 153 CHAPTER XIX. REFLEX NEUROSES. A. W. REDDISH, M. D. First, what is a neurosis? It is a functional nervous dis- ease, or a derangement of the function or office of a nerve. In the auditory nerve it is manifested by a singing and roaring in the ears; in the optic nerve by the blurring of vision and specks before the eyes ; in the olfactory nerve by exalted or de- ranged olfaction; in the sensory nerves by formication and pain; in the vaso-motor nerve by the spasms of the arterioles and disturbed circulation; and in the motor nerves by irregu- lar and spasmodic movements. What is a reflex action? As most of the movements and operations of the body are conceded to be produced by re- flex actions, it is well to understand this subject. Reflex ac- tions are involuntary, and are of two kinds reflex actions in health and reflex actions in disease. The former are always regular, and have a purpose in view, while the latter are irregular and purposeless. It is of the latter that I intend to write. So, after a few preliminary words on reflex actions in health, I will proceed with the subject of this paper. If a stimulus is applied to the extremities of an afferent nerve, the impression is carried along that nerve to a reflex center, then back over an efferent nerve to, it may be, a re- mote part of the body, and an action produced differing in kind from the stimulus, but corresponding with the function of the efferent nerves so affected. Well known instances of this action are legion, and have been observed from remote times. For instance: Tickle the sole of the foot and the leg is withdrawn ; or let a strong light fall upon the retina and the pupil contracts; place a strong acid on the tip of the tongue and muscles of the face are immediately set in motion. There is one other point : If a slight stimulus be applied to the right foot, the leg draws up; if this stimulus be in- 154 ORIFIGiAL SURGERY. creased, both legs will draw up; and if it be still further in- tensified, it will be reflected along motor nerves that arise from points higher up in the spinal cord, until all the muscles of the body are thrown in motion. Observe the application of this law to reflexes in disease further along in the paper. Reflex action in disease is caused by irritation of the peri- pheral extremity of an afferent nerve. This nerve may be either cerebro-spinal or sympathetic. This irritation passes to a reflex centre, and is then reflected over an efferent nerve, when a functional derangement takes place. This reflex action or functional disturbance it must be understood, is not the re- sult of chance, but is governed by an inflexible law. Every ir- ritation must produce its own reflex action. Gastric irrita- tion produces frontal headache. Renal irritation produces oc- cipital headaches. Worms and other intestinal irritations in children produce spasms. Slight irritations only produce twitchings, and adults in whom reflex actions are considerably diminished, similar irritations produce no result whatever. In this case the sympathetic or afferent nerve, and the cerebro- spinal the efferent nerve. Among other well known examples may be mentioned spasms from teething, epilepsy from sexual irritations, tetanus and trismus from penetrating wounds in- volving the cerebro-spinal nerves. The fact that this is very common in the horse and does not occur at all among other animals, verifies the facts that modifying causes exist, and in- hibition which must always be taken into consideration. Dr. Stevens whom Dr. Ranney quotes on "Lectures on Nervous Diseases, ' ' proves quite conclusively that chorea may generally be cured by correcting visual defects, refractive or muscular. Other well-known and frequently verified examples are in- continence of urine from phymosis, and nausea, and vomiting from irritation of the internal os uteri. This is most frequent- ly observed during pregnancy, where flexions and versions ex- is to such an extent that the nerves of the internal os are pressed upon and severely irritated. Aside from pregnancy, various uterine diseases will produce these identical symptoms, such as prolapsus and inflammations, flexions and versions. ORIFIC'IAL SURGERY. CHAPTER XX. ORIFICIAL REFLEXES CLINICALLY ILLUSTRATED. S. G. A. BROWN, M. D. The term reflex is applied to an action which consists in the refiexation by an efferent nerve of an impression conveyed to a nervous center by an afferent nerve. All reflex or excito- motory movements are regarded as being executed independ- ent of consciousness. That we may better understand this re- flex excitation and appreciate its intrinsic worth in the diag- nosis and prognoses of disease, I will cite a few cases which have come under my own observation. Case 1. Miss J., age 30, of good family history, had been an invalid for fifteen years. The first symptom noticed was a slight limping, a lameness of the right hip upon moving. This was soon succeeded by pain from which she suffered more or less until the event of her recovery. At times the pain was ex- cruciating, unbearable, especially after retiring for the night, often compelling the patient to get out of bed. The pain was at times sharp, at other times a dull ache, extending from the right hip, laterally and posterially, downward toward the knee, somewhat to the outside of the sciatic nerve. There ex- isted, at the time of my examination, an atrophic condition of the large gluteal muscle and the tensor vaginae femoris. Her health appeared to be good, excepting, of course, this trouble. When she came under my care she was unable to walk to my office, a distance of two blocks. She had been under the care of all the prominent local allopathic physicians, yet was con- tinually growing worse. During the first six months she was under my treatment I prescribed such remedies as I believed to be homeopathically applicable to the case, also using galvan- ism, and hot sitz-baths on retiring at night. The result was a slight alleviation of the pain and transient amelioration of other symptoms. Upon closer examination I was informed 156 OEIFIC1AL SURGEfcY. that at each menstrual nisus she suffered untold agony ; also, between the periods was inconvenienced with a thick, whitish leucorrhea. I insisted upon a thorough examination and found a stenosed condition of the cervix, a fissure of the rectum, and an extensive catarrhal condition of both these mucous tracts. My treatment was now directed toward these parts, relieving the catarrhal affection, dilating the cervix, healing the fissure, and using the galvanic current a few days before each cata- menial period, for several months, applying the cathode to the hypo-gastrium and the anode in the uterine canal. Relief was immediate, recovery quick and permanent; the result, more than I had expected. Six months have now elapsed, during which she has had no pain, and can walk with the greatest ease and freedom. Case 2. Mrs. S., age 35, was delivered of her fourth child January, 1895. Her physician, in order to hasten delivery, used manual force. From the hour of the child's birth she be- gan to decline, at times suffering very severely. I was called to see her April 16th ; found her very restless, nervous, suffer- ing much pain in the region of the uterus, together with great dyspnrea and diffused pain in the chest. Upon examination I found a thin, brownish, watery discharge from the vagina, ex- coriating the external genitals and inner surfaces of the thighs, and a lacerated cervix sensitive and inflamed. She informed me this condition had existed three months, or from the date of her confinement. Also that her former physician had found it necessary to keep her continuously under the influence of opiates in order to relieve the great pain and severe dyspno?a. I relieved her of what morphia tablets she had by placing them in my satchel, and prescribed arsenicum, 3x, a powder every two hours, promising to call the next day. That night I was awakened from my pleasant dreams of the life of a country doctor, and was hurried, more asleep than awake, to her bed- side, to find her in a state of high nervous excitement. She declared she was dying and implored immediate succor. Her husband demanded that I restore the stolen morphia tablets. This I kindly did by substituting arsenicum tablets, 30th tri- turation. Marked improvement began within fifteen minutes, ORIFICTAL SURGERY. 157 and at the end of an hour I was enabled to return home. On my arrival next day I found a marked amelioration of all symptoms, she having passed a quiet night. Improvement con- tinued for the space of three weeks, when the excoriating dis- charge once more made its formidable appearance. Receiving the consent of both husband and wife, I operated upon the lac- erated cervix, cleansing it first with absorbent cotten, removing the plug of mucus in cervical canal by means of a curette, and then performing the Emmet operation. The result was most flattering. Improvement began at once, and she made an un- eventful recovery, all her chest and heart troubles disappear- ing immediately and simultaneously. Case 3. Miss L., age 19, of a romantic, poetic, bilious tem- perament, otherwise apparently healthy; would at various in- tervals, from intuition, an overloaded colon, or otherwise, launch off into paroxysms of poetic ecstasy, during which pa- per, ink and temper reigned supreme, the whole culminating one Sabbath afternoon in a violent outburst of acute mania. I was hastily summoned and found her yelling lustily that this "world is all a dream," and frantically endeavoring to "kick the devil off the earth," while her father and two other gentlemen were endeavoring to hold her in the "old arm- chair," and trying to pacify her by holding her mouth shut. Belladonna tincture certainly deserves much credit for hav- ing come to our aid in this most trying moment, but she was never entirely relieved until I loosened the much-adherent hood of her clitoris. This cured her of her poetic fancies and brought her to her senses within ten minutes. It has now been a year and there has been no signs of a recurrence. Might there not be others who, having this great desire to launch off into the sea of poetry and the beautiful, could likewise be benefited by some similar simple operation? Case 4. Mr. II., age 40, bachelor, has had annually re- curring attacks of hay fever. During these attacks he suffered greatly with nasal coryza, lachrymation, profuse perspiration, sternutation, etc. I used all our prominent hay fever reme- dies, allium cepa, sabadilla, (natrum) muriaticum and naph- thalin, the only result being a slight alleviation of the suffer- 158 ORIFICIAL SURGERY. ing, to recur next year. He informed me that during these at- tacks he could breathe with the greatest difficulty only, and that his nostrils felt raw and were sensitive to touch. Upon examination I found an almost complete stenosis of the nos- trils, due to the inferior turbinated bones on both sides being swollen. Cocaine gave temporary relief, but the cure was not complete until applications of the compound tincture of ben- zoin were made. The recovery was rapid, and he has now passed two summers entirely relieved of his old enemy. There is one point in this latter case to which I desire to call your especial attention, namely, that the reflex irritation here was found in one of the upper openings of the body and not in the lower. Dr. Pratt says : ' ' There is one predisposing cause for all forms of chronic diseases, and that is a nerve waste occasioned by orificial irritation at the lower openings of the body." The above case, as Dr. Bryson, of Pittsburgh, remarked, was ''cured under Dr. Pratt 's theory, but not un- der Dr. Pratt 's practice." If the orificial theory be true at all it must be true in its entirely. In my last paper before you I cited a case of asthma which was entirely cured by the ad- ministration of arsenic, and simple dilatation of the rectal sphincters. Today, did time and space permit, I could cite a case of asthma which yielded to no treatment until hypodermic injections of ergot and the internal administration of baryta jod, reduced a hypertrophied tonsil to its former natural size and volume. The relief was then immediate and permanent. Surely there is more in this world than we wot of, and the prophet has truly said our bodies are "fearfully and wonderfully made." I believe all chronic diseases to be aggra- vated by some reflex irritation, and they cannot be perma- nently cured until the cause is removed. Many cases of dys- pepsia have their seat of aggragation in the rectum. Many epileptics could undoubtedly be greatly benefited and probably cured were more attention given to their generative organs. Nasal polypi have caused asthma, and a bean in the ear has produced convulsions. If we desire to become physicians in reality, relieving patients more promptly and thereby gaining more credit for ourselves, we must study our patients more and OBIPIC1AL SURGEEY. 159 their diseases less; we must first find out the cause and then remove it; we must investigate all cases a posteriori and not a priori; we must be what we pretend to be, endowed with wisdom. We are aware, when a nerve is excited, it conveys the im- pression to the nerve-cell in the cerebral cortex or gray sur- face of the brain. This stimulates neighboring cells like a wave circle, so that the disturbance spreads on all sides, as all brain substances which are contiguous and adjacent to the primary irritated nerve-cell decompose and transmute their energy in- to other places and into other forms. Thus we can easily see why an adherent prepuce may produce convulsions, and why a collection of smegma may be a causal factor in the pro- duction of acne. Further, physiology has plainly instructed us that the cerebral cortex receives its stimuli from both the external and the internal nerves of the organism, i. e., it receives impres- sions from both the cerebro-spinal and the sympathetic ner- vous systems. Max Nordau, he of degenerate fame, has aptly expressed it thus: "The cerebral cortex receives its stimuli, not only from the external nerves, but also from the interior of the organism, from the nerves of separate organs, and the nerve centers of the spinal cord and the sympathetic system. Every excitement in these centers affects the brain-cells, and arouses in them more or less distinct presentations, which are necess'arily related to the activity of the centers from which the stimulus proceeds. . . If we, from some cause, maybe ^n affection of the heart or lungs, cannot breathe freely, we have not only a hunger for air, but also accompanying ideas of an uneasy nature, presentiments of unknown dangers, melan- choly memories, etc." Thus it can readily be seen that many chronic affections are produced or aggravated by reflex irri- tation ; that the irritation of an organ begins at its mouth : that remote organs may become involved, reflexly ; and that if we would be successful in eradicating these chronic troubles, we must remove the cause, applying our healing hands to the source. 160 ORIFIC1AL SURGERY. CHAPTER XXI. THE NECESSITY OF THE CONSIDERATION OP RE- FLEXES IN MAKING DIAGNOSES. P. S. REPLOGLE, M. D. I find in the practice of medicine we are too apt to take things as they appear, not as tihey really are. Our patients complain of pain of certain organs of the body and we at once jump to the conclusion that all we need to do is to prescribe the indicated remedy for that organ and our patient is cured. But how often we are mistaken and find things are not what they seem. We find there is something lacking. A patient improves for awhile and we begin to flatter ourselves upon our wonder- ful skill, when lo, we are greeted with the information, "Doc- tor, my old troubles have returned." Now, when we reflect a few moments, in the light of orificial surgery we find we are at fault. In making our diagnosis we have not recognized re- flex action or the real source of the disease. We have simply treated effect, not cause, and I hold no man can treat chronic diseases without recognizing the Philosophy of Orificial Surgery. To suggest to you the importance of recognizing reflex action in making our diagnosis and treating especially chronic diseases, I will mention a few cases in practice : Mr. S., aged 22, a university student, rushed into our of- fice saying, "Doctor, I have heart disease, give m'e something, quick." We quieted the young man, examined the heart care- fully, but could find no organic heart disease. On account of the great anxiety, redness of face, full rapid pulse, etc., we prescribed aconite. In two or three weeks our patient returned with the same symptoms, stating that the medicine helped him at first but he was as bad as ever. The spells were about the same as they had been for two years. Something must be ORIFICIAL SUEGERY. 161 done or he had to give up his studies and leave the University. His father was a physician and expected me to care for his boy while in our town. I was desperate, but orificial surgery came to my rescue. I told the young man I must examine his rectum. He insisted there was nothing wrong with him there and never had been. I insisted there was, and succeeded in examining the rectum. I found an irritable rectum with a few pockets. I inserted a blunt hook into one of them, caus- ing him to faint. I sent him to his home with a written diag- nosis to his father, which impressed him so favorably that he telegraphed for me to come and operate. I performed the American. In due time the son returned to school and was able to carry two extra studies, and was one of the brightest students in the University of Illinois. I desire, however, to say by way of parenthesis, once afterward he came to my of- fice having the same symptoms as formerly. I gave him a few doses of aconite, which helped him immediately and perma- nently. It is now two years since the operation, and with this exception there has been no sign of the old troubles. I will describe an additional case : A man, afflicted with indigestion, vomiting, etc., for years. At one time was unable to retain anything in his stomach for about twenty days. Had pain and especially in the pyloric orifice. The case was diagnosed catarrhal gastritis, obstruc- tion of the pyloris, cancer, etc., and prescribed for by the most eminent physicians of this country. The vomiting was almost continual and the patient was quite weak and emaciated. In this condition the American operation was performed. Silk sutures were used and the four days they remained the irrita- tion of the stomach was fearful. He could not retain a table- spoonful of water or nourishment. The sutures were removed in the evening, the patient turned over in bed and attempted to vomit. He failed. He took nourishment four times during the night and about four times a day for three or four weeks, when he regained his former weight and strength. These are only two cases selected from a large experience in orificial work, but they, like all the others, illustrate the importance of recognizing orificial reflexes. SECTION IV. The Technique of Orificial Surgery. ORIFIC1AL SURGERY. 165 CHAPTER XXII. THE TECHNIQUE OF ORIFICIAL SURGERY. C. S. ELDRIDGE, M. D. To have a general knowledge of certain kinds of surgical work which a surgeon desires to do without first having seen such work done, imposes a task in operating less easy than is the case where one has been an assistant or a deeply inter- ested looker-on. An operation upon the cadaver is beset with no dangers; the heart-beat and respiration are not present as possible sources of anxiety to the thoughtful, conscientious operator. He proceeds with all deliberation and without in- terruption from the flow of venous or arterial blood. He has no concern as to the consequences of shock, and proceeds sim- ply as a mechanic. In the field of amputations, and resection in laparotomies, as well as most other surgical procedures, so much has been written and so many excellent cuts presented that little is to be desired in the way of further information. Concerning ori- ficial work, however, comparatively little information has been afforded the profession. I have been flooded with letters from brother practitioners in all sections asking for instruction as to the methods of procedure in orificial work; and as all do not buy a work on orificial surgery, I have deemed it best to answer through our best medium, the Journal of Orificial Surgery. In order to determine whether orificial troubles exist or not, a few instruments are absolutely necessary. I consider the following indispensable: bivalve rectal speculum, blunt hook, vaginal speculum (Sim's or any good bivalve), uterine sound, a bottle of lubricant and a gynecological chair or table for examination. The position on the left side with knees well drawn up is the one I like best for examination in either sex. With patient in this position the rectum, vagina, uterus and 166 ORIFIG1AL SURGERY. prostate can all be examined. The initial step in an exami- nation should be to pass the finger, well lubricated, into the rectum or vagina. The state of the sphincters can in this way be determined, and, according to sex, the uterus and its ap- pendages, or prostate, gauged as to size, tenderness, etc. A little experience soon renders the digital touch of great diag- nostic value. Man's prostate is to him what woman's uterus is to her; therefore any disorder of these structures should be carefully noted, as diseases of them are prevalent the world over. Here conjoined manipulation establishes its claims to superior excellence in determining the morbid conditions, if any exist, of the uterine appendages. Examinations of the nose, ears and mouth come under the head of orificial examinations ; but as the troubles most preva- lent are found in the rectum, uterus, vagina and urethra, I shall only refer to those in this article, which I wish to make brief. If a patient comes into your office away below par in the matter of health, and the usual routine of questions generally employed, examinations and past forms of treatment have failed to clear up and benefit the case, examine the dependent outlets of the body; ask if chronic diarrhoea or constipation exist; ask for and insist upon an examination of the rectum and urethra^ the uterus or prostate. To do this is to find, in a great majority of cases, chronic in type, piles, pockets, papillae, carunculae, granulation of the endometrium, one or all as ex- citing causes. I proceed with these cases as described, and usually find the bulk of them are susceptible of not only bene- fit but radical cure. Now, if I find these orificial troubles to exist and straightway remove them by surgical methods and my patients get well, there can be no mistake in diagnosis. The rectum is seldom examined. Why should we not examine this part of the economy? Simply because it is the channel through which defecation is effected, should it escape inspection and treatment? Certainly not. Many physicians, however, give it the right of way and leave it to take care of itself. There is not an organ or a structure of the male or female economy that should be allowed an immunity from ex- ORIFICTAL SUEGEEY. 167 animation. A little tact and firmness almost always will en- able the physician to push his examination as far as he de- sires and as far as is necessary in these cases to arrive at cor- rect conclusions. There is a great difference in patient so far as suscepti- bility to pain is concerned. Some are so profoundly influenced by the introduction of a speculum into the rectum that syn- cope follows. I have never failed to find, in such cases, a diseased state of the last inch of the bowel. Some are greatly distressed by even the gentle introduction of the lubricated finger. To attempt the use of a speculum in such a case would be a folly and a failure. It is a rule with me, in these cases, to advise an examination during a state of anaesthesia, of course being prepared to do any operating the revelations of the case suggest. A rectum too sensitive to stand examinations without ether I always find the seat of morbid structural changes. A tight sphincter is an index of trouble in the pile-bearing inch of the rectum. I find this the case without exception. To not locate orificial trouble is to make but poor head- way in diagnosticating chronic ailments. By it reflex causes are found and pathological phases determined. After the rec- tal speculum is introduced, it should be opened slowly by gent- ly approximating its handles, care being observed to go only so far with dilatation as patient is willing to tolerate. To go beyond this point will inflict excruciating pain and probably lose you a patient. The set-screw maintains dilatation at any point desired. When the speculum is introduced and blades separated, the blunt hook should be employed for the detection of pockets and papillae, as these are pests most frequently found, creating appalling nerve waste, which we see revealed in the endless array of chronic maladies. A pocket is a solution of the continuity of the mucous membrane of the rectum, and may be likened to a pocket in a slipper case such as hangs upon closet doors. They are easily detected by the blunt hook, which, if held at the right angle, easily slips into them. A papilla is a teat of elevation of tis- sue on the surface of the rectal mucous membrane; and if a 168 ORIFIGlAL SUKGEEY. person ever had one and at the same time maintained a maxi- mum standard of health, I would like to know it. No such case has ever come under my observation. External piles it requires no skill to detect. When these are found, pockets are usually found which antedate them. I treat all cases of external piles with a clamp of my own in- vention, which cuts and clamps simultaneously. By its use, enormous external haemorrhoids are removed with the loss of less than a tablespoonful of blood. Straight needles two and a half inches long are passed behind the clamp, armed with carbolized silk. After this the clamp is removed, when the severed edges of tissue are coapted by tying the suture silk already in place. Before tying, the tissues included in the ser- rated portion of the clamp should be trimmed off close to, but not beyond, the clamped tissue. In rectal operations, the lithotomy position I like best. The mode of operation for removing pockets and papillae is as follows: Patient in dorsal decubitis, thoroughly anesthet- ized. Just here examine pelvic viscera by digital touch or conjoined manipulation to avoid injuring the uterus, ovaries or prostate if these organs are unusually large or in a state of chronic inflammation, as by the use of the rectal speculum about to follow, great damage and aggravation of already ex- isting troubles might ensue and the operator be charged with ignorance, negligence, and making his patient worse instead of better. Now gently introduce the bivalve rectal speculum, well soaped, the rectum first having been treated the same way; and by compressing its handles dilate to the extent of separat- ing the blades of the instrument an inch or even a little more. At this juncture, have an assistant take charge of the handles of the speculum so that the blunt hook can be employed by the operator for the detection of pockets. When one is found into which the blunt hook passes, a long-handled tenaculum is used and passed from the top to the bottom of the pocket, en- gaging only mucous membrane. Now a pair of double curved scissors are used to cut the pocket out from top to bottom. Only slight haemorrhage follows this procedure. If a papilla is encountered, lay hold of it with tissue forceps and with scis- ORIFIC1AL SURGERY. 169 sors cut it off level with the mucous membrane. Any internal haemorrhoids that are found should be seized with a small clamp (I have devised one for crushing internal piles) so as to prevent bleeding; and when well pinched they should be removed with the double curved scissors. The curved variety is employed to avoid cutting contiguous tissue. I have the greatest satisfaction in using the little clamp mentioned as it so thoroughly controls haemorrhage. When the rectum is rid of piles, pockets, papillae, one or all, look for blind fistula and if such trouble is found, make the opening co-extensive with the cavity beyond it and curette thoroughly. To touch the fistulous tract, after curetting, with carbolic acid, one to ten or twenty, would not be amiss. As the internal sphincter is presided over by the sympa- thetic, over-distension of it should be gradually, carefully, yet completely accomplished. Respiration is sometimes profound- ly affected by too vigorous dilatation. When this phenome- non is observed, stop the dilatation or modify it according to the necessities of the case; never, however, leave a patient after having done work upon the pile-bearing inch of the rec- tum without doing as a finishing feature as an indispensable auxiliary complete dilatation, carried usually in adults to the point of closing the handles of the speculum. This es- sential part of orificial work frees the sympathetic of its bur- den and allows the capillaries immediately to fill. The truth of this is easily demonstrated; take a patient worn down with nerve waste to the extent of habitually having cold hands and feet. When such a patient is put on the operating table, the extremities are found to be cold. After complete dilatation, examine and they will invariably be found warm. What does it? Indisputably an improved capillary circulation. After operations upon the rectum, there is in a small percentage of cases, some pain at- tended by a smarting which compresses wrung out of hot water to which Pond's Extract in small quantities has been added, will very soon stop. Occasionally where much rectal work has been necessary, an example of powerful reflex action is shown by inability to operate the vesical sphincter; reten- 170 ORIFIGTAL SURGERY. tion of urine is temporarily established and sometimes for a day or more a catheter must be called into requisition. Such things as these impress me greatly in studying reflexes. Whenever a patient stops breathing under ether, don't get excited, elevate the patient's heels, essay artificial respira- tion and other irrational maneuvers. Simply pass a rectal speculum and quickly open it a little; it will astonish and please the most incredulous to see the response of the respira- tory center and start breathing instantaneously. The shock or impetus given the sympathetic distribution of the internal sphincter will put things in motion as expedi- tiously as the great Columbian Exposition machinery was when President Cleveland touched the magic button. Only a trustworthy assistant should be allowed to administer the an- aesthetic during orificial work. Beside him, it is necessary to have two other assistants, one upon either side of the operator, to pass instruments, hold speculum, tenaculum, blunt hook, clamp, control irrigation, etc. A hard table and a good light are desiderata to be appreciated. I use a Kelly cushion to con- duct water and debris into a portable washbowl placed at the operating end of the table. Thorough curetting and ample stretching quickly disposes of that painful trouble known as fissure of the anus. Orificial work does not mean rectal work alone; there- fore, every meatus that is too small, whether congenital or not, should be enlarged cutting from above downward, a grooved director being used to guide the knife. The prostatic urethra is a locality prone to various forms of difficulty that cause much suffering, mental and physical, in the male portion of the community; therefore, a sound well soaped should be passed to ensnare secretions. When mucus is found adhered to the instrument, it shows a lesion of the mucous membrane usually about the opening of the ejaculatory ducts, possibly at some other point likely in the veru montanum. Sounds sub- sequently passed once in a week or ten days usually tone up such cases for me. The female urethra should be examined for carunculae and if any are found, they should be cut out or re- ORIFIC1AL SURGERY. 171 moved by the Paquelin cautery. To do the rectal work and leave carunculae would insure a fiasco. In vaginismus, I use the rectal speculum and thoroughly dilate the vagina with it, removing before I stop, every portion of the inflamed hymenic fringe. Ragged mucous membrane is treated the same. If there be any undue sexual excitement so as to make it a feature, I look for the clitoris which is liable to be found hidden almost out of sight by a tight and overlap- ping hood. I remove enough tissue at the commissure to free the organ, this being virtually a female circumcision. Remov- ing smegma completes the treatment here needed. The ablation of the clitoris is as a rule barbarous, inhu- man and unscientific. Free it, and good results will follow; modification and not annihilation is best. If a cervix be found with a cicatrix, dilate thoroughly and remove it. Let me ad- vise nay more, warn you, however, against dilating a uterus that has an old scar in its cervix, which scar is responsible for reflex disorders. To dilate and leave the cicatrix behind as an enlivened element of danger, will not add to that surgeon's glory who does it. CHAPTER XXIII. SURGICAL JUDGMENT. CURTIS M. BEEBE, M. D. The first principle to be observed in the practice of ori- ficial surgery, as in all surgical work, is thorough surgical cleanliness. Infection of a wound from an unclean atmosphere or improperly cleansed instruments or hands not made per- fectly aseptic, will be the greatest barrier to success to those not trained in hospital service. The second principle to be observed is the selection of the case. Not all cases of chronic disease, and very few cases of acute disease, are amenable to orificial treatment. For ex- ample, cases of pulmonary or intestinal tuberculosis are not 172 OEIFIC1AL SURGERY. favorable subjects for orifieial surgery after they have de- veloped a temperature above the normal. Pus cases are not proper orifieial cases until the pus has been evacuated and thorough drainage established. Then, repair may often be hastened by attention to orifieial details. Third, each case should be diagnosed as accurately as is possible, in order to state positively to the patient and friends the length of time of treatment. Some cases require only one month, while others demand one or more years. The prognosis is of the utmost importance to our patient. Fourth, all of the sources of irritation should be diligent- ly sought at the first examination, and each one should re- ceive attention according to its importance. Two cases of uterine fibroid presented themselves for treatment at about the same time and for nearly the same symptoms. Both were subperitoneal. One was as large as an orange; the other filled the pelvic basin. Both suffered from headache, which was described as excruciating and unbear- able. Both had obstinate constipation and backache. Both had grown from posterior uterine wall, and rested heavily upon the rectum. Both had large hemorrhoids, as would be expected from the direct pressure. The American operation, with thorough flushing of the colon, repeated several times, relieved the headache and backache almost completely. The tumors are both diminishing slowly in size under the galvanic current and the iodide of calcarea, 2x trit. The large tumor is now about the size of an orange, and the smaller one not larger than an egg. Each patient has had about twenty elec- trical treatments. The American operation gave immediate and permanent relief of the symptoms most complained of, and has undoubtedly assisted in the reduction of the tumors. Mrs. S., from South Carolina, visiting in Chicago, present- ed the following history: Age 45, anjemic, could see through her ears, emaciated, tenderness over liver, skin wrinkled and yellow, suffered from headache and neuralgia. Neuralgia un- doubtedly malarial in origin, as she has been a victim of chills and quinine. Had passed blood from rectum with stools for more than a year. The American operation, followed by dila- ORIFIC1AL SURGERY. 173 tation with rectal plugs after three or four weeks, left her prostrated, and I sent her home with some misgivings. It is now one year since the operation. She has gained 43 pounds, and says she is perfectly well. It has been my observation that cases of anaemia require from three to six months to furnish them rich blood. Having several cases of anasmia under treatment, most of them passing the food more or less undigested, I had an opportunity of test- ing homoeopathic treatment with and without orificial aid, some patients refusing orificial treatment. Gale, phos., aresni- cum and other remedies were employed in the cases not op- erated upon, but almost every case became discouraged and disappeared from observation before the cure was completed. The orificial cases went through the uterine packing, or Ameri- can operation, or both, and after a few weeks began to gain both in color and weight. Of many cases of constipation, only a very few have re- sisted orificial treatment. One case of chronic pyelitis was cured after six months' faithful prescribing, after the orificial work had put new life into a wreck of a human being. Pour cases of sciatica have been thoroughly cured by persistent and repeated applications of orificial philosophy. The result of much labor and study has convinced me that my failures have not been from any defect in the philosophy, but from my imperfect or unwise application of its principles. CHAPTER XXIV. ORIFICIAL SURGERY ITS DANGERS AND POSSIBILI- TIESA PREVENTIVE MEASURE. E. H. PRATT, M. D. I feel more than ever the importance of laying especial stress upon the fact that orificial surgery is an edged tool, capable not only of infinite good, but also of infinite harm. That it is not merely local work, but has a profound effect 174 ORIFIC'IAL SURGERY. upon the capillary circulation of the entire body; and that it is not to be undertaken with impunity, or to be carried out without a proper degree of caution. Submitting patients to the shock of a thorough operation in orificial work at the office and permitting them to walk, ride or go about their business as before, is hazardous in the extreme. Several deaths have already been caused by this practice and more will be caused unless it is stopped. Galen claimed that any power that instantaneously affect- ed the entire circulation of the body was a dangerous one and must be handled with extreme care, and his observations were undoubtedly correct. Orificial surgery is one of these meas- ures. As quick as thought, dilatation of the lower openings of the body lifts the flood gates of the circulation and flushes the capillaries universally. The conditions must be right, the subsequent care adequate to the severity of the measure, in order to employ the process with safety. This calls to mind the fact that, whereas, in all cases of chronic disease, there is orificial irritation, we must consider how this irritation can be taken away and the undue tension of the sphincters relieved without danger to the patient. Some constitutions are strong and can bear this sudden shaking up with perfect safety and magical benefit. Others are so sensi- tive as to be unable to tolerate the shock with safety. How can we handle these more delicate cases and ac- complish our purpose of relieving the irritation and correct- ing the stenosis of these parts; knowing its profound effect upon the whole system, at the same time, always do good and never harm A blow that a professional pugilist would stand with im- punity would probably kill men who were unused to such se- vere concussions. There is such a thing as becoming inured to shocks and that fact can be employed to advantage in ori- ficial methods. In your weak, delicate subjects it would be well to begin with a gentle dilatation of the rectum, with the occasional passing of a sound, and employing these methods at long or short intervals according to the necessities of the case. ORIFICIAL SURGERY. 175 and subjecting the patient between times to other means of flushing the capillaries, such as massage, spinal fomentations, static electricity, abdominal respiration, etc. After the patient has been carried by these milder meas- ures to a point where they fail to any further improve his condition, by that time his system has become sufficiently ac- customed to the flushing of the capillaries occasioned by the methods employed, that he is ready for whatever surgical work may be necessary to put the parts in proper condition. The anaesthetic may then be employed and even the se- verest forms of orificial methods, not only with safety, but with the happiest of results. Too much stress cannot be laid upon this thought for, to the casual observer unfamiliar with the effect of orificial work, it seems such a simple matter to do a little pruning and dilatation under an anaesthetic, that they can scarcely believe the effect upon the entire system will be so profound as it really is. After a few patients have been killed and paralyzed and rendered insane by the careless handling of the work, the op- erators will acquire a more profound respect for it; but all these unhappy experiences can be saved if they will only take warning from those who have already had experience, and handle the work with the proper degree of caution. By thus preparing the patient for the final work by re- peated flushings of the capillaries, by dilatations and other measures, much of the debris of the system which has long been stagnant, is aroused and carried away and when the necessary operation is finally performed, there is much less general disturbance of the system for the patient to contend with. His powers are less taxed and his benefit is correspond- ingly more speedy and satisfactory. It is a very good plan in delicate cases when it comes to the operation after the preparatory work has all been done, to administer a hypodermic injection of a small dose of morphine at the time of beginning the anaesthetic. This reduces the amount of anaesthetic required, lessens the shock to the sys- tem, and insures a satisfactory reaction. [H. M. C. is better than morphine. Ed.] 176 ORIFIG1AL SURGERY. Orificial surgery has passed through a terrible test of its merits up to the present time. It has appealed to the profes- sion and asked for simply the incurable cases; it has solicited simply the debris of professional work; the cases which have been incurable by all other measures combined; the offscour- ings of professional practice. It has sought for the paralytics, asthmatics, dyspeptics, insane and all other incurable affec- tions; cases so sleepy in the march of life that it seems as though little short of Gabriel's trumpet could speak loud enough to them to once more arouse their systems to healthy action. Orificial surgery has proved its remarkable power to arouse active reaction in this class of cases, and thousands up- on thousands of suffering humanity have been restored to health and happiness by the employment of its measures which before were doomed to lingering disease and premature de- parture from this life. The measures employed for this class of cases have been severe, but the cases were severe. When nature sleeps, a meas- ure whose aim is to arouse her will will have to be propor- tioned to the profundity of the slumber; but all this vast amount of experience with orificial methods accumulated by the small army of workers in this new specialty has proven one thing beyond question, namely, the power of the work. When opium, or morphine, or cocaine, or chloroform, or ether, or any other narcotic has been imbibed to the point where death is imminent, so imminent indeed that artificial respiration, electricity, nitrite of amyl, inversion of the pa- tient, transfusion and all other means known to the profession for resuscitating a narcotized patient have been of no avail, orificial methods have been repeatedly employed with success. It is now becoming very widely known that the rectal bivalve is the greatest resuscitator on earth. It has sobered the drunken, awakened the narcotized, revived the asphyxiated ; and dilatation of the anus has also repeatedly introduced the stillborn infant to its first gasp of breath when its life seemed a forlorn hope. OEEFIC1AL SUE&EBY. 177 Now that it has proved itself such a power and has cured such a large percentage of cases which by other means have been incurable, in its next stage of development it will be con- sidered as a means of prevention as well as cure of disease; for as stupid as humanity is in some respects, it really does a little quiet, sober thinking once in a while; and there is a phrase apropos in the present connection which has long been crystallized as an axiom of human experience, namely, "it is easier to prevent than it is to cure." In surgery everybody knows that if you can cure bed- sores, you can prevent them and people must be aroused to the same philosophy in chronic diseases if they can be cured they can be prevented. It takes terribly harsh and severe measures when they are desperately ill to cure them. It will take much milder and gentler forms of treatment to prevent them getting sick. This principle is well illustrated in the history of den- tistry. It is within the memory of all of us when the main business of the dentist was to pull teeth aid furnish false sets. It was bloody work, painful work, destructive work, but it stopped the toothache and enabled people to masticate their food a good deal better than they could with a mass of irri- table decayed teeth in their mouths. But what a change. The best dentists today do not pull teeth at all or, at least, in very exceptional cases. They regard it as a poor compliment to their skill if they cannot take a badly dilapidated mouth and restore it to a good condition without tooth pulling. And the people have become so enlightened upon this subject that they know now that tooth pulling is unnecessary and that if they will only go to a dentist in time, when the cavities are very small, by keeping their teeth in constant repair, they can retain their natural teeth during their lives. So, the dentists have already run this gamut of their ex- perience. They have stopped destroying and have educated people to the point where their main work is in the line of prevention; and what a grand progress to have made in such a short time as they have been at work in this direction, 178 ORIF1CIAL SUKGERY. Does this not furnish us an example of what will be re- quired of Orificial Surgery? If it can take this army of broken-down, dilapidated, distorted and badly maimed mass of humanity, all included in the general list known as chronic diseases, and cure such a large proportion of them, it can cer- tainly, by earlier attention to the lower orifices of the body, prevent them. One of the difficulties of the situation lies in the fact that the orificial irritation which does the most mischief is not pain- ful and consequently presents no symptoms of which the pa- tient is conscious, and he does not know he is out of order and wasting his nerve power unless he is told so by a competent examiner. Sexual waste is not painful, spasmodic contraction of the internal sphincter caused by the presence of pockets or pa- pillae or any other form of irritation in the last inch of the rectum is not painful and these sources of nerve waste can go on indefinitely until the reactive power of the patient is well- nigh spent, without the patient being in the least degree con- scious of any form of irritation whatever. The dentists have had the advantage over us in this re- spect; when the tooth is decayed to a sufficient extent the pa- tient will suffer enough pain to drive -him to the operating chair for relief. But the nerve waste which orificial surgeons are seeking to correct is so painless, because it is that of the sympathetic nerve instead of the cerebro-spinal, that it takes a high degree of education to comprehend that the entire list of human ills, in all their varieties, may be induced by morbid conditions so remote from the part apparently affected. In other words an appreciation of the meaning of peris- taltic actions and of reflexes and other topics essential to the knowledge of orificial principles involves a degree of educa- tion which will necessarily require much time to accomplish, but it must be done. Sick and suffering humanity are appealing to us for relief so strongly that we cannot escape the cry, but must struggle on in the great work we have undertaken. ORIFIG1AL SURGERY. 179 I visited the other day one of the State Insane Asylums of Wisconsin. There were over six hundred inmates of this in- stitution. No effort is made, whatever, to cure these cases ; they are simply clothed, housed, fed and sufficiently guarded to prevent injury to themselves and their fellow prisoners. There is another and still larger institution of the same kind in the State. There are still more such institutions with still more inmates in the State of Illinois ; and these two States are no exceptions to the other States. The insane of this country are among the hundreds of thousands with not a voice raised or a hand lifted for their re- lief. If the people only knew, if the doctors only knew that this entire army of howling maniacs were simply suffering the tortures of physical distress which it is possible to remove, and that fully three-fourths of them could be restored to their right minds, their health and their friends by the application of orificial methods in a few weeks' time, our task would be a lighter one. My friend', tlrs fact is not known, it is not believed; but you and I know it and our task is no light one, to enlighten the public and the profession in this direction. The help which is at our command must be extended to the insane and our duty will not be well done until the magical action of ori- ficial work is made possible for this most distressed and piti- ful class of chronic sufferers. Chronic sufferers generally can shift for themselves. They can read, they can investigate, they will hear of the accom- plishments of Orificial Surgery and apply for relief in due time without any effort upon our part. All we have to do is to cure cases and the good news will spread ; but it will not reach the insane in this way. These poor victims of reflex irritation have lost their judgment and have been deprived of the very means by which otherwise they could search for res- pite from their pitiable condition. It is your duty and mine to see to it that the attention of the authorities who have charge of this class of cases is at- tracted to the curative power of orificial methods and that suf- ficient pressure is brought to bear upon them to induce them 180 ORIFIG1AL SURGERY. to give their patients the benefit of the work. Such cases can- not be taken to sanitariums, they cannot be treated well at their homes. The place to inaugurate the treatment is right in the insane asylums themselves. It is not enough for these cases that the grounds are am- ple, the surroundings pleasant and that they have food, light and air and general hygienic measures. They had all these at home but they have gone daft from the physical conditions of their bodies; and is it not a crying Bhame that not a hand is lifted anywhere to pull these thorns from the flesh, to relieve these agonizing sufferers from their living death? For my part, although I am not pugilistic, my blood boils and I feel like joining a crusade in this direction; and here again comes in the thought that prevention is better than cure. These cases are desperate ones and will require the se- verest of measures. What a grand achievement it wjll be for us when people begin to recogn : ze the fact that it is no more n? *:ural to lie, or commit adultery, or steal, or to violate mental laws, than it is to limp or wheeze or cough or show physical weakness in any particular; when these aberrations from correct rules of liv- ing will be regarded as disease and we will be permitted to employ our knowledge of orificial principles earlier in the his- tory of our cases, when we can be appealed to to keep bodies in order, to prevent disease rather than to cure it ; having now proved the power of the work and what can be done in the most desperate of all classes of cases, even after hope has be- come forlorn and visions of future health and happiness have grown dim. Let us agitate this subject until we arouse our kind to an appreciation of the fact that chronic diseases can be prevent- ed ; that it is more essential to keep the lower openings of the body in repair than it is the upper ones; that it is not neces- sary to wait until one is at death's door to receive the ad- vantage from the knowledge which orificial surgeons possess; but, that it is much better to submit to an occasional examina- tion and be kept in order, thus insuring healthy peristaltic ORIFICIAL SURGERY. 181 actions, an even distribution of the blood current, universally successful and satisfactory nutrition and its attendant bless- ings. In other words, let us work on in our field of labor until the world at large begins to realize that it is easier to prevent than it is to cure, and that what can be cured can certainly be prevented. CHAPTER XXV. A CONSIDERATION OF ORIPICIAL METHODS AND OPERATIONS. E. H. PRATT, M. D. If we have succeeded in our purpose thus far, it will be evident to those of our readers who have kept the thread of our logic, that all chronic cases, upon examination, will be found to present some form of orificial irritation sufficient to explain the lowered vitality which has permitted them to re- main in an abnormal state. In all forms of chronic diseases, therefore, from functional derangements to the deeper forms of pathology, the lower openings, which involve the waste of sympathetic nervous force, and which are, therefore, responsible to a certain ex- tent, for a lack of reactive power on the part of the patient. Chronic diseases always have two causes, a predisposing and an exciting cause. If we are correct in our position, ori- ficial irritation is the predisposing cause of chronic diseases generally. If this be true, the first step in the treatment of chronic cases should be to remove the first cause ; that is, to correct the orificial irritation and stop at once the prodigal waste of nerve force involved. How to accomplish this with safety and with certain benefit to the patient is a great prob- lem, which we shall now consider as thoroughly and carefully as is consistent with the space and ability at our command. 182 ORrFlCTAL SURGERY. Orificial surgery is an edged tool it can cure, it can also kill. After all other means known to the medical profession for the relief of human suffering have failed to re-establish health, orificial surgery can, in a majority of cases, produce such startling and satisfactory results as to be a perpetual surprise and consolation even to those who are familiar with its marvelous power. It often seems well-nigh impossible to become familiar with the application of the work to the vari- ous forms of chronic diseases, to escape entirely the feeling of astonishment at the rapidity and surprising transformations which are common in the experience of every orificial surgeon. When a human being has suffered from asthma for twenty years to a distressing degree, until life has become a burden, to see the entire difficulty disappear like magic from a piece of surgical work, which should not occupy more than fifteen or twenty minutes in its performance, will always astonish the operator, no matter how many times such wonderful trans- formations may come under his observation. When dyspepsia, which has been so persistent as to require the use of a stomach tube daily for a number of years, disappears in a single day as the result of a little orificial work, the change will always be an awe-inspiring one to the operator. When an eczema of many years' standing will entirely melt away without the aid of medicine in the short space of a week's time, and some- times sooner, under the magic touch of orificial surgery, it never ceases to be a wonder how such results can be accom- plished. One orificial surgeon who has been familiar with the mar- velous action of the work for many years, writes only recently, "The effect of the work upon cases of phthisis in the first and second stages is truly startling in many cases." Another emi- nent practitioner of extensive orificial experience is still sur- prised at his marvelous successes in his treatment of cases of insanity. Insomnia, constipation, chronic diarrhoea, epilepsy, par- alysis, dropsy, exophthalmic goitre, neuralgia, chronic head- aches, etc., are repeatedly cured with such marvelous com- ORIFICTAL SURGERY. 183 pleteness and rapidity as to be a perpetual surprise even to the most experienced operators. But there is another side of the picture which should never be lost sight of. All cases are not brilliant ones ; nor do all result satisfactorily in the end. Orificial surgery can not only rekindle the blaze of life when it is burning low, but it can also extinguish it. It should always be remembered that it is not merely local work, but that it Always exerts a pro- found effect upon the entire capillary system of the body, af- fecting profoundly all its functions and conditions. How will it be possible ever to tell the story of its curative action graphically, and at the same time represent the mis- chief which it is capable of doing, so that every doctor who employs it as a means of cure will always make such wise se- lection of the cases in which he deems it applicable, that he will invariably employ it for good, and never for harm? Such excellence of judgment has never yet been achieved with any other remedial measure. Drugs, massage, electricity, baths, mental therapeutics, and all other healing measures at the com- mand of the medical profession, are likewise agencies for either good or harm, according to the skill with which they are ad- minstered. And even with these measures humanity is fre- quently hurt, as well as helped; it is often permanently in- jured, even to the point of death, as well as satisfactorily re- lieved of its distresses. So long as human judgment is thus prone to err in everything else, it is scarcely to be expected that orificial surgery, which is more potent for good, and con- sequently for harm, than any other measure, will be employed with any greater degree of skill and judgment. Our duty to the profession will have been done when we have presented not only the good of which the work is capable, but also the harm; and we shall endeavor, before our task is ended, to so truthfully represent not only the possibilities of the work, but also the work as it actually is, recording its fail- ures as well as its successes, that to all fair-minded members of the medical profession it will be made to appear in its true light, neither embellished by the gaudy coloring of excessive 184 ORIFICIAL SUROERY. enthusiasm, nor obscured by the over-caution of a too excess- ive conservatism. Let us take it for granted, then, that all sufferers from chronic disease are also possessed of orificial irritation, and that their permanent recovery demands its removal. We are then prepared to consider the application of orificial princi- ples and methods to chronic diseases, and to estimate them at their true value. Orificial work is not necessarily operative work, and in the employment of the philosophy the orificial surgeon will readily divide his cases into two classes: first, those demanding operative interference; and second, those who can be cured, or sufficiently benefited by simpler orificial measures. Hippocrates wrote that all measures which produce a sudden change in the circulation of the body are dangerous ones and should be handled with extreme caution. We can endorse the wisdom of this statement, and therefore begin the consideration of the application of orificial surgery to the treatment of chronic diseases with the caution that great care and judgment must be exercised in the employment of orificial methods. Let us first consider briefly the non-operative measures at the command of orificialists and the cases to which they are ap- plicable. In general terms these consist of dilatation of the sphincter-guarded openings of the body and the application of heat and cold, and dryness and moisture, and massage and electricity employed locally. DILATATION. In all cases where dilatation is to be practiced, it is bet- ter to make use of graded sizes of cylindrical tools in prefer- ences to valvular ones, when practicable, because it involves an evener dilatation and less bruising of the parts. Dilatation is servicable in the rectum, in the male and female urethra, in the vulva and vagina, and in the uterus. Considering dilata- tion of these parts in the order in which they have been named, we will first speak of the dilatation of the rectum. For this purpose rectal plugs are frequently serviceable. ORIFIC1AL SURGERY. 185 DILATATION OF THE RECTUM. It is well to begin with the smaller sizes and pass on to the use of the larger ones as the parts become accustomed to their use. Rectal plugs can be employed daily, or weekly, or bi-weekly, and can be immediately withdrawn after insertion, or permitted to remain for half an hour or two hours, at the discretion of the surgeon, the size employed depending upon the comfort of the patient, and the length of time they are al- lowed to remain introduced depending upon the extent of re- action which it is desirable to secure. Dilatation of the anus affects more profnundly the respi- ration, and consequently the capillary circulation, than that of any other of the lower openings of the body. In health, nature secures a daily flushing of the capillaries by the pas- sage of large, solid masses of faecal matter. In cases of chronic constipation and chronic diarrhoea, the system fails to receive its daily benediction of renewed vitality, and suf- fers from a lack of it. The rectal plugs may be made to act as a substitute for natural dilatation in such cases, and un- aided by other measures, will often restore the habit of the bowel to a normal state, after which their use can be aban- doned. The dilators can be used daily in such cases until they have established a satisfactory reaction and the habit becomes normal, or until the irritation which they sometimes induce causes a feeling of pressure at the base of the brain, or local soreness, when their use should be suspended for a time until the irritation has passed away, after which they can be again employed and their action continued until health is restored, or they fail to be of further service to the patient. Rectal dilatators may be employed not only by physicians, but may be entrusted to the keeping of intelligent patients to be used at their own discretion. The use of a rectal dilator when one is tired is more invigorating than stimulants. They are also of service in resuscitating a patient from an epileptic seizure, or a fainting fit, from opium or other poisoning, and from drowning. They are remarkably efficacious in aiding a new-born infant to its first gasp of breath, and in establishing reaction after prolonged illness, as typhoid fever, diphtheria, 186 ORIFICIAL SURGERY. pneumonia, gastritis, etc. They are good for a tired brain and a tired body and are perhaps superior to any other general or remedial agent as an invigorating tonic. In severe cases, as those of convulsions, it is well to use the larger sizes at once, allowing them to remain in position at the discretion of the at- tending physician. The attention of the laity, as well as the profession, should be attracted to the action of the rectal dilators, until the fact becomes well known and established, that anal dilatation flushes the capillaries of the body universally, thus immediate- ly equalizing the circulation and thereby relieving local con- gestions wherever they may be located, be they in the head, kidneys, stomach, liver or elsewhere. If the most important truth which the orificial philosophy has presented to the world were to be selected, it would be that anal dilatation flushes the capillaries, and has a tendency to readjust the inharmonious action of a diseased body, what- ever form its deviation from normal standards may take. The benefit of heat or cold, or the alternation of the two, may be added to that of dilatation by employing what is known as the Eldridge dilators, these being the same form as those al- ready mentioned, differing from them in the possession of an adjustable top, upon the removal of which the hollowed di- lators can be filled with hot or cold water at pleasure. Some- times the prolonged application of combined heat or cold and dilatation at the anus is invaluable as a means of resuscitation. We can recall one case in which a knowledge of this fact was the means of saving a life. A pregnant woman near her confinement was suffering with acute Bright 's disease, which terminated finally in convulsions, demanding her immediate delivery. The child was safely delivered and lived, but soon afterwards the mother suffered a return of the convulsions in such a severe and persistent form that it was deemed neces- sary to keep her under the continued action of chloroform for many hours in succession. For three hours she stood the se- vere ordeal without the convulsions and without apparent harm. After that time she became gradually cyanotic, her chest filled with mucus, and the further administration of ORIFICIAL SURGERY. 187 chloroform became extremely dangerous. At the same time it was deemed equally dangerous to permit her to awaken from the anaesthetic, as sufficient time had not yet elapsed to ensure her against the return of the convulsions. In this extremity, a rectal dilator was inserted, through which a return stream of hot water could be passed thus administering to her the double effect of dilatation and dry heat at the anus. Imagine the feeling of delight which her physicians experienced when they saw the cyanosis disappear and the circulation of the lungs become so thoroughly established as to be entirely cleared of their obstructing mucus in the short space of five minutes' time. And this, too, while she was still inhaling the fumes of the chloroform. After employing the heat and dilatation for about fifteen minutes it was discontinued, and she was again safely narcotized for several hours, when once more it was necessary to resort to the same measures for re-establishing her vitality. She was kept anaesthetized by chloroform by the aid of the dilatation and heat occasionally applied at the anus, for eighteen hours, after which, as all convulsive symptoms had passed away, she was permitted to awaken from the an- aesthetic. The convulsions never returned and she made a rapid recovery, which in her case we are satisfied would not have been possible had it not been for the employment of the heat and dilatation. When the case is extreme, as in threatened death from chloroform not like the case just described, but in case of a sudden cessation of respiration and circulation, or in cases of drowning, or convulsions, or syncope the bivalve speculum is perhaps more serviceable than the rectal plugs, as dilatation in such cases is needed beyond the capacity of the plugs ; al- though great care must always be exercised not to overdo the dilatation, because it is possible in any case to put out a flick- ering flame of life in a careless effort to merely fan it back into a steady flame. As we have no interest whatever in the sale of tools, never having patented an instrument of our invention, nor possessed any interest whatsoever in their sale, we feel at liberty to speak freely of their general usefulness. 188 OBIFICTAL SURGEEY. The rectal plugs are not desirable as means of dilatation for operative purposes, at least, unless still larger sizes are employed than those already in the market. The bivalve speculum employed under an anaesthetic is so satisfactory a means of securing a proper degree of dilatation in all cases where an operation upon the anus is contemplated, that it will in time come to be universally relied upon for this purpose. The manner and proper time for securing dilatation for oper- ative procedure will be discussed in connection with the va- rious operations upon the rectum to be later described in this series of articles. One word more about dilatation of the anus before we dis- miss the subject. From the remarks already made it will be inferred that it is of great service as a general measure in the various forms of chronic disease. It is also serviceable for some forms of local trouble. Unaided by any other measure, the use of the rectal plugs will relieve both bleeding and blind piles. They will overcome, in a great majority of cases, a con- stricted anus, and will strengthen and restore to a normal state a relaxed enervated one. They will not take the place of the more radical measure of orificial surgery by any means, at the same time they occupy an important place in the list of orificial measures. It must always be remembered that the work is orificial and not rectal and that in an effort to correct rectal conditions it will almost invariably become necessary to consider the condition of the other orifices in the pelvic region. DILATATION OF THE FORESKIN. This has been practiced by a good many physicians in cases of contracted prepuce, in hopes to avoid the use of the knife, and the practice is favored by a large number of intelli- gent practitioners of medicine. Personally we have been so satisfied with the more radical forms of procedure where the foreskin is in an abnormal state, that we have never given the process of dilatation a sufficient trial to enable us to deal with the subject fairly. Where the foreskin is either too long or too tight, we have been so accustomed to the operation of circumcision, and to the OEIFIC1AL SURGERY. 189 dorsal slit, and been so satisfied with results obtained that we have had no occasion to abandon the practice for the purpose of experimenting with dilatation. For this reason we should like to hear from those who have practiced dilatation as to the degree of satisfaction which they obtain from it. DILATATION OF THE MALE URETHRA. It is best accomplished by the use of graded steel sounds. Personally we prefer the Van Buren sound, and are accus- tomed to the English numbering. The double sounds, which we have had constructed, were designed to economize in num- ber and weight of instruments, and are in every way satis- factory. The sounds, like the rectal plugs, have a general and local use. As sexuality is sustained by the sympathetic nervous force, the tonicity of the sexual organs may be taken as an index of the quality and character of peristaltic actions throughout the body. States of sexual excitability indicate an irritable condi- tion of the involuntary muscles which surround all iftbular structures, and patients suffering from this affliction arc prone to active congestion of whatever part may be weakest or most severely taxed. On the other hand, sexual weakness or atony is an index of weakened peristaltic actions, and an invariable precursor of whatever passive congestions the general system may be subject to. The employment of sounds, either hot or cold, or both, is a necessary remedial measure for these opposite conditions. While it will allay irritability of the sexual organs and its ac- companying general sympathetic hyper-aesthesia, it will also restore wasted sexual powers to their normal condition, and thus act as a universal sympathetic tonic. They may be in- serted and immediately withdrawn or permitted to remain from half an hour to two hours; they may be employed either hot or cold, or employed both hot and cold at the discretion of the surgeon, as in the case of the rectal plugs. Unlike the rectal plugs, however, they should never be used by the pa- tient, but always employed solely by the physician. Any one of ordinary intelligence can introduce a rectal plug of proper 190 ORIFIG1AL SURGERY. size without detriment, but the proper use of male soimds is a matter of such delicacy that they are often harmful even in the hands of physicians themselves. We cannot, therefore, too strongly urge even physicians to be cautious in their use. When they are to be employed for their general effect upon the entire system, the size of the sound, the length of time it should be left in position, and the question as to whether it should be employed hot or cold, or both, depends entirely upon the reactive power of the patient. In cases of nervous irritability, where reaction is speedy, the mere intro- duction and removal of a warm sound will give the sympa- thetic nervous system a sufficient impetus to restore it to a normal state. In states of sympathetic anaesthesia, however, where all the bodily processes are sluggish and indolent, it may be necessary to leave a warm sound in position from half an hour to two hours, and follow this with the introduction of a cold sound, which should be left not longer than one or two minutes, repeating the process once or twice a week until symptoms of general and local reaction manifest themselves. No routine ti jatment for the use of sounds can be laid down which will be applicable to all cases, but always cases must be individualized and the sounds employed according to the wants of each case. There is a urethral dilator invented by Dr. Nils Bergman, of the Lincoln Park Sanitarium, by means of which vibratory dilatation can be secured in the prostatic urethra, which serves a good purpose, especially in atonic cases. In merely local affections of the urethra, where the nerve waste has not sufficiently drained the general reservoir of sym- pathetic nervous force to fluctuate the general condition of the system, the use of graded steel sounds may also be demanded. In the treatment of abnormal sexual excitability, as well as for the cure of stricture and gleet, they are indispensable. They are equally indispensable in the treatment of impotency. As in all other tubular structures dilatation will overcome un- due tension, and will also restore integrity. Sounds are there- fore equally serviceable in the spasmodic conditions of the urethra and in flabby states of the same canal. This dis- ORIFIC'IAL SURGERY. 191 tinction should be made, however, in the treatment of these opposite conditions: In contracted and irritable states, the sounds should be employed warm, and should not be left long in position ; in the opposite condition, they should be employed either cold or alternately hot and cold, and should be per- mitted to remain in position for a varying length of time, in order to secure a satisfactory degree of reaction. By referring to another article of this series it will be seen that the most important part of the male urethra is the prostatic inch. From this it will be appreciated that, in em- ploying urethral sounds for any purpose whatsoever, they should always be made to enter the bladder, as their efficiency in influencing sexual conditions depends upon their action upon the prostatic part of the urethra. To better illustrate the influence of sexual conditions over the general circulation, it may be well to describe two cases, one showing the influence which the foreskin exerts upon the general health of the body, and the other illustrating what can be done with urethral dilatation, even in extreme cases. Some ten years ago we were called upon to consider the case of a child nine months old. The child had never slept well since its birth, and vomited most of the food that was taken into its stomach, and was so emaciated that it weighed one pound less than it did when it was three months old. After prescribing for the child to the best of our ability for a month or two, and succeeding in doing nothing more than merely enabling it to retain what little food it could swallow, we advised a change of climate. After a three months' absence I was again consulted in regard to the case, and to my distress found that the child had not been improved by its trip. On the contrary, in addition to its previous dif- ficulties, marasmus and wakefulness, it had become dropsical in the lower half of its body. Feeling my inability to treat the case successfully, I called Professor J. W. Streetor in counsel. The child appeared to be making an effort to cut the upper front teeth, and its gums were lanced. A change of treatment was suggested by Dr. Streeter, which was consci- entiously followed out, but to no purpose. 192 ORIFIC1AL SURGERY. Being thoroughly nonplussed as to the cause of the mal- nutrition which the case presented, I had the child stripped and made an examination of the lower part of the body its spine, its liver, etc. At that time I did not appreciate the in- fluence of sexual conditions over nutrition. In fact, this was one of the cases that set me to thinking profoundly of the in- fluence of the sympathetic nerve and its use in the economy of the system. As I was taking a complete invoice of every thing I could observe about the body, however, I examined the penis, and found that the opening was quite a small one in fact, so small that it was with difficulty that I could bring the point of the penis to view. I attracted the attention of the mother to the condition, and told her of the evil effects of an adherent foreskin upon the future morals of the boy, and told her that it was a wholesome measure to secure freedom of this part, al- though I could not promise that it would have any influence upon his present condition. She told me to do whatever I thought best. The child was so weak that I feared to circum- cise it, nor did I appreciate at that time that it was important to do so. So I took a grooved director and thoroughly loos- ened the foreskin from the glans penis, liberating a small amount of smegma. With a scalpel I then slit the foreskin along the dorsum, and instructed the mother to pull the edges of the wound apart several times a day, so that they would not adhere together and reproduce the strictured condition. The next day when I called the mother informed me that the child had slept all night for the first time in its life, and had awak- ened in the morning hungry. Without medicine or any other treatment the child continued to improve, until at the end of a week all symptoms of dropsy had entirely disappeared and the patient was apparently convalescent. This was a great professional surprise, and I at once began to ponder upon the reason for such a remarkable effect from so simple a measure. My reflections were considerably disturbed in about two weeks, however, when the mother again summoned me to ex- amine her boy. There was a surprise in store for me at this visit of an entirely different character. To my deep chagrin, the dropsy had returned, but instead of taking the form of ORIFICIAL SURGERY. 193 swollen limbs and abdomen, which it assumed on its first ap- pearance, it came back in the form of hydrocephalus. Water had accumulated in the cranial cavity to such an extent that the head was of an enormous size, the frontals were bulging, and the bones of the head had so separated that a finger could be placed along any of the cranial sutures without impinging upon bone tissue. The forehead protruded so prominently be- yond the face that the eyes seemed to have moved back into the. head. The weight of the head was such that the child was wholly unable to support it and it had to be carried on a pil- low. The mother, of course, was desperate and had given up all hopes of the child's recovery. I asked her if she had kept the foreskin retracted and the lips of the wound separated. She said she had. I asked to examine the boy, and she re- fused to permit me. After an hour's struggle with her, how- ever, reminding her of the marvelous effects of the previous work, which showed conclusively that the foreskin was the cause of the child's ill health, I finally secured an examina- tion and to my gratification I found that the mother had failed to do her part satisfactorily. The edges of the wound had healed together, the foreskin had been permitted to become again glutinated to the glans penis, and the parts were really in a worse condition than before they had been touched. I now insisted upon and succeeded in performing circum- cision upon the child. From this time on improvement began, and in the course of two weeks the hydrocephalus had entirely disappeared, at which time the case was safely and finally dis- missed. The child has grown into a healthy lad, and has never been ill since the experience which I have just related. After such an experience I was thoroughly convinced that the condition of the parts and the end of the penis exercised considerable influence over general nutrition. Another case. I was summoned by Prof. L. C. Grosvenor, of Chicago, in counsel in a case of dropsy. The pa- tient was a man about fifty years of age and presented a truly pitiable appearance. He had been sitting in a chair, eating and sleeping in a chair, wholly unable to assume the recum- bent position for two months and a half. He had anasarca to 194 OBIFIC1AL SUEGERY. an extreme degree. In the lower limbs it was so extensive that the skin seemed to be stretched to its possibilities; it was glazd from its extreme tension. Several punctures had been made in the skin about the ankles to relieve the pressure, and around these openings there was a slight tendency to eczema. The face was badly puffed and mottled in appearance, as were also the arms, hands and in fact the entire body. There was also considerable ascites. The pericardium was partly filled with water, and there was hydrothorax of the left pleura to such an extent that the cavity was three-fourths filled with water, the right side being clear. Prof. Grosvenor is an exceptionally good prescriber, and I felt that in that respect I was in the presence of my su- perior, so I remarked to him, "Dr. Grosvenor, if I could start that man's capillary circulation do you suppose it would be of any benefit to him?" He replied, "Most certainly." "Very well," said I, "you have been trying for two months and a half to do it with drugs and have failed. It is useless for me to attempt to improve upon your prescriptions. On account of the man's inability to lie down it is impossible to employ rectal dilatation, but the introduction of urethral sounds will certainly have some effect upon his capillary circulation, al- though the case appears like a hopeless one." The doctor ex- pressed his willingness to follow my suggestions, as well as his lack of confidence in the measure. Prof. Grosvenor is an hon- est man, however, and freely admitted that his prejudice against the measure was from lack of knowledge of its useful- ness, and from no other cause. He therefore consented to fol- low out any line of treatment that I would suggest. I re- quested him to procure a No. 14 Van Buren sound, pass it into the urethra and let it lie there for about five or ten min- utes, and then remove it, and continue with the medicine he was already giving the patient. He found some difficulty in gaining the consent of the members of the family to the meas- ure, but finally succeeded in accomplishing the introduction of the sound as agreed upon. Five days later we again met in counsel on the same case, and much to my gratification I ob- served that the skin about the ankles and feet was less shiny, ORIFIC1AL SURGERY. 195 less eczematous, and beginning to display faint wrinkles up- on its surface, showing a decrease in tension. The ascites was about the same, but the hydrothorax was markedly less, the left thoracic cavity being not more than one-half full of fluid, whereas at the first time I visited him it had been three-fourths full. The expression of the face was less anxious and its mot- tled appearance had greatly disappeared, the breathing was much better, and in many other respects the patient was re- markably improved. I advised another introduction of the sound and the other treatment continued as before. I never saw the man again, but was informed by Dr. Gros- venor that at the end of a week from the time of my first visit the man was able to assume a horizontal position in sleeping; three days later lie was so far relieved as to be able to ex- ercise in the open air; one month later he was so completely restored to health that he resumed his business and has been a well man ever since. It should be mentioned that the sound was used at an in- terval of every five days for several times after my first con- sultation with the doctor. This man had never had gonorrhoea ; had always been a temperate, virtuous man in every respect, and the only symptom which would suggest a sexual tonic in his case was a diminution in sexual activity, which had been increasing for four or five years previous to his attack of dropsy. I believe that at the second examination I made an ef- fort to examine the rectum, but obtained no satisfaction from it as the parts were so dropsical and the position so uncom- fortable for the patient that it was deemed best to defer at- tention to this part. The subsequent recovery of the case ren- dered it apparently unnecessary, so that what rectal trouble he has still remains statu quo, unless the mere dilatation of the rectum employed in making the examination has cured it. This case was an extreme one and exceptionally happy in its results. But it is no less a satisfactory illustration of the influence which urethral conditions exercise over the general system and what can be done in the way of general repairs by urethral dilatation. 196 ORIFICIAL SURGERY. Results are not always so satisfactory, although they are more frequently so than the general profession dreams of. Before closing the present article we must call attention once more to the fact that sexual conditions are frequently influenced by the rectum, and that it is needless to expect to overcome abnormal sexual conditions without due respect be- ing paid to the last inch of the rectum. It is often necessary, therefore, to alternate the use of sounds and the use of rectal plugs in order to secure satisfactory results. It may be re- marked, however, in general, that a longer time may be al- lowed for reaction from urethral dilatations than from dilata- tion of the rectum. In other words, the rectal plugs may be used to advantage at shorter intervals, as a rule, than would be proper in the employment of sounds. CHAPTER XXVI. ORIFICIAL SUGGESTIONS. E. H. PRATT, M. D. Orificial surgery has presented to the medical world a large number of original operations, and also a great many im- provements in already established methods of surgical pro- cedure applied to the organs of the pelvis. These operations have, most of them, been already so frequently and clearly de- scribed from time to time in the pages of the Journal of Ori- ficial Surgery, as well as in other periodicals, that it would scarcely be worth while to invite your consideration to any of them, but rather to the great fact that many cures can be ef- fected, and a wonderful amount of good accomplished, in both acute and chronic diseases, generally and locally, by orificial methods which do not involve an operation. Many cases de- manding operative interference as a sine qua non of recovery are ill-conditioned for it, and the nature of the work to which I desire to call your attention is beneficial also in such cases as preparatory work. The measures are also useful as after- treatment following operative procedures. ORIFIC1AL SUEGERY. 197 The chief measures at the hands of the orificialist to which I desire to call your attention are: First. Water. Second. Massage. Third. Sounds. Fourth. Tampons and rectal plugs. Fifth. Local feeding. First, water. This time-honored remedy for the ills of humanity is not yet sufficiently appreciated by doctors in gen- eral and orificialists in particular, and therefore deserves first consideration. It has long been used as a douche in pelvic cellulitis in women, but its soothing influence, when poured over the pudenda, has not been sufficiently appreciated or taken advantage of. These pelvic organs are supplied by pen- cils of nerve trunks starting from common centers, so that influences, either beneficial or harmful, applied at any of the terminal nerve-fibers of this pencil can be felt and influence the irritability, and hence the blood-supply and the functions and pathology of any of the parts supplied by the remaining fibers of the various pencils of nerves. For instance, an ir- ritation at the neck of the bladder in the male, as from a stone in the bladder, can cause pain and irritability at the point of the penis. This physiological fact can be utilized by recognizing the applicability of the converse of this proposi- tion that applications made to the point of the penis can in- fluence the neck of the bladder. As a result of this suggestion it will be found serviceable to hold the point of the penis in water, as hot as can be borne, for a few minutes after the passage of sounds, in both acute and chronic inflammation of the urethra, the bladder, and also the kidneys. The influence of the heat to the point of the penis extends along the entire urinary tracts, because the nerve-supply of these organs comes from a common center. The same fact can be utilized in the female by douching the pudenda with hot water for inflammatory conditions of the bladder, vagina, uterus, ovaries and tubes, and also the kidneys. 198 ORIFIGTAL SURGERY. Hot water applied to the anus will check the hemorrhage of bleeding piles, and also the hemorrhage following slit-work upon the rectum. It will also speedily remove ecchymosis and soreness of the anus. In cases of chronic constipation o*irri- tation or congestion of the sexual organs, a teacupful of hot water thrown into the rectum daily, preferred after the bow- els are moved, and to be retained, will be found of great utility. Cold water, if introduced into the rectum, or into the vagina or male urethra, is liable to induce rheumatic and neu- ralgic afflictions, and is not to be commended ; but upon the pudenda and outside of the anus it is often very beneficial in restoring tonicity to parts which have lost it, and in arousing the general reactive powers. After its use the parts should be thoroughly dried with a towel and rubbed and chafed until a satisfactory degree of reaction has supervened. In resuscitating patients who have collapsed from an an- esthetic or a narcotic of any kind where dilatation of the rectum, urethra, or uterus has proved insufficient, water, as hot as can be used without blistering, poured over the pu- denda will many times afford satisfactory stimulation, and aid materially in inducing general reaction. It is a wholesome measure to bathe the base of the body daily in either hot or cold water as a sanitary as well as an in- vigorating measure, hot water being preferred in those of a neuralgic or rheumatic tendency, and in an individual of poor reactive power, cold water being otherwise preferred. Second, massage. It is serviceable in the rectum for slug- gishness and atony of the organ, being especially serviceable in cases of chronic constipation. In irritability of the anus, and also in hemorrhoidal conditions, it is an agent of great utility. Care should be taken, before employing it, to have the parts thoroughly douched and lubricated with vaseline, so that the proceeding may be neither poisonous to the manipu- lator nor uncomfortable to the patient. Through the rectum massage can be employed for chronic prostatic troubles. In acute prostatitis it is a dangerous agent, as it is liable to be followed by such energetic reaction as to cause abscess, or, what is still more liable, orchitis, especially if the upper part ORIFIG1AL SURGEKY. 199 of the prostate is bruised so as to injure the prostatic terminus of the ejaculatory ducts. For chronic affections of the pros- tate, however, where a wholesome reaction is desirable, the measure is exceedingly effective, although care is always re- quired in the manipulation of the prostate to prevent harmful results. Massage of the sexual organs in either sex is contra- indicated in acute conditions, but in chronic affections, pre- senting either hypertrophy or atrophy, it is one of the most reliable of measures for restoring the sexual organs to their equilibrium. To employ the measure for good instead of harm requires some considerable knowledge of the art, as well as a purity of purpose on the part of the manipulator, and for this reason alone is not to be carelessly prescribed or employed. Third, male and female sounds. These are serviceable, not merely to overcome strictured conditions and secure free vent for the discharge of secretions and excretions, but they are wonderfully effective in restoring sexual tone to organs which for many causes have been unduly depleted. In irrita- bility of the organs hot sounds should be used, while in atony they had better be employed first hot and then cold. The length of time for which they can be used to advantage will vary from a period of two or three minutes to as many hours, the question being always one of surgical judgment, which is to be based solely upon personal experience and knowledge of the case under consideration. The frequency of their repe- tition is always a matter of surgical judgment, as sometimes for a brief period their daily use may be beneficial, while at other times an interval of one, two, or even four weeks may not be too long. Their use is serviceable, of course, not simply for their local effect, but for their influence over the entire sympathetic nerve, and consequently the general bodily nu- trition. Fourth, tampons and rectal plugs. Vaginal tampons have for many years been freely employed in gynecological work. They were formerly constructed of cotton, but of late years wool has been preferred. Their early use was mainly as a means of uterine support. For this purpose they have been, 200 ORIFIG1AL SURGERY. to a great measure, dispensed with, the employment of pes- saries and operative procedures supplanting them. As a ve- hicle for the topical application of drugs to the vaginal vault, however, they are still in favor, and probably always will be. The employment of tampons in the sigmoid has never, until the invention of the sigmoid speculum, been of practical utility. Now, however, they are frequently employed as a vehicle for the application of medicine to the sigmoid, and for this purpose are frequently of inestimable value. Ulceration and irritability and catarrh of the sigmoid are mischievous conditions which have been almost entirely overlooked until late years. But now they are known to be so common a source of reflex mischief that sigmoidal treatments have grown in favor with the profession, and one of the most effective means of medicating the sigmoid is by means of medicated tampons. A tampon can be placed in the sigmoid and permitted to re- main there until expelled with the descending feces. Irriga- tion of the sigmoid by means of Cole's sigmoid irrigator, or some similar instrument, is a rival of the sigmoid tampon, be- cause its employment is sometimes quite as effective and its use involves less discomfort to the patient and less skill on the part of the doctor. Cases are frequent, however, in which the irrigator is not adequate to the purpose, and sigmoid tam- pons are the only satisfactory means of meeting the demands of the case. Rectal plugs are of ancient origin, for they were in use as long ago as when Pompeii was buried by the ashes and lava of Vesuvius. From time to time, however, their usefulness has been forgotten by the profession. The traditional soap suppository of midwives, for constipated infants, is probably a relic of a previous knowledge which was in the possession of the profession, but long since forgotten. The present medical era, however, is marked by a concerted movement on the part of medical men, and laymen as well, in the direction of anal dilatation. It has been found serviceable, not only in anal stenosis, but also in general debility, as its action is more stimulating than whisky, and a greater tonic than any pre- scription of drugs known to the medical fraternity. Anal di- ORIFIC1AL SUEGERY. 201 latation deepens inspirations, flushes capillaries and inaugu- rates general nutrition. The most common forms of accom- plishing this is by means of rectal plugs of graduated sizes. The size employed, the length of time for which it is to be re- tained, and the frequency of its use, all have to do with the irritability or the sluggishness of not only the anus but of the entire individual. The object of their employment is always in all cases to secure either local or general reaction, accord- ing to the purpose for which it is employed. There are many forms of rectal plugs now upon the mar- ket, but as they all have the same object in view, and are equally efficacious, there is scarcely ground for choice in their selection. The Weirick, Young, Linn, and other makes too numerous to mention are scarcely to be considered as improve- ments upon the original pattern known as the Pratt rectal plug. In selecting rectal plugs it would be well to secure those which are hollow and provided at their base with two tubes, connecting with their cavity. Over one of these tubes the pipe of a fountain syringe can be employed, while over the other a waste-pipe is fixed, and by means of this arrangement, while dilatation is being secured, the action of either heat or cold can also be brought into service. As the uses of anal dilatation are already pretty widely known, and at any rate they are too extensive to be enumer- ated in the present paper, further comment in the present con- nection is unnecessary. Fifth, local feeding. It has long been known to the pro- fession that the body, in general, can be fed with some con- siderable degree of satisfaction by the application of local foods, either to the skin or to its accessible mucous mem- branes, that of the rectum being, as a rule, preferred. But the employment of nutritious liquid to transform mucous and skin surfaces from the pallor of sickness to the flush of health has certainly been overlooked and forgotten until very re- cently. The fact that bovinine was serviceable in the treat- ment of chronic varicose ulcerations led to its employment in gangrene and inflammatory conditions, and then to restore 202 ORIFICTAL SURGERY. strength and tonicity to the rectum, vagina, and in some cases the urethra, until now the knowledge is rapidly spreading, and local conditions of pallor are being made under its in- fluence to take on a ruddier hue. Where a vaginal hyste- rectomy or an operation for laceration of the cervix or per- ineum, or any form of rectal work is contemplated for the re- lief of the case, if the parts involved present the appearance of malnutrition to such an extent as to hazard the success of the work, soaking the parts once or twice daily with bovinine for a few weeks will institute such an improved condition of the parts to be operated upon as to insure success where other- wise defeat would have been inevitable. Other nutritious prep- arations than bovinine in all probability would be equally ser- viceable, but as this agent has given satisfactory service for local feeding, it has left insufficient excuse for experimentation with other and uncertain, because untried, products. If due respect is paid to this suggestion of local feeding as preparatory treatment for operative procedure where it is demanded in delicate cases, surgical work will score an in- creased percentage of success, and consequently escape much of the censure which otherwise must await its employment, for even the most skilfully performed surgical operation is doomed to failure if the parts operated upon are too feeble to react, too starved to heal. CHAPTER XXVII. THE CONFIRMATION OF EXPERIENCE. C. E. SAWYER, M. D. It is an easy matter to make assertions or to originate theories, but it is quite another thing to promulgate plans of treatment in this advanced age of medical science that will serve, as has orificial surgery, to revolutionize the general practice of medicine. That orificial surgery has attained this end is no longer questionable. In evidence we had public OBIPIG1AL SURGERY. 203 institutions conducted and operated upon its principles alone, colleges with special chairs for its teaching, hospitals with ample wards for the care of its patients, sanatoriums with sep- arate departments for its eases, and surgeons without num- ber who were daily practicing its laws of cure, this too, when but a little more than a decade had elapsed since its founder re- vealed to the medical profession his plan of benefiting the mul- titude of heretofore incurable invalids. Then it was new, un- tried, unpracticed; an infant unable to stand alone, without experience to guide or practiced hands to direct, starting forth on its mission of mercy, accepting for its subjects the worst of the leavings and culls of former medical and surgical practice. It has from this beginning, under circumstances most ad- verse, reached in its application from the simplest functional disorders to the profoundest organic disease. From the many trials thus incurred it has of necessity met some failures, some rebuffs, but it has also scored many victories impossible to other means, and today stands recognized as a great force in the combatment of disease. As its fields were all unexplored, and as the armamentarium to be employed in its use was at first restricted to a few crude instruments, and as the direction of its course was in the hands of novices, it is not to be won- dered at that it met with some criticism, the justice of which is appreciated by none more than the ardent supporters that have continued to uphold its banner through the trying hours of its experimental stage. Because of the forced empiricism in its use, no conscien- tious doctor ever sought its benefits without feeling a certain degree of hesitancy in its application, and until sufficient time had elapsed whereby certain fixed rules could be formulated it was always a question to conservative surgeons how much might really be expected, how much could honestly be prom- ised. To those who have been faithful in the application of its principles, earnest in their observation of its uses, and hon- est in their conviction of its results, I do not believe there is one who doubts its efficiency or but that has been benefited by its employment. To him who assumed the responsibility 204 OBIFICTAL SURGERY. of its operations and after-treatment without sufficient knowl- edge and skill, there no doubt has come disappointment. Unfortunately, many physicians have become imbued with the belief that orificial surgery is applicable to all forms of disease in all classes of cases; that all of the operations are simple, and the after-treatment of little importance; that no special surgical ability is required, no professional skill need- ed; all that is to be done is to operate a position false in every particular. It is useless to attempt a work of such mag- nitude as that of orificial surgery without a proper apprecia- tion of its requirements, and yet many doctors, after an at- tendance of but a single course of these most interesting clin- ics, return to their homes and advertise themselves as special- ists in this department, the presumption of which is only out- ranked by the unreasonable promises they make their patients. If this paper has no other object it is to be hoped it may impress upon the present new attendants at these clinics that time, study, observation and thorough application of all ori- ficial principles are to be duly understood before being war- ranted in attempting the role of an orificial surgeon. To sup- port the grand and growing superstructure which affords to suffering humanity its greatest boon, whose chief object is betterment, whose possibilities are unlimited, and whose cli- max is the ultimatum of every true surgeon's life the cure of disease it is well that we each look with careful scrutiny into the details that make such results possible. Experience confirms the opinion that the only failures of orificial philosophy come either from a lack of foresignht in the selection of cases, unscientific and unskilled application of methods, or a lack of proper consideration of after-treatment principles. To prevent the unjust criticism that results from these shortcomings it is necessary that more attention be given seemingly little things, for therein lies the success of orificial surgery. Orificial surgery is not a "cure-all." It simply has its place among the most valuable forces in the cure of disease, and that place is in keeping with the judgment used in its employ- ment. In consequence we must bow in deference to the find- OBIFIC1AL SURGERY. 205 ings of experience in choosing fitting subjects for its applica- tion, for vast importance attaches to their proper selection, and too much care cannot be employed in this regard. Origi- nally there was no guide to direct in this matter, but now we are old enough to have established some fixed rules by which to be governed, and as it is experience and observation that counts, I submit mine for what it is worth in offering the fol- lowing suggestions, hoping that their careful consideration may make possible some useful deductions. Candor and frankness are two cardinal principles in the success of any surgeon's work, and they are not less essential in orificial surgery than elsewhere. It is both unwise and un- professional to make promises in which there is the slightest doubt as to fulfillment. It is far better that the patient as- sume the risk of the operation without undue persuasion, for it is much more satisfactory to all to give more than is prom- ised than to promise more than can be given. All that is ever admissible is a plain, candid statement of facts, never over- estimating the possibilities, never under-rating the risks, al- ways leaving the patients to decide whether or not they wish to accept the question it brings. All operative work should be preceded by a careful, thorough examination of the individual before submitting them to the necessities of an anesthetic or the risk of an operation. Finding serious organic complica- tions, it is always advisable to proceed carefully, for orificial surgery is a double-edged sword liable to cut both ways, and may aggravate as well as cure. With due consideration of this fact many unfavorable results may be foregone, and many calamitous terminals an- ticipated. Considerate observation demonstrates that the best grounded exceptions taken by the opposition to orificial sur- gery are based upon the fact that sufficient weight is not given to the matter of selecting cases. There is no more reason in a haphazard manner of choosing orificial cases than in select- ing general surgical operative cases, and the failures that re- sult from care in this particular can not be less injurious to one than the other. The realms of orificial surgery are wide enough 206 OBIFIG1AL SUROERY. without assuming undue risk or inviting criticism, and it is unnecessary to engender discredit or ridicule by doing unrea- sonable things. That we may not justify the charge of absurdity we should in all cases selected use the greatest discretion, being sure that we have good and reasonable grounds upon which to base con- clusions. Next in importance to the selection of cases come modes of operation and methods to be employed. Here again experience teaches that the best rule to be followed is that of conservatism, remembering always that the milder forms of treatment are oftentimes capable of the greatest good, and un- less the indications are clear cut or the immediate necessities imperative, it is always advisable to consider carefully all the bearings of the case, weighing well all of its questions. There is no more reason in submitting a patient to an American oper- ation or a hysterectomy unless the gravity of the case demands it than there is in amputating a leg for a corn or of doing a laparotomy for a laceration. The orificial surgeon who serves orificial principles best is he who appreciates the power of the force he is wielding, and who understands well the requirement of the case he is treat- ing that he may use with certainty the means to be employed. Because an individual is willing to submit to the surgeon's desires in the matter of operation it is not necessary to impose the most heroic measures, for in so doing he may overstep reasonable bounds and injure rather than benefit. It is better by far that discretion be the watchword and the simpler meth- ods be tried first than that discredit, dissatisfaction and com- plaint be brought against orificial principles. This is not only true of orificial operations in general, but is just as true of each in particular, for as they, as a whole, have their indica- tions, so have they separately, and it becomes every orificial surgeon who would succeed best to learn for himself the im- portance of individualization both in regard to cases chosen and methods employed. Having once decided upon the course of pursuance, care in the preparation of the case and thor- oughness in the execution of means are of the next importance. No case, no matter how slight the form of treatment to be em- OBIFICTAL SUEGEBY. 207 ployed or the malady to be relieved should be regarded lightly, for much importance attaches to having the ground well pre- pared before the seed is sown. To this end every patient should be placed in the most favorable condition for surgical procedure. To meet this end it is required of all that careful aseptic means be adopted in the preparation of all cases. No orificial surgeon is justified in compromising orificial princi- ples by considering lightly any case under his observation, for if so considered by the surgeon it is sure to be by, the patient, consequently the moral effect, which is of so much importance in all surgical work and which experience will not allow us to disregard, is lost and thus we are robbed of one of the influ- ences that serve an important purpose in the treatment. If a case is to be considered at all it is worthy all the knowledge and skill the surgeon possesses, and nothing short of his b?st efforts should be given. This rule is just as applicable in minor operations as ma- jor ones, and care in this regard is just as necessary in one as the other, for, as the supporting power of the foundation is, so is the magnitude of the superstructure, and final results may always be anticipated in proportion as the details are ex- ecuted. Thus far we have been dealing with matters of import af- fecting the form and method of operation, and to that end we have been judicious in selecting cases. We have chosen with discriminating care the meaiis to be employed and our pros- pects of ultimate success are correspondingly favorable. This, to the casual observer, would seem all that was necessary, but the experienced surgeon knows that were he to quit even here, many cases that otherwise might be recorded as cures, react as failures. All the possibilities have not been achieved, for in the after-treatment comes much of vital interest to every orificial case. As well might we expect the stump of an am- putated limb to require no other attention than simply the op- eration for removal, as to hope for favorable results from ori- ficial operations without proper after-attention and treatment. This not only includes the careful treatment of the wound and the favorable adjunct measures such as electricity, massage, 208 OBIFIC1AL SURGERY. etc., etc., but it has to do as well with habits of life and modes of living. Many cases are aggravated and complicated by errors in diet, unfavorable environment, and lack of health-giving regi- men, and to disregard attention to these demands is to fail in achieving the possibilities in many cases. Many times in my ex- perience have I had cases referred to me still serving time as chronic invalids after favorable operations had been per- formed, simply because proper regard had not been paid the matter of after-consideration. More than useless is the effort to cure the hand of a burn with the member still in the fire, and yet many such useless efforts are put upon orificial sur- gery by many of its would-be friends and supporters. If there is a matter which should be in ground in every orificial surgeon's mind it is that of looking with careful scrutiny into habits, surroundings, and modes of life of all who seek the benefits that come from orificial principles well applied. The following cases will serve to illustrate the responsi- bilities orificial philosophy has been made to bear as well as the importance of a thorough consideration of all direct and concomitant circumstances either directly or indirectly re- lated to each and every case: A few weeks ago a woman twenty -three years of age, of good family history, was brought to us in the following con- dition. She was weak, anemic, nervous, sleepless, pallid, with poor appetite, constipated bowels, hectic fever and a slight cough. Lying as she did on the stretcher that was used in con- veying her from her home, she looked, as she was, an abject object of misery and discomfort. For three long years she had been paying tribute to the throne of disease, an altogether too willing subject. Such had been her invalid habits that her physical force had been lowered to an extreme degree, her blood was thin and colorless, her secretions impoverished, her vital forces depressed and her mental powers obtunded. Upon making inquiry as to what lines of treatment had been adopted in her case I learned that she had tried all of the drug provinces, proprietary and prescribed alike, she had also OEIFIC1AL SURGERY. 209 been a subject more or less of Faith Cure principles and Christian Science treatments and thoroughly applied orificial principles had altogether failed to relieve her of her bondage. This at first seemed strange to me for I felt sure that orificial principles were well indicated and knowing the ability of the surgeon who had operated on her, I did not question the ef- ficiency of his work. A careful physical examination demon- strated that such was the case for all of the orifices were in prime condition, consequently I was led to look for shortcom- ings in unfavorable environments or imperfect after-treat- ment and herein I found cause sufficient for the lack of favor- able results. I learned that she had been continuously under the influence of a constantly sympathizing mother and a no less sympathizing sister and, worse than all, an undetermined doctor. From this association she had been led to believe that all forms of exercise were harmful, that the most limited diet- etic measures were to be employed and that pains and aches and distresses were to be looked for. Some of the rules by which she was to be governed whose erroneousness are self-evi- dent, were as follows: She could eat nothing but liquid food, she must take nourishment when she chose, regardless of time day or night, she could bear no sunlight, even imagining the exposure incident to the proper ventilation of her room, dan- gerous, she must have a light burning during the entire night in her sleeping apartment, was only bathed when she was forced to and only exercising when she could not avoid it. Such were the unfavorable conditions in which she was found when operated upon, and these same conditions re- mained uncorrected after the operation, consequently the lack of benefit from the orificial treatment. Although orificial phil- osophy was well indicated and should have cured, yet under these circumstances it did not, nor could not, effect the changes that were necessary and the failure was charged as a failure to orificial surgery, the propriety and justice of which I leave for each of you to judge. Just yesterday my attention was called to a woman 38 years old who had been an invalid for twelve years; during every day of this time she had been under the surveillance of 210 ORIFIG1AL SURGERY. a doctor and one or two trained nurses. She had lain for the last thirteen months on her right side and back, never having turned over in all that time. She is extremely nervous, every little noise, every unaccustomed sound is very distressing to her; even a ray of sunlight adds to her discomfort. During all this time the entire household have submitted to her dicta- tion, and she demands that every footstep shall be muffled, every tone subdued, every action qualified, every condition modified, everything changed to meet her personal demands. Her home has been transformed into a hermitage, her children sent away because of their innocent prattle, and her husband driven to seek refuge in other society than that of his home. All this, in my opinion, because of a lack of determination on the part of the medical attendant and the proper execution of methods of education to the reinstatement of health at the time best indicated. How apparent the benefits to have been derived from orificial philosophy in this case, and yet when I tell you that one of our best surgeons did "all round" orificial work, and did it as well as could have been done, and that she still remains in the condition I have depicted, your natural inquiry will surely be, Why? The answer is easy. Operated on at her home, taken from the table and put back into the same bed, coddled by the same relatives, attended by the same nurses, surrounded by the same environments, she could not possibly be other than the same fault-finding, unreasonable, complaining, unhappy, sick individual. This could not be otherwise, and yet if you were to ask the surgeon who did the work for the cause of failure he would more than likely charge the result to failure of orificial principles and allow his fail- ure to stand in condemnation of orificial philosophy. These are but two of the many cases that we meet every day. Such observations are not by any means infrequent, yet I think you will all agree orificial treatment combined with reason in after-treatment should have cured them both, and that it failed simply because it was expected to do more than any close observing reasonable surgeon would dare to have asked any other form of treatment to do. ORIFIC'IAL SURGERY. 211 Thus we find orificial philosophy hampered in its possi- bilities, charged with incompetency and continuously dis- credited by those who should know more of its requirements, think more of its demands and be more just in their criticism. In these two simple and markedly apparent cases we have proof of the necessity of a better knowledge of all matters per- taining to the demands of the treatment in whose success we are most interested. Realizing our past shortcomings, let us all be more careful, more painstaking, always alert for obstruct- ive causes and earnest in the defense of orificial principles. With discretion in selecting eases, judgment in applying methods and consideration in after-treatment principles, the confirmation of experience will ever be most favorable. CHAPTER XXVIII. SURGICAL DUTIES OF THE GENERAL PRACTITIONER. E. H. PRATT, M. D. Regardless of the multiplication of specialties in the prac- tice of medicine by far the greater number of practitioners must necessarily be all-round men. Especially is this true of those who practice in the smaller cities and towns and in the country. In medical meetings and medical literature the gen- eral practitioner may suffer neglect, because, in the first place, he is exceptionally modest and unobtrusive, and in the second place, much that he would be inclined to speak or write about would seem commonplace in comparison with the exhaustive and technical dissertations of specialists. And yet the all- round man always has been, is and always will be, the ideal doctor, the man who is supposed to know a little of everything, but not everything of anything. While the increasing intelli- gence of the general public demands a higher grade of all forms of medical service, the people as a whole still look up to and depend upon their family doctor as their very best friend and safest advisor upon all topics connected with their physi- cal well being. 212 ORIFIG'IAL SURGERY. It is useless for the specialist to aspire to the influential position occupied in the family circle by the general prac- titioner. The specialist is respected in his specialty, but how- ever much he may know of other things confidence in his opinion stops with his professed knowledge, and only as the family physician indorses whatever he says or does outside of his own professed line of work does his opinion inspire confi- dence. Such always has been, is now and ever will be the case. The all-round man, the general practitioner, the level headed, evenly balanced and universally intelligent doctor of medicine who can deliver women and cure the children, who can guide his patients safely through all forms of acute dis- orders, and has something to suggest for those who are chron- ically ill, regardless of disease type, is the doctor, the ideal medical man, dear to the hearts of the people, and the best and most perfect representative of the practice of medicine. He is something of a diagnostician and something of a prescriber; he is something of a chemist and something of an anatomist and physiologist; he is something of an electrician and some- thing, whether he recognizes it or not, of a psychologist; he is something of a medical man, but also something of a surgeon. This assertion is purposely framed in the present tense. Time was within the memory of us all when the family doc- tor could get on quite satisfactorily with a little knowledge of surgery, but that time is now gone by and the general prac- titioner of today, while he must know more of drugs and chem- icals and diseases generally, must also know more of surgery than his predecessor. One of the most important qualifications for the general practitioner is a full appreciation of his own personal limita- tions. He should have knowledge enough of all departments of medicine and surgery to make him fully alive to any situ- ation in which he is placed, and if he finds his own personal knowledge of any difficulty he may encounter is inadequate for its successful solution, he must be wise enough to immedi- ately recognize his own deficiencies and supplement them with such advice from special workers as his case may stand in need of. OEIFIC1AL SURGERY. 213 The surgical knowledge demanded of an up-to-date prac- titioner has greatly increased of late years. To be sure while technicalities have greatly multiplied many of these are non-es- sential and can be safely omitted ; but the fundamental princi- ples of modern surgery should be thoroughly mastered by ev- ery family practitioner. These now include not only a knowl- edge of fractures and dislocations and their proper treat- ments, of inflammations and neoplasms and the sequences and significance, but also of modern bacteriology and pathology. It is no longer to the credit of any practitioner of medicine, regardless of his distaste for surgical practice, to ignore or refuse to recognize the germ theory of disease. However much he may prefer to limit his practice to the prescribing of drugs, he is criminally negligent of his position of high trust as the family guardian of health if he neglects to give due and practical recognition to the surgical growth of the last few decades of surgical study. Personally he may feel an aversion to the lancing of an abscess, and so far he is not to be blamed, but it is his business to recognize the existence of an abscess, appreciate the importance of its proper surgical treatment and as early as possible call for whatever surgical help his case may stand in need of to guide it to a successful issue. Were it not for the fact that sins of omission are of equal magnitude to those of commission the responsibilities of the general practitioner would be greatly lessened. But he has no right to be ignorant of the surgical necessities of his patients, and it is his plain duty in case he is not himself a practical sur- geon, to supplement his own deficiencies with adequate assist- ance. In other words, he must be possessed of sufficient knowl- edge to recognize surgical cases whenever they are entrusted to his keeping, and either give them the surgical attention called for in person or direct them where to go for it. Major surgical operations should never be essayed by a man in the general practice of medicine except in emergency eases, where the circumstances render such practice unavoidable. It is all right for the general practitioner who is something of a sur- geon, to repair lacerations of the cervix and perineum, to un- dertake the dilatation, curettement, and packing of the uterine 214 ORIFIG'IAL 6URGERY. cavity, to operate for the removal of hemorrhoids, pockets and papilla?,, to evacuate superficial pus cavities and treat burns, scalds, fractures, and dislocations, but it is not right for the general practitioner to assume the responsibility of operating upon rectal fistulas or strictures, to perform hysterectomies or laparotomies, to resect joints or amputate limbs, to trephine skulls or meddle with caries of the spine or other deep seated bones, to attack chains of enlarged lymphatic glands or en- eurisms, to operate upon the kidneys or bladder, to attempt the extirpation of deep seated tumors or evacuate deep-seated abscesses. And this chiefly for two reasons: The first one is that his community would not be liable to forgive him for dis- astrous results from surgical procedure regardless of the skill exhibited or the general merits of the case, for a single surgical disaster might ruin his good name, which long years of service had established for him in his community; and however com- petent he may be to render skilled surgical service, he can- not afford to hazard his general reputation by assuming heavy and unnecessary responsibilities in a single case. The other reason is that it would scarcely be possible for one whose time was mainly spent in the general practice of medicine to ob- tain sufficient practice in the handling of major surgical cases to become an expert, and he would do neither his patient nor himself justice in reckle'ssly assuming a role he was not well schooled to fill. There is less danger, however, of a general practitioner undertaking too great surgical responsibilities than there is in his overlooking needed expert surgical work for his patrons. His tendency to rely upon mere prescribing for the cure of chronic cases is his great weakness, and consequently the one which should be chiefly guarded against. Aside from the great surgical progress instituted by the establishment of the germ theory of disease, the times in which we have lived have disclosed the marvelous fact that for what used to be considered chronic medical cases there is now a most radical, efficient and satisfactory surgical cure. Obsti- nate cases of chronic rheumatism, dyspepsia, nervous prostra- tion, spinal irritation, headaches, eczema, bronchitis, paraly- ORIFIG1AL SURGERY. 215 sis. and other forms of severe and persisting organic and tis- sue disturbance in all their various types have shown them- selves easily amenable to a peculiar surgical procedure, which has clone more to solve the problem of chronic disease for the human race than has yet been appreciated by the profession in general. Of this great fact the general practitioner, of all others, should be made aware. The surgical work called for in such cases involves in the majority of instances little suf- fering and small risk of life, and is so startling and effective and phenomenally satisfactory as to deserve universal recog- nition and employment in well selected cases. To be ignorant, careless, or indifferent to this great surgical help in the treat- ment of chronic diseases generally is not to the credit of any general practitioner of the present time. I have reference now to what is commonly known as ori- ficial surgery. This type of surgical procedure, by means of which the general nutrition of the entire body and all its or- gans can be influenced is based upon universally recognized anatomical and physiological facts, and its practicality is no longer a matter of conjecture. By orificial measures the sleep- ing energies of the body can be wakened, reactive power can be aroused, improved capillary circulation can be universally established, and an impetus given to the restoration of health in all forms of chronic diseases in a more certain, permanent, speedy and in every way satisfactory manner than can be fur- nished by any other known remedial agent. Thousands of the advanced medical thinkers of the age have put the orificial philosophy to test now for many years, and the result is its permanent establishment as a powerful remedial factor in the history of medicine. Its establishment in reality will mark an era in the treatment of chronic diseases. It is not the purpose of this paper to discuss in detail the orificial philosophy or the surgical measures by which the ori- ficial thought is put in practice, but rather to merely call at- tention to the matter and remind the general practitioner that the chronic cases which baffle his prescribing skill and refuse to respond satisfactorily to other more commonly recognized measures at his command are unquestionably candidates for 216 ORIFICIAL SURGERY. orificial work, and this fact should always be borne in mind and for the sake of his own reputation and the good ol his patients should be made use of in times of need. Every gen- eral practitioner should master the principles of orificial sur- gery, should see to it that the children which he delivers be not permitted to suffer from adherent foreskins and hoods of the clitoris, from pockets and papillae and simpler forms of rectal troubles for children do have rectal troubles fully as fre- quently as they suffer from derangements of the eyes, ears, nose or throat, and preventive work in the pelvic region, which has in mind the release of terminal nerve fibres of the sympa- thetic system from undue impingement, is the most important mesaure by far known to medical men in the sphere of pre- ventive medicine. As we live, develop, recover and maintain health and life by means of the sympathetic nerve, let us by all means relieve its accessible fibres from all undue impinge- ment and the nerve waste thereby involved, and thus permit the natural life forces to have full sweep in performing their bodily functions. This is the sole purpose of the orificial thought, and it is serviceable not only in the cure of the chronically sick but also in the prevention of disease. The surgical duties of the general practitioner could be treated much more exhaustively with profit and still not half the truth be told, but short, suggestive papers are best for society purposes, and enough has already been said to serve the purpose for which this paper was intended. CHAPTER XXIX. NERVE IMPINGEMENT IN OPERATIVE SURGERY. E. H. PRATT, M. D. They say that a human being has two minds the con- scious and the unconscious or, as Hudson calls them, the ob- jective and the subjective. Granting this to be true, it is easily demonstrable that the objective or conscious mind is the animating principle of the ORIFIGIAL SURGERY. 217 cerebro-spinal system, and that the subjective or the uncon- scious mind in a like manner vitalizes the sympathetic nervous system. The conscious mind, which animates the cerebro- spinal system, receives impressions from the outer world and echoes back its judgments through the agency of the afferent and efferent nerves. By the afferent nerves it sees, hears, smells, tastes and feels. By means of the efferent nerves what- ever the conscious mind wills and thinks can be transferred into physical expression. These nerves, or telegraph wires, of the cerebro-spinal system touch at their distal ends the sur- faces and tissues of the body, and at their proximal ends com- municate with the gray matter of the brain and cord. No con- scious sensations reach the ego from the world of sense except as they are transmitted along cerebro-spinal nerves, and no action of the voluntary muscles is accomplished except as com- mands emanating from the gray matter are carried to striated or voluntary muscular fibres by means of cerebro-spinal nerve filaments. In a corresponding manner is the unconscious or sub- jective mind provided with a nervous apparatus called the sympathetic system, by means of which it receives at its cen- tral stations, or ganglia, bodily reports of the wants and con- ditions of the various organs and tissues, and from which it dictates perpetually the unceasing activity of the involuntary muscles. All of the activities of the body which are not chemical are accomplished by tubular structures, some small and some large ; the sweat and sebaceous glands of the skin, the race- mose glands and simple follicles of the mucous membrane, the salivary glands and the pancreas, the gall ducts and the geni- to-urinary tracts, the blood-vessels, bronchial tubes, lym- phatics, and the alimentary canal, each and all of them owe their activity to coatings of the involuntary muscular fibres, whose action is dominated by the sympathetic nervous sys- tem, the blood-vessels being the only exception, and yet not an exception, for the peristaltic action of the blood-vessels is influenced by the sympathetic nerve, although not exclusively the motor influence from the cerebro-spinal system joining 218 ORIFIC'IAL SURGERY. that of the sympathetic, thus forming a combination of in- fluences from both nervous systems for the control of the circulation. The sympathetic nervous system, like the cerebro-spinal, has both afferent and efferent nerves. By means of the af- ferent nerves bodily wants and conditions are made known to the nerve centers. It is by the efferent nerves that the in- voluntary muscular fibers are kept in operation. The sympa- thetic nervous system, like the cerebro-spinal, listens to both harmonies and discords, to joyful and distressing communica- tions, is thrilled by delightful inspirations or benumbed by shock, by its system of telephone or telegraph wires called nerves. There is this difference, however, in the alarm cry of the two systems: When alarming reports come from the outer world to the cerebro-spinal centers and the harmony of its domain is seriously disturbed, they express their discom- fort in the language of pain, while the alarm cry of the sym- pathetic system is told in the form of functional derangements. By means of repeated intercommunications the two nervous systems can be mutually cognizant of each other's operations, and aid or antagonize each other in their daily work, as they are harmonious or discordant. The conscious mind can be terrorized by suggestions of danger from the offices at the distal ends of its wires, and the unconscious mind may refuse to sympathize with the alarm and perform its functions per- fectly, regardless of the consternation prevailing throughout the cerebro-spinal system. On the other hand, the unconscious mind can be badly demoralized by irritations conveyed to the nerve centers along its afferent nerves and the functions over which it presides be seriously disturbed and the conscious mind, although perfectly aware of the mischief going on, may refuse to heed the distress of its companion sovereign. Perfect specimens of humanity, in which the conscious and unconscious minds work in unison, are indeed rare and have little use for doctors. Our business is with those whose house is divided against itself. The foregoing anatomical facts have an important bear- ing in the consideration of nerve impingement m operative ORIFICIAL SURGERY. 219 procedures from the simple fact that the nerves of either sys- tem are through trains and that the communications which pass along them, either from the world of matter to the world of mind, or from the world of mind to the world of matter, are sent from their extremities and not in their continuity. Especially is this true of the cerebro-spinal nerves. If an ul- timate nerve filament of the cerebro-spinal system be micro- scopically examined it will be found to consist of a central thread, or axis cylinder, which is the nerve proper, an insu- lating medium more or less fatty in its nature, called the white substance of Schwann, and an enveloping tubular sheath of membrane called by some the neurilemma, in each case the in- sulation extending the entire length of the filament from the brain substance at one end to its terminus in the tissues at the other end. At its two extremities only is the axis cylinder exposed and sensitive to impressions. The distal terminals of the sensory or afferent nerves of the cerebro-spinal system are located chiefly in the integument, and are very thickly placed in the papillary layer of the cutis vera. This is why injuries of the surface of the body, as burns and lacerations, are pain- ful and dangerous from shock in proportion to the amount of skin surface involved rather than to the depth of the injury, for alarming intelligence from a chorus of nerves can produce more bodily apprehension than can be set up by a few indi- vidual fibers. The terminals of the motor or efferent nerves of the cere- bro-spinal system are found chiefly in the voluntary muscles, and the main effect of injury to them is loss of muscular pow- er. The nerves of the sympathetic system differ from those of the cerebro-spinal in that they possess no axis cylinder, ap- pearing like prolongations of gray matter enclosed in a deli- cate neurilemma. For this reason, while communications pass along them from the two extremities of the nerves, the im- pingement of the nerve trunks in continuity is more disastrous than in the case of the cerebro-spinal nerves. When, a nerve of either system is severed or ruptured, or excessively im- pinged upon, communications to the nerve centers may be made from the point of injury or impingement, but not so dis- 220 ORIFIG1AL SURGERY. tinctly as from the nerve terminals, because of the protection extended by the neurilemma, and in the case of the cerebro- spinal system by the insulating medium of the white substance of Schwann. Operative surgery involves not only the making but the closing of wounds. The making of wounds is always prescribed by the necessities of the case. In the extirpation of tumors and foreign bodies, in the excision of joints and the removal of dead bone, and in the evacuation of abscesses and the open- ing of cavities, the nature and extent of the wound involved is prescribed by the nature of the work to be accomplished. It must be long enough and deep enough and convenient enough to be adequate to its purpose. But it is in the closure of wounds that there is great room for improvement, and it is the object of the present paper to call the attention of sur- geons to the necessity of a more extended respect for the ana- tomical considerations which we have briefly outlined than has been their wont in the closing of wounds after all forms of operative procedure. The surgical habits of today are seriously at fault in that they involve unnecessary pain, shock, and thereby endanger not only the success of the operation itself but the general prosperity of the patient. In behalf of suffering humanity I beg leave to plead for a reform of surgical practice in two particulars, viz. : The co- aptation of all wounded skin surfaces by subcutaneous stitch- ing, and the avoidance, as far as possible, of the nerve impinge- ment involved in the ligation and clamping of tissues en masse. Let us then first consider the subcutaneous closure of sur- face wounds. When a stitch which pierces the skin upon both sides is tightened, it impinges steadily and severely upon the terminal ends of the afferent or sensitive nerve fibers of the cerebro-spinal system which have their distribution within its grasp. The distress occasioned is not only a source of general discomfort and of more or less consternation to the conscious- ness of the patient, but involves also an undue activity in the underlying voluntary muscles, for the afferent nerves are close- ly associated with the corresponding efferent ones, thus plac- ORIFICTAL SURGERY. 221 ing muscular action and surface sensation in sympathetic as- sociation. A subcutaneous stitch which will fully as satisfac- torily accomplish the coaptation of the skin margins dispenses with much of this discomfort, owing to the fact that a moder- ate impingement of the nerve trunks is materially less painful, and consequently less harmful, than an equal impingement of nerve terminals. In amputations, in resections, in abdominal, thoracic and cranial work, and in perineal work, a subcutane- ous stitch is equally effective with the present practice of skin piercing and pinching, and it is attended with so much less pain, shock and general discomfort to the patient that it should become a universal practice. There are two ways of accomplishing subcutaneous stitch- ing. One is longitudinally, and the other perpendicularly, to the wounded surfaces. The stitch should puncture the deeper layers of the cutis vera, care being taken merely to avoid wounding the papillary layer. The deep layers of the skin are sufficiently tense and substantial to afford all the support ne- cessary for the closure of wounds. The subcutaneous method of stitching has the advantage also of causing less interference with the capillary circulation of the parts involved, and there- fore insures a better healing than is obtained by the common method of coapting wounded skin surfaces by skin piercing and impingement. Now as to the avoidance of nerve impingement by the ligation and clamping of tissues en masse. There are five exceedingly bad surgical habits which seem to me to need correction. They need correction because they are clumsy, unsurgical, unscientific and cruel in their nature, unsatisfactory and frequently disastrous in their effects, and because they are wholly unnecessary. The sooner they are abandoned, therefore, the better it will be for both surgeons and their patients. In all cases they involve the severe im- pingement, either by clamp or ligature, of large masses of tissues and their contents, nerves and all, en masse; in all oases they, therefore, produce unnecessary shock to the pa- tient, and in all cases they endanger the vitality of the con- 222 ORIFICIAL SURGERY. stricted stump and tend to the formation of sloughs, thus fa- voring secondary hemorrhage and septic conditions. The five bad surgical habits referred to are: 1st. The deep sutures so frequently employed in closing abdominal wounds, in the operation for laceration of the per- ineum, and in the American operation. 2nd. The ligation of the omentum where its amputation is demanded. 3rd. The ligation in segments or en masse of the broad ligaments, or of the uterus itself, or of both, in the removal of ovarian and fibroid tumors by the abdominal route. 4th. The clamping or ligating of the broad ligaments in vaginal hysterectomy. 5th and last. The removal of hemorrhoids by ligation. Let us briefly consider them in the order mentioned. First bad surgical habit: The deep sutures so frequently employed in closing abdominal wounds and in the operation for laceration of the perineum and in the American operation. The practice of employing deep sutures in the closure of abdominal wounds and by deep sutures I mean those which penetrate the entire thickness of the abdominal walls on either side I am glad to say is no longer universally practiced, but nevertheless it is sufficiently in vogue to deserve brief mention in the present connection. Deep abdominal stitches afford no added security to the wound, interfere with the nutrition of the part, add materially to the danger and the suffering of the patient by the added pain and shock which they involve, in- vite inflammatory action, are in no way essential to recovery, and in every way are mischievous and undesirable. They not only unduly pinch and distress the outer integument within their grasp, but also the peritoneal surfaces, and their grasp upon the recti muscles induces muscular spasm without ex- cuse for it. In closing abdominal wounds in the median line it is suf- ficient to coapt the wounded margins of the peritoneum, the severed sheaths of the recti muscles, and by subcutaneous li- gation the severed margins of the integument in three sep- arate continuous sutures. Where the abdominal wound has ORIFICTAL SURGERY. 223 been made laterally and it has been found necessary to sever muscular tissue, in such cases it will be necessary to coapt the severed muscular fibers. But in no case should muscles be stitched when their fibers have not been severed. In closing a perineum deep stitches are necessary to coapt the posterior extremities of the sphincters vagina? and the transversus perinei muscles, but only two or three stitches are necessary and these should not include the skin. The needle should enter the wounded surface close to the margin of the skin upon one side, pass through the extremities of the mus- cles to be reunited, and find its exit close to the skin on the op- posite side, so as to avoid skin impingement. Subcutaneous stitching can be relied upon for the surface coaptation. One reason for failure to secure satisfactory results in the American operation is that the stitching employed is not only of the variety of skin puncturing and pinching, which we have al- ready considered, but that the stitches are frequently so deep as to pierce the fibers of the external sphincter muscle, there- by inducing spasmodic contraction of the same and tearing the ma 'gins of the wound apart or, in cases where healing takes place, inducing a clumsy and strictured condition which requires subsequent correction. Subcutaneous stitching prac- tically solves the only remaining problem of the American operation and robs it of its terrors. The pain following the subcutaneous stitching in the American operation is so greatly reduced that the patients seldom suffer, sphincter contractions are avoided, healing by first intention is secured, and quicker and more satisfactory results are thereby attained. The superiority of the subcutaneous stitching, both in the deep and superficial threads, is surprising both in the healing of the parts and in the comfort of the patient. Second bad surgical habit: The ligation of the omentum where its amputation is demanded. It is mainly to avoid squeezing sympathetic nerve plexus that the wadding together of the omentum, by the application of a tightly drawn ligature, is objected to. The hemorrhage can be easily controlled by a running stitch, which includes each blood-vessel in a separate loop and, when it is tightened, 224 ORIFIG1AL SURGERY. ligates the blood-vessel and successfully controls the hemor- rhage without pinching the other omental tissues. This is by no means difficult of accomplishment and takes but a trifle more time than is required to ligate the omentum en masse, and avoids undue nerve impingement. Third bad surgical habit: The ligation in segments or en masse of the broad ligaments, or of the uterus itself, or of both, in the removal of ovarian and fibroid tumors by the ab- dominal route. The sympathetic plexuses of nerves inclosed within the folds of the broad ligament are large and correspondingly in- fluential in the bodily economy; and whereas it is always in order to ligate blood-vessels to control hemorrhage, it is never in order to tie nerves, especially when it is just as easy to con- trol the hemorrhage without doing so. There are two places on each side of the female pelvis where hemorrhage is liable to be encountered in the removal of the ovaries and uterus, and these are at the outer and inner edges of the broad ligament, the first place being marked by the point where the fallopian tube and ovary meet, and the other being situated just below the angle of the attachment of the fallopian tube to the uterine margin. The dissection of the ovary and tube from the broad ligament can be started at the outer extremities and, when the blood-vessels are sev- ered, it is a simple matter to secure them with artery forceps. As the fallopian tube and the ligament of the ovary are care- fully dissected away, should other blood-vessels be encoun- tered, it is an easy matter to seize them with forceps. In this manner the dissection can proceed as far as the uterus, at whose margins the hemorrhage which occurs can also be se- cured in the same manner. A continuous suture can now be applied along the severed margins of the broad ligament, be- ginning at its outer margin, and at every point where an ar- tery forceps seizes a blood-vessel a loop of the continuous su- ture can be thrown around it sufficiently tight to secure the artery and at the same time coapt the wounded margins of the broad ligament, so that no wounded surface shall be left in the peritoneal cavity. This practice can be followed as far as ORIFICIAL SUEGERY. 225 the uterus, at which point one or more additional loops of the continuous thread will be needed to secure the bleeding ves- sels in the grasp of artery forceps. The other side can be treated in a similar manner if it is operated upon. The uterus itself, if it is to be removed, can be amputated on a level with the floor of the pelvis, or even below the internal os, by the flap method without the slightest difficulty. It never bleeds to any extent, and there is not the slightest excuse for choking it with a ligature. The margins of the uterine flaps can be coapted by the same threads which formed the lateral continuous sutures and, as they meet in the middle, can then be tied together. By this process ovarian and fibroid tumors, regardless of their size, can be easily and expeditiously removed without tying anything except blood-vessels, securing even these with loops of the continuous thread which coapts the wounded margins of the peritoneum, and after the work is performed all the relics of the operation left in the pelvis are simply the absence of the organs and a narrow, uninterrupted seam from the outer mar- gin of one broad ligament to the outer margin of the other. Of course, where extensive adhesions are present, modifications of this procedure will be called for. But there is no excuse on any occasion for the ligation or clamping of masses of tissue, as is now so commonly practiced. The difference in the de- gree of shock to the patient, and the difference in the degree of health subsequently attained by this method of securing the stump and the ordinary methods in vogue is simply re- markable, and the method just described has so much to com- mend it, and it is so entirely free from every objectionable feature, that there is little excuse for the continuance of the practice of securing pelvic pedicles by the old method of either clamping or ligating large masses of tissue. Fourth bad surgical habit: The clamping or ligating of the broad ligaments in vaginal hysterectomy. There are many serious objections to the employment of either clamps or tissue ligatures in vaginal hysterectomy. The danger of wounding the ureters or the intestines where ad- hesions are present is not inconsiderable, nor is secondary hemorrhage from the sloughing which is usually induced, un- 226 OEIPICTAL SUEGEBY. common; and, so far as the employment of clamps is con- cerned, they are liable to slip their hold and fail of their pur- pose to control the hemorrhage, in addition to the irritation and inflammation which they set up, and the distress to the patient while they are retained in position for twenty-four or forty-eight hours. But these and many other objections, which may fairly be urged against securing the broad ligaments in the grip of either clamps or ligatures, do not properly concern the purpose of the present paper. The great objection which is our present concern, and the only one your attention should be invited to in the present paper, is the fact that when the broad ligaments are squeezed by either clamp or ligature to so sufficient an extent as to con- trol hemorrhage, not only the blood-vessels but all of the in- tervening tissues are badly pinched ; this means, aside from a considerable expanse of peritoneal surface, the large plexuses of sympathetic nerve fibers which lie within its folds. The effect of excessive and protracted pinching of these important plexuses of nerves is to induce severe functional disturbance not only in the remaining pelvic organs but in all functions of the body that are dominated by the sympathetic nerve, for the distress telephoned by these plexuses to the sympathetic nerve centers creates a great disturbance of the entire sympa- thetic nervous system. The removal of the uterus and its appendages in cases where such an operation is demanded, and in which the va- ginal route is decided upon, can always be accomplished by dissection. In fact, many cases are operable by this method that are inoperable by the clamp and ligature methods, and hence there are no operable cases which cannot be satisfactor- ily handled by the dissection method. The field of operation is always within view, and as blood-vessels are wounded which, of course, is frequently the case it is a simple matter to seize them with artery forceps and either ligate them as they are encountered or secure them in the subsequent clos- ure of the wound. The details of accomplishing this will be found in another section of this book, giving in full the tech- nique of this operation. As long as nerve-pinching in vagina! OBIFJGIAL, SURGERY. 227 hysterectomy is both harmful and unnecessary it seems but reasonable to conclude that it ought to be abandoned. Fifth and last bad surgical habit: The clamping or ligat- ing of hemorrhoids. Professor Agnew, while holding a college clinic, presented to the class a case of fistula. The man was placed under the influence of ether and the case successfully operated upon and in due time dismissed. A year later the same man presented himself to the same clinic, and the same man gave him the same anesthetic, and the same sur- geon, Professor Agnew, proceeded to operate upon him for hemorrhoids. The patient took the anesthetic just as kindly as he had done the year previous. When he was profoundly asleep Professor Agnew proceeded to remove the piles by the orthodox process of ligation but, strange to relate, as soon as he tightened the ligature around the first pile tumor the anes- thetist called his attention to the general condition of the pa- tient, who had stopped breathing and was rapidly becoming cyanotic. Professor Agnew rose from his chair, observed that the man was breathless and rapidly becoming pulseless. Active measures for his resuscitation were immediately inaugurated. Artificial respiration was practiced with the patient in the horizontal position, and also with the head and shoulders de- pendent. Electricity and all other means at the command of Professor Agnew and his assistants were employed, and proved unavailing. The man's spirit went out, and neither Professor Agnew himself nor any of his attendants nor any of the gen- tlemen present seemed to think far enough or know enough to cut the string which was all this time strangling the pile tumor and terminal filaments of the sympathetic nerve, and by sym- pathetic communication was paralyzing the action of the phrenic and pneumogastric nerves. Professor Agnew himself clearly and carefully described the case in all its painful de- tails in a prominent medical journal, and yet I have seen no comment either in that journal or in any other upon the ig- norance manifested in this case concerning the disturbance to the respiration which follows injury to the rectal nerves. The death, was, of course, attributed to the action of ether, and yet the patient had taken it safely the year before and was acting 228 OKIFIGTAL SURGERY. kindly under its influence at the time of the last operation un- til the very moment at which the ligature was applied about the pile tumor. This point was very carefully made by Pro- fessor Agnew himself in his description of the case, and yet it never occurred to him that the ligating of the tumor had any- thing to do with the man's respiration, and that the cutting of the string which bound the tumor, accompanied by slight dilatation of the sphincter, would have immediately restored the man to animation. This is by no means the only death which has occurred from the ligation of hemorrhoids and which has been attrib- uted to the action of the anesthetic. But aside from its imme- diate danger, the practice of ligating hemorrhoids has no pos- sible excuse for existence. This method of treatment was in- augurated at a period in rectal surgery when there were no proper instruments with which to expose rectal tissues and place them at the command of the surgeon. The fear of hem- orrhage in an inaccessible position was the excuse for the measure. But that excuse has long since passed away. By means of modern rectal instruments the rectal tissues can be so thoroughly brought into view that the operating field in anal surgery is as perfectly under the observation and control of the surgeon as is any other part of the human body, and there is no longer the excuse of necessity to uphold the contin- uance of this barbarous practice. If a tumor is to be removed let it be amputated, and if the part bleeds let the blood-vessels be secured by ligation if necessary, although the fact is that in hemorrhoidal work it is very rarely called for. It is not my purpose in the present paper to consider the various methods of treating hemorrhoids and discuss their comparative merits, but simply to protest against an undue and unnecessary nerve impingement in rectal work as in all other operative procedures. The nerve impingement of ce- rebro-spinal fibers may induce muscular contractions, either clonic or tonic, and is responsible for much of the pain, irri- tability, inflammation, sepsis and death of surgical cases. The OEIFIGLAL SUBGERY. 229 nerve impingement of the sympathetic system disturbs func- tions and lowers vitality. As, then, the impingement, by clamps or ligatures, of nerve trunks of either the cerebro-spinal or sympathetic sys- tem in cases where the shock which it occasions does not im- mediately kill, disturbs, devitalizes and more or less perma- nently maims the patient upon whom it is practiced, it should in all reason be eliminated as far as possible from all sur- gical procedures. CHAPTER XXX. ABDOMINAL SECTION IN THE LIGHT OF ORIFICIAL PHILOSOPHY. E. H. PRATT, M. D. Laparotomies are performed by the present generation of surgeons for the relief of a large variety of troubles. Not presuming to give an exhaustive list, let us consider a few of the more common complaints for which the operation is under- taken. It is done for appendicitis, acute and chronic, it is done for biliary calculi, for gunshot and stab wounds, for fib- roid and cancerous tumors of the omentum and female pelvic organs, for the removal of diseased ovaries and tubes, for ven- tral fixation of the uterus, and as a means of diagnosis some- times for the general abdominal cavity and sometimes for the pelvic cavity. In the removal of ovaries, tubes and tumors of various kinds, the present practice is to ligate or clamp all pedicles either inside or outside of the abdomen. The central thought in orificial surgery is to avoid the un- due impingement of nerve fibres, whether in a normal or ab- normal condition. This great principal finds its application not only in treating the sphincter guarded opening of the body, but wherever wounds are closed or stumps are treated. 230 ORIFIG1AL SURGERY. With this thought in mind, what suggestions have we to make to laparotomists ? First, as to the external abdominal wound. Is it necessary to employ deep sutures, which clutch with a more or less vise-like grip the sensitive abdominal wall, including the recti muscles and a large area of skin surface? Does this not cause unnecessary contraction of muscular fib- res, and by choking the tissues produce an unnecessary de- gree of nerve tension and discomfort, if not danger? If the sheathes of the recti muscles were intact, the abdominal cavity would have its normal protection so far as the middle portion of the abdominal wall is concerned. The peritoneum has no tendency to displacement, and as it heals very quickly where its edges are coapted a continous suture in the peritoneum is all that is required to sufficiently protect the peritoneal in- jury; and as for the integument, instead of clutching large bunches of it in the severe grip of a tightly drawn ligature, it is much neater, more comfortable, just as safe, and conse- quently more satisfactory to coapt merely the margins of the integument by a nicely adjusted continuous suture. By thus stitching together the various tissues of the abdominal walls separately, the surgeon is able to avoid all undue pinching of the tissues and to do away with much of the shock that fol- lows laparotomies. In the opening of the peritoneum for peritonitis, for ab- scess, for gall stones, for appendicitis, or for gunshot or stab wounds, orificial surgery has nothing to suggest to general surgery, except in the securing of the abdominal wound. It is worthy of mention, however, that many cases of appendi- citis and typhlitis in the chronic form have been to all appear- ance permanently and perfectly cured by orificial surgery ap- plied to the lower openings of the body. It has been my pleasure to handle a few cases of abdominal abscess in this manner successfully without the aid of laparotomy, although there are frequently recurring attacks of appendicitis; while we would suggest the employment of orificial surgery as a pre- liminary operation, it may be best later on to remove the of- fending appendix to avoid the possibility of future attacks of acute inflammation. OKIFIC1AL SURGERY. 231 In the amputation of the omentum for cancer or other tu- mor, instead of ligating the omentum in sections and thus doing violence to a broad area of tissue freely ramified by sympathetic nerve fibres, it would please orificialists to see the wounded margins secured by a continous suture, employing a single turn of the suture, or, if the operator prefers, a liga- ture of catgut at the bleeding points to secure the hemorrhage. In removing large ovarian tumors we see no reason for ligating or clamping the broad ligament, and now that we have come to know the harm of tying large bunches of tissue, and the ease with which the hemorrhage can be secured and the wound excluded from the peritoneal cavity by a nice coaption of the severed margins of the peritoneum, we hope to see this improved method of speedily handling the pedicles of ovarian tumors universally adopted by laparotomists. The same re- mark will apply to those cases in which the ovaries and tubes, although of small size, are so disorganized as to demand re- moval and the operator prefers to take them away by the ab- dominal route. In the treatment of fibroids, especially when they are in- trauterine and intramural, orificial surgery has an important message to send to those who are in the habit of removing these frequent growths by the way of the abdomen. If the tu- mors are movable and no larger than a foetal head weighing perhaps from one and one-half to three pounds, it is much more preferable to remove the tumors by the vaginal route than to take them out through the abdominal section. It in- volves less bruising of the peritoneum, less handling of the in- testines, and is in every way the more desirable operation, es- pecially in view of the manner of performing hysterectomy which orificial surgery has presented to the world. If the tu- mor be too large, however, to be removed by way of the vagina, and the abdominal route is decided upon, it chills the blood of the orificialist to contemplate the unnecessary squeez- ing of tissues, the shock and sloughing with its danger of sep- sis, involved in the methods at present in vogue for accom- plishing the desired object. 232 ORIFICIAL 6URGEBY. We will not take the time to rehearse the various methods at present employed of choking the broad ligaments and uter- ine stump, for they are all objectionable, whether by clamp or ligature; but simply offer as a substitute a much more hu- mane, successful and at the same time easier accomplished method which has already been described in orificial writings, which has the following points in its favor : It wounds large arteries only in occasional cases, for under all circumstances in securing the patient against hem- orrhage it ligates only blood-vessels, and under no circum- stances pinches by ligature or clamp either muscular, areolar, peritoneal or uterine tissues, thus avoiding undue impinge- ment of all nerve plexuses, and doing away with the danger of sloughing of the stump and leaving no wounded surface ex- posed in the peritoneal cavity. Much of the danger from shock, from inflammation and from blood poisoning is thus very easily avoided, and the better way is not more difficult of accomplishment, is not as difficult as the more dangerous methods which we are desirous of seeing abandoned. What has been said of fibroid tumors is equally true of cancerous degeneration of the ovaries, tubes and body of the uterus. Whatever can be done in this unfortunate class of cases by opening the abdominal cavity can be better, more thoroughly and more satisfactorily accomplished by respect- ing the suggestion already made than in any other way. For those who rely on the use of clamps and ligatures to choke off tissues which they fear will bleed, the cases which are sessile, either ovarian and tubal or uterine troubles, will be found im- practicable for operation. These can be easily and success- fully handled by the method we are presenting. It will always be necessary, in all probability, to make ex- ploratory incisions in the abdominal cavity for diagnosing ab- dominal difficulties located above the dome of the pelvis, and in many cases for pelvic troubles themselves, for there is a large class of pelvic difficulties in women that can be better examined and treated by the vaginal route, which at the pres- ent time are subjected to the abdominal section. Where the uterus is movable, an easier, safer and more satisfactory ex- ORIFIC1AL SURGERY. 233 animation of the lower pelvis can be made by entering the peritoneal cavity either in front or behind the uterus than can be made from above. Small-sized ovarian tumors, and the tubes in cases of pyosalpinx, are more easily and safely re- moved by way of the vagina than through the abdominal opening. This class of cases, formidable in their nature, which it is difficult to handle satisfactorily from above, can be reached with a degree of success from below. I refer to those cases where a local sub-acute peritonitis has succeeded in glue- ing the ovaries to the walls of the pelvis, and so completely covering them up as to make their detection from above a matter of extreme difficulty. Such cases are usually bilateral, and the removal of the uterus is invariably essential to a cure. With this organ removed, and a T-forceps securing a grip up- on the upper edge of the broad ligament which marks the situ- ation of the fallopian tube, the tubes and ovaries can be read- ily located and extracted from their bed of inflammatory de- posits. In such cases the ovaries are friable and can be taken away only in fragments. But the importance of the removal, we believe, is not sufficiently appreciated by surgeons who are not familiar with the orificial philosophy and the story it tells of the mischief accomplished by the pinching of nerve fibres by contracting tissues. In the reports of laporotamies as published in current lit- erature one frequently reads of cases in which, as the ovaries were imbedded and showing signs of inflammation, they are permitted to remain unmolested. To an orificialist, however, who understands that the cicatricial tissue is perpetually con- tracting with time, and that when it involves an ovary it is squeezing that organ tighter and tighter as the days go by, occasioning more and more sympathetic nerve waste, and do- ing more and more violence to the harmony of the entire body, it seems of more importance to remove these imbedded ovar- ies, whether they be large or small, and release the terminal nerve fibres which cover this surface from their unnatural con- striction in this cobweb of perpetually tightening fibres than as though the organs presented a much more magnified form of pathology and were free to expand as their unnatural pro- 234 ORIFIGTAL SUEGEBY. portions increased. Ovaries of this nature can be excavated from their living tomb through the vagina, where it would be very difficult and perhaps dangerous to attempt their removal by abdominal section. As to ventral fixation of the uterus, for the correction of retroflexion it may be the best way, but for picked cases Alexander's operation and one or two retroflexion operations already published in orifieial writings seem, for many reasons unnecessary to mention in this article, prefer- able. SECTION V. The Rectum. ORIFKflAL SURGERY. 237 CHAPTER XXXI. NEUROSES OF THE RECTUM AND ANUS. H. L. TOWNSEND, M. D. The rectal and anal neuroses are so widespread, so simple and obvious at times, yet so complex and remote at others, that we should not be surprised to find in them a subject for deep thought and thorough investigation. The subject is an obscure one and has never been exhaustively studied but by a limited number, viz.: Ultzman, Matthews, Kelsey, White- head and Pratt, the latter of whom has brought out more clearly than all the others the reflexes and the pathological conditions growing out of such nerve-waste. Etiology. It may be set down at the outset that the rectum, like other* parts of the intestinal canal, and the stom- ach, bladder, urethra, etc., has complex motor secretory func- tions which are capable of derangement through the nervous system, and reacting on the nervous system when so deranged. It is unnecessary to cite in analogy the profound impression which even slight gastric disturbance may make upon the brain and its functions, causing vertigo, neurasthenia, spasms, and even confirmed epilepsy, or the violent urethral chill and ac- companying pyrexia which the most careful introduction of a catheter causes in some cases. Speaking again by analogy, if the existence of phimosis in childhood can cause serious reflex disturbances, it requires no argument to show that an irritation of anus or rectum may also cause disturbance. Nervous reaction to all bowel troubles is profound in a degree. In the rectum, however, or in the terminal portions, we find what does not exist in any other part of the intestines a full supply of sensory nerves. Hence we have added to the sympathetic system the possibility of sensory neuroses, of which the peculiar disease known as fissure of the rectum is a typical example. Before considering the different varieties of 238 ORIFICIAL SURGERY. rectal neuroses, it may be well to inquire in general what de- gree of severity and importance these have as compared with the neuroses of other parts of the body. Are they, like those of the stomach, capable of inducing disease in the brain and nerve centers by long-continued irritation? Can mere rough handling cause dangerous or fatal collapse as in the case of the bladder? Can radiating pains or general malaise and debility such as follow disease of the ovaries be traced to local disease of the rectum? These questions can be answered in the af- firmative in a large number of cases. In many directions they are similar, in others less severe, and still in others are ob- scure and baffling, yet not the less real and troublesome. Structural changes whether acute or chronic, classed as neu- rasthenia, and marked by abnormal, exalted, reflex excitement, are prone to affect the rectum. The causes to which we al- lude are mainly those that produce other neuroses, flushing, vertigo, incontinence or retention of urine. Vesical tenesmus, etc., are most common in anemic persons in early life. Over- study or business anxiety, great fear, etc., may often be found to have brought such individuals to a state of extreme prostra- tion. It cannot be disputed that there is a class of such cases analogous to that in which impotence, spermatorrhea, etc., are the chief troubles, where the rectum and anus are the seat of neuroses. Fear or shocks to the nervous system often pro- duce involuntary movements from the bowels; or on the other hand, constipation may follow great mental strain of any kind. Some obscurity must be admitted to exist as to the exact ner- vous mechanism involved in these symptoms. Through the hypogastric plexus of the sympathetic nervous system which is in intimate relation with the sacral, the uterine or vesical and lumbar spinal nerves, the anus, rectum, and genito-urinary organs are intra-related. (Echard.) Not only do they react on each other as when operations on the rectum cause retention of urine, but they are both sub- ject to the same impression from the central nervous system. Vasomotor neuroses of the lower bowel have only been studied in the last few years; and to Prof. Pratt is due the honor of its demonstrative action, both curatively and patho- ORIFIG'iAL SU'RGEBY. 239 logically. An example of its effect is demonstrated very for- cibly in at least fifty per cent, of all cases by the use of the rectal speculum, under partial or full expansion, by its arterial depression which as soon as removed disappears. Alteration of blood pressure is a natural result of their disturbance. The region of the anus is peculiarly rich in sensory nerves, while the upper portions are nearly devoid of sensibility. Hence diseases such as ulceration in the upper portion are painless; while small lesions about the anal verge are acutely painful. The nerve distribution about Hilton's white line which is so plain to be seen under full dilatation is where the sensory ends and the sympathetic begins. Hyperesthesia of the anus will be invariably found to be present where there is local irritation from hemorrhoids, proctitis, fissures, etc., while a normal rectum will bear the insertion of a small speculum or the oiled finger without pain; where slight disease will make the rectum so sensitive that an internal examination is nearly impossible and if persisted in will cause pain for several days. In this state of hyperesthesia which is common in the rectum, the part is the most sensitive in the whole body, not excepting the eye, urethra or bladder. It is therefore not unaccountable that the element of pain is so prominent in all rectal troubles. Closely associated with hyperesthesia is neuralgic trouble of the rectum and anus. Undoubtedly cases are found in which severe pain in the lower bowel is accompanied by some local lesion. This may or may not be associated with motor neu- roses such as tenesmus of the bladder or rectum. It is some- times a concomitant of brain or spinal disorders, sometimes it is purely local. Purely nervous forms of pruritis ani are not very uncom- mon, and such are the most stubborn cases to cure. Medicines and local applications show but meagre results; but a thor- ough dilatation and removing all irritating pathological con- ditions will restore a normal condition or will put the patient in a condition where medication will avail. Reflex pain is a common form of rectal neuroses in a bad case of hemorrhoids, wounds or injuries to the anus or severe proctitis. Local pain is often less severe than the radiating in parts more remote. 240 ORIFICEAL SURGERY. Severe lumbar pain is a constant symptom of rectal disease, particularly of the pile-bearing inch, which was very marked in a case I operated on the 8th inst. The patient located the pain at the upper part of the sacrum, and thought the disease was higher up than at the verge. Examination failed to find any trouble above the pile-bearing inch. At that point, within the grasp of the sphincters were two large hemorrhoids which I removed. When the patient was fully out from under the anesthetic he said the dull ache was gone. I simply cite this case as one example out of many in my experience. When there is a great irritation of the anal membrane, a pain like that of cystitis, with or without vesical tenesmus and retention is usually felt. Like that of cystitis the pain is often referred to the glans penis, and is accompanied by a frequent mic- turition. Its cause is explained by the arrangement of the ner- vous supply above mentioned. Motor neuroses of the rectum and anus are intimately con- nected with the sensory. Painful tenesmus of the bowels in dysentery may exist without local disease of any kind. The oft repeated evacuations create congestion, and the rectum tries to expel its own mucous membrane. It is probable that in a normal condition it is empty, except just before defeca- tion, and is not physiologically in any sense a receptacle for retaining fecal matter. Rectal spasm is a constant symptom of proctitis, but it, like neuralgia, may exist without local disease. Spasm of the sphincter alone is also found as a local expression or a general neurotic condition, and as a result of fissure, piles, etc. On account of the large sensory nerve supply at the anus, there is much more nerve reflex disturbance in spasm of the sphincter than in rectal spasm, i. e., prostration, faintness, etc. Motor-urinary reflexes are among the most obvious and easily explained effects of irritation, disease, or surgical in- terference about the rectum. The pudic branch of the sacro-coccygeal plexus is a com- mon source of the inferior and medium hemorrhoidal nerves which innervate both the sphincters ani, and the lower third OEIFIC1AL SU-BGEEY. 241 of bladder and sphincter vesicae. Spasm of both is a natural and usual result of irritation. In the female the vagina receives its nerve supply from the same branches; and in a large majority of rectal and vaginal operations temporary retention of urine occurs. There is a constant tendency to vesical spasm in rectal trouble and vice versa. The normal evacuations also tend to occur simultaneously, entirely apart from the will. Enuresis in children is to be explained partly by reference to the same nervous mechanism. Before the age of one year there is no involuntary resistance of the sphincters; and discharge of urine and feces take place whenever there is the slightest ex- pulsive force. Control of the sphincters ani begins at the end of the first year ; control of the urinary sphincter not until the age of two years (Ultzman), or after dentition. After this age bed wetting in children should be considered abnormal. The reason for its description here is that it is amenable to treat- ment. While in itself a local bladder neurosis, pure and sim- ple, it furnishes an excellent illustration of the favorable im- pressions that may be made upon the nerves through the nerves of the rectum and anus. All, or nearly all of the old writers attributed the cause of bed wetting to functional disturbance of the nerve supply of the vesical sphincter. No one supposed that this affection was in any way connected with disease of the rectum, until Professor Pratt thoroughly demonstrated it by orificial methods. Did indirect treatment of rectal irrita- tion relieve and cure vesical diseases of that nature? If rectal reflexes are so profound when disturbed, why not take advan- tage of them to impress the nerve center favorably in a great variety of nervous troubles. By dilating the sphincters and smoothing off all pathological conditions as near as may be, it flushes the capillary circulation and that in time improves the nutritive function, nerves, and tissue, starting the patient on the upward road to health. A single dilatation is not enough in all cases to arouse the sluggish nervous system from its slumbers; but the repetition with the use of the rectal plug is sufficient, if the patient has had first a thorough dilatation un- 242 OBIFICIAL SURGERY. der an anesthetic. As soon as all soreness is gone, begin the use of the plug at intervals of every other night, leaving it from ten minutes to half an hour. CHAPTER XXXII. RECTAL SURGERY CONSIDERED IN ITS RELATION TO GENERAL SURGERY. E. H. PRATT, M. D. The general principles underlying all pathology are uni- versal in their application, whatever tissues of the body may be involved. Cases calling for surgical attention differ in no wise so far as the principles upon which their repair is based are concerned, from those which are able to dispense with sur- gical attention. Capillary circulation, cell destruction, removal of the debris, cell proliferation and a supply of material to accomplish this are considerations of universal application in all forms of physical disorder, medical and surgical. Surgical practice is always an apology for better work. It is destructive in its character, severe in its application, and should always be appealed to as a last resort for the relief of human suffering. While it is a matter of deep consolation to be provided with this last resort, to be possessed with the ability to save the whole by the sacrifice of a part, it is also to be lamented that the beginnings of destructive changes cannot be detected in sufficient time and that our knowledge of other remedial meas- ures is not fully adequate to keep the machinery of life in har- monious action without permitting it to become so disarranged as to demand surgical interference. In the present state of development of the medical pro- fession, however, surgeons are in constant demand and sur- gical practice is honorable and indispensable. The possibili- ties of relief from surgical praitices are constantly increasing, and I am glad to feel that the general tendency of surgical thought is toward conservatism. ORIFIC1AL SURGERY. 243 There is a fascination about wounding and healing, about drawing blood and stopping it, about cutting away disease and leaving health, that combines in its elements of attraction the innate love of mathematics, of punishment of the guilty, of reward of the good, of curiosity and heroism. Operations upon the dead are not classified as surgical proceedings; they are nothing but anatomical dissections. The human house has opened, its inhabitant has moved out, disintegration is immi- nent, and to dub a mere anatomist as a surgeon would be a misnomer. The practice of surgery presumes the existence in its subject of proper reactive power, of a vital force, of life, of a soul, element, or whatever you may choose to call it. When this spark of vitality is flickering like a dying ember, when it is so far gone as to be beyond recall, no reputable surgeon would be unmanly enough to plunge his scalpel into the almost lifeless flesh. The first question which a surgeon is called upon to decide in a given case, therefore, is whether or not his patient still retains sufficient tendency of life to enable him to sustain the meditated attack upon his vitality. Surgical measures involve shock and presume upon reaction. Is the patient in question still sufficiently alive to rebound, or will the severity of the proposed treatment hasten the exit of the vital spark? All chronic pathology implies depleted energy. There is a nat- ural tendency in human nature towards health and harmony, and when a human system permits the continuous presence in any part of a morbid condition, it is simply because it can't help it. So that this bit of pathology, wherever it may be found, is an expression not only of local mischief, but also of deep depreciation in the tone of reactive power of the entire body. A disorganized joint, too dilapidated for repairs, is tax- ing a poor organ beyond endurance. If the patient yet retains a considerable degree of vigor an operation upon the joint, re- moving the debris and establishing drainage may be under- taken with full confidence that the general health of the pa- tient will be improved and the harmony of the rest of the body restored by applying correct surgical principles to the 244 OBIFIG1AL SURGERY. sick joint. But if the appeal to the surgeon has been late, if the life of the patient is at so low an ebb that the very process of repairing the joint will involve greater shock than the pa- tient is able to react from, the conscientious surgeon will re- fuse to shorten an earthly existence by a too bold interference and simply say it is too late, and do what he can to make the remaining days as endurable as possible. The question which I shall propose for your discussion is, are there any means heretofore neglected by employing which the general health of a patient can be improved; by wfiich his stock of vitality can be increased ; by which his re- active power will be so materially added to as to increase the possibility of major surgery, or possibly dispense with a con- siderable portion of it? And shall not only present the ques- tion for your consideration, but take radical grounds in the affirmative. Yes, there are measures which have been neglect- ed, which if employed, will bestow upon any patient, surgical or medical, increased vitality, which will render all major op- erations less dangerous and more helpful, and which will dis- pense with the necessity of quite a percentage of major sur- gical work which would otherwise be impossible or imperative. The thought to which I shall attract your attention in this direction has been employed by hundreds of doctors upon thou- sands of patients, and has won for itself such widespread rec- ognition as to absolutely demand from all would-be surgeons, as well as doctors, careful consideration and appreciation. If you will consider that the lower openings of the body are in such close sympathy and communication that they suf- fer together and must get well together ; that rectal disease ex- ercises a profound effect upon sexual conditions, and that sexual conditions influence the condition of the rectum; and if you will take it for granted that the sexual system has been placed in repairs, I can then discuss the mutual relations be- tween these rectal conditions and major surgery with a clear conscience. A healthy rectum is essential to normal peristal- tic action, to a normal capillary circulation, to general vi- vacity, to the presence of a substantial reactive power. The converse of this is also true. In weakened peristaltic action, ORIFIC1AL SURGERY. 245 enfeebled circulation, lowered vitality and deficiency of re- active power there will always be found upon examination some form of rectal pathology, more especially in the last inch of the organ. To employ, then, major surgery upon an enfeebled sub- ject without recognizing and removing the nerve waste oc- casioned by the concomitant pathology, is an omission on the part of the surgeon which demands severe censure, and from now on will receive it. A surgeon has no right to be behind the times; he has no right to refuse to recognize the progress of the age in which he lives ; and when a new thought has gone far enough to be a mattei jf special study by thousands of physicians and surgeons, to be introduced into the curricu- lum of a number of medical colleges in good standing, and to be practiced as a means of cure in many sanitariums, * * * it has gone beyond the dictum of any one man or set of men, and has so completely won its right to public recognition as to stamp the surgeon who refuses to give such of his patrons as may need it the benefit of its teachings, as a back number in the medical profession, and one wholly unfit to assume the great responsibilities of surgical practice. First of all, the surgeon must appreciate the effect pro- duced upon respiration and circulation by dilating the anal sphincters. It is of untold importance in patients who behave badly under an anesthetic, and is the greatest means for re- suscitation from collapse caused either by the anesthetic, loss of blood, or surgical shock. The general surgeon, then, should always have a bivalve rectal speculum at his command whenever a patient is anes- thetized for any purpose whatsoever, perfectly regardless of the condition of the rectum. In cases of great debility, where a capital operation is called for, even if the surgeon does not endorse all of the methods recommended by orificial surgeons for securing increased nutrition and vitality, he cannot con- scientiously refuse to give his patient the benefit of a uni- versal flushing of the capillaries which can always be secured by dilating the sphincters, which may be thoroughly done if the patient be anesthetized, and which may be easily done 246 ORIFIG1AL SURGERY. without an anesthetic to a sufficient extent to stimulate per- manently and materially the weakened forces of a delicate pa- tient. The surgeon should not forget also, in anesthetizing a patient, that in cases which have inhaled large quantities of the anesthetic employed without the proper stupifying effect, that rectal dilatation will materially assist in producing nar- cosis and save the patient from the unhappy after-conse- quences of a too free use of the anesthetic material. A gen- eral surgeon should recognize the fact that when the capillary circulation has been thoroughly re-established by skillful rec- tal work, many serious affections of the deep-seated tissues and organs of the body which otherwise would require the em- ployment of major surgery, will disappear if sufficient time be allowed for the improved circulation to accomplish its legiti- mate and reliable reparative process. The general surgeon should also recognize the fact that in all cases of pathology calling for major surgical procedure, his patient upon examination will present some form of rectal pathology, which, if allowed to remain uncorrected, will han- dicap peristaltic action throughout the entire body, and ma- terially interfere with the success of his work. The proper course for the general surgeon to pursue, therefore, when con- templating an operation, is either to correct all rectal trou- bles as a preparatory proceeding, allowing some weeks ^i months to elapse, as the case may be, before proceeding with the major work; so as to permit his patient to receive the full benefit of whatever rectal work the case may have required; or in cases where the patient is reasonably vigorous and pre- sents but minor rectal pathology after performing the major operation called for, he should immediately give his attention to the rectum and correct whatever he finds out of order in that locality before permitting the patient to awaken from the influence of the anesthetic. Whatever rectal work may be done in a given case, it should always be supplemented by such after-treatment as will ultimately secure for the patient a di- latable anus free from all forms of irritation. Rectal surgery will thus, when its importance is properly appreciated, become the hand-maid and chief ally of major ORIFIC1AL SURGERY. 24? surgery; and its employment, although it will not always dis- pense with major surgical proceedings, will materially dim- inish their number, render more successful those which are un- avoidable, thus decreasing mortality and adding materially to the longevity and healthfulness of the races of men. I see by referring to the papers presented at the various State societies of the present year, that the profession are be- ginning to realize that we live by peristaltic actions; that these are dependent for their vigor upon the great sympa- thetic nerve; that the wastes and supplies of the sympathetic nerve are, therefore, legitimate and essential objects of care- ful consideration and study by all members of the medical profession. Surgeons as well as doctors must recognize this recent advance in medical science and take advantage of its principles. It would not be proper in the present paper to descend from the general principles to details, either of method or pathology, but my object will have been fully accomplished if I succeed in arousing the members of this Surgical Associa- tion to a realization of the fact that there is a relation of great importance always existing between rectal and general sur- gery, and enlisting their hearty co-operation in a careful study and consideration of the subject. We must not carry conservatism to the point of obstinacy. We must not ignore newly found facts if they are facts. We must not stand still when the rest of the world is moving. We owe it to our patients and to ourselves to be honest, earnest and safely progressive. CHAPTER XXXIII. THE TOILET OF THE RECTUM. T. J. APPLETON, M D. The use of water in the toilet of the rectum is of very great importance and, with very few exceptions, should be used by every one, young or old. 248 ORIFIG1AL SUKOEEY. The method employed is very simple. A common foun- tain syringe is the best instrument, and tepid water the best temperature. The rectum should be douched with a small quantity of water while in a sitting posture, immediately after stool, repeated two or more times, not allowing the water to pass into the colon. This can be avoided by passing off the water at the first urging. Then dry the parts with some soft paper or, better still, a wet cloth. This procedure is to be employed in fairly normal cases and as a hygienic measure, just as we would care for the teeth or any other part of the body; but for obvious reasons this is of more importance. The rectum, physiologically considered, is a repository for nothing; consequently, when anything remains in it, harm results, and after stool there will always be some adherence, if not considerable accumulation, both externally and in- ternally. That externally is always removed, but internally very rarely. The internal adherence causes harm, but the ex- ternal, if allowed to remain, would not cause constitutional harm. The one appeals to the cerebro-spinal nerves, the other to the sympathetic. This procedure employed in normal con- ditions of the rectum will prevent most all of the rectal path- ology, and therefore resulting constitutional troubles. Used in abnormal states, it reduces congestions locally and at dis- tant points; but to obtain the best results in the latter class, the temperature and amount of water must be varied to suit the case. Usually it is best after cleansing the rectum to in- troduce the tube and allow water to pass in and out at the same time, using simply a common tube instead of a recurrent, thereby getting the action of the water and temperature on the last inch. It is a very valuable assistance in preparing cases for radical operations, and also in the subsequent treat- ment of them, and renders annoying cases simple and kind, cold or hot, or both kinds of water can be used in neurasthenic cases in the same manner with excellent results. Rectal and colon flushing are of great benefit in diarrhea of any kind, and will cure very many cases without any other means being employed. ORIFIC1AL SURGERY. 249 Dr. Hall has recommended a method of colon-flushing that has done a great amount of good, but it goes too far in non- pathologic cases, and cases where the colon is normal but the rectum is diseased. The colon is a repository, and should not be indiscrimi- nately unloaded ; one of its functions is absorption of nutrition, and another is secretion of mucus that lubricates the lining so as to prevent injury and facilitate onward movements of con- tents. The action of water, when too freely used in the colon, is to wash away the mucus, unloading it too soon and causing colic. However, it is a move in the right direction, and has done much good and little harm. Many cases of rectal disease can be cured by office treat- ment, when the toilet outlined here is coupled with it. Some gynecological cases baffle the doctor by fecal accumulation, thus keeping up congestions in the parts he is working on, which go on kindly if the rectum is looked after. The en- larged prostates of old men, and of others not so old, are prob- ably caused in very many cases by this unhygienic condition of the rectum. So many cases called by the laity "water trou- ble," "bladder trouble," or "kidney trouble" are simply cases of this prostatic enlargement due to rectal irritation; but doc- tors prescribe medicines, and the patients take everything almost, while the use of a few sounds, rectal plugs, and rectal- douching after stool give relief at once. This is not a panacea for all the ills of life, but it gives an amount of comfort more than commensurate with the time and trouble employed carry- ing out the procedure. I do not know of any other theory of the cause of so many rectal troubles as the one mentioned here. If you do not think there is comfort in this toilet, try it a short time on yourself, then you will recommend it to your friends. 250 ORIFIG1AL SURGERY. CHAPTER XXXIV. A FEW POINTS ON THE ANATOMY AND PHYSIOLOGY OF THE RECTUM POCKETS AND PAPILLAE. E. H. PRATT, M. D. It is not our purpose to rehash in the present connection the contents of already existing text books upon the anatomy of the rectum ; but there are some facts and fancies about the rectum which seem to have been either overlooked or misun- drstood in previous writings upon this subject, and a few of these we may profitably discuss. We shall consider the rectum from an orificial standpoint and therefore confine our attention exclusively to the last inch. At its upper portion, the rectum, which is a continuation down- ward of the sigmoid flexure of the colon, has four coats the serous, muscular, cellular and mucous. But this lower part has three the serous coat being dispensed with, its entire structure being made up of muscular, cellular and mucous tissues. Immediately above the last inch the middle portion of the rectum is a bag so distended as to constitute the most ca- pacious expansion of the intestinal tract below the stomach. The last inch presents a sudden narrowing of the canal, con- stituting its most constricted portion. It is directed downward and backward. Its upper boundary is the upper edge of the internal sphincter; its lower boundary is the very margin of the anus, gripped by the lower fibres of the external sphincter. Let us first consider a few points of the anatomy of this part and a little later on mention somewhat of its physiology. In order to present what we have to say on this subject in an orderly manner let us give our attention briefly, first, to the mucous membrane, next to the areolar tissues and lastly to its muscular structure. First, then, what of the mucous membrane lining the last inch of the rectum? Below it thickens and pales into the in- ORIFICIAL SURGERY. 251 tegument with which it is continuous. Above it softens and blushes into the rosy lining of the middle portion of the rec- tum, so that the natural color of the mucous membrane of this part presents a delicate shading, from the pale color of the skin observed at the anus, to the deeper reddening above. If the surface of the perineum be examined, it presents a very delicate raphe, extending in the female, from the an- terior margin of the anus to the posterior fourchette of the vagina. In the male, starting as in the female at the anterior margin of the anus, and then extending along the whole ex- tent of the scrotum and continuing along the lower surface of the penis as far as the margin of the foreskin; just as though a man's skin were a closely fitting bag into which he had been carefully crowded and the mouth of the bag subse- quently united along the base of the body. The mucous membrane of the body (for there is but one, as all mucous surfaces are but continuations of one common tract) is merely an internal skin which meets the external skin at its inlets and outlets. Its inlets are in and about the face and here the transition from skin to mucous membrane is quite abrupt. At the margin of the lips, at the edges of the nos- trils, at the borders of the eyelids, skin structure seems sud- denly to change into the more delicate organism which we call mucous membrane and the line of union in each case is so well marked and apparent as to be readily observed by the naked eye. At the lower openings of the body, however, the change is not so abrupt. In the male, the lining of the fore- skin which is called mucous membrane is quite similar in tex- ture to its covering which is called skin and the dividing line between the two is not finely drawn. So, too, at the vulva. The skin which covers the labia ma- jora passes so gradually into the mucous membrane which pro- tects the labia minora that the line is by no means sharply drawn. At the rectum in either sex, the skin instead of pass- ing so abruptly into mucous membrane as to present a sharp dividing line, as at the margin of the lips, continues into the rectum for some distance as skin, growing more and more deli- cate until finally at a point corresponding to the upper bor- 252 ORIFICIAL SURGERY. der of the internal sphincter, every vestige of skin structure which is still left suddenly disappears and from there upwards the lining of the intestine is mucous membrane proper. Upon careful examination of the rectum with a bivalve speculum, or what is better, by means of T forceps, everting the last inch of the rectum, the fine line which unites the skin and the mucous membrane at this point can usually be ob- served by the naked eye. More properly, then, the last inch of the rectum is lined not by mucous membrane but by a deli- cate formation of the skin which approaches the structure of the mucous membrane at its upper margin and which becomes more characteristically skin in structure at the anus. This lining of the last inch of the anus, be it considered skin or mucous membrane, however, is smooth in texture when well distended by means of the large sized bivalve speculum and in a healthy state presents a uniform color, gradually fading as mentioned before, from the ruddy color of the mu- cous membrane to the pale appearance of the integument at the anus. Its superficial covering is squamous epithelium, its deeper layers of the columnar variety. The squamous form of epi- thelium stops at the upper border of the internal sphincter where the delicate line already mentioned marks the spot where the last trace of skin structure fades away; and above that the epithelial lining of the rectum is entirely of the col- umnar variety, thereby constituting the membrane of which it forms a covering, a genuine, full-fledged mucous membrane. As the papillary layer of the skin is more marked than the corresponding layer of mucous membrane, so the lining of the last inch of the rectum presents a much more perfect papillary growth than is found in the mucous membrane above. This means that it is more highly organized and thoroughly sup- plied with terminal nerve fibres and vascular loops. Right here it may be well to call attention to a subject upon which there exists at the present time a great difference of opinion. It concerns the appearance of the mucous mem- brane at this very point, namely, at the upper margin of the internal sphincter where the last vestige of skin passes away OEIFIC1AL SURGERY. 253 and mucous membrane proper begins; where this boundary line is marked by a very delicate raphe, if I may so call it; and where surgeons and anatomists differ as to the normal appearance of the part ; and where the debate is still on as to whether the formations called pockets and papillae, which often appear in this locality, are to be regarded as anatomical or pathological. Let me make a few quotations previously to defining my own position on the subject. The following short paragraph is found on page 309 of Bell's Anatomy of the Human Body, published in 1829: "The internal coat of the rectum does not deserve the name of villous nor of papillaris. Its surface is smooth, and there are often distinctly seen little foramina like the mouths of ducts or follicles, in part the source of the mucous discharge, which is sometimes poured from this gut. Towards the anus the folds become longitudinal, and terminate in the notched- like irregularities of the margin." On page 380 of the edition of Cruveilhier's Anatomy, pub- lished in 1847, occurs the following descriptive language with reference to the mucous membrane of the rectum: ' ' The skin around the borders of this orifice which is con- stantly closed, contains a great number of sebaceous follicles and covered with hair in the male, it passes deeply into the orifice to become continuous with the mucous membrane and presents a great number of radiated folds which are effaced during dilatation. The point at which it becomes continuous with the mucous membrane is deserving of notice. It is with- in the rectum at a distance of several lines from the anus prop- erly so called, and is marked by a waved line which forms a series of arches or festoons having their concavities directed upward. Sometimes there are small pouches in the situation of these arches opening upward. From the angles at which the arches unite more mucous folds proceed, and small foreign bodies detached from the faeces, are often retained in the culs-de-sac, and become the causes of fistulae." 254 OEIFIGTAL SURGERY. In Morton's Anatomy, published in 1849, on page 317, he says: "The anus is about an inch in front of the os coccygis. Its external margin is of a darker color than the surrounding integument, is supplied with sebaceous follicles and more or less covered with hair. The epidermis becomes very dark over this surface and terminates within in a true epithelium. The point at which the skin becomes continuous with the mu- cous membrane is deserving of notice. It is within the rec- tum at a distance of some lines from the anus properly so called, and is marked by a waved line, which forms a series of arches or festoons having their concavities directed upward. Sometimes there are small pouches in the situation of these arches opening upward. The mucous membrane of the rectum is remarkably thick and vascular, and forms a column below which pursues a longitudinal course, and being crossed by folds of the same membrane towards the anus, gives rise to the pouches just mentioned." Morton has thus quoted Cruveilhier, giving him proper credit, thus showing that he merely endorsed the sentiments of his predecessor without probably any personal investiga- tion of the subject. On page 50 in Homer's Anatomy and Histology, published in 1846, occurs the following: "The mucous coat of the rectum is thick, red and fungous, and abounds in mucous lacunae and glands. It is smoothly laid above, but below it is thrown into superficial, longitudinal folds called columns. At the lower ends of the wrinkles, be- tween the columns, are small pouches of from two to four lines in depth, the orifices of which point upward; they are occa- sionally the seat of disease, and produce, when enlarged, a painful itching. An original observation of Dr. Physick, on the nature of these affections, and the remedy for which consists in slit- ting them open or removing them, induced me to look for the ordinary natural structure, which I have ascertained to be as now described." In Vol. II, of Essays on Practice of Medicine and Sur- gery, published by Lea & Blanchard of Philadelphia, in 1841, ORIFICIAL SURGERY. 255 is an article by Reynell Coates, M. D., in which he speaks con- cerning pockets in the following manner: "Sacculi of the Anus. The venerable Emeritus, Professor of Anatomy in the University of Pennsylvania, had been in the habit of noticing in his former annual course of surgical lectures, a peculiar condition of the anus, in which there ex- A vertical section of the anterior parietes of the anus, with the whole canal dis- played so as to show the relations of the sacculi of the middle region, and their rela- tions to the surrounding parts, their orifices being marked by bristles. A. A. Columns of the Rectum. B, B. Rudiments of columns. C. Internal Sphincter. P. External Sphincter I. Rudimentary or imperfect Sacculi. K. K. Radiated folds of the skin, terminating on the surface of the nates. n. A bristle in one of the sacs. ists certain well-defined pouches or sacs within the canal, which by occasionally arresting small portions of faces, or minute foreign bodies, give rise to great inconvenience, and demand the performance of a peculiar operation for the relief of the patient. (See Art. III.) Dr. Horner, in prosecuting some ex- aminations, post-mortem, with the view of elucidating this 256 ORIFIG1AL SURGERY. subject, was surprised to find a series of semilunar valvules within the canal, such as have been hinted at, by certain anatomists, as an occasional occurrence, but the existence of which has been repeatedly denied by others. His attention being once fairly called to this structure, Dr. Horner discov- ered these valvules in every body which he examined for the purpose, and therefore draws the legitimate conclusion that they are normal and constant. The following description is drawn from the appearances presented by four different prep- arations, taken promiscuously from a considerable number which the Professor did us the favor to submit to examination, and the accompanying figure has been executed from one of them. Immediately below the margin of the internal sphincter we find a series of membranous pockets or sacculi, correspond- ing in number with the grooves between the columns of the rectum, one of which grooves is directed towards, and termi- nates in, each of the culs-de-sac. On the outer side the sacculi are lined by the mucous membrane of the grooves, prolonged into the intervals of the hemispherical eminences already no- ticed, but which are not sufficiently distinct, after death, to be well represented in a drawing from nature. Internally, or on the side next the canal, the saculli are completed by portions of loose membrane, which are processes from the reverted integuments lining the canal below. Each of these loose portions is attached at either end to the base of one of the columns of the rectum, and its free margin hangs in a curve between these points, thus forming a purse with the mouth presenting upwards, and resembling, in some degree, one of those formed between the valves of the aorta and the parietes of that vessel. Unlike the sacculi said to be sometimes formed by the intersection of the transverse and longitudinal folds of the rectum near the upper part of the anal canal, these pockets may be compressed, but cannot be obliterated by the distention of the anus. Their number, form and po- sition must necessarily vary, with those of the columns and swellings, which give them attachment; and, like the columns, some of them are frequently rudimentary. The upper mar- ORIFIG1AL SURGERY. 257 gins of these pockets, taken collectively, appear to form the festoon mentioned by Cruveilhier as the termination of the cuticle. The importance of the relations between these pockets and the phenomena of fissure, stricture, etc. are subjects for fu- ture examination. As to their physiological uses, this is not the proper place to discuss all the ideas which they suggest; suffice it to say, that numerous mucous follicles appear to dis- charge themselves into their cavities, and that the passage of faeces must compress them and expel their contents, thus aid- ing in the lubrication of that part of the anal canal which is invested with cuticle, and therefore less capable of protecting itself, particularly at the moment when this lubrication is most necessary. The occasional existence of such sacs, or, as they have been termed, lacunas, or valves in the anus, has been no- ticed by several writers: M. Ribes, one of the most laborious investigators of the pathology of the rectum, refers to Glis- son, Ruysch and Morgagni, as among the number. This gen- tleman, in an essay written some years ago, stated that he had been totally unable to detect them in the course of his dis- sections, though pursued for twenty-five years. He mentions, indeed, three or four depressions apparently lined with exter- nal integument, and perfectly smooth, placed in the anus, four or five lines above the margin, resembling the dilatations of the aorta and pulmonary arteries after the removal of the sig- moid valves, but he could not detect any opening or loose mem- brane about them. It seems probable, then, that he was de- ceived by the collapse or obliteration of the cavities, which pre- vented his observing the free margins of the valves, as they have been improperly called ; this is the more probable, as his attention was particularly directed to the condition of the parts when in a diseased state, from the existence of fistula in ano. (Recherches sur la situation de 1'orifice interne de la fistule a 1'anus. Rev. Medicale, 1820.) In a more recent es- say on the same subject, M. Ribes describes these pockets with considerable accuracy, stating that he has found in one sub- ject, four, and in others, three depressions, protected by their loose, semilunar, velvet-like covering, and that in the inter- 258 ORIFIGTAL SUBGEBY. vals between these, others less developed were noticed. (Mem- oires de la Societe d 'Emulation, IX, 107.) Nowhere, however, are the precise position and connections of these parts de- scribed with accuracy, though the author just quoted remarks that they are externally in contact with the hemorrhoidal plexus, and that the slightest wound or ulcer on their inner surface must endanger the occurrence of fistula. Many authors have described the appearance of culs-de- sac somewhat similar to these pouches, formed by transverse dupllcatures of the mucous tissue just above the anus or in the upper portion of its canal, passing from one column of the rectum to another. No doubt they may occasionally exist, but M. Ribes declares that he has never been able to detect them. The numerous partial partitions of the rectum, sometimes formed by the mucous membrane still higher up in the canal, are altogether beyond the range of the present article, and cannot be confounded with these more constant and regular valvules." Again on page 123: ' ' Preternatural Pouches or Cavities of the Anus. This is a peculiar form of disease of the anus, rare, indeed, but much less so than some that have been already described, although it appears to have escaped the notice of surgical writers. Though agreeing in location and perhaps arising from similar causes with some forms of occult fistula and abscess of this region, it differs from them essentially in its progress, symp- toms and requisite treatment. It was first made known to the profession by Dr. Physick, under whose care a case oc- curred very soon after his first settlement as a practitioner in Philadelphia in 1792, and it was regularly described by him in his annual course of surgical lectures. Most of the patients who have been brought to Dr. Physick for advice in consulta- tion by other practitioners, have been thought to labor under an imaginary complaint or under neuralgia of the anus; and there is no reason to suspect that some of the cases described as neuralgic, by various authors, have been really instances of the disease of which we are now speaking. ORIFK1AL SURGERY. 259 The symptoms which mark the presence of these preter- natural cavities are as follows: The patient sometimes makes little or perhaps no complaint during the intervals between the stools, etc., etc. In operating, it is necessary to remove the greater part of the internal covering of the cavity, together with the orifice, in order to insure a cure ; for if any portion is allowed to re- main beneath the orifice, the same sluggishness of tissue may continue in this remaining part, and after the wound pro- duced by the operation has healed, a cavity of smaller dimen- sions may still subsist, and give rise to a return of symptoms. After the excision of the inner parietes, no disposition to re- traction in consequence of the loss of substance is evidenced by the cicatrix, or at least, no such disposition has been yet observed in any case not complicated with other diseases; a circumstance that proves the wide difference between the con- dition of this cavity and that of a suppurating or granulating surface. The mode of operating devised by Dr. Physick for the re- lief of this complaint, (one which has proved successful in every instance,) consists in drawing down the membranous covering of the cavity by means of a bent probe, and then re- moving the whole of this portion, or as much of it as possible, by the scissors, taking care to include the orifice by which the probe enters, in the part excised. The opposite surface is thus laid completely open to the anal canal. It must be borne in mind that several of these cavities may exist at the same time, and that after the patient is relieved by the cure of these, others may be formed consecutively, in some instances. In one case particularly, numerous operations were successively performed during a period of several months for the extirpa- tion of a series of these sacs which were developed one after an- other, on the same side of the canal, in the same individual. The surgeon should therefore repeat the operation as often as necessary, until the complaint is effectually eradicated ; and it is evident that due attention to the habitual condition of the bowels, so strongly insisted on in the preceding sections, is 260 ORIFIG1AL SUEGEBY. equally imperative here, if we would completely remove the causes of the disease. We cannot quit the present subject without expressing the pleasure we enjoy on this, as on all other occasions, in se- curing to the rightful claimant of services rendered to hu- manity; yet it is mournful to reflect that the vast funds of knowledge and experience accumulated by one who has filled, so long and so honorably, the first station among American surgeons, should remain accessible to but a small portion of the medical public. They lie chiefly buried in his own mind, or in the memory of those who have enjoyed the happiness of attending his deeply impressive discourses. Abroad, a great surgeon whose avocations prevent him from publishing the results of his experience, has always his reporters. The novel opinions of Sir A. Cooper, of Depuytren, etc., reach us almost as soon as uttered, through the medium of the press; but on this side of the Atlantic, we have been shamefully negligent of our own claims to distinction. That no one who has enjoyed the privilege of hearing the clinical remarks and the public lectures of Dr. Physick, has stepped forward to do justice to the Professor and the Profession, is not only a matter of sur- prise, but a just cause of national regret. How small a por- tion will be ultimately rendered to Ca?sar, of all that bears his image and superscription." These preternatural pouches of cavities of the anus, as they have been called by Dr. Physick, were undoubtedly elongated and ulcerated pockets. Had Dr. Physick possessed a good rectal bivalve with which to examine the rectum, or even T forceps with which to evert it, and been aware of the fact that the rectum could possess mischievous pathology with- out presenting local symptoms, he would have given the world a better lesson in Orificial Surgery and they would not have forgotten it so soon. Nevertheless, the able surgeon deserves great credit for what he accomplished with merely a bent probe, without speculum or without knowledge of the influence of rectal con- ditions over the capillary circulation and deserves the full credit for the first discovery of rectal pockets. ORIFIC1AL SURGERY. 261 Horner was not very generous or fair as will appear from the preceding quotation in permitting these cavities to be called sacculi Horneri when his own investigations were made as a result of the previous investigations and discoveries of Dr. Physick. In fact, these historical clippings suggest a slight degree of professional difference of opinion. Dr. Physick would fish for pockets blindly with a blunt hook and cut out all he could find, undoubtedly puncturing the bottom of them in his crude way of examining, so they appeared longer than they really were ; while Dr. Horner, because he found them in a few dead bodies, regarded them as purely anatomical forma- tions and chronicled them as such. Had he known that shal- low pockets even when not ulcerated were a source of mis- chief and could cause reflex disturbance in any part of the body, and that they were a positive failure for anatomical pur- poses, he would have given them a more careful consideration than he has done in this misleading paragraph. As it was, however, he did the best he could and told all he knew about them and a little more ; his observations and opinions are not extensive, as 118 words hold them both comfortably. With our present knowledge of rectal pockets, which is much greater than was possessed by these gentlemen, it is in- teresting to scan these pages of medical history. On page 660, Vol. II., Gross' Surgery, published in 1862, the writer says: "The singular affection of the anus, first de- scribed by Dr. Physick, under the name of the encysted rec- tum, is occasionally met with, though comparatively seldom. A more appropriate appellation for it would be sacciform disease of the anus, as it consists simply in an altered condition of the sacs, pockets or pouches naturally existing in this situation, to the number, in many cases, of eight, ten, or even a dozen, as seen in Fig. 414, from a specimen in my cabinet. These sacs are always very small in early life, but as their development is regularly progressive they are capable of acquiring a consid- erable size, especially if, as not unfrequently happens, they form a receptacle of hardened fosces, inspissated mucus, or small extraneous bodies. From these and other causes, not always very obvious, they become the seat of morbid action, 262 ORIFICIAL SURGERY. as inflammation, suppuration and ulceration, often attended with exquisite torture. A number of pouches may be thus af- fected simultaneously, or one after another may become in- volved, until nearly the whole of the anus may suffer. The size of the individual pockets varies from that of a small depres- sion, hardly capable of holding a split pea, up to that of a cavity large enough to admit the point of the little finger. The disorder occurs only, or principally, in old subjects, whose lower bowel is habitually distended with fo3eal matter, and who suffer much from the congestion of the ano-rectal tissues. POUCHES OP THE RECTUM. Gross' Surgery Sacciform enlargement of the anus is generally tardy in its progress and insidious in its character, its existence being frequently not suspected for years. For a long time the pa- tient is merely conscious of uneasy sensations in the parts; vague as to their nature and uncertain as to their recurrence. Frequently one of the earliest symptoms complained of is a feeling of pressure or weight just within the anus, or a dis- tressing itching similar to what is produced by the presence of ascarides. As the disorder proceeds, but generally not until it has made considerable progress, the patient begins to experience pain, especially immediately after defecation, lasting often several bourse after the act has been completed ; it is commonly of an aching, burning, or smarting character, and is seldom confined to parts more immediately implicated, but is apt also to extend to the buttocks, perineum, back and thighs. It is not, however, after every evacuation that there is severe pain; ORIFIG1AL SURGERY. 263 cases occurring in which it is entirely absent or nearly so, for days together, depending probably upon the fact that the af- fected pouches are sometimes completely emptied of their con- tents, and, of course, relieved from pressure. An increased se- cretion of mucus is usually observed, but it is rare, except when the sacs are inflamed or ulcerated, to see any discharge of pus. 264 ORDFIG1AL SURGERY. No spasm of the sphincter muscles accompanies this af- fection, as is the case in fissure of the anus. To ascertain the real nature of the disease, careful exploration is necessary, the instrument used for the purpose being a common pocket probe, the end of which is bent into a hook, and passed up and down the anus from one part of its circumference to the other. As it is drawn along it becomes entangled in the valve-like folds of the sac, the seat, size and sensibility of which are thus fully revealed, and which is generally so transparent as to. al- low the probe to be perceived through it. The examination is always painful, and it may, therefore, be made while the pa- tient is under the influence of chloroform. The proper remedy for this complaint is excision of the valve-like fold of the af- fected sac. To do this all that is required is to draw it down with a tenaculum or seize it with the forceps and snip it off. If the bottom of the pouch is in an ulcerated condition it would be well at the same time to scarify its surface, in the hope of plac- ing it thereby in a more favorable condition for speedy repara- tion. If several sacs are involved they should all be operated upon at one sitting." The cut in Gross' Surgery, which has been reproduced here together with the quotation, presents the author's idea of the natural appearance and location of these so-called ana- tomical structures. The preceding cut, taken from the British Medical Journal, gives one the same impression concerning rectal pockets, sacs, or pouches, as they have been variously called. These little structures have been noticed in a few additional places in medical literature, but as the remarks about them are similar to those already given it is needless to multiply quotations. Dr. Physick seems to be not only the discoverer of the condition, but also the only original thinker who has given them his attention. It is too bad that he was not a writer as well as a worker. He was evidently a great man whose works have been unchronieled. The cures which he made by excising rectal pockets in this way, made such a profound impression upon his time, that the ORIFIG1AL SURGERY. 265 tradition of them still lingers in the minds of some of the older practitioners of our time. There has also come down to us a murmur of the disrespect and senseless storm of ridicule and opposition to which he was treated by his professional breth- ren for the great and original work which should have re- ceived their praise instead of their blame. If he wrote upon the subject, his writings have been ma- liciously expunged from medical literature. Had he realized when he cured people by excising rectal pockets, that he was standing by the great ocean of orificial truth, from whose shores he was simply picking a pebble, his tongue would cer- tainly have been loosened, his pen sharpened and the imprint of his work upon the medical profession would have been more indelibly made. Let us honor him for his originality, for possessing the courage of his convictions, regretting only that he did not leave to posterity a larger inheritance. It seems as though orificial surgery should have been born at this time. In all the quotations which we have made and in others which we might make, they are described, not as con- stant conditions, but as frequently occurring, and yet they are incongruously dubbed anatomy. But concerning the anatomical quotations we have just made, it seems to me some effort should be made to correct the erroneous impression which these writings have made upon the profession and which they are still making upon the minds of those who rely for their knowledge upon so called authority rather than upon their own investigations. It is a common thing in any department of history for mis- takes to remain uncorrected so long or so imperfectly, as to be recognized as facts by the succeeding generations. We still speak of the rising sun, although everybody knows that the sun does not rise. We still call our native land, America, al- though were justice done, it would be known as Columbia. The arteries were so named because they were supposed to contain air. They still retain their name although we are better in- formed as to their contents. In the same way rectal pockets 266 ORIFIGTAL SURGERY. have so long been described as anatomical formations that it will be a Herculean task to erase the name from anatomies and transfer it to works on pathology. There is one point which favors the possibility of this achievement and that is that they have not been recognized very generally even by anatomists. Gray and most other anatomists do not even mention them. Their existence has not been taught in medical colleges and the great body of medical men today are not aware that there is such a thing in existence as a rectal pocket or sac. There is a good deal of writing upon this subject at the present time, but I am sorry to say that the majority of writ- ers, instead of exercising an independent judgment, have sim- ply looked up the musty records on the subject and are doing what they can to reproduce the original erroneous notion con- cerning them. They are trying to prove that pockets are an- atomy and are unwilling to recognize them as pathology. I would suggest to these gentlemen that they do a little more independent investigating before they add their influ- ence to any further extent to such a serious professional er- ror. Rectal pockets are not anatomy, they are pathology. The impressions which will be made by the previous cuts in this article are erroneous in the extreme. A rectum presenting the appearance as illustrated in these cuts will not be found once in a hundred cases. And when it does exist, it is a very sick rectum, indeed, and wholly unfit to pose as an ideal anatomical one. The cuts give a very correct idea of the location of pock- ets when they exist, but they give a very erroneous idea as to the frequency and symmetry of their existence. It is easy to understand why this great mistake has been made and why it has remained so long unconnected: In the first place, anatomies are compiled from observations upon the dead; and orificialists will find no difficulty in comprehending why these formations should be found frequently in dead bodies. In the next place, the importance of the rectum has never been and is not now fully appreciated and consequently has been neglected. True, hemorrhoids, fistulas and fissures and also cancer of the rectum have been subjects for pro- ORinClAL SUEGERY. 267 f essional attention all along the history of medicine ; but what the preceding race of doctors did not know about the rectum would fill volumes. They did not know that dilatation of the rectum would affect the respiration, that it would flush the capillaries, that it would resuscitate the drowned, arouse the narcotized, sober the drunken, awaken the anaesthetized, etc., etc. ; that its pathology exerted any special influence as a predisposing . cause in chronic diseases. I think one would have to search the medical literature through endless pages before he would find an article on atrophy of rectal tissues. Even satisfactory rectal specula have never been in existence, so far as we can find out, until the present time. Search London, Paris, Vienna, Berlin and other European centers of medical education for a satisfactory in- strument with which to explore the rectum even now, and your disappointment will perhaps convince you that the in- struments heretofore employed for examining the rectum have been wholly inadequate for the purpose, and you will be bet- ter prepared to believe that medical literature is both imper- fect and incomplete in its dealings with rectal pockets. Europeans have much to learn from Americans upon the subject of the rectum and yet the great body of American practitioners are wholly unfamiliar with the proper appearance of a normal rectum, not to mention the pathological one. Several years ago, at the meeting of the Illinois Homoe- opathic State Association, held in Peoria, I presented a report upon the subject of pockets and papillae in which the following language occurred: "They are as common as piles; more prolific of mischief than you would believe without a special acquaintance with them, and still they have been hitherto almost unknown to fame and very much neglected. "Our current literature contains little or no mention of them, and only in a few isolated places in medical lore will you find any indication that they have ever been discovered; and nowhere, so far as I am aware, are they well described or properly noticed. This paper, therefore, is but an act of jus- 268 OBIFIG1AL SURGERY. PEN SKETCHES OP POCKETS AND PAPILLAE BY DR. NILS BERGMAN, LINCOLN PARK SANITARIUM, CHICAGO. Normal rectum, smooth, dilatable, presenting neither pockets nor papillae. Single club-sliaped papilla. Two broad-mouthed pockets, one shallow and one deep. 3 Rectum presenting papillae, sharp-pointed variety. Single club-shaped and bifurcated papilla. Three stages In pocket development frequently seen side by side, ranging from a mere depression to deep form. ORIFICIAL -SURGERY. 26$ tice to a condition which should have received earlier atten- tion, and although in itself but a feeble effort, it is to be hoped that it will inaugurate a line of thought and investiga- tion that will in time place the complaint where it belongs in the regular index of all standard surgical works." \ Double papillae with pocket between, common, ll! \ Marrow pockets, one .shallow and one deep. Papilla with pocket behinu i; The white transverse line in these cuts illustrates the line of union between skin and mucous membrane, and is located at upper border of internal sphincter. Before writing that paper I had carefully investigated the subject and was perfectly satisfied in my own mind as to the nature of rectal pockets. I had settled to my own satis- faction the question as to whether they were anatomy or path- ology ; as to whether an individual was better off with them or without them; as to whether they had better be let alone or completely exterminated. The position which I took at that time was a radical one, pronouncing them pathological appearances and advising their removal under all circumstances. Since the presentation of that paper I have had these conditions under constant observation 270 ORIFIC'iAL SURGERY. and treatment. I have examined several thousands of rec- tums and feel amply qualified to express a reliable opinion as to the nature of pockets, and to offer advice concerning them, that I feel confident will bear well the test of time. It does not seem to me in the least degree either audacious or hazardous to differ in opinion upon this subject with those who possessed no means of properly examining the rectum, who under-estimated the importance of rectal pathology and who consequently have bestowed very little attention and thought upon the subject ; especially as my surgical experience in this matter has been preceded by ten years practical teach- ing of anatomy in a medical college. The mere fact that a man has written a book and died years ago, does not constitute him a reliable authority upon any subject. In the long ago, the world was not so old as it is now, and for one, I completely disown and cast aside the chains of tradition, that make superstitious and timid souls mere slaves to an embryonic past. The human body is built upon the same plan today that it was a few centuries ago, and observation is as valuable now as formerly, and knowledge upon almost every subject has ac- cumulated and should be permitted to modify opinions that are obviously erroneous, in spite of the fact that those who expressed them have gone so far away that they cannot re- vise the future editions of their own works. Permit me to mention a few facts in this connection con- cerning rectal pockets. Fact No. 1. Rectal pockets are by no means a constant condition. It is very common to encounter rectums wholly devoid of the formations. Fact No. 2. It is exceedingly common to find rectums possessed of merely one pocket ; to find others possessed of two pockets ; to find yet others possessed of three or four pockets. Fact No. 3. It is quite uncommon to find rectums pos- sessed of more than from five to eight pockets. Fact No. 4. Occasionally an operator will encounter a rectum which possesses from ten to fifteen. The greatest num- ORIFIC1AL SURGERY. 271 ber of pockets which I have seen in any rectum has been seventeen. Fact No. 5. It is not uncommon to find, in the same pa- tient, pockets in different stages of development, situated side by side; one of which will present merely a red spot above this dividing line between the skin and mucous membrane, lo- cated at the upper border of the internal sphincter as already described. Close to it will be another red spot which will en- gage the point of the blunt hook for perhaps a thirty-second or sixty-fourth of an inch. Adjoining this will be a third into which the blunt hook will pass for perhaps an eighth of an inch. SHABP ft SMITH CHIM60 Fact No. 6. When the patient possesses but a few rectal pockets, the location of them is by no means constant. In one case it will be a single pocket under the prostate ; in another it will be a single pocket 011 the side toward the coccyx. Still another case will have but two, located laterally. Fact No. 7. The pockets vary much in depth and also in width, sometimes being so shallow and narrow as to require the point of a dull tenaculum to engage them, and this for only a very short distance. At other times the inverted tube will be so long that the blunt hook, a cut of which is pre- sented, is not of sufficient length to sound its depths. At other times the pocket will be wide mouthed and shallow, at other times wide mouthed and very deep. Fact No. 8. Sometimes pockets are very numerous but very small and shallow (this is especially true in cases of at- rophy of the rectum), in other cases presenting a large number of pockets that will be both long and large, these latter being more characteristic in cases presenting hypertrophy of tissues. Fact No. 9. In children rectal pockets are more numer- ous, as a rule, than they are in grown people, suggesting the thought that they may be possibly the product of foetal devel- 272 ORIFICTAL SURGERY. opment, which time is expected to eliminate after the manner of the hymen, the adhesion of the hood of the clitoris, and the contraction and adhesion of the foreskin; in which case they may serve to explain, as suggested by Dr. Holbrook, one of the causes of hemorrhoids; the irritation occasioned by the destruction of these delicate structures, serving to induce a congestion of the blood vessels of the rectum. The following cut illustrates not only the location of pockets but also the manner of detecting their presence by means of the blunt hook. It is taken from the first edition of my work upon orificial surgery. Care must be taken to handle the instrument gently so as not to perforate the bottom of the pocket in making an ex- amination. The presence of pockets occasions no discomfort to the patient and they are therefore wholly unconscious of their existence. One or more must be badly ulcerated or in- flamed, indeed, to be the seat of any sensations whatever, as they would have to penetrate far enough to involve the ter- minal nerve fibres of the cerebro-spinal system, which are lim- ited in their distribution to the margin of the anus. ORIFICIAL SURGERY. 273 Fact No. 10. The removal of rectal pockets, be they one or a dozen, is never detrimental in the slightest degree to the health or happiness of the individual ; it disturbs no func- tion, causes no inconvenience or disorder of either the rectum or any other part of the body. Fact No. 11. On the contrary, it is the unanimous opin- ion of those who are in the habit of removing rectal pockets, and they are now a large army of operators, that the practice is universally beneficial to the functional activities and health of the entire body of the patient operated upon. I have yet to learn of a single surgeon who has once en- gaged in the practice of removing pockets and papillge, to ever in the slightest degree repudiate the practice. But on the con- trary, he holds it in high esteem as his experience becomes more extensive. It seems as though the testimony of these gen- tlemen should be given more consideration than the mere the- oretical opinions of those who have simply talked, but not worked. Experience is a teacher deserving consideration. Fact No. 12. There is no more satisfactory work in the whole scope of medical practice, judged by the standard of health and satisfaction enjoyed by the patients, than the re- moval of rectal pockets from those who are unfortunate enough to possess them. Fact No. 13. Contemporary writers upon this subject who are defending the extermination of pockets on the ground that they are anatomical formations and should be permitted to remain unmolested unless in an ulcerated condition, display by the nature of their remarks that they have never been in the habit of removing rectal pockets and consequently are wholly ignorant of the action of such work ; that they have taken their cue from the so-called authorities upon this subject, whom we have just been considering, and are consequently wholly in- competent to express an independent and reliable opinion upon the subject. They owe to the profession an apology for their presumptuous writings, and, if they are gentlemen, they will be sure to make it before another decade has gone by; and if they are not gentlemen, the medical world will soon find it out 274 ORIFIC1AL SURGERY. and give little heed to their utterences. Time's debris will soon bury them out of sight. Conclusion. In view of the preceding facts the conclus- ion is inevitable, that if pockets are anatomy, they are very ir- regular, unreliable and useless anatomy ; and that, inasmuch as their removal restores their possessor to health, where his bodily functions are disordered, they are bits of anatomy which we are better without and which consequently should invari- ably be dispensed with. PAPILLAE. In the same location where pockets are found, namely, at the upper border of the internal sphincter, many times are seen small conical projections which, from their shape, are well named, papillae. They are little teats which vary in size and length from the point of a pen to the last joint of the lit- tle finger. They are usually transparent at their tips but some- times are club-shaped and even bifurcated and without trans- parency. They usually occur singly, although sometimes they appear in pairs, in such cases uniformly presenting the mouth of a pocket between them. I have been able to find them men- tioned in standard medical literature in but two or three places and yet they are very common. A few magazine writers of the present day are ignorant enough, and foolish enough, to dub these anatomical forma- tions, and enter into an active debate for their preservation. The so-called authorities scarcely mention them. Their re- moval is invariably followed with very marked beneficial re- sults to the patient, whatever may be the nature of the re- flex trouble from which he is suffering. These two conditions, pockets and papillae, I consider the most mischievous of rectal troubles, because their location is such that the irritation which they occasion induces a clonic spasm of the internal sphincter muscles, thus inaugurating a perpetual nerve waste of the sym- pathetic ; and no work in surgery is so magical in its action, so marvelously effective in its operation, as the smoothing of this upper border of the last inch of the rectum, by removing from ORIFI1AL SURGERY. 275 it all pockets and papillae which it presents ; and by dilatation, removing the undue muscular tension which their constant presence has occasioned. In the cut which illustrates the presence of the blunt hook in a pocket, may also be seen three small papillae. They are never above or below this line of union between the skin and the mucous membrane; they are probably hypertrophied con- ditions of the papillary layer of the margin of the skin at this point. Their removal is easily effected by means of either tenaculum or forceps and a pair of curved scissors, through a speculum. The cut shown elsewhere will illustrate what I be- lieve to be the best speculum in existence for purpose of ex- amination and operation upon the last inch of the rectum. The normal lining, therefore, of the last inch of the rec- tum is perfectly smooth when dilated by the bivalve speculum, presenting neither excavations nor prominences, and above passes as uninterruptedly into the mucous membrane of the middle rectum as the skin passes into the mucous membrane at the margin of the lips. As a thorough discussion of the entire anatomy of the rec- tum is not attempted in the present series of articles, simply those points in the anatomy and physiology of the part will be mentioned, which seem to the writer to be inadequately or er- roneously considered in the standard text-books. Sufficient was said in the last article concerning the mucous coat; and the remaining two coats, the cellular and muscular, will need but brief consideration. The cellular, sub-mucous or vascular coat, as it is some- times called, loosely binds together the mucous and muscular coats ; so loosely, in fact, that the mucous coat is capable of a considerable degree of mobility without materially disturb- ing the muscular structure very much as the skin can be moved quite freely over any part of the body without dis- placing deeper tissues. The cellular coat performs the same service here as areolar tissue does elsewhere in the body. It is a flexible bond of union between adjacent tissues, and also serves as a nidus for blood vessels, nerves and lymphatics. It can thicken and bulge with the products of congestion or in- 276 ORIFICIAL SURGERY. flammation, or it can flatten and waste in the starvation of atrophy. Its chief ambition seems to be to identify itself with whatever may be the tendency of the other structures of the rectum. There is only one anatomical point in this connection that seems to call for consideration. All anatomists agree in their description of the lymphatics, cerebro-spinal and sympa- thetic nerves, and the arterial and venous supply of the last inch of the rectum. But concerning the veins of the hemor- rhoidal inch, I believe that the common description is errone- ous in one particular. Gray says: "The hemorrhoidal plexus surrounds the low- er inch of the rectum, being formed by superior hemorrhoidal veins (branches of the inferior mesenteric) and the middle and inferior hemorrhoidal which terminate in the internal iliac. The portal and general venous systems have free communica- tion by means of the branches composing this plexus." Gray omits mentioning the fact that in addition to these veins there is a system of veins found in the last inch of the rectum which has no anastomosis whatever ^ with the veins which he describes. They start in blind extremities, thickly scattered throughout the areolar tissue of the hemorrhoidal inch and, as they coalesce above, terminate in the hemor- rhoidal plexus which he describes. A few anatomists jnake mention of these veins, but instead of describing them as possessing a uniform caliber, represent them as considerably dilated at their extremities, resembling in appearance a bunch of grapes. This I believe to be wrong. In their normal state, these veins are of uniform caliber, no larger at their blind extremities than where they Coalesce to form larger veins. As varicose veins in the lower extremities, in the sper- matic cord, in the labia majora or anywhere else in the body, have crossed the boundary lines of anatomy and become path- ological, so the veins under consideration, when their extremi- ties have ceased to be tubular and become spheroidal are vari- cose and therefore pathological. ORIFIC1AL SURGERY. 277 The condition commonly described as hemorrhoids, con- sists mainly of a cluster of such varicosities. To be sure, a hemorrhoidal enlargement contains one or more arterioles, one or more enlarged venous canals belonging to the hemor- rhoidal plexus, etc. ; but if the tumor be carefully dissected, This cut illustrates the appearance of the lower rectal veins, which begin in (blinded extremities, after they become varicose, and as they occur in hemorrhoids. Hemorrhoids consist mainly of clusters of these dilated ends of veins, imbedded in areolar tissue. An occasional author mistakes these for anatomy; but, in their anatomical condition, these extremities do not bulge but are of the same caliber as the veins of which they are the beginning. [This cut is from a pen sketch by Nils Bergman, M. D., of Lincoln Park Sanitarium, Chicago.] it will be found to consist mainly of a cluster of these dilated radicals, we are considering, varying in size from a millet seed to a marrowfat pea. There are sometimes but two or three in a single hemorrhoid, but more frequently there are ten or fif- teen and often many more in a large hemorrhoidal tumor. These enlarged vein terminals lie imbedded in the areolar tissue throughout its entire thickness, from the mucous mem- 278 ORIFIG1AL SURGERY. brane to the muscular structure, and are as carefully packed in it as eggs in a box of sawdust. They are scattered every- VJ1M \'HE- P- Fig. 281. Rectal veins seen from without: Amp. rectal pouch or ampulla; P, skin at margin of anus reflected; SE, external sphincter; VHE, external or inferior hemorrhoidal vein; VHI, internal or superior hemorrhoidal vein; VHM, middle hemorrhoidal vein. This cut is taken from' the American Text Book of Surgery. It il- lustrates the venous anastomoses of the last inch of the rectum, but in one respect is incomplete. The superior hemorrhoidal veins are repres- ented as starting in blinded extremities. This is partially true; but these veins also anastomose with the other veins and the blinded ends should extend lower down as far, indeed, as the internal sphincter. Others with blinded extremities should also be shown still lower down, between the sphincters, and opening into the other veins. where throughout the areolar tissue of the last inch of the rec- tum and a circle of them is often found completely surround- ing the circumference of the rectum, just above the internal sphincter. ORIFIC1AL SURGERY. 279 Their enlargement in this position constitutes what is properly called internal piles. Their enlargement in the are- olar tissue between the two sphincters, constitutes, together with the other morbid structures which accompany them, what should be known as middle hemorrhoids. Only when pro- truding with the rest of the hypertrophied tissue, below the margin of the anus, are they properly described as external hemorrhoids. Sometimes a single rootlet of this class of veins becomes dilated, engorged with blood which soon clots and forms a small hard spot, more or less painful, which feels to the touch of the finger like a veritable buckshot covered by the mucous membrane. The common size of these veinlets, when their hemorrhoidal tendency is fairly carried out, is about that of a grape seed. This subject will be more thoroughly and satisfactorily discussed when, in this series of articles, we come to the spe- cial consideration of hemorrhoids, which at the present time is foreign to our purpose. The muscular structure of the last inch of the rectum consists of two sphincters, an upper and lower, which guard respectively its two extremities. The upper sphincter is mere- ly an aggregation of the circular fibers of the muscular coat of the intestine and is dominated by the sympathetic nerve, its fibers being of the involuntary type. The lower sphincter is a voluntary muscle and consequent- ly supplied by the cerebro-spinal system of nerves. An ex- perience at one of the earlier orificial clinics so beautifully il- lustrates this point, that it seems worthy of narration in this connection. The patient had been anaesthetized, and, desiring to illustrate the action of rectal dilatation upon the respiration, I requested a friend present to dilate the sphincters and ob- serve the effect upon the breathing. As at that time there was no good speculum for purposes of dilatation, the gentleman in- serted his thumbs and forcibly distended the anus. The audience present had been hushed to silence so as to watch the effect of the dilatation. Although dilatation was thoroughly performed, the breathing of the patient was not in the slightest disturbed, and a shade of disappointment was 280 ORIFIGTAL SURGERY. seen on the faces of the spectators as well as upon the coun- tenance of the operator. Not satisfied with the test, the op- erator himself attempted another dilatation. Instead of em- ploying his thumbs, however, he inserted the index and ring fingers of both hands, introduced back to back, and far enough to secure a good grip upon the internal sphincter. Immedi- ately upon spreading the fingers the expected suspension of respiration occurred. In fact, the respiration of the patient seemed to be under the control of the operator, and could be suspended or liberated at will. The evident explanation of this experience was simply that the invited guest with his thumbs impinged merely upon the fibers of the external sphincter which is supplied by the cerebro-spinal system, while the operator himself, by securing a good grip upon the internal sphincter, appealed to the sym- pathetic nerve, and thereby influenced the respiratory move- ment. The experiment was repeated several times in this ease, so that the point was emphatically established. It is not possible to demonstrate this fact in all cases, as many times the sympathetic system is in such an anaesthetic condition as to be incapable of responding in this peculiar manner to even extreme dilatation. When the last inch of the rectum, therefore, is in a nor- mal state, its internal opening at the upper border of the in- ternal sphincter is perfectly smooth, entirely free from pock- ets, papillae or any other form of irritation, and presents a nar- row white line where the invaginated skin changes to mucous membrane. The space between the sphincters presents more or less deeply reddened color above, which gradually fades into the pale skin color of the anus. The lower opening is perfectly smooth when dilated, and thrown into very fine and uniform folds of skin when contracted. It is not sensitive to touch, and the introduction and spreading of the bivalve speculum can be accomplished without pain. The inch contains no redundant tissue, no spots of discol- oration, but presents over its entire surface a uniform color as described. A distended bivalve renders every portion of it perfectly smooth. ORIFIC1AL SURGERY. 281 CHAPTER XXXV. RECTAL SURGERY FROM AN ORIFICIAL STANDPOINT. E. H. PRATT, M. D. Normal rectums are seldom encountered in the chronically sick. The reasons for this we have endeavored to explain in the preceding articles of this series. We have also tried to make it clear that the restoration of the rectum to a normal condition is an invaluable, and usually a necessary element in the recovery of general health. When the last inch of a rectum is in a pathological condi- tion, the sphincters guarding it are excited to undue and unre- mitting tension. As the parts which are unduly pinched are in a morbid state, double nerve waste is thus involved : the nerve force which is required to .keep up the over-action of the sphincters, and the exhaustion arising from an unremitting and excessive pinching of diseased terminal nerve fibers. The rectum as a nerve center has been sorely neglected by our medical ancestry. Never until the last few years was it even known that the depth of inspirations upon which all the machinery of the body hinges was profoundly affected by rectal conditions. If a rectum were in pain, and swollen or sore, it could command the attention of a doctor equally with other complaining organs ; but the idea that there could be a painless rectal pathology, shortening respirations, weakening peristaltic actions, inducing sexual irritability, and perpetu- ally sapping the vitality of the entire organism, has been very foreign to the medical mind of the past, and is more difficult than it should be in some cases at least to find acceptance in the medical mind of the present. But such is the case, nevertheless, and the most satisfactory cases in the practice of orificial surgery are those which have never complained of rectal troubles and present no symptoms that would lead the examining physician to suspect the existence of any form of rectal irritation. 282 ORIFIOIAL SURGERY. In all chronic cases, therefore, the rectum should be care- fully examined and its pathology corrected, whether its ab- normalities take the form of atrophy or hypertrophy, hyperaes- thesia or ansescthesia, and whether its sphincters present un- due tension or undue relaxation. In other words, it is high time that the profession appreciate the importance of rectal conditions and realize that the testimony of the patients them- selves as to the presence or absence of rectal pathology is perfectly inconclusive and unreliable. RECTAL BIVALVE. Those who have never systematically examined the rec- tums of their chronic cases must be prepared for a good many surprises, not only as to the unexpected conditions which they will encounter, but also as to the effects which they will pro- duce by correcting these conditions. In examining a rectum, it is quite common for doctors to be satisfied with what they are able to ascertain from the sense of touch by the mere insertion of their index finger. This common practice of superficial observation is scarcely suf- ficient to deserve the name of an examination, and yet it too frequently passes for such. Such a procedure may diagnose hypertrophy, but it could scarcely detect the more profound pathology of atrophy. It could disclose the inner opening of a fistula, perhaps, or a row of papillae, but it could not detect incipient hemorrhoids, or rectal pockets, or a zone of sub- acute inflammation which frequently lines the last inch of the rectum, and which could be detected only by the sense of sight. ORIFIC1AL SURGERY. 283 Those who are just beginning their acquaintance with rec- tal conditions will insist upon a careful examination of the rectum before they feel justified in placing a patient under an anesthetic for operative procedures, or even for purposes of examination. Experienced orificialists, however, feel so con- SHARP a SMITH CHICAGO TENACULUM. fident of finding some form of rectal irritation in those who are suffering from any of the forms of chronic disease, that they frequently anaesthetize a patient for purposes of exami- nation, and operation if deemed necessary, without previous inspection, realizing that rectal dilatation, as it flushes the capillaries of the entire body, institutes nutritive changes which are always to be desired. Anaesthetics are as harmless in orificial work properly performed as they are in parturition and therefore not to be dreaded. ARTERY IFORCEPS. Deeming, then, that a healthy rectum is a thing to be de- sired, the next problem which confronts the doctor is how to secure it. The volunteers in the form of remedial measures in a rectal campaign are numerous. Mental therapeutics is as ambitious to attack sick rectums as it is sick stomachs, sick headaches and other physical maladies. Prescribers of drugs are as confident that they can cure all forms of rectal disease 284 ORIFIC1AL SURGERY. as they are that their drugs are adequate to all other bodily discords. Magnetic healers would attack hemorrhoids with as much confidence as they would lumbago, insomnia or dyspep- sia. The advocates of a water cure would expect to accom- plish everything desirable in the way of rectal repair by ene- mata and compresses. The advocates of external applications for the cure of human ills have furnished the profession with a variety of rectal ointments worthy a World's Fair exhibition, and the hypodermic syringe would feel deeply chagrined if, after its achievements in the relief of rectal mischief, it should not be employed when a rectum needs a doctor. T FORCEPS. Orificial surgery is modest in some respects, and is willing to wait patiently until all of these various measures have been tried and proved ineffectual at present. It is no farther am- bitious than of being the last resort, but it does demand recog- nition and a fair trial before a case of chronic disease is aban- doned as hopeless. With this understanding it makes no apology for anes- thetizing a case, placing it in the dorsal position, with the knees well flexed upon the thighs and retained there either by some apparatus or by assistants, drawing the patient down close to the edge of the table, and placing opposite the operator a tray which contains a rectal bivalve, a blunt hook, two or three tenaculums, a dozen or more artery forceps, eight or ten T forceps, a probe, a grooved director, a long pair of scissors ORIFIC1AL SURGERY. 285 curved at the tip, plug forceps, a pair of Hall's sigmoid for- ceps, and one or two pairs of ordinary tissue forceps. An- other tray should also be close at hand, containing absorbent cotton, small squares of sterilizzed gauze to be used as sponges, a quarter of a yard of antiseptically prepared China silk and a T bandage. GROOVED DIRECTOR. Some operators would suggest a few additions to the tray of instruments, in the shape of one or two clamps and a Pa- quelin cautery. As in the course of time, however, these sur- geons will undoubtedly learn to dispense with these instru- ments, we will leave them out now. The use of the various instruments mentioned and illus- trated will appear as the various operations, which will be called for in rectal surgery, are described. After the patient is anaesthetized and placed in position, it is proper to make a digital examination merely to determine the presence or absence of strictures and tumors. LONG CURVED SCISSORS. The rectal bivalve is now to be inserted and the rectal tissues exposed and carefully examined around the circum- ference of the last inch. This examination will assist in de- termining the form of operation to be selected. The word "assist" is used intentionally, because there is a general rule which may be laid down as a safe guide in a large majority of cases ; namely, the thoroughness and extent of the operative procedure should depend not entirely upon the local condition 286 ORIFIC1AL SUKCiKKV. which is presented but be influenced somewhat by the general condition of the patient. In the severer forms of chronic ail- ments, where a profound effect is necessary to arouse a proper degree of reaction throughout the system, it is often necessary to replace the last inch of the rectal mucous membrane with one drawn down from above, although the appearance of the rectal tissues upon examination might not seem, especially to an uneducated eye, to warrant so severe a proceeding, as in such cases the rectal tissues are usually pale and atrophied, and so completely worn out as to occasion an extreme degree of nerve waste. And yet such rectums are often regarded by those who should know better as perfectly normal. On the other hand, it is quite possible to handle very se- vere forms of local mischief in the shape of hemorrhoids, fis- sures, pockets and papillae, ulcers, etc., without resorting to a complete removal of the entire pile-bearing inch. The more delicate the case, the more complicated, pro- found and remote the physical disorder from which the pa- tient is suffering, the more necessary it is to completely remove every vestige of rectal irritation and to thoroughly flush the capillaries of the body and appeal as strongly as possible to the latent energies of the system ; whereas in cases which pre- sent a condition of general health and merely some severe form of rectal disease, the extirpation of the mucous membrane of the last inch of the rectum is to be avoided if possible. It is important to settle the fate of this last inch the very first thing, because the form of operation to be selected will decide at what stage of the operation dilatation will be em- ployed. No operation should be performed upon the rectum without dilatation. If the last inch is to be sacrificed, the dilatation should precede the operation. But if it is to be merely smoothed and trimmed, this work should be done be- fore dilatation is practiced, so as to avoid as much as pos- sible any swelling, laceration or hematoceles, which would be likely to be induced in the practice of dilating. There is another point of value in determining the form of operation to be selected, which should be mentioned in this connection : namely, the sensitiveness of the patient to rectal ORIFIOTAL SURGERY. 287 dilatation. There are cases occasionally encountered in which the function of respiration is so profoundly affected by rectal dilatation that the mere introduction of the closed speculum will produce an immediate suspension of respiration. There are cases where a rough and violent use of the rectal speculum could kill. There are other cases which are so profoundly anaesthetic that even extreme dilatation of the anal tissues will produce no appreciable effect whatever upon the respira- tory organs, as anaesthesia is a deeper seated nervous affection than hyperaasthesia, as paralysis is a graver affection than ex- citability. The cases in Avhich there is no appreciable general response to rectal dilatation, as a rule demand more thorough work than will be needed to do justice to the more sensitive ones. It is more important, therefore, to remove the last inch of the rectum in conditions of anaesthesia than in those of hy- peraesthesia of rectal tissues, regardless of the apparent rectal pathology presented. In subjects, therefore, who are afflicted with very grave affections, be they tubercular, glandular, syphilitic, or nervous, if the function of respiration be quickly and profoundly affected by rectal dilatation it will probably not be necessary to renew the last inch of mucous membrane. But if, in addition to a serious malady of some other part of the body they display a total indifference to anal dilatation, the operation upon the rectum should be a thorough one, per- fectly independent of the appearance of the tissues. There are severe forms of rectal disease which also de- mand the complete removal of the hemorrhoidal mucous mem- brane. Aggravated cases of hemorrhoids, with excessive hy- pertrophy and prolapse of the tissues, are best treated in this way. In operating upon fistulas in ano, it is usually desirable to remove the last inch of mucous membrane from the rectum so as to exterminate the other rectal pathology which always accompanies this condition, and at the same time effectually close the internal opening of the sinus. In complete laceration of the perineum, the best results are secured by combining the perineum operation with the removal of the last inch of the rectum, after the manner de- scribed in another section of this book by Dr. W. E. Green.. 288 ORIFIG1AL SURGERY. After carefully considering all these questions which de- termine the nature of the operation to be performed, in case it is decided to renew the hemorrhoidal area, the first step in the operation should be a careful and thorough dilatation of the rectum and a complete cleansing of the sigmoid flexure of the colon. This is best accomplished by the careful handling PLUG FORCEPS. of the rectal bivalve. First in order is dilatation of the rec- tum. The bivalve is to be inserted with the handles in a de- pendent position and the blades carefully opened. If the ef- fect upon the respiration be profound, the administration of the anaesthetic should be stopped and the speculum removed. As soon as the stertorous breathing has ceased the instrument can be again introduced and dilatation resumed. Sensitive HALL'S SIGMOND FORCEPS. patients should always be carefully watched during the process of dilatation, and also given ample time to recover from its effects before the work is again proceeded with. The system soon becomes somewhat accustomed to the action of the specu- lum, so that even in these sensitive cases the profound action of the dilatation gradually diminishes and enables the sur- geon in a short time to accomplish his purpose satisfactorily. ORIFIGTALr SURGERY. 289 The manner of dilatation is to be determined by the amount of shock desired, remembering that every time the anus is opened the impulse of the speculum is felt throughout the capillary system. If the case be sensitive and easily af- fected, the blades of the speculum should be opened very slowly and carefully, and succussious and vibratory motions with the instrument dispensed with. But if the case be a sleepy one, requiring a vigorous shaking up to awaken a gen- eral reaction in the system, the dilatation should be accom- plished by a succession of rapid vibratory motions, which are calculated to appeal energetically to every twig and branch of the circulatory tree. In all dull cases it is perfectly safe to dilate to the ca- pacity of the bivalve, as this degree of dilatation seldom pro- duces even the slightest degree of paralysis of the sphincters. Occasionally cases will be encountered in which it will be found necessary to supplement the action of the bivalve with the employment of the index and middle fingers of each hand, inserted back to back and separated until in the judgment of the operator a proper degree of dilatation has been secured. The cases which call for successive dilatations are rare, but are met with in two classes of rectums in exactly opposite conditions. One class presents such a distended condition of the anal tissues that the complete expansion of the rectal spec- ulum scarcely puts them upon tension. They are cases accom- panied with prolapsus of the rectum. Dilatation carried to the point of fairly stretching the anal tissues will induce a healthy reaction, which, with subsequent treatment with hot douches and electricity, will eventually restore the parts to their proper tone. Again, sphincters will occasionally be encountered so ir- ritable and yet so elastic that the complete expansion of the rectal bivalve fails to overcome their undue tension, and as soon as the instrument is removed, even after it has been held in the anus completely expanded for several minutes, they will immediately return to a condition of spasmodic stricture. Such cases also call for a more thorough dilatation than can be se- cured by the bivalve, and further dilatation can be effected 25>0 ORIFIC1AL SURGERY. either by the fingers after the manner just described, or by the employment of Sims' vaginal specula. It is fully as well in such cases to perform sub-mucous section of the sphincters as to lacerate and bruise the parts by over-dilatation. The manner of performing sub-mucous section upon the sphincters will be described in a later article. The dilatation of the sphincters is now to be followed by thorough cleansing of the sigmoid flexure af the colon. This is to be accomplished as follows: TISSUE FORCEPS. The speculum is to be introduced with the handles down- ward and closed. The handles are now to be raised and the speculum is to be pushed carefully but completely into the rectum as far as it will go with ease. If the tissues of the middle rectum be redundant, and the progress of the instru- ment obstructed by folds of the upper rectum, while the right hand is gently crowding the instrument upward, the index finger of the left hand is to be introduced on the upper side of the rectum and sufficient grip secured upon the sphincters to straighten the rectum sufficiently to permit the speculum to -pass well into its cavity. As soon as the instrument refuses to make further progress in the direction of the insertion, the handles are now turned to the right of the operator and the left of the patient, pressing them closely against the but- tocks as they describe the first quadrant of the complete circle which they are ultimately to make. The handles are now to be carried farther on in the same direction until they press against the perineum, closely hug- ging the surface of the skin in their course. If the speculum has been properly handled thus far, the surgeon should now be able to depress the handles until they are horizontal with the body, quite past the upper extremity of the rectum and into the sigmoid. The termination of the rectum at the beginning of the sigmoid is so much narrower than either the rectum or the sigmoid that it appears to be guided by a dilatable sphinc- OKIPIC1AL SURGERY. 291 ter, which can usually be recognized as the speculum passes through it. Thus far the blades of the speculum have been closed. The hand of the operator is now placed upon the handles of the speculum and the blades are opened more or less thor- oughly, according to the resistance of the canal. In many cases the calibre of the gut will be so small as to permit only a slight separation of the blades. In other cases, the blades can be opened to their full extent without the slightest resistance. Great care should be exercised not to employ force in opening the blades of the speculum, but to desist as soon as resistance is encountered. After the blades have been opened they must not be again closed until the speculum has been complete- ly withdrawn. After opening the blades, while the speculum is in the sigmoid, the nozzle of a fountain syringe, filled with boracic acid solution, is to be introduced into the rectum and the intestine well flushed. By a gentle vibratory action of the blades of the speculum, secured by different degrees of di- latation, the sigmoid can thus be thoroughly rinsed and all faecal matter and mucous which it contains brought away. The speculum is to be withdrawn either by completing the cir- cuit of the handles or by returning upon the original semicircle which they described during the introduction of the instru- ment, care being exercised to keep the blades wide enough to insure against any pinching of the rectal tissues. The specu- lum can be introduced in this manner as many times as is ne- cessary to completely evacuate and cleanse the sigmoid. After this has been accomplished, it is well to introduce the specu- lum into the sigmoid once more, spread its blades as previously described, and by means of the long Hall forceps carry a rope of antiseptically prepared wool well into the sigmoid. This rope should be six or eight inches lond, and be secured by a string fastened about its lower extremity to facilitate re- moval. In carrying the wool into this position, the grooves in the speculum must be remembered, and great care be exer- cised to use no violence in pushing it upward, as it is a very easy matter to puncture the intestine by even the slightest de- gree of violence. 292 ORIFIC1AL SURGERY. After the wool has been well packed into the sigmoid and rectum, the forceps are to be placed against its lower ex- tremity so as to hold it in position while the speculum is be- ing withdrawn. The process just described is known as packing of the rectum,' and is just as serviceable in rectum and sigmoid trou- bles as dilatation and cleansing are in the male or female urethra, in the vagina, or in the uterus. The wool is to be removed as soon as the last inch of the rectum is denuded of its mucous membrane, and before the stitches which unite the mucous membrane and skin are separated, in cases where that procedure is undertaken, but may be left in position for a day or so in slit work. We have no hesitancy whatever in recom- mending this measure as one of the most serviceable in the treatment of rectal diseases. We have employed it upon sev- eral hundred cases and have never yet had occasion to regret it. It does not weaken the gut, but strengthens it. If there are strictures it aids in overcoming them. If there is an ab- normal dilatation, it strengthens the gut and aids it in re- turning to its normal state. In chronic proctitis, it arouses a desirable degree of re- action and stimulates recovery. It does not predispose the pa- tient to invagination of the intestine, but is in every way a valuable and commendable procedure. Having employed the measure many hundred times and observed no harm from its use, but on the contrary, universally beneficial results, we have no hesitancy whatever in recommending the measure to the profession as an exceedingly valuable and reliable means of strengthening, cleansing and in every way benefiting the lower part of the large intestine immediately above the anus. It does more than this, because the nervous connection of the sigmoid is exceedingly extensive. There is a very close asso- ciation between the mucous lining of the sigmoid and the blad- der in both sexes. It also influences profoundly the great solar plexus and all its branches. As it furnishes a reservoir in which the faecal matter is usually carried for some hours be- fore it is precipitated into the rectum, it is very liable to con- ORIFIC1AL SURGERY. 293 ditions of chronic inflammation, ulceration, and their concomi- tants, abnormal contraction and mucous or muco-purulent discharges. CHAPTER XXXVI. HEMORRHOIDS. E. H. PRATT. M. D. Hemorrhoids are as old as the human race, and so is their story. But in the present article we shall strive to avoid serv- ing a medical hash upon the subject and simply present some considerations that will not be found in the text-books at least to our knowledge. The text-books of this and past gen- erations treat exhaustively of the nature of hemorrhoids, of their symptoms, and also of their causes. Hemorrhoids which do not cause local symptoms have heretofore been regarded as of so insignificant a nature as not to require attention, but if they induced bleeding, prolapsus, pruritis or pain, causing the patient sufficient local discomfort to induce him to consult a doctor they were of sufficient importance to deserve examina- tion and treatment. But if the patient was always questioned before an examination was instituted, and if no conscious symptoms of discomfort were elicited no local examination was deemed necessary. This has been a grave error on the part of medical men, for it is now known that hemorrhoids as well as other pathology of the last inch of the rectum can play all manner of pranks with the human machinery and yet cause no local discomfort whatever. An examination in chronic cases is not complete without an examination of the hemor- rhoidal inch, and as the profession has made the mistake of this omission so long it is high time a reform was instituted, and we are delighted to say that it has been and is progressing with remarkable satisfaction and rapidity. The orificial phil- osophy, although it is still young, has already achieved a wide reputation, and has taught the profession a good many les- 294 ORIFIC1AL SURGERY. sons upon this subject of reflexes, in spite of the fact that there is still a large army of medical practitioners who still remain unenlightened. The sale of rectal specula in the United States within the last ten years has been something enormous, and it will be s'till greater in the next ten. The instrument makers of Chicago inform me that the sale of the Pratt trivalve has ex- ceeded the sale of all other specula combined. However, as it has long since been superseded by a better one, the bivalve, this latter instrument will soon undoubtedly take the lead in general practice. I was unable to find a good rectal speculum in all London or Paris, and as the surgical shops of the United States abound in a large number of patterns of useful instru- ments, it is but natural to conclude that in rectal surgery Europe must learn her lessons from America. It is perfectly proper for the rectum to be supplied gener- ously with veins, but when they become sufficiently dilated to obtrude themselves on the attention of the surgeon, to a sufficient extent to be classified as hemorrhoidal structures, they have passed the bounds of anatomy, have become path- ology and call for surgical interference. I am not quite satisfied with the common division of hem- orrhoids into simply external and internal, by external mean- ing those which extrude from the anus, and by internal those which are concealed. It is much more convenient to divide them into three classes, and I am in hopes that this classifica- tion will be universally adopted : namely, internal, middle and external; by the internal meaning those which are above the internal sphincter, by middle meaning those which are found between the two sphincters, by external those which protrude after any prolapsus which may exist has been restored. In- ternal and middle hemorrhoids may protrude in cases of pro- lapsus, but this should not cause them to lose their identity be- cause they can be easily replaced, and we desire a name for those which cannot. One naturally infers from reading the common descrip- tions of hemorrhoids that dissection of these tumors has not been common and but a few writers describe them properly. In another chapter will be found cuts and a brief description ORIFIC1AL SURGERY. 295 of the veins of the rectum, from which a correct idea as to the formation of hemorrhoids can be gained. It will be seen by referring to this description that hemorrhoidal structures may be merely varicosities of continuous veins which anastomose with the venous network of which they are a part; or they may be a mere cluster of enlarged terminal veinlets which are peculiar to this region of the body. In any case a hemorrhoid- al tumor is not simply one large vein, but a bunch or cluster of veins. They are usually accompanied by more or less hyper- trophy of the areolar and mucous tissue, and their mucous surface is more or less softened and disorganized. It is im- possible that such a surface can present a normal condition of terminal nerve fibres, and from an orificial standpoint this is a point of even greater value than a mere enlargement of the venous structures of a hemorrhoidal tumor. The mere fact that the veins of the rectum are a little ab- normal in size is a matter of very little consequence in itself. But the additional fact that the abnormal thickness of the part induces an undue and continuous tension of the sphincters, es- pecially of the internal, and that the abnormal contraction im- pinges upon a diseased set of terminal nerve fibres is of a good deal of consequence. It is therefore of extreme importance, especially in cases of reflex trouble, that they should be treated surgically rather than medically, as medical treatment would simply reduce the calibre of the blood vessels, relieving the congestion of the part somewhat, but would not cure the diseased terminal nerve fibres of the part involved. The extermination of the tumors and the surface covering them as well is therefore the most satisfactory treatment, and the only treatment which will yield lasting benefit to the patient. This is an indirect argu- ment against the employment of the hypodermic syringe and of the common practice of relying upon ointments and general medication for the cure of hemorrhoids, and suggests still fur- ther that even thorough dilatation of the rectum as practiced by Professor Verneuil of Paris, and his followers, is by no means sufficiently radical to be permanently efficacious. 29t> ORIFIGiAL SURGERY. TREATMENT. Extravagant cases of hemorrhoidal enlargements, accom- panied by protrusion, may call for one of the three methods previously described of removing the entire pile-bearing inch and renewing it with tissue brought down from above; these methods being the clamp operation, the English operation and the American operation. But if the general health of the patient is all that could be desired and he is free from all forms of reflex trouble and his sufferings are merely local, it is much better to avoid, if possible, the entire extermination of the last inch and rely upon what is now commonly known as the slit method for the correction of the hemorrhoidal con- dition. This method is perfectly satisfactory, and sufficient for all cases of hemorrhoidal affliction except the most aggra- vated ones; and as the recovery from the slit operation is so much quicker, the after-treatment so much simpler, and the appearance of the rectum ultimately secured so much more natural in every way, it is by all means to be preferred. The treatment of hemorrhoids by excision has always been the dream of the profession, the only objection to the method and the only reason for not giving it the preference above all other methods being the danger of hemorrhage. Most of the text-books were written before the days of desirable rectal specula and of T forceps, and the operators of previous years had not yet discovered a way of placing the anal tissues at the command of the operator to a sufficient ex- tent to place him in proper command of the situation sur- gically. But by the aid of the improved specula of late years, of T and artery forceps, and the knowledge of the fact that by the aid of these instruments the bowel tissues can be easily everted and placed entirely at the command of the operator, the objection to the treatment by excision on account of hem- orrhage is completely and thoroughly removed, and the author of rectal surgery of today who ignores this fact and still clings to the barbarous practice of removing hemorrhoids by ligature and clamp and cautery ought to be ashamed of himself and owes an apology to his readers for what must be either his ig- norance and stupidity or else his bigotry and mulishness. OKIFIC1AL SURGERY. 297 The medical profession would esteem it poor surgery to amputate a limb with a string or remove a tumor by ligation. If they wish to remove a limb they simply cut it off, stop the hemorrhage and dress the wound. If they attack a tumor in other parts of the body they follow the same sensible plan of simply dissecting it out, securing the blood vessels, and end at a single sitting all destructive processes. Why they should abandon their surgical principles and choke hemorrhoids to death, tying with their cruel strings not only the blood ves- sels but the nerves of the part involved, making an ugly slough, inevitably producing an unnecessary degree of surgical shock and inviting sepsis, is difficult to understand when it is really such a simple matter to trim hemorrhoids away neatly and completely at a single sitting and without the slightest difficulty or danger. I feel that I am not doing the slightest injustice to other methods in asserting that excision of hemorrhoids in ordinary cases is the only reliable and satisfactory way of treatment. It should never be dangerous; it should always be perfectly satisfactory to both surgeon and patient and there is not the slightest excuse for longer denying it its proper position as the best treatment for hemorrhoids that is middle and external hemorrhoids. Internal hemorrhoids are usually accompanied with more or less prolapsus, and as a rule call for the removal of the last inch of the rectum and are not proper subjects for the slit method as slit work above the internal sphincters is unsafe. External hemorrhoids are either acute or chronic. ACUTE EXTERNAL HEMORRHOIDS. The acute form is very painful and presents one or more small tumors just outside of the anal orifice, which can be seen to bulge more or less prominently and can be felt to be small, round, hard bodies varying in size from a coffee grain to a hazel nut. They are exceedingly painful to the touch, and are a source of great discomfort to the patient when either sitting, standing or walking. They are in reality small hsema- toceles, existing either in a dilated terminal veinlet or lying embedded in the areolar tissue as a result of a rupture of the 298 ORIFIG1AL SURGERY. venous coats. The treatment for these is very simple and very satisfactory, affording immediate and permanent relief from all soreness and pain. They simply require a lancing suffi- ciently free to permit the removal of the clot. A curved pointed bistoury is a satisfactory instrument to employ for this purpose, and as soon as a longitudinal incision is made into the small tumors the clot can easily be squeezed out through the opening or dug out with a small spud, cuts of which instruments are here appended. It is well afterwards to apply a small pledget of absorbent cotton moistened with Pond's Extract, full strength, between the nates, with instruc- tions to renew it each day for two or three days, after which it can be dispensed with. No confinement of the case is neces- sary. CHRONIC EXTERNAL HEMORRHOIDS. Chronic external hemorrhoids are soft, fluctuating, venous tumors about the anus, unaccompanied by soreness except in cases of pruritus, in which cases the soreness is not due at all to the hemorrhoids but to the inflamed condition of the integu- ment. Sometimes external hemorrhoids are prominent flabby structures, and sometimes they have dwindled to such an ex- tent as to become mere shreds of doubled integument which dangle about the anus, causing undue activity of the sebace- ous glands and occasionally pruritis, merely from the redun- dancy of the tissue. It is not desirable to remove them unless the patient is under an anaesthetic as they are not in them- selve mischievous, either locally or generally, and their re- moval without an anaesthetic would be painful. Almost in- variably, however, when chronic external hemorrhoids exist there will be sufficient pathology within the anus to justify ORIFIGIAL SURGERY. 299 the employment of an anaesthetic, and while the internal parts are being put in repair these chronic external excrescences should always be smoothed away with the scissors. The cats should always be made radiating from the centre of the anus like wheel spokes from a hub and a sufficient amount of tissue should be removed to leave the parts nicely and smoothly cov- ered after the wounds have healed. It is plastic work and calls for a quality in the surgeon which if directed in a clothing line would have made him a tailor. Through the wounds in the integument the underlying nodules of hemorrhoidal tissue will appear like grape seeds embedded in the areolar tissue and should be excised. No bleeding of consequence will occur, and the excision should be carried to the complete extermination of all the hypertrophied and hemorrhoidal tissue. No speculum would be required in dealing with either the acute or chronic forms of external hemorrhoids. No sutures will be necessary. MIDDLE HEMORRHOIDS. When middle hemorrhoids, namely those existing between the two sphincters, are to be treated by excision some form of rectal speculum will be needed. The bivalve is by far the best instrument for this purpose. There are two kinds of mid- dle hemorrhoids, which may be classified either as active and passive or as acute and chronic, the former classification per- haps being preferable because in the term acute as employed by surgeons is usually implied an active process of inflamma- tion which involves pain and suffering, which is not true of either variety of middle hemorrhoids. PASSIVE MIDDLE HEMORRHOIDS. After the speculum is introduced into the rectum and di- lated to a sufficient extent to thoroughly smooth out the mu- cous membrane lining the last inch, distinct tumors of a pur- plish color will frequently be seen, swelling out on the exposed rectal surfaces, protruding prominently into the field of vision perfectly regardless of the amount of dilatation practiced. These are what may be called the passive or chronic middle hemorrhoids. They are between the sphincters, and no amount of dilatation seems to discourage their prominence. 300 ORIFIG'IAL SURGERY. ACTIVE MIDDLE HEMORRHOIDS. In some cases, however, after the speculum has been in- troduced and opened widely the mucous membrane at first ap- pears perfectly smooth and almost normal in color. Upon re- laxing slightly the extreme dilatation, however, and waiting for a few moments, the mucous membrane, which at first ap- peared smooth, gradually begins to bulge into the field of the speculum, oftentimes to such an extent as to cause the oppo- site sides to come in contact. The bulging does not usually present a smooth even surface, but is nodular and very much in appearance like small brain convolutions, showing distinctly the large veins beneath the thin covering of mucous membrane. By again practicing extreme distension the surface becomes smooth and all hemorrhoidal appearance vanishes. For hemorrhoids of this nature I would suggest the name active, the objections to the term acute being as just stated. Patients who are troubled with this form of hemor- rhoids usually suffer a slight prolapsus at stool, which is read- ily corrected by pressure. There is seldom bleeding, this symptom being confined chiefly to the chronic and more promi- nent form. INTERNAL HEMORRHOIDS. By internal hemorrhoids are meant those which appear above the internal sphincter. From the internal sphincter, pursuing their tortuous course upward, under the mucous coat of the rectum will occasionally be seen numerous large varicose veins, which stand out like cords on the surface of the rectum as far as can be seen through the field of the speculiL'i. These are rare cases, occurring mostly in old people, and are usually accompanied with enlargement of the veins of the lower extremities ( scrotum and spemratic cord, or labia majora, as the case may be, and deserve the name of hemorrhoids simply because they are enlargements of the hemorrhoidal veins. Internal hemorrhoids, more properly speaking, are hemorrhoidal tumors, varying in size from a split pea to an English walnut, which cluster around the bor- der of the internal sphincter and which are formed, like the ORIFIC1AL SURGERY. 301 passive middle hemorrhoids, of clusters of over-dilated venous terminals. If one of these bunches of hemorrhoids was care- fully dissected and separated from the connective tissue in which it is imbedded they would have much the appearance of a blackberry, the dilated extremities or veins clinging more or less closely to a central stem. These internal hemorrhoids occur in cases of extreme re- laxation and atony of the rectum, characterized by more or less prolapsus at stool, and are frequently hemorrhagic. TREATMENT OF MIDDLE HEMORRHOIDS. Whether of the active or passive variety, middle hemor- rhoids are commonly treated by a great many rectal specialists by one of two methods, according to the surgical skill of the operator. The hypodermic syringe is the favorite weapon with which these structures are attacked by timid and unsurgical practitioners in diseases of the rectum. This treatment has one advantage, that is, that it can be employed at the office and does not necessitate the confinement of the patient, except in occasional instances, in which, as a result of bad judgment on the part of the doctor he has attacked too large a growth or one in which there was a tendency to prolapsus at stool, in which case the grip of the sphincters prevented the return of the tumor and inaugurated inflammatory processes. It also occasionally happens that the puncture has been made too deeply and gives rise to rectal abscesses and other unhappy se- quelae. Those who practice rectal surgery, however, in the proper sense of the term, more usually prefer one of two meth- ods, which are described and endorsed by nearly all of the text-books upon diseases of the rectum, namely, ligation and clamping. Another method of treatment which is somewhat in vogue should also be mentioned, namely, dilatation and a thorough kneading and bruising of the hemorrhoidal tissues with the thumb and fingers, with the idea of instituting some acute in- flammatory processes, which cause subsequent contraction and more or less complete annihilation of the hemorrhoidal pro- jections. 302 ORIFIC1AL SURGERY. Prescribers of drugs internally and advocates of heraor- rhoidal ointments are usually ambitious to try their skill at exterminating middle and internal hemorrhoids. If such doc- tors as these latter can stop hemorrhage and correct the pro- lapsus they lay claim to a cure, because the external evidences of existing hemorrhoids have disappeared, and they have no use for a rectal speculum. It is not necessary in the present article to describe these various and more or less effete measures that is, effete with those who have learned a better way as they are all more or less unsurgical, unsatisfactory, and should be supplanted by the only perfectly satisfactory, safe, and, it seems to me, sen- sible way of annihilating these objectionable growths, namely, EXCISION. The only objection that has been raised against excision of hemorrhoids has been that of hemorrhage. It is conceded that the removal, by some process, of hemorrhoidal growths of the middle variety is not only desirable but imperative, and ex- cision would be by far the most desirable manner of accom- plishing this, could the danger from hemorrhage ever be over- come. The introduction of the bivalve speculum, T forceps and tenaculum, together with a more accurate knowledge of the construction of hemorrhoidal growths, has now accom- plished this desideratum. And as this operation is the only one which receives our endorsement in cases which are not of sufficient magnitude to call for the American operation, we will confine our description of operative procedures to the process of excision. In excising external hemorrhoids all redundant tissue should be cut away level with the skin surface, so as to leave the anus smooth and free from redundant tissue. There are no large nerve trunks, no blood vessels of any considerable size, and no muscles that are endangered by such a proceeding, and the operator can shape the parts to his liking with impunity. Not so, however, with the middle hemorrhoids. If he follows the same plan here he is liable to wound large blood vessels and be confronted with troublesome hemorrhage, and ORIFK-1AL SURGERY. 303 is also in some danger of cutting through the muscular coat of the intestine and endangering the tonicity of the bowel or making possible the formation of a subsequent fistula. To practice excision upon middle hemorrhoids the bivalve speculum should be carefully inserted and opened just wide enough to permit the hemorrhoidal tissue to protrude into its field. The lower end of the hemorrhoid to be operated upon is then to be seized with a tenaeulum, which should not be made to penetrate deeply into the tumor. A pair of surgical scissors, curved at the point, may then be employed to remove a longitudinal strip of mucous membrane from the hemor- rhoid along its entire length. The cut should start just back of the grip of the tenaeulum, so that the tenaeulum remains attached to the strip to be removed. The blade of the speculum should now be opened somewhat wider, so as to spread the lips of this wound while the operator clips away with the scissors the hemorrhoidal tissue which protrudes through the opening. By holding the scissors partly open and pressing with the blades upon the denuded surface, the small grape-like projec- tions of the hemorrhoidal structure will appear between the points of the scissors, and can then be clipped off, together with the redundant areolar tissue. By a skillful manipulation of the scissors in this manner the entire hemorrhoid can be removed piecemeal without in the least injuring the larger blood vessel underlying the tumor, to which the separate parts of the hemorrhoid are tributary. Hemorrhoids as large or larger than the end of one's thumb can in this manner be entirely removed without the loss of any considerable amount of blood. And by applying this process around the entire circuit of the anus a generous crop of hemorrhoidal tissue can be satisfactorily and successfully dispensed withr. The larger clusters of hemorrhoids will usu- ally be found on the sides of the rectum and in front and be- hind, there usually being spaces between these masses which are free from the offending structures. In case, through accident or carelessness, the operator should cut deeply enough to wound the underlying* vein or artery, and he should encounter more hemorrhage than he 304 OKIFICIAL SURGERY. expected, it is a simple matter to seize the blood vessel with a pair of artery forceps, which are to be left dangling from the wound while the rest of the circumference of the anus is being examined and operated upon. One or two minutes is a sufficient length of time to leave the artery forceps in position if they are constructed sufficiently strong to crush the tis- sues. Ligature of the anal blood vessels is almost never ne- cessary, as the hemorrhage is very easily and speedily con- trolled by artery forceps at the time of the operation and sub- sequent hemorrhage is so insignificant as to require no at- tention whatever. Great care should be taken in this operation to avoid denuding the entire circumference of the last inch of its mu- cous membrane. At least three or four strips should be left unmolested. It matters little how narrow they are so long as their continuity is undisturbed. It is remarkable to what extent the last inch of the rectum can be denuded of its mucous membrane with impunity if one is simply careful in this par- ticular. Subsequently the mucous membrane seems to grow from the margins of the unmolested strips, and is reproduced so perfectly as to leave scarcely a trace of the surgical pro- cedure. Greater care must be exercised in operating in this way upon active than upon passive hemorrhoids. The large purple and protruding tumors that fall into the field of the speculum as soon as it is opened have little ten- dency to bleed, and the operator is usually surprised in his first experience to find with what impunity he cah dissect these structures away, with the loss of but a few drops of blood. The active hemorrhoids, however, which disappear when the speculum is widely opened, and which gradually fill with blood after it has been partially closed and held in position for a short time, had better be handled a little more cautiously, as they consist of less of what may be called the grape-seed structure and owe their existence to excessive dilatation of the single veins or arteries. Hemorrhoids of this class, which we have called active hemorrhoids, will bleed more or less pro- ORIFIC1AL SURGEEY. 305 fusely in the process of excision, and the artery forceps will quite frequently be called into requisition. It is unnecessary, however, in any variety or extent of hemorrhoids to lose any considerable amount of blood in the process of complete extir- pation by this method, which is now known as the slit method. All of the cuts in the mucous membrane are made longi- tudinally with the intestine, and the lower margin of the cut must be carried down as low as the anus, as the hemorrhoidal structures usually extend to this point; and in cases where they do not the parts heal better if the wound starts at the anus. It is well to make the circuit of the anus with the speculum two or three times as in the first time around the operator is very apt to overlook one or more hemorrhoidal rootlets, which if left unmolested would permit a reappearance of the tumors, although on a much smaller scale. After the hemorrhoids have been entirely excised the anus should be thoroughly dilated with the bivalve, care being taken not to do this with sufficient violence to tear the sphincter muscles. Should this accident happen the muscle gives away, almost In- variably at its posterior aspect, and by denuding the surface of the mucous membrane at this point it can be very easily stitched together, a proceeding, however, which is very sel- dom called for. The bivalve speculum, the T forceps, by means of which the parts can be seized and brought well into view, and the artery forceps, have robbed the excision operation entirely of all danger of hemorrhage, and placed it when it does occur so completely at the control of the operator that this, the only objection to the excision process, is now entirely overcome ; and there is no longer any excuse on the part of rectal sur- geons for indulging in what should be obsolete, and what is the barbarous and unsurgical practice "of treating hemorrhoids by either injection, clamp, ligature or bruising processes. Where the patient is free from reflex disturbances and merely suffers the local inconvenience of middle hemorrhoids no other operative procedure will be called for, and the rectal surgeon who handles the excision process with merely ordinary skill will be so pleased with the ease and success of the method as. 306 ORIFIG1AL SURGERY. to willingly employ it in lieu of all others. What hemorrhage is occasioned by the operation occurs in the presence of the operator and is placed under his easy control by the aid of the instruments already mentioned. No stitching is required, no subsequent attention is necessary except what is necessary to keep the parts in a cleanly state while undergoing the pro- cess of healing. It dispenses with the formation of abscesses, the unwholesome process of sloughing, and all of the ob- jectionable features of the other methods referred to. TREATMENT OF INTERNAL HEMORRHOIDS. These are above the internal sphincter, and consequently must be handled with greater care, as the circular fibres of the rectum just above the sphincters will not contract sufficiently to control the hemorrhage should accident or necessity in- volve it. As internal hemorrhoids are usually accompanied, how- ever, with more or less prolapsus, they almost invariably de- mand the American operation for their extermination, and the process of excision is not so well adapted for their treatment as it is for hemorrhoids of the middle variety. Although per- sonally we frequently employ this same process of excision for internal hemorrhoids, we are loath to recommend it as a general practice for fear that some operator in cutting a little too deep or unskillfully will have occasion to regret its em- ployment. Internal hemorrhoids are best treated by the American operation. CHAPTER XXXVII. THE SLIT OPERATION. CORA SMITH EATON, M. D. The slit operation is Dr. Pratt 's modification of the old method of excision of hemorrhoids. Indications. 1. Where there are scattered pile tumors of the middle and external variety not involving the entire inch. ORIFIC1AL SURGERY. 307 2. Where, perhaps, the whole inch is seriously affected but the tissues are so stiff or so friable that elasticity and strength are lacking to allow pulling down of the tissue to cover the denuded inch as required by the American. Contra Indications. 1. When the entire inch is involved and the tissue thickly padded with enlarged veinlets. These cases will be difficult to clear up by slit operation and require the complete American. 2. Where there is extravagant hypertrophy of tissue in- volving the entire inch. Here, also, the American or clamp is required. 3. Where there are internal hemorrhoids, that is, those located above the clasp of the internal sphincter. The conse- quent liability to hemorrhage indicates an operation with sutures as in the American. Preparatory Treatment. The day previous, give light diet, laxative, and thorough flushing in knee chest position. The day of the operation, repeat the flushing and allow no food. Instruments. The instruments needed are rectal bivalve speculum, sharp hook or tenaculum, short curved scissors, T- forceps, artery forceps, full curved needle and holder, silk and catgut sutures. Description. The operative technique is as follows: A thorough, but gentle, intermittent dilatation of the sphincter, with the rectal bivalve, should be practiced until the muscle is well relaxed. The rectal speculum is now inserted and opened to expose the hemorrhoidal inch, first antero-poster- iorly, and then withdrawn and reinserted for the lateral por- tions. The operation may be done with the speculum thus held by an assistant ; but easier yet is to dispense with the speculum after the slit is made and seize the anal margin with T-forceps and evert the inch over the left forefinger, thus doing the work quite outside. The first incision is the slit which gives the operation its name. A sharp hook picks up the mucous mem- brane over a pile tumor, and a pair of short curved scissors removes a narrow strip 1-16 inch wide, extending from the 308 ORIFIG1AL SURGERY. anal verge to the upper margin of the hemorrhoid. Always begin this slit at the lower margin of the anus, even if the hemorrhoid is quite far up, as the healing is much better. Next, by opening the speculum wide or by pushing the hemor- rhoid up through the slit with the left forefinger, over which the membrane is pulled down, the slit stretches open, and the enlarged veinlets are then easily snipped off with the scis- sors. The areolar tissue and all are to be cleanly removed down to the muscle. There is no excuse for wounding the sphincter muscle, for it can be plainly felt as an elastic but resisting band by the left forefinger underneath. By chang- ing the position of the speculum, or by pulling down new sec- tions with T-forceps, the entire circumference of the inch is thus gone over, and each pile tumor treated through a new slit. If necessary, the slit may be made an inch wide, and the underlying tissue cut out thoroughly down to the sphincter. The undisturbed strips between the slits need be only one- quarter to one-sixteenth of an inch, and only four or five in number so long as they are straight, and left in perfect con- tinuity from the anal margin to the internal sphincter, "like spokes in a wheel." If there is hemorrhoidal tissue under them, the strip can be pulled aside by a sharp hook and all veinlets and areolar tissue removed, and still the reproduc- tion of the mucous membrane lining the hemorrhoidal inch will be perfect. It is wonderful how the surface renews itself. All hemorrhage is easily controlled, as it is all in view, thanks to T-forceps and rectal dilatator. Only spurting ves- sels need be noticed, and they will be closed by pressure of artery forceps for two or three minutes. After the operation is done, the natural contraction of the sphincter stops all oozing within its clasp the only hemorrhage which can come after the operation is finished will come from arteries above the internal sphincter, and careful examination will disclose any such. A catgut stitch embracing the vessel will insure no further trouble. After removing all middle hemorrhoids, allow the everted inch to return within the grasp of the sphincter, and remove OElPIGlAL SURGERY. 300 all external hypertrophy by lifting each bunch with the ten- aculum and cutting it off clean. There are no arteries here to bleed, and nature will quickly cover up the denuded surface. The respiration may be affected by the dilatation with the speculum or by the pinching of the T-forceps. In such cases remove the instrument and anesthetic as soon as breathing becomes labored, and give the patient a moment to recover from the shock. You can soon proceed without trouble. As a rule, each pile removed seems to lighten the burden of re- flexes, and the patient breathes easier as if thankful for one more sorrow lifted. No sutures are" needed. Dressing. A tight roll of sterilized gauze the size of the thumb is smeared with calendula cerate and placed in the grasp of the sphincters, with a silk cord tied to the protruding end to facilitate removal. This plug stimulates natural con- traction and applies a healing medicament. Powdered boracic acid should be sprinkled freely over the anus and a pad of cotton and gauze held snugly against the parts by T-bandage. The plug is left not longer than an hour, and removed sooner if the breathing is not satisfactory, or if the patient awakens sufficiently to complain of the pain. Its removal may cause a momentary pang, but relief follows. After-treatment. Keep the parts smeared with calendula cerate and powdered with boracic acid. Pain will be en- countered in only a few cases. It is promptly controlled by a spray from the fountain syringe, using two quarts of calen- dulated water (one teaspoonful to the quart), hot as can be borne, repeated as frequently as required. Cham. 3x or hyper. 3x given internally every five minutes sometimes acts magic- ally. If pain persist, % gr. morphia should be given hypo- dermically. The patient is kept in bed a week. Liquid diet until after the first stool, which is allowed on the fourth or fifth day. The stools must be made soft by mild laxative and lubricated by 4 oz. of sweet oil given per rectum half an hour before the enema. Pain following the stool should be treated like that following the operation. Daily stool by enema thereafter un- til natural movement is possible. Then healing will be facili- 310 ORIFICIAL SURGERY. tated and comfort secured by having the patient use every night for about two weeks a rectal suppository of aesculus, haraamelis and hydrastis. Advantages and Disadvantages. The advantages of the slit operation are simplicity, rapidity, and comparative pain- lessness, from the fact that no sutures are used. The disad- vantages are only such as arise from imperfect work. First and chief, liability to recurrence by reason of the incomplete removal of hemorrhoidal tissue is the chief one. A secondary operation will remedy this. Second: Hemorrhage never met, except as the result of carelessly wounding and overlooking blood-vessels above the internal sphincter. My operations for hemorrhoids number forty-two, the American or clamp eleven and the slit operation thirty-one. In the thirty-one slit cases I have had satisfactory results with the following exceptions : 1. Hemorrhage, one case, from a cut above the internal sphincter, overlooked after dilatation. Patient had stools of blood every hour or so from 1 p. m. till 10 p. m., when it was reported to me. She was much weakened by this time. Chloroform was given immediately, and I closed the gap with catgut sutures. Subsequent recovery without incident. In only three cases, during operation, did I deem it neces- sary to use sutures or ligatures to prevent possible hemor- rhage. 2. Recurrence, four cases, requiring secondary opera- tion. Three of these cases were probably due to insufficient removal. The fourth was from an error in judgment in not using the American in the first place. This patient, even since her second operation, though now in good health and previ- ously an invalid, never fails to tell me she "still has piles," meaning rectal sensitiveness and occasional pain after stool, though no prolapsus. Careful after-treatment, which she re- fused to take, might suffice. The American would settle the matter forever. ORIFICIAI, SURGERY. 311 CHAPTER XXXVIII. SLIT OPERATION UNDER COCAINE. CORA SMITH EATON, M. D. There are many cases presenting symptoms of local dis- comfort and of sympathetic disturbances in other parts of the body, from hemorrhoidal growths. Some of these patients cannot afford either the time or the money for an ideal surgical removal of the hemorrhoids at the hospital. It taxes our in- genuity to relieve these patients while conforming to their conditions. Several of these have been treated at my office with gratifying results after the method described in the fol- lowing case: Mrs. A. M. L., aged 45, past the climacteric, no lacera- tion, but a tendency to prolapsus of all pelvic organs, although the uterus retained its normal anterior curve. She came be- cause of vesical irritation, evidently gonorrheal, which sup- position was later confirmed by confession of her husband, who is a traveling man. There was much tenesmus, urging oozing of greenish discharge from the urethra, general bear- ing down and aching of hips and external genitals, extending into the thighs. The bladder trouble was completely cured in about six weeks by hydrozone irrigation, two teaspoonfuls to the quart, and by cantharis Ix internally. The uterus was also propped up by hydrastis cerate tampons, and eventually retained its normal height in the pelvis. Notwithstanding this improvement, the aching m the genitals and thigh continr-ti, and made her life a burden. As a last resort I carefully ex- amined the rectum and found internal hemorrhoids. Placing the bivalve speculum in the rectum, with patient in the knee- chest position to throw a good light into the field of operation and make it more accessible, I selected two pile tumors for the first treatment, and injected into each -one about four minims of a 4 per cent, solution of cocaine, freshly prepared from P. D. & Co. tablets. I then seized the apex of one pile tumor 312 ORIFIG1AL SURGERY. in a pair of forceps, and with curved scissors amputated the hemorrhoid, paying no attention to the bleeding, which was profuse. I similarly treated the cocainized hemorrhoid on tne other side of the rectum. On removing the speculum the bleeding stopped at once under the contraction of the sphinc- ter. She was directed to apply four or five times a day a cerate made of hydrastis and hamamelis and aesculus, to wash out the rectum with a cupful of weak hamamelis solution after each bowel movement, and to use svapnia, one-grain supposi- tories, for pain, if necessary, the first day or two. She was obliged to keep quiet for a few days, although not confined to the bed. After two weeks the surgical treatment was re- peated in other parts of the rectum, and this course followed out until all hemorrhoids and papillae were removed. The patient reports complete relief from the troublesome symp- toms, and says she feels like a new woman ,and cannot thank me enough for having cured her without hospital operation. There are several other cases with a history of similar relief from office operations. I never have the slightest trouble from the cocaine anesthesia, as I give strychnine 1-30 grain by mouth before using it. The free bleeding removes danger of toxic effect. Following the operation, before the patient is sent home, I have her take ^4 grain morphine by mouth, and require her to rest for an hour or so at the office. CHAPTER XXXIX. TREATMENT OF HEMORRHOIDS. C. A. PAULY, M. D. It is said that hemorrhoids have existed as long as the hu- man race. From as far back in medical history as we are able to trace, hemorrhoids have been divided into two varieties, external and internal. Both may be present in the same pa- tient at the same time, yet they can always be distinguished from each other. ORIFICIAL SURGERY. 313 External hemorrhoids originate in a subcutaneous plexus of vein surrounding the anus; they are below the sphincter muscles and are not connected with the rectum proper, nor can they be placed above the external sphincter and be made to remain there. Internal hemorrhoids originate above the sphincter mu.]e, and they never appear below unless induced by straining, which may be due to constipation and other causes. The external sphincter is the dividing line between the two varieties; all below the muscles are called external, all above internal. There is still a third variety (middle) found on the dividing line, and it is often hard to determine which variety they partake of external or internal. Very few people have reached the age of fifty without having suffered with external piles, and possibly internal, without being conscious of the latter. For convenience ex- ternal hemorrhoids may be divided into three forms: The first is a round or elongated tumor formed by the extravasa- tion of blood in the subcutaneous tissue at the margin of the anus, caused by the rupture of a dilated vein. The tumor ap- pears suddenly and, while not of a serious nature, is very an- noying. On examination the physician finds a hard and in- flamed tumor filled with a clot of blood. The treatment is simple. Make an application of a 4 per cent, cocaine solution, wait a few minutes for the numbing ef- fects, then with a curved bistoury make an incision through the mucous surface, radiating from the anus as a center. In- stead of squeezing the tumor to remove the clot, use a spud ; dress the wound with a piece of carbolied silk or iodoform gauze placed in the sac, to be removed the next day. Hama- melis or calendula cerate can be applied to the sac until the inflammation subsides and the soreness disappears. If the pa- tient will not submit to such simple surgical measures, put him to bed and have cold compresses or hot poultices applied to the parts, and wait for the inflammation to subside, if not for the clot to be absorbed. The second form of external hemorrhoids is a tumor com- posed of enlarged or varicose veins located at the margin of 314 ORIFIC1AL SURGERY. the anus the tumors may be multiple and surround the anus. This variety differs from the first by not being circumscribed, not coming on suddenly and not being formed by extravasa- tion of blood. The formation is gradual and the patient is not conscious of the tumors until their increased size causes pain and uneasi- ness during the act of defacation and for some time after- wards. On examination the anus may present almost a nor- mal appearance. If the patient strains, the vessels become turgent, the surface about the anus looks purplish and the tumors soon present themselves. The treatment advocated is carbolic acid injections, electrolysis and the cautery. The two latter I have never used, and with carbolic injections I have never had satisfactory results in treating tumors having their origin outside of the sphincter muscles. For the re- moval of this variety I prefer rectal dilatation with the bi- valve speculum, and have the patient use the rectal plugs. By their use the circulation through the veins can be re-estab- lished and in time the tumors will disappear. Furthermore the use of the plugs will overcome constipation which is often the exciting cause. In cases requiring surgical work in or about the rectum, necessitating the use of an anesthetic, these tumors if present would be removed at the same sitting. The third variety of external hemorrhoids is composed mostly of skin and connective tissue. It may be the remnants of the first two varieties. It has lost its vascularity and pre- sents itself in the shape of tabs or redundant tissue. One other cause might lead to its formation : irritating discharges from disease within the rectum. This form or variety is often very troublesome; the tumors become inflamed, the mucous surface cracked or fissured, and the secretions about the anus cause pruritis; the latter is often persistent, keeping the pa- tient awake most of the night. Treatment : The patient will seldom consult the physician or surgeon when the tumors are quiescent; they will have to be in a state of inflammation or the pruritis is severe before the patient will ask for relief If the tumors are small inject a few drops of a 4 per cent, so- lution of cocaine, grasp the tumors with forceps and snip off ORIFIC1AL SURGERY. 315 with scissors. The slight bleeding that follows can be ar- rested with styptic cotton. If the tumor is large inject co- caine at one or more points. Snip off tumor and unite edges of wound if necessary with catgut. The slit operation is pref- erable for external hemorrhoids if the tumors are vascular. Should the patient object to surgical treatment, local applica- tions will give relief and correct the trouble for a time. For the inflammation that might be induced by discharges and the rubbing of the parts to relieve the itching, application of cold water and the use of different ointments such as belladonna and opium with cosmoline, campho-phenique and benzoated oxide zinc ointment are all good and will give relief. Rectal injections of hamamelis, hydrastis or boracic acid will be bene- ficial. Applications of carbolic acid and sweet oil (1-10) to the fissures will be curative and quiet the itch.ng tumors. For internal medication graphites and salicylic acid should be thought of. Internal hemorrhoids are varicosities of the superior and middle hemorrhoidal veins. They are divided into two varie- ties, capillary and venous ; sometimes a third is given arterial. Capillary hemorrhoids are rare; when present they are found high up in the rectum or down near the sphincter; each tumor is composed of the terminal branches of an artery and a vein joined by a capillary. The tumors resemble a strawberry in appearance. Their surface is granular and covered with a very thin membrane. The delicate structure accounts for the free hemorrhage which often takes place from the slightest bruise to the membrane. The leading symptoms of a capillary liemorrhoid is the daily hemorrhage from the rectum. On ex- amination the blood can be seen coming from the strawberry- like surface of the tumors. Treatment. A thorough application of nitric acid to the surface of the tumors will complete a cure. Seldom will the second application be needed. The venous form of internal hemorrhoids is the most common. It is void of the capillary net work and is composed of a mass of anastomosing veins bound together by connective tissue. The veins are tortuous and dilate into sacs or pouches. Entering the base of these 316 ORIPIC1AL SURGERY. tumors, one or more arteries can be found, often of large size. An obstruction to the portal circulation causes the tumors to become quite large. Irritating discharges and long detention of fecal matter in the rectum cause the tumors to inflame and bleed readily. Straining at stool will have a tendency to force them below the sphincter muscles. If the exciting cause is not removed the muscles soon become relaxed and the tumors remain out- side. Inflamed piles that come down with each stool, and are constricted by the sphincters, are very painful. The tu- mors may be easily reduced at first, but are liable to fire up from different causes, such as over-indulgence in eating and drinking, and become so swollen that the patient will not be able to replace them. When called to a case of this kind the patient should be placed on the face with pelvis elevated. Apply 10 per cent, cocaine ointment to the piles; wait ten minutes for the numbing effect. Then try to reduce the tumors by passing a well-anointed finger into the bowel to relax the sphincters, and with the other hand gently apply pressure, trying to empty the tumors of their superfluous quantity of blood and to carry them above the grasp of the sphincter mus- cles. Failing at reduction, apply ice; after waiting an hour try again to replace the tumors; if failure is the result, apply ice for relief. If ice remains on the piles any great length of time it will cause too much sloughing. The muscular constric- tion of the piles also cause sloughing. The application of a soothing ointment, followed by warm poultices, will give re- lief until the tumors become smaller and can be replaced. Treatment. Before recommending a surgical operation for the removal of piles, it is wise to consider whether the case is one in which surgical procedure is justifiable. Internal hemorrhoids are symptoms of disease in a number of the vis- cera, such as stricture of the rectum, diseases of the bladder, enlarged prostates, stricture of the urethra and diseases of the uterus, also diseases of the liver, kidneys, heart and lungs. If it is possible to remove the exciting cause by curing these dis- eases of the viscera involved, the hemorrhoids will disappear. Medical treatment might be the course to pursue nux vom- OEIFIC1AL, SURGEKY. 317 ica, sulphur, aloes, collinsonia, podophyllum, aesculus and hamamelis, are all excellent remedies, and should be thought of in diseases of the different viscera with hemorrhoidal symptoms. The use of carbolic acid by injection for the cure of in- ternal hemorrhoids is greatly condemned by the profession at large. Notwithstanding the strong objection to this mode of treatment, many cases have been and many cases can be cured with this treatment. I have been successful with the carbolic injection used in the strength of 1-10, and have never seen any bad results. However I prefer surgical measures for the removal of piles, but many patients will not submit to the knife, as they express it. If the general health of the patient is good and his sufferings are merely local, carbolic injections may be all that is needed to remove the hemorrhoids. [A 50 per cent, solution of carbolic acid in olive oil is better. Ed.] Surgeons of the older school have devised many different operations for the removal of hemorrhoids. At the present day they recommend but two, the ligature and clamp and cautery operation ; ocassionally a third, the Whitehead or English operation. The ligature is crude surgery of the past. The clamp and cautery operation has little to recommend it. The burn- ing causes great pain, especially if the skin is involved in the operation secondary hemorrhage is likely to occur. Slough- ing takes place, healing of the parts is slow and often trou- blesome, contraction is common, caused by the formation of scar tissue, which is non-elastic and liable to ulceration. In conclusion I wish to make the following statement : For the removal of internal hemorrhoids the modified clamp and the American operation if performed by skillful operators, will give better and more satisfactory results than either the clamp and cautery or the English operations. 318 ORIFIG1AL SURGERY. CHAPTER XL. THE AMERICAN OPERATION IN HEMORRHOIDS. EUG. HUBBELL, M. D. The American operation was devised by Dr. Pratt, of Chicago, whose experience in rectal surgery has been greater, probably, than any other surgeon in America. It is designed for those aggravated cases of hemorrhoids where the clamp, ligature, or Whitehead operation was formerly employed. It is to my mind the most perfect method at present known for the radical removal of the pile-bearing inch. It is really the only surgical operation except the English or Whitehead, for these aggravated cases. It differs from the English in that the operator begins at the upper border of the hemorrhoids and dissects downward to the anal verge, instead of com- mencing at the anal verge and working up. The advantages are: 1. A more even division of the mucous membrane at the upper end, which is difficult to obtain in the English operation. 2. Greater rapidity in removing hemorrhoidal tissue. 3. Better control of hemorrhage, consequently less loss of blood. The clamp or ligature operations are clumsy, bungling, nerve-pinching, tissue-crushing means that often produce un- favorable results. The American completely eradicates all tendency to hemorrhoids. It leaves but little, if any, stiff, un- wieldy cicatricial tissue in the grasp of the sphincters, hence incontinence of feces seldom if ever occurs. A brief descrip- tion of the operation may not be out of place here : The bowels should be thoroughly emptied and cleansed prior to the operation; antiseptic conditions secured; the pa- tient anesthetized ; on operating table dorsal position, thighs strongly flexed on the abdomen and held by two assistants; the sphincters thoroughly dilated by Pratt 's bivalve speculum, ORIFIC'IAL SURGERY. 319 also the sigmoid, which is then packed. The hemorrhoids are then seized by T forceps and completely everted, the forceps being held by assistants. Commencing at the upper border of hemorrhoidal tissue the mucous membrane is severed trans- versely around the gut, then dissected from the sphincters to the line of healthy tissue outside where it is severed. The severed end of mucous membrane should now be drawn down and freed from connective tissue attachments for an inch or so from its end, to let it more freely come down to be finally sutured to the skin, so as to nicely coapt the cut surfaces at the outer sphincter. A dry dressing is best applied; this cov- ered with antiseptic silk, and then a pledget of cotton, and all held in place by a T bandage. The patient should be confined to the bed for two weeks, bowels moved by enemata after third or fourth day ; sometimes a little smoothing of the cicatricial rim may be required. I wish to cite a few cases only : Case 1. Mrs. S., of Faribult, aet. 52, has suffered from protruding and bleeding piles for ten years, is very weak and anemic. The American operation was made in February, 1894, at her home. The amount of tissue removed was very great. She made an uneventful recovery, regained her health, and the anus is today as smooth and perfect as if there never had been a pile there. Case 2. Mr. J., of Owatonna, aet. 33. Man of fine phy- sique ; has suffered for several years with hemorrhoids. Amer- ican operation made April 5th, 1894, entirely cured him. He was up and at his office the tenth day; result remains perfect. Case 3. Miss R., of Redfield, S. D., aet. 16. Very slen- der, weak, despondent, anemic and lifeless; had pockets, papillae, erosions of bowel with hemorrhoids. The American completely restored the rectal pathology and started her out on the pathway of health. Case 4. Mr. D., of this city ; occupation, typesetter. Had to give up his work last December on account of "piles." I made the American in his case also, but his recovery was not uneventful. On the fourth day after the operation he arose and emptied the bowels of large hardened feces without use of anema. Two or three stitches were torn out, leaving a lit- 320 ORIFIC1AL SURGERY. tie gap which did not granulate well. I again replaced him upon the table and repaired the gap, but it would not unite and it soon began to slough. I again anesthetized him, made a sub-mucous division of the sphincters, and then got union. He was impationt and discouraged at one time, but he is now happy, cheerful and well, and at his old place at work. Had my instructions been carried out, and he had an enema to soften the stool, it would have saved protracted and painful convalescence. This is the only case where I have employed the American operation in the removal of hemorrhoids in which I have had any unpleasant features. The American is used in many other rectal complications not within the province of this paper to discuss. CHAPTER XLI. THE AMERICAN OPERATION. E. H. PRATT, M. D. The space allotted for the leading article for the present month is so limited that it will be impossible to do justice to any subjct requiring extended consideration. We will, therefore, make a few brief suggestions concerning the Ameri- can operation. It has been pretty fairly discussed within the last few months in various medical societies, and the medical mind is at the present time considerably divided upon the question of its merits and demerits. In some future number of the Journal we shall give the operation another and more extended consideration than we can do in the present article, so as to do what we can toward clearing away many of the vexed questions in which the operation, its application and results at the present time seem involved; but for the present we shall stop with just a few practical suggestions concern- ing the technique of the operation. One of the things to be desired in the operation is to en- sure immediate union of the parts so as to avoid retraction of OKJFIC1AL SURGERY. 321 the mucous membrane, cicatrization of the surface, and the evil consequences which are liable to follow such a result. There are five things which have a tendency to prevent im- mediate union: First, lowering the position of the internal sphincter, bringing its lower fibres within the grasp of the external sphincter and making the parts clumsy in their action. Second, the rupture of the sphincters. Third, malnutrition of the mucous membrane at the time of the operation, which renders impossible the rapid repair of any wound made in it. Fourth, intermittent spasms of the sphincter muscles, doing violence to the suturing, and causing the stitches to cut through their attachment to the mucous membrane. Fifth, the too close amputation of the integument. These difficulties were one or more of them experienced in the earlier operations, and have had much to do with the un- satisfactory results so frequently and harshly commented up- on by the critics of the operation. Now that it is possible, however, to eliminate every objectionable feature in the op- eration, there is no longer necessity for unsatisfactory results, and in the course of time it will win its way into much more general favor than it at present enjoys. The operation is so perfectly invaluable in such a large number of cases that those who have learned of its great power in the cases demanding it are delighted that the only really objectionable features connected with the operation have been overcome. That the loss of the normal sensations of the anus and of the control of the bowels to even the slightest degree do not necessarily and should not result from the American operation is most thoroughly shown to any fair-minded person who will carefully investigate the operation and its results in a consid- erable number of cases, and he will find that the disastrous results are exceptional, whereas if they were the necessary consequences of the operation they would be universal. More than that, in these cases the unhappy results complained of are by no means beyond relief, for secondary work, properly per- 322 ORIFIC1AL SURGERY. formed, will completely remedy them. But the discussion of the subject will be taken up again when we come to a more thorough consideration of the operation in all its bearings. For the benefit of those who may not yet have fully solved the problems of the operation, we will briefly consider the points mentioned in the order of their enumeration. First, lowering the position of the internal sphincter, thus bringing its lower fibres within the grasp of the external sphincter, and making the parts clumsy in their action. The internal sphincter muscle clings to the mucous mem- brane, which it encloses more or less closely, being loosely held in contact with it by delicate areolar tissue. After the rim of mucous membrane lining the last inch of the rectum has been taken away and the severed margins of the mucous membrane are united to the severed margins of the skin, the mucous membrane, of course, is pulled down to a more or less extent according to the redundancy of the tissues. As the mucous membrane lining the rectum is always sufficiently re- dundant to render the operation possible without any consid- erable degree of tension upon it, no harm results to the mem- brane itself; but as it is brought down from above it brings with it the internal sphincter muscle, and before it is fastened to the integument this muscle should be carefully loosened from the mucous membrane around its entire circumference by the aid of a pair of sharp-pointed scissors or a spud. In seiz- ing the severed margin of the mucous membrane with T-for- ceps, for the purpose of bringing it into position for suturing, the forceps impinge also upon the severed extremities of the longitudinal fibres of the gut. As the fibres are somewhat pale it is not easy to distinguish between them and the under surface of the mucous membrane except for the tension which they exercise when traction is made upon the forceps. It does no harm, therefore, and an operator is less liable to do violence to the mucous membrane if, instead of trying to pull the longi- tudinal fibres loose from the mucous membrane, he takes pains to sever them close to the attachment of the forceps. As soon as the longitudinal fibres of the rectum are thus severed close to the attachment of the forceps and completely around the ORIFIC'IAL SURGERY. 323 circumference of the gut, the loose areolar tissue which sep- arates the mucous membrane from the muscular coats can be easily loosened with the spud or a pair of closed scissors, and the sphincter muscle, which is always within sight, can thus be very easily pushed back from the mucous membrane until as much mucous membrane has been bared of the muscle as was amputated during the operation. When this is care- fully accomplished and the mucous membrane is stitched to the integument the internal sphincter will occupy its normal position and thus escape being enclosed in the grasp of the external sphincter. The action of the muscle is not in the slightest interfered with, and no harm ever comes from thus loosening it and leaving it in its normal position while at the same time the mucous membrane is slid down to meet the in- tegument. Second, the rupture of the sphincters. Some sphincter muscles are exceedingly friable, and if di- latation, which is always to be practiced before the operation is performed, is in the slightest degree violent, or if it be rap- idly accomplished, some fibres of the external sphincter are very liable to be ruptured. The rupture invariably takes place at the posterior commissure. After the strip of mucous membrane has been removed and the longitudinal fibres of the rectum are severed, while the T-forceps are still gripping the lower border of the severed mucous membrane, by their aid the rectum can be brought down and the parts everted, so as to bring the external sphincter thoroughly into view. If it is found to be even partially ruptured it is better to coapt its margins by one or two catgut ligatures, for although it might heal without this protection, nevertheless the suturing ensures it. Third, malnutrition of the mucous membrane at the time of the operation, which renders impossible the rapid repair of any wound made in it. After the patient is under an anesthetic and the parts thoroughly cleansed for operation, during the process of di- latation it is an easy matter to observe the degree of tonicity possessed by the mucous membrane. If the tissues are so 324 ORIFIG1AL SURGERY. softened that moderate dilatation produces more or less edema and causes small hematoceles, if it is so friable that it bleeds and lacerates under manipulation, then it is morally certain that it does not possess sufficient integrity to hold the neces- sary stitching. Upon the slightest provocation, as vomiting, coughing, an early passage of the bowels, or spasmodic action of the sphincters, the stitches will cut through the mucous membrane and retraction will take place. Such cases should not receive the American operation, regardless of the appar- ent need for it, but measures should be inaugurated to restore to the mucous membrane its tonicity, which can be done in from two weeks to three months, according to the reactive powers of the patient, at the end of which time the operation can be successfully performed. The measures by which the tonicity of the membrane can be restored are systematic di- latation, the application of heat and cold both over the pu- denda and buttocks and within the rectum, and local feeding, the latter being best accomplished by the daily use of small injections of bovinine, which can be diluted in cases too irri- table to endure its application in full strength. The daily application of water as hot as can be borne, to be immediately followed by ice water, over the pudenda and base of the body, is an exceedingly effective measure in re-establishing the cap- illary circulation throughout the pelvic organs and thus re- storing their integrity. Dilatation can be accomplished either by the rectal speculum or, what is better, by some form of rectal plugs "Weirick's, Young's, Linn's, Pratt 's, or any other of the numerous varieties in which the market abounds. These can be used at the discretion of the surgeon in charge, and ac- cording to the instructions given for their use already laid down in a previous number of the Journal. Electricity should also be enumerated in the list of tonic measures. Where the mucous membrane lining the rectum is in a condition of malnu- trition, the weakened condition is liable to extend the entire length of the colon, so that in employing electricity it is well to insert the rectal electrode not only into the rectum itself, but well into the sigmoid, and by means of a fountain syringe flood the large intestine with water strongly impregnated with ORmCIAL SURGERY. 325 salt. In this way the electrical current can do good service not only for the rectum itself, but along the entire length of the large intestine. Both the galvanic and the faradic currents will be found of service, and may be employed at the same sit- ting. After the rectal electrode is removed it is well to intro- duce the sigmoid speculum, and after a succussion of the sig- moid, while the instrument is being held open by the operator it can be expelled by the patient, thus not only clearing the sigmoid of any fecal matter that may be present but also dilat- ing the anus at the same time. These treatments may be given daily, or less often, at the discretion of the surgeon. It is good practice to employ electricity in this manner and follow its ap- plication with the use of hot and cold water as just mentioned, all at the same sitting. Of course in many cases the sexual system, regardless of sex will demand more or less attention ac- cording to its condition, as in cases where the mucous mem- brane of the rectum is atrophied there will be a corresponding condition of weakness of the sexual organs, and this must be corrected in order to secure the results desired from the treat- ment of the rectum. The means for re-establishing sexual tone have already been considered in a previous number of the Journal, and consequently need not be repeated in the present connection. Fourth, intermittent spasms of the sphincter muscles, do- ing violence to the suturing and causing the stitches to cut through their attachment to the mucous membrane. This has been one of the serious problems of the operation, and until recently has not been satisfactorily solved, the hy- podermic use of morphine being almost the only means at our command for controlling them, and even then the exhibition of retching or coughing or sneezing or laughing was to be dreaded. There is now a very satisfactory solution of this problem, and singular as it may appear, it is nothing more nor less than the employment of a subcutaneous stitching of the skin side of the wound. The continuous stitch may pierce the mucous membrane as formerly advised, but instead of piercing the skin it is made to transfix only the cutis vera, 326 ORIFIG1AL SURGERY. never entering the skin far enough to impinge upon its papil- lary layer. The needle may be either entered perpendicularly or longitudinally to the wound, the only point being to confine it to the deeper parts of the cutis vera. In this manner a beau- tiful coaptation of the very margins of the skin and the margins of the mucous membrane is secured ; at the same time it avoids almost entirely the subsequent pain and soreness resulting from the operation as previously performed. The patients consequently require less morphine, a large number indeed not requiring any, and the spasmodic action of the external sphinc- ter seems to be almost completely avoided. As a consequence union by first intention is almost uniformly secured, and there is also no subsequent stricture to contend with. Fifth, the too close amputation of the integument. When the operation has proceeded so far that the mucous lining of the last inch has been amputated, peeled downward, and is held dangling below the anus by the forceps which are still attached, care being taken not to exercise more traction than is necessary to merely straighten the mucous membrane to be removed, a groove will be observed completely surround- ing the anus, which marks the angle at which the perpendicu- lar tissues are continuous with the horizontal ones covering the buttocks. In the earlier history of the operation it was advised to amputate the integument right at this angle. But since it has been found advisable to sever the longitudinal fibres of the gut and peel back the internal sphincter, thus more freely liberating the mucous membrane, it has been found that a corresponding allowance must be made in the amount of the integument amputated. There is less tendency to re- traction of the mucous membrane, and consequently the skin will not be drawn so far inward as in the operation earlier performed. For this reason, instead of making the amputa- tion of the integument at the bottom of the groove just men- tioned, it is better to remove less of the integument. The am- putation may be made along the line a quarter of an inch from the bottom of the groove, of course on the side to which the mucous membrane is attached. This will avoid all danger of ectropion of the mucous membrane. Cases of ectropion can be ORIFIGIAL SURGERY. 327 remedied by a subsequent operation, but it is much better not to produce them. In the points mentioned the American operation has been very materially improved, and it is possible that still further improvement may be instituted, so that, when performed with proper care and precaution and used as a last resort for the cure of cases for which milder measures have proven them- selves inadequate after thorough trial, it need never be con- demned, nor even dreaded. The operation has now been per- formed with such pronounced success in so many hundreds of cases, in which the gratitude of the patients for their restora- tion to health has been so warmly and repeatedly expressed, that the establishment of the operation in its present degree of perfection will have to be chronicled as one of the greatest surgical accomplishments of the age. The orificial philosophy does not depend either for its universal establishment, or for its permanence of recognition, upon any particular method either of operation or of treat- ment, and the success or failure of the American operation, or any other operation employed by the present practitioners of orificial surgery, cannot in the slightest influence the sound- ness of orificial teachings, for these are based upon the well- known facts of anatomy and physiology, which must always remain until the plans of creation undergo material change. The favor, therefore, with which the American operation is ultimately received by the medical fraternity is a matter of comparative indifference to the true orificialist. He will be very glad, indeed, to abandon the operation, as indeed he will hysterectomy, laceration of the cervix, perinea! section, or any other formidable surgical procedure, whenever simpler means will accomplish his purpose. The early removal of pockets and papillae, and a proper attention to the foreskin, frenum and meatus of the male, and hood of the clitoris, meatus, vulva, cervix and positions of the uterus of the female, will undoubt- edly in the course of time dispense with all forms of major work in the pelvic organs. But until pelvic hygiene is begun in infancy and continued throughout all earth life, major op- erations upon the pelvic organs will be repeatedly called for; 328 ORtFIClAL SURGES?. and among them will be the American operation, for although it will always occupy the position of a last resort, patients will be abundant who have so neglected themselves before applying for relief that nothing but a last resort measure will be ade- quate to the case. The American operation has unquestionably come to stay, and the very best that we can do is to be as con- servative and as skillful as possible in our employment of it, and be very sure that we make use of it only as a last resort, either as a local measure or as a means of re-establishing gen- eral nutrition, for this is all it was ever invented for or rec- ommended for, and all that it should ever be employed for. So long as through neglect or other causes last resorts are sometimes needed, we have every reason to be grateful for the American operation, as for all other extreme measures which are our sole reliance in times of great need. CHAPTER XLII. RECTAL DISEASES FISTULA. T. E. COSTAIN. M. D. In the whole range of surgical pathology no other disease is so prevalent or succumbs so readily to judicious treatment. Many of these diseases are due to irregularities of habit, mode of living, and lack of proper care of the part. Many may be mistaken for prostatic condition, or cystitis. In order to dif- ferentiate a careful examination, both visual and digital, is necessary. Anatomically considered, the rectum is that part of the alimentary canal from the sigmoid to the anus. Considered nervously it is that from the left one-half of the transverse colon to the anus, because the inferior mesenteric plexus of nerves supplies all of that part alike, and as the fecal mass is often lodged in the left one-half of the transverse colon and sigmoid, it makes these two so closely associated with the rectum as to almost become a part of it. You will remember ORIFIC1AL SURGERY. 329 that the rectum has three coats; one, the peritoneal, only cov- ering a portion of it, the mucous and muscular coats continu- ing to the anus. The arterial supply is the superior hemor- rhoidal from mesenteric, inferior hemorrhoidal from internal pubic. Veins correspond in names to the arteries. Nerve sup- ply is from sacral plexus, and sympathetic from mesenteric and hypogastric plexuses. Before proceeding further I want to call your attention to the intimate relation existing between these nerves and the genito-urinary tract, branches from the same nerve supplying both. And often the rectum may be at fault, with the pain re- flexed to some part of the genito-urinary tract. Guarding the anus we find two sphincter muscles, the external and the internal sphincters. Reinforcing these two muscles we find the levator ani, the action of which is to compress the sides of the rectum and neck of the bladder, and in the act of defeca- tion when the sphincter contracts to open the anus. It also has a slight sphincter action and aids contraction of the anus when the sphincter is destroyed. The external sphincter surrounds the outer margin of the anus, and is found surrounding the lower portion of the gut, but not intimately connected with it. The internal sphincter, on the other hand, lies immediately around the gut and is in- timately and closely associated with it. We will now consider and classify diseases peculiar to the rectum, remembering at the same time that from an orificial standpoint local pathological conditions not only cause local discomfort but affect the general nutrition of the body. We will now consider rectal diseases from a local stand- point. Before taking up the consideration of individual rectal disorders we will talk in a general way of the subjective symp- toms which will call the patient's attention to the part, and later objective symptoms, which we can see by examination. As I have already told you, the fact that you cannot glean from the patient anything which would suggest any local dis- order is no reason why you should not inspect and examine this part for yourself. Often the irritation is carried by me- tastasis to remote parts of the body and does far more dam- 330 ORIFICIAL SURGERY. age to the patient's health than if extensive local pathology existed. Pain will exist with fistula, fissure, acute hemor- rhoids, ulceration, and morbid growths. In fissure the pain is out of proportion to the local lesion, usually coming on during the act of defacation and lasting afterward for some time. It is of a hot, smarting character, and radiates toward the coc- cyx. Pain due to fistula is more often found in the acute stage than later, when it becomes chronic. This pain takes the char- acter of inflammatory pain, which is found in an abscess any- where. In acute hemorrhoids the pain is in proportion to the size and number of the tumors and the amount of the sur- rounding inflammation. In ulceration, unless it lies directly in the grip of the sphincter, the pain is only of a minimum amount. In malignant diseases the pain depends largely upon the extent and location of the disease, being much greater if situated between the sphincter muscles. If the disease be high up, even though extensive, very little or no pain would be felt. By inspection you will know prolapsus retg, external hemorrhoids, polypi, and villous growths. Hemorrhage maj be seen and may be a symptom of bleeding hemorrhoids, pro- lapsus, fissures, ulcers, strictures, malignant disease, polypi, wounds, and the presence of foreign bodies in the rectum. Blood may indicate acute inflammations and ulcerations of the intestines or stomach. By digital examination or by exposing the field with a speculum the Pratt speculum being the best for this purpose you can note all the foregoing and can ex- amine for pockets and papilla? and middle and internal hem- orrhoids, strictures, ulceration, complete fistula, pus, etc. The patient's own diagnosis should never be taken, and even the family physician's diagnosis should be supplemented by an ex- amination by yourself. An enema should be given when pos- sible before examination, as a fecal mass may obstruct the up- per rectum from view on the introduction of the speculum. Position. For an ordinary digital examination the semi- prone or Sims position is most convenient, but the lithotomy position will be best if you wish to explore the field higher up in the rectum. Very often it will be difficult to make more than a digital examination without an anesthetic. The amount ORIFIC1AL SURGERY. 331 of pain caused by the use of the speculum will not be well borne in sensitive cases. As a rule in these cases the digital examination will determine whether an -anesthetic will be ne- cessary, and a further examination can be made under anes- thesia if further explorations should become necessary. If the digital examination be carefully made it will give you much valuable information ; first, note the strength of the sphincter muscle. A tight sphincter denotes irritation in the last inch of the rectum pockets, papilla 1 , fissures, etc., and an inordi- nate amount of nerve waste. A weak sphincter denotes deep- er situated trouble; it means a weakened system, a weakened sympathetic nerve, or, worse still, a malignant disease of the rectum. By sweeping the finger around the rectal wall pa- pillae, hemorrhoids, fissures, strictures, etc., and in the male prostatic conditions may be found, and in the female the uterus may be found pressing on the rectal wall and its position may be readily noted. The examination having been made, a diagnosis of the case determined upon, we now come to the proper methods of handling the various diseases liable to be found in that part. We will first take up the subject of the fistula in ano. There are two classes of these cases ; those who suffer only a local discomfort, and those who suffer with profound reflex disturbance in addition to the local disturbance. The pudic nerve, which is a branch of the cerebro-spinal system, is re- sponsible in itself for many nervous reflexes; but when we consider its action in the sacral region with the sympathetic system, we have a wire to the central office of both systems, over which the messages from a broad surface of decomposed tissue are constant. The superiority of the train of reflexes depends somewhat upon the power of each nerve to resist them. In cases where the disturbance is local we find the pa- tient in apparent good health. These cases, however, have a very much weakened, sympathetic nervous system, and in con- sequence its normal function is greatly disturbed. In other cases we find not only disturbed function but a weakened and emaciated body and a train of nervous disturbances, which at first glance seems almost beyond our aid. 332 ORIFIG1AL SURGERY. Irritation from the terminal nerves of the rectum affects not only the adjacent organs, but the liver, stomach, heart, in- testines, and the equilibrity of nerve force. The heart is af- fected directly by the lateral chain of sympathy directly to the cerebral ganglia and the intermingling of the fibers from the solar plexus and pneumogastric nerve. The hypogastric plexus conveys impressions to the stomach and intestines through the gastric plexus and its branches to Auerbach's and Meissner's plexuses, the whole being a branch of the great solar plexus. This same action occurs in other organs mentioned and causes a variety of nerve symptoms which would reach almost all the nervous phenomena known to be due to the constant ir- ritation of any of the lower openings. A fistula in ano may be defined as a non-granulating sinus with two openings, one upon the surface and the other within the rectum. The inner opening usually lies between the sphincter muscles. Fistula in ano is the result of an abscess either external or internal to the sphincter muscles, and of many recognized forms among them are the complete, blind external, blind in- ternal, horseshoe, recto-vaginal, recto-vesical. These forms may again be divided into fistula due to pyogenic cocci and those of the tubercular type. We will consider fistulas in general from the latter stand- point. The first thing to be done with a case of this kind is to get a diagnosis of whether the trouble is due to tubercular bacilli or pyogenic cocci, such as staphyloeoccus or streptococ- cus, or bacillus foetidus, or to either of them singly and com- bined with tubercular bacilli. This can be accomplished by making a culture of the pus immediately after or at the time you make the examination. This culture should then be sub- jected to the proper tests and a slide for the microscopicaf ex- amination made. After you have become convinced that tu- bercular bacilli are or are not present, you know whether the case is going to be an extremely difficult and tedious one or one in which you have hope for an early closing up of the ORIFIC1AL SURGERY. 333 entire trouble. In my experience the treatment of the two is radically different. In the case of fistula of the pyogenic origin alone, I would recommend, before operating, that all proper care should be taken to cleanse the wound as much as possible. Irrigate with an antiseptic solution for a day or two, if necessary putting on the antiseptic wet dressing continuously for twenty-four or forty-eight hours, and make the wound as near antiseptic as is possible under the circumstances. By observing thoroughly aseptic and antiseptic technique during the operation we can hope for a wound which will heal readily after the following method : If the fistula is a single, complete one, with the inner opening between the sphincters, lay open the tract up to the margin of the sphincter muscle. Now feel for the hard cord running into the wall of the bowel, and dissect from the up- per point toward the bowel; grasp these loose ends in a pair of plug or T forceps, and dissect the cord out clean. The mu- cous membrane of the bowel can be brought together by some stitches, closing the internal opening; deep sutures can then be passed, if necessary, through the mucous membrane, but preferably from the outside, approximating the wound. These stitches can then be continued down through the wound, af- ter dissecting out the bottom of the open wound most thor- oughly, and the parts stitched together completely. In case healing fails to take place by first intention, the wound can be treated very readily, or such part of it as does not heal by subsequent cleaning up of the wound, or by stitching it if the wound is already clean. In the case, however, of a tubercular fistula, there is no use bringing it together at all, because it will not heal. This should be treated as an open wound, and should be packed with iodoform or nosophen gauze, and this dressing changed and the wound cleaned night and morning and after each bow- el movement, the first bowel movement taking place about the fourth day. After a time this dressing will become ineffica- cious, and it will tax your patients and knowledge of drugs of every variety to get the wound active at all. Cauterization, 334 ORIFIG1AL SURGERY. either by carbolic acid, nitrate of silver, or the various other agents known to be good, or by electricity, using the positive pole, will aid you for a time; jute saturated with balsam of Peru, packed into the wound, will stimulate granulations, and is of itself a thorough antiseptic ; in fact, I have seen it clean up wounds when nothing else seemed to be of any service. flodum-Miller will be found very effective. Ed.] If the wound should become clean and granulations fresh, an effort should be made to bring the edges together by putting in either a button or quill suture. The suture of any material tied will cut through the tissues, in spite of the most persistent care, as the tissues around a tubercular fistula become softened and lose their integrity to a great extent. You may be able to gain quite a little by this suture, sometimes healing it entirely, but in any event it is a long and tedious process. Success is yours if you will continue your efforts, as I have never known them not to be healed in the end, with possibly a single exception, and this exception left before the wound was entirely healed, because it took so long. It is sometimes difficult to find the internal opening either with the finger or with a probe. In such cases as these do not take it for granted that it is a blind fistula, but dry the finger, pass it inside the rectum, throw iodine through the opening, and as it oozes through you will find the finger stained, show- ing an internal opening exists. If, however, you get no stain on the finger, you may be pretty certain that the mucous mem- brane of the bowel is intact. Many other staining fluids can be utilized for this purpose. [H 2 O 2 is excellent. Ed.] In a case where there is a multiple fistula the treatment is the same, except that each tract must be followed very care- fully to its terminus. Occasionally you will find at what ap- pears to be the terminal end an opening leading off into the tissues in some other direction. With a soft probe you can outline these offshoots and treat them accordingly. Every variety of fistula should be thoroughly eradicated by removing all the hardened tissue wherever found, and it is impossible to heal the wound so long as a vestige of it remains. ORIFIC1AL SURGERY.' 335 Many modes of treatment have been and are recommend- ed, the elastic ligature being highly recommend- ed in the text books. But I have seen at least one very dis- astrous result following its use. The sphincter muscle was sep- arated widely and the tissues surrounding the anus so softened that they retained very little of their former integrity and taxed all the resources of the surgeon to bring the parts into anything like a normal condition. For this reason I would place it in the same class as the ligation of hemorrhoids out of date. When handling a fistula all the points of irritation, whether pockets, papilla 1 , hemorrhoids, fissures, ulcers, etc., which the surgeon may observe at the lower part of the bowel, should be eradicated before the work is complete, as they tend to handicap the healing of the wound by abnormal contraction of the sphincter muscles. CHAPTER XLIII. STRICTURES AND ULCERS OF THE RECTUM. E. H. PRATT, M. D. ORGANIC STRICTURES. They are not common. Their origin is some form of ulcer- ation, usually syphilitic or cancerous, although stricture of the rectum may occur from inflammatory processes following ab- scesses or injuries. They may be located at any point in the rectum from the anus to the junction of the rectum with the sigmoid flexure of the colon. They may take the form of one or more constricting bands or narrow the calibre of the entire rectum. They may exist in any form or to any extent in a rectum which is movable or in one which is held in the firm grip of inflammatory products. They may extend around the entire circumference of the gut or appear only on one side of its lumen. 336 ORIFIGTAL SURGERY. Strictures of cancerous origin usually surround the entire circumference of the intestine when first observed, and their favorite location is at the upper end of the rectum. Those re- sulting from syphilitic ulceration may narrow the calibre of the intestine at one point or may extend the whole length of the rectum, constricting the canal irregularly at different places. In all cases of stricture of the rectum, whether syphilitic, cancerous or traumatic, the last inch will be found more or less completely disorganized and will call for the attention of the orificial surgeon. If the stricture is low down in the rectum and the tissues are movable, it is better to perform the high American and remove the entire mass of cicatricial tis- sue, especially if it completely encirle the intestine. Where this is impossible, however, the American operation should not as a rule be performed until a thorough effort has been made to correct the difficulty by the aid of curette, scalpel, bougies and medication ; as the oft repeated treatments which the stricture would call for would interfere with the healing of the Ameri- can and be rendered unnecessarily painful. In bad cases of stricture the slit work is usually preferable. If the origin of the stricture be cancerous, the relief from the orificial work, dilating, curetting and packing, and even from extirpation, where it is possible, of the strictured portion will be merely temporary and colotomy will be needed sooner or later in order to make the few remaining days of the unfortunte patient even tolerable. Although I have known of a few eases where cancer- ous stricture located at the upper end of the rectum has been successfully held in check by curettings, dilatations, packings and injections with medicated solutions for from two to five years, yet these are exceptional cases. Strictures from syphilitic origin, however extensive and formidable the appearance, usually result satisfactorily after persistent and careful surgical attention. They are more likely than those of cancerous form to be located in the vicinity of the anus and are consequently easier of access. In a case of stricture located more than three inches from the anus great care must be taken in either curetting, cut- ORIFIGIAL SURGEKY. 337 ting or dilating not to rupture the intestine, as the peritoneal cavity is liable to be entered and poisonous matter be carried into it. An opening made in the intestine or the peritoneal cavity by a bougie is not necessarily fatal, and the danger will be in proportion to infectiousness of the tissues punctured. Large bougies have been pushed through the rectum into the abdominal cavity in cases of atrophy of the rectum without the slightest ill effects. At the same time, less formidable wounds through more poisonous structures have proved speed- ily fatal. At any rate, great care is to be exercised in hand- ling the upper part of the rectum. Lower down in the organ, cutting, rupturing and lacerating intestinal walls is not so se- rious a matter, the main danger being one of hemorrhage, which is usually easily controlled as it is readily brought with- in observation, when it is a simple matter to seize the bleeding points with artery forceps and ligate or torsion them. In any rectal case, stricture or otherwise, after the pa- tient is anesthetized and placed in position the first rectal exploration should be a digital one. If a stricture be encount- ered and situated within reach, one or two fingers of the ex- ploring hand may be employed as a dilator. If a smooth, nar- row band of cicatricial tissue is all that narrows the calibre of the intestine this may be nicked posteriorly, after which the tissues can be torn through with the fingers, bougies or rectal speculum at the discretion of the operator. When, however, the stricture is a longer one and the surface is covered with un- even growths of offending tissue, the curette may be freely employed to accomplish its removal. If the lower part of the rectum be in a normal condition and the stricture is at its up- per portion and at the same time movable, T forceps or tenacu- la may be brought into service to invaginate the gut so as to bring the stricture within reach. Traction can be made upon these instruments by assistants while the surgeon explores with his index finger, with bougies or sigmoid speculum, according to the demands of the case. Through poor judgment or acci- dent should the intestine be torn at this point so as to expose the peritoneal cavity the opening should be immediately stitched with catgut sutures. Great judgment is required in 338 OBIFIC1AL SURGERY. these manipulations to adapt the amount of traction and handling to the integrity of the tissues so as to accomplish the object of the surgical procedure and at the same time avoid the dangers of undue violence. EXTIRPATION OF THE RECTUM. This is not a proper subject for present consideration, and it is so satisfactorily treated of in the standard text-books that even if it were germane to our present theme it would be an unnecessary affliction upon the readers to publish a considera- tion of this subject, as we have nothing new to suggest except, perhaps, that where resection of the gut is contemplated it is well to save the sphincters, so that the patient may be able to retain control of the bowels. It is quite possible in some cases to split the sphincters anteriorly and posteriorly, resect the diseased portion of the rectum if it be freely movable, and at- tach the separated extremities of the intestines together so as to completely fill in the gap and then re-unite the sphincters at their separated points. The cases which make this opera- tion possible are exceedingly rare but very satisfactory for the time being. Such cases, however, are usually cancerous and are prone to recur after a few months, or at most, years. In selecting bougies for treatment of strictures the soft rubber, olive-tipped, French bougies with a canal in the cen- ter are most desirable. The central canal is especially valu able in the treatment of cases in which the stricture is located high up. In such cases the folds of the rectum frequently ob- struct the passage of the bougie, and it is a material aid to its employment to expand the rectum with tepid water, as can easily be done by inserting the nozzle of a syringe into the outer extremity of the canal of the bougie. After the gut is well distended the bougie is the more readily guided into its proper channel, and when its olive tip is once engaged the fur- ther progress of the bougie through the stricture is made with comparative ease. The following is a cut of the instrument: Larger and larger sizes of bougies should be employed at the time of the operation until further dilatation of the intes- tine would rupture it. In the subsequent treatment of stric- ORIFICIAL SURGERY. 339 ture of the rectum these bougies are indispensable. It is desir- able not only to force them through the stricture, but to per- mit them to remain in situ for from fifteen minutes to two hours according to the irritability of the case. The steady FRENCH BOUGIE. pressure of the instrument compels a change in the circula- tion of the part and excites a healthier action throughout the tissues, as a result of which stimulation and absorption of the inflammatory products follow. The bougies in some cases may be used daily while in others it would be harmful to employ them oftener than once in two weeks, according to the state of irritability of the rectum existing at the time of their em- ployment. PRATT SIGMOID SPECULUM. In some cases, either following the bougies or instead of them, the new sigmoid speculum which I have lately devised, and of which the following is a cut, will be found a very ser- viceable instrument. It should not be used where a fissure of the tissues has already been started as there is danger of pro- ducing a lacerated wound into the peritoneal cavity. No rules for the use of either the curette or bougie, or even one's fin- ger, can be laid down. In either case the treatment must be individualized and surgical judgment employed. 340 ORIFIG'IAL SURGERY. After dilating with first the fingers, then the bougies, and lastly the sigmoid speculum, if it be employed. It is well to hold the tissues apart by means of a sigmoid plug made of a long strip of surgical wool which may or may not be rolled in antiseptically prepared china silk and medicated according to the judgment of the surgeon. This can be introduced by means of Hall's sigmoid forceps and the speculum. The fol- lowing is a cut of a plug for the upper part of the rectum, held in the grasp of a pair of Hall's forceps and ready for carrying into position. This is best done through the sigmoid speculum, WOOL, PLUG. although occasionally, where the tissues are very friable and the employment of the speculum would be dangerous, a small plug can be carried under the guidance of the index finger of the disengaged hand well into position without its aid. The plug may be left separating the walls of the stricture for a length of time varying from a few hours to a day or so, accord- ing to circumstances. The plug is secured at one extremity by a piece of silk thread. This thread should be of sufficient length to permit of its protrusion from the anus at least three or four inches, as there is such a thing as reversed peristalsis and it has frequently happened that the plug, string and all, have been retracted well into the intestine and occasioned no inconsiderable amount of anxiety. Of course no great harm ORIFICTAL SUBGEKY. 341 would be done, as eventually a vis a tergo of accumulated fecal matter would insure its final discharge. But it is better to re- tain possession of it so that it can be removed at the discretion of the surgeon. The plug can be medicated as desired, al- though it is not our intention in the present series of articles to mention the use of drugs, either locally or internally, deem- ing it but proper as we are writing for all schools of medicine, to leave this much-vexed question untouched. Still there are four local applications which are so efficacious in cases of can- cer or syphilitic affections that 1 am sure no one will be offend- ed at my mention of them. They are mentioned in the order of their apparent value as gleaned from an extensive experi- ence : Bovinine, magnetic rock oil, listerine and hydrastis canadensis. The first three may be employed full strength, saturating the plug with them freely before its introduction. The hydrastis, however, should not be used stronger than twenty or thirty drops to a quart of water. In bad cases of stricture several successive treatments may be required under an anesthetic, at varying intervals, the length of which is to be determined by the improvement in the case, it being a universal surgical rule to let well enough alone, and while the patient is gaining to a satisfactory degree to per- mit him to keep on doing so unmolested by surgical inter- ference. SPASMODIC STRICTURES. Spasmodic strictures of the rectum are usually located either at the amis or at the junction of the rectum with the sigmoid flexure of the colon, occasionally somewhere between these points. Spasmodic stricture of the anus is the common- est, most unobtrusive, and yet most mischievous affliction of disordered humanity. At this point of the intestinal tract the largest part of the rectum is suddenly constricted into the nar- rowest portion. Its veins sustain the entire weight of the blood columns in the portal circulation, and are consequently ex- ceedingly prone to congestion. It is systematically distended, rasped, bruised, scratched, and not infrequently torn by rough concretions of fecal matter which are forced through it. It is 342 ORIFIC1AL SURGERY. never examined or put in repair or subjected to the slightest attention except in extreme cases of distress; and yet it is so uncomplaining an organ, so far as the language of pain is con- cerned, that its membrane can suffer a surprising degree of disintegration and present various forms of serious pathology without even attracting the attention of its possessor. The lower inch of the rectum is doubly guarded: An ex- ternal sphincter constructed of voluntary muscular fibers sup- plied by the cerebro-spinal system, and consequently under the control of the will, and about an inch higher a large bundle of circular fibers of the involuntary type, supplied by the sym- pathetic nerve and consequently acting unconsciously so far as bodily sensations are concerned. It is at this upper part of the last inch of the rectum right within the grip of the internal sphincter, where the spasmodic strictures are most common and most serious; most common because they are painless and un- noticed; most serious because the strictured condition is in- duced by any pathological state of the lining membrane, so that sympathetic force is wasted prodigally in two ways: First, by the nerve power whieh it takes to unremittingly hold in undue tension the sphincter muscle ; and second, by the fact that in its spasmodic action it is gripping down upon diseased terminal nerve fibers which are distributed upon the diseased mucous surface. If the stricture be of long standing so that the muscle is unduly thickened and shortened, it may be necessary after pruning the mucous membrane of pockets, papillae and hem- orrhoids to make a submucous section of the sphincters. This should always be accomplished laterally. In performing the operation a strip of mucous membrane at least half an inch wide must be left intact upon one side of the rectum. The bi- valve speculum is then to be introduced and its blades suf- riciently separated to put the sphincters in a condition of firm tension. A sharp pointed bistoury is then to puncture the skin at the margin of the anus. Through this opening a blunt pointed, narrow bladed bistoury is to be entered and made to pass perpendicularly outside of the sphincters, its flat surface being toward the intestine. The index finger of the hand ORIFIC1AL SURGERY. 343 which is not employed with the knife should now be introduced into the rectum and curved around the upper border of the in- ternal sphincter, and while held in this position the knife is to be pushed upward until its dull point can be felt by the in- serted finger. The knife should be crowded upward until it pierces the muscular coat of the intestines, leaving nothing to separate the end of the knife from the point of the finger but the mucous lining of the intestine. The cutting edge of the knife is now to be turned toward the gut, and as the handle is pushed outward and the knife withdrawn, the point of it is to be kept in close contact with the finger which has been in- serted into the bowel, so that the muscular fibers can be com- pletely severed while the finger and knife are approaching the anus simultaneously. If all the fibers are not cut by the first effort the knife can .be re-entered and the work completed. In this procedure both the sphincters are severed as usually both of them are strictured. I have never known this proced- ure to induce a permanent condition of incontinence of the feces and have never had to regret its employment. Cases call- ing for it, however, are not common, as in a great majority of anal spasms dilatation, when accompanied with a proper hand- ling of the lining membrane of the intestine not forgetting the intimate relation between the sexual organs and the rectum and the consequent necessity for correcting all morbid condi- tions of the sexual organs at the same time is sufficient to effect a permanent relief. Spasmodic constriction of the upper part of the rectum is due to one of two causes : The presence of an ulcer, which is exceedingly rare except in cases of syphilitic origin, and some disorder of the sexual apparatus. In the female it is usu- ally the internal os uteri, or a condition of retroflexion or retroversion ; in the male it is prostatic irritation. When the stricture results from ulceration of the rectum, the repair of the last inch of the rectum, curetting and cauterizing of the ulcerated surface and thorough dilatation of the sphincters by means of the sigmoid speculum will readily afford permanent relief. Where the trouble is due to sexual disorders it is worse than needless to persevere with attention to the rectum, as the 344 ORIFIC1AL SURGERY. stricture will be perpetually reproduced until the cause is re- moved. Such cases will teach the rectal specialist that he must be a good orificialist in order to handle the rectum successfully. The great problem of reflexes perpetually confronts the rectal surgeon. Where the cause of the rectal spasm has been apparently removed and induced nerve tension continues to stimulate undue contraction, the secondary faradic current of electricity applied by means of a bipolar electrode is invalu- able. An electrode constructed and employed by Dr. C. A. Weiriek has proved so serviceable that a cut of it is here in- troduced. RECTAL ELECTRODE. The rounded end is metallic, the long staff which pro- ceeds from it is made of rubber-covered spiral spring wire which not only secures flexibility of the electrode but conducts the current to the metallic ball so as to constitute it one of the electrodes. The other electrode consists of half an inch of metallic band grasping the outer surface of the rubber tubing at a variable distance from the metallic ball. Into a hole in this band the other pole of the battery is attached. Both the electrodes are to be introduced into the rectum. The pole is to be buried as far as the stricture, while the metallic band is retained within the grip of the anus. As soon as the elec- trodes are in proper position the battery is started. The posi- tive pole is connected with the metallic ball and the negative with the metallic band. The treatment should not be given oftener than every other day and in some cases a longer in- terval is desirable. In all cases of stricture of the rectum, whether organic or spasmodic, orificial work should accompany or precede the treatment of the stricture, as satisfactory results cannot other- OBIFIG1AL SURGERY. 345 wise be permanently secured, especially in stricture of the spasmodic variety. ULCERATION. The subject of ulceration of the rectum has been prac- tically covered in what we have said of strictures and so will need no more consideration. They are to be curetted, cauter- ized and medicated locally and internally. When practicable it is good practice to dissect them out and close the wound with catgut sutures. They are not as common as one would in- fer from much of the writing upon rectal diseases. As the lower openings of the body suffer simultaneously, their cure demands simultaneous or alternate treatment. One of these lower openings cannot be successfully rescued from pathology, while other openings are permitted to remain in a pathological state. CHAPTER XLIV. F1STULJE-IN-ANO. E. H. PRATT, M. D. This is by no means a new subject for professional con- sideration for extensive discussions of fistula can be found scattered throughout the pages of medical history from the very beginning of the first volume. Although the trouble is an old one so far as the human race is concerned, there are some new suggestions of value as to its treatment which have resulted from the professional progress of the last few years. We do not aspire in the present article to a complete and exhaustive discussion of the subject of fistula 1 , desiring merely to present a few practical sug- gestions in connection with it, premising just enough gen- eral consideration of the subject to ensure a clear under- standing of the suggestions to be made. The common division of fistnlae into internal, external, and complete seems to us quite satisfactory. The internal and 346 ORIFIG1AL SURGERY. external fistulas are otherwise known as blind or incomplete, as they open upon but one surface, either skin or mucous mem- brane, whereas the complete variety open upon both surfaces, thereby making a small but false passage from the outside of the body into the intestine. The inner opening of the com- plete fistulae and the opening of the internal are usually lo- cated between the sphincters. As to internal fistulae, the opening is into the intestine. In the case of external fistulas, the opening is through the in- tegument in the vicinity of the anus. Any of the three forms of fistulas may be merely tubular and of uniform calibre, or they may be sacculated and branch- ing like the limbs of a tree. EXTERNAL FISTULAE. External fistulae are blind tubes or pouches imbedded in the areolar tissue about the anus and opening upon the sur- face of the integument by one or more mouths in the vicinity of the anus, sometimes close to its margin and sometimes a few inches removed from it. They are usually relics of ischio- rectal abscesses which have degenerated into a pus tracks or sinuses, either single or branching. As they open only upon the skin surface their cure does not involve any attention what- ever to the rectum proper. Ischio-rectal abscesses, although at the time of their occurrence usually regarded by the pa- tients, and sometimes by the surgeon, as quite formidable sur- gical difficulties, seldom cause any trouble and, after a thor- ough evacuation of the confined pus and cleansing of the cavity and a few packings of iodoform gauze, are permanently cured. Occasionally, however, they are left to ulcerate their way through the integument unaided by the surgeon's scalpel and as soon as a small opening has partially relieved the pressure of the confined pus the opening again closes, to yield once more only upon a re-accumulation of the purulent matter and return of 'the pressure from within. A repetition of this process per- mits the burrowing of pus in many directions in the loose are- olar tissue about the anus, or results in a thickening of the inflammatory zone which limits the pus cavity. So although ORIFIC1AL SURGERY. 347 the pus ultimately may establish an avenue of exit sufficient to drain the cavity with comparative freedom, the walls of the pus sac have become so thoroughly organized as to fail to col- lapse and solidify when they cease to be held apart by an ac- FIG, 1. Probe passed through fistula entering in labia majora near clitoris and coming out in rectum between sphincters. First stage of American operation performed. T forceps retracting integument. Artery forceps seizing bleeding points. T forceps seizing severed margins of mucous membrane. cumulation of pus. Especially is this the case with tubercu- lous subjects; and tubercular degeneration is very liable to af- fect the inflammatory zones which constitute the pus walls of these ischio-rectal abscesses. There is an intimate nervous con- nection between the organs of respiration and the tissues about the anus. The abdomen is bounded practically by two dia- 348 ORIFIG1AL SURGERY. phragms; an upper one, which separates it from the heart and lungs, and a lower one, which forms the floor of the pelvis, the posterior part of which constitutes the tissues which support the anus. Like a pair of twins, these diaphragms sympathize with each other in their action. Coughing, sneezing, laughing, breathing, sighing, speaking every effort which involves the entrance and exit of air into the lungs calls into play the upper diaphragm. It rises and falls in the regular rhythm of respira- tion, or contracts suddenly and violently as in coughing or sneezing, or doubles itself into profound contortions of muscu- lar effort in laughing, coughing, etc. And as surely as a shad- ow clings to the object which casts it, hugging it closely, re- gardless of the rate of speed or its direction, so surely does the lower diaphragm or the floor of the pelvis repeat with remark- able fidelity both the rhythm and the intensity of the action of the upper diaphragm* This sympathetic and mutual activ- ity on the part of these twin structures is accomplished by in- timate nervous connections, which can be readily demonstrated upon the cadaver or gleaned from any standard work upon the human anatomy, or verified by observations upon the living body. As the rapidity and depth of diaphragmatic respira- tions are instantaneously echoed by the pelvic floor, abnormal conditions and contractions and degrees of inactivity and im- mobility on the part of the pelvic floor modify to the exact ex- tent of their existence the freedom of action and degree of tension of the upper diaphragm. These two diaphragms are twins for life. They suffer together and enjoy together. They work together and they play together. They not only relax and contract together, each supporting the other, but they suf- fer and writhe and neglect the proper performance of their functions in common. This is the reason why rectal troubles are so prone to induce affections of the lungs, and also why lung troubles aggravate and retard the recovery of rectal dif- ficulties. The fact is, that patients suffering from lung troubles always, without exception, present upon examination some form of rectal pathology, and the lung trouble perpetn- ates and aggravates the rectal disorder, and the rectal dis- order, on the other hand, aggravates and protracts the lung OBIPIC1AL SURGERY. 349 trouble. This fact has not been fully appreciated by the medi- cal profession, and it will be a good many years yet in all prob- ability before they realize the importance of correcting rectal pathology as an aid in the cure of all forms of diseases of the lungs. Fro. 2. Grooved director passed through fistula. Bistoury in position for laying open the track. It will sever the external sphincter. Severed edge of integument after redundant tissue has been trimmed away. An exceedingly common form for rectal diseases to assume in cases of lung trouble is some form of fistula?. This fact has Been well known for many generations, not only to the medi- cal profession but also to the people themselves. By the ig- norant the existence of fistula? in consumptives has been re- garded as an outlet for the tubercular poison, and it has been deemed dangerous to attempt their cure in such cases. The foundation for this professional and public fallacy probably lies in the fact that the old method of operating upon fistulas where it has been associated with weak lungs has been un- happy in its results, and therefore was deemed meddlesome surgery. The reason surgical interference with this difficulty 350 ORIFIC1AL SURGERY. in cases suffering from lung trouble has been unfortunate lies in the simple fact that the operators did not recognize other rectal troubles which were also present, and as they gave at- tention only to the fistulas their patients were no better but rather worse for their interference. Fio. 3. T forceps retracting severed margins of fistula. Tenacula inserted in floor of fistulous track and employed to raise and straighten the track for its dissection. Curved pointed scissors with one blade buried be- neath fistulous track in position for dissecting it out. The variety of fistulas occurring in tubercular subjects is more apt to be of the internal or the complete form rather than the external, although the external variety is not exempt from association with lung pathology. The external variety of fis- tulas is the least harmful to the general health of the patient ORIFIC1AL SURGERY. 351 and, although occasionally deeply situated, is perhaps the easiest form to cure. All that most cases require is a generous external opening, a thorough curetting of the fistulous cavity or track, a repeated packing with iodoform gauze or jute, ac- cording to the requirements of the case, and a douching with some form of medicated solution such as bichloride of mercury, carbolic acid, calendula, etc., until solid tissue has been built up by the granular process to the surface of the integument. Where the wound is sluggish and the granulations unhealthy, an occasional curetting and cauterizing with the actual cau- tery, blue vitriol, nitrate of silver, or carbolic acid, may some- times be required to keep the granulations sufficiently healthy to insure permanent and satisfactory repair. A valuable meas- ure in such cases is the occasional application of iodine, full strength, or the daily application of a weakened solution. If these few suggestions are carefully followed little trouble will be encountered in eradicating thoroughly and completely the form of fistula known as external. Sometimes, however, in cases of long standing the fistulous track will be so thickened and hardened that it will be necessary to remove it more or less completely by the aid of tenaculum and scissors in order to secure a healthy granulating surface. INTERNAL AND COMPLETE FISTULA. The internal and complete varieties are not so easily mas- tered, as their cure involves the correct handling of the last inch of the rectum, and also the sphincter muscles. The in- ternal opening of both these forms of fistulas is in a large ma- jority of cases, as previously mentioned, in the space between the two sphincters, and it may be found anywhere around the circumference of the anus, either in front or behind or on either side. It is quite common in either of these forms of fistula? for pus tracks to burrow upward as well as downward, and in a circular horseshoe form around the anus, as well as in either of these directions. They may consist of single tracks or ramify in various directions. It is exceedingly rare to find them possessed of more than one opening upon the mucous membrane surface, and as it is usually somewhere in the last L_LH(l Oi 352 ORIFIC1AL SURGERY. inch of the rectum, their successful treatment is not difficult if they are properly handled. As they are invariably accom- panied with other forms of rectal pathology, the first step in their cure is the performance of the American operation. The last inch of the mucous membrane of the rectum, which will be found to contain their internal openings, is to be carefully and thoroughly dissected away after the manner already described. FIG. 4. T forceps seizing deep covered sutures. Margins of skin coapted by continuous catigut suture. Severed margin of integument prepared for the attachment of the mucous membrane which is to be brought down from above and secured to it by a continuous catgut suture, thereby completing the American operation. The lower part of the severed mucous membrane is now to be seied with forceps and brought well into view. The fistula can then be tracked in all its ramifications. If it be a blind or internal fistula and burrow upward by the side of the rectum, the sphincters are to be severed, their margins held apart by T forceps so as to bring the track well into view, when it is to be dissected out if practicable, or curetted and packed with 38 3 J JOG ORIFICTAL SURGERY. 353 iodoform gauze if it be too deeply situated for complete re- moval. The sphincters are now to be stitched together in front of the packing and the mucous membrane drawn down and carefully attached by a continuous suture to the severed margins of the skin around its entire circumference. This process converts the internal fistula into an external one, which will yield very readily to the treatment already just described FIG. 5. T forceps seizing ligature. Ligature. American operation to be completed by a continuous catgut suture fastening together skin and mucous membrane. The deep sutures beneath the fistula are now to be tied, and parts dusted with quinine or iodoform and the operation is complete. for that variety. In case, however, the blind fistula is of the horseshoe variety, its track is to be completely laid open and dissected out, after which the American operation is to be com- pleted. No further trouble need be apprehended from the blind fistula. In the complete variety, the treatment of the case depends upon the extent of the ramifications of the pus track. If it be a single straight track, having its external opening near the anus, the external sphincter, behind which it invariably passes, 354 ORIFIC1AL SURGERY. is to be severed either with a pair of scissors or a knife upon the surface of a grooved director, and while the extremities of the severed muscles are held apart by T forceps, the track can be dissected out, after which the muscle and margins of the track can be carefully brought together with a continuous catgut suture. The American operation is then to be com- pleted. In case, however, the areolar tissue about the nates has been thoroughly honeycombed by branching sinuses, the fis- tula will take the appearance of a shrub. Its central stem will be a single track, which has one internal opening, such as has been described, and will be found between the sphincters, and numerous branches wandering out into the areolar tissue of the buttocks and opening upon the surface of the skin by apertures varying in number from twelve to fifteen. In such cases, after treating the central track or stem of the fistula as already described and completing the American operation, each of the numerous branches of the sinus is to be dilated by grad- ed steel sounds and for this purpose the graded female sounds are satisfactory instruments. They are then to be curetted and tubed with soft rubber tubing, or packed with small ropes of jute. Daily cleansing of these numerous branching sinuses will be needed to complete the cure. Peroxide of hydrogen, bichloride, iodine, carbolic acid, calendula, nitrate of silver, and other medicated douches will be found serviceable in com- pleting their eradication. Dr. Terry's plan of douching these sinuses frequently, and never employing the same solution twice in succession, thereby surprising the parts with a wash to which they have not become accustomed, is a very valuable one. The accompanying cuts illustrate the method of handling the simpler variety of complete fistula?. There are several other and satisfactory ways of operating upon fistulae which we will not take the time to describe. If the fistulas are un- accompanied by other forms of rectal difficulty, it will be bet- ter worth our while to give these our first consideration. As the last inch of the rectum is always pathological in these cases, the American operation is invariably demanded, and ORIFIC1AL SURGERY. 355 consequently it is scarcely worth our while to give extended consideration to measures which we do not deem advisable. When fistulas are healed by dilatation, by curetting, by some form of cautery, or by a thorough system of douching and medication, as it is frequently possible to do, other forms of rectal pathology accompanying them remain uncorrected and the fistulae are prone to recur, in addition to the fact that the cure of the fistulae in such cases, does not save the patient from the nerve waste induced by the contracting of the sphincters upon the morbid terminal nerve fibres of a diseased last inch. It is a matter of common experience to find patients suf- fering with pulmonary tuberculosis who are afflicted at the same time with rectal fistula. There is a widespread and at the same time erroneous impression that the presence of a fistula is conducive to the longevity of the consumptive and that to cure it is disastrous to the patient. This impression is preva- lent not only with the laity, but among the less enlightened members of the medical profession. So much so is this th(j case that where a consumptive is possessed of a fistula he not only has the impression that the cure of the fistula would pre- cipitate his consumptive tendencies and materially shorten his days, but a large percentage of the medical fraternity are averse to operating upon the fistula? of consumptives. In some cases the prejudice goes even beyond this, and it is even be- lieved by both laymen and some doctors that the cure of a fis- tula in one who is otherwise apparently well is liable to induce pulmonary consumption. It has been frequently rumored that fistula is beneficial to consumptives, and a few medical men who entertain this idea are mistaken enough, and have the courage of their convictions to such an extent, that when cases of consumption who have no fistula apply to them for relief they are in the habit of establishing fistulas, believing it to be for the best interests of the patients. All this, of course, is most thoroughly wrong. Most cases of pulmonary tuberculosis, sometimes in advanced stages, but in a very large percentage in the earlier stages of development, are easily curable by the aid of orificial methods, and those who have anal fistulae are 356 ORIFIC1AL SURGERY. almost uniformly the easiest ones to cure. The experience up- on which these erroneous impressions have been formed comes probably from two sources. The first is that those who have operated upon fistulae have ignored other rectal conditions present, as pockets, papilla? and hemorrhoids, operating solely upon the fistulae, so that the patients were still possessed of rectal trouble, and although the irritation caused by the fis- tulae might be removed this would still continue its baneful influence upon the strength of the patient, and tubercular ten- dencies developing after the operation could be easily laid, by a prejudiced man, to the work done for the cure of the fistula, whereas, in reality, it was the uncorrected rectal troubles that were working their mischief. Another cause for the prejudice against operating upon fistulae comes from the imperfect manner in which it has heretofore been accomplished. The orthodox manner of oper- ating upon fistula? which has been in vogue for generations past and which, it is lamentable to state, is still in vogue, is, either with or without the aid of a grooved director and scis- sors or knife, to lay open the fistulous track from its one or two openings upon the skin surface to its usually single open- ing upon the surface of the mucous membrane. As a fistula, however, invariably passes behind the external sphincter, and occasionally the internal, in this operation not only the skin and mucous membrane are severed, but one or both sphincters. The bottom of the wound is then cauterized with actual cautery or caustic, packed with gauze, so that the margins of the wound can be kept apart, and the wound is made to granulate from the bottom. This antiquated and barbarous proceeding has so many and weighty objections that there is no longer the slightest excuse for its employment, and those who still advo- cate this method should be brought by some means to its com- plete abandonment. The objections to this method are that the severing of the sphincters and the practice of keeping them apart in this way until the wound is filled from the bottom and is skinned over by cicatrization is liable to induce perma- nent incontinence of feces. In the next place, when the opera- tion is done upon patients where tuberculosis is already well ORIFICIAL SURGERY. 357 seated, the wound seldom heals and the patient, instead of be- ing benefited by the operation, is simply furnished with an added misery to contend with. But the third and best reason is that there are several better ways, which should be familiar to every surgeon who essays the cure of rectal fistuloe, especi- ally in consumptives. For those who object to the use of the knife there is a sim- ple method of dealing with the main track of a rectal fistula by means of the actual cautery which is very satisfactory. First of all, before the fistula is treated, the rectal speculum should be introduced and whatever other rectal trouble is found present should be attended to. Papillae and hemorrhoids should be removed, fissures should be dissected out or curetted, scarified and cauterized, hemorrhoids should be excised, and the anus property dilated to the extent at least of the bivalve. In dilating the anus, a series of secussions with the rectal speculum should be made in order to arouse the reactive pow- ers of the patient as much as possible. No danger need be ap- prehended in the employment of the bivalve, as when it is em- ployed to its full capacity it will not rupture the sphincter muscles or induce incontinence of feces. Many times, indeed, dilatation is needed beyond the capacity of the rectal bivalve, and the two first fingers of the two hands, introduced back to back, will be found necessary to secure a proper degree of di- latation. The sphincters should not be stretched to the point of the giving way of their fibres, but just short of that. After the last inch of the rectum has been thoroughly examined and properly trimmed and dilated, the condition of the fistula is to be examined. There are three kinds of fistulas ; one opening into the rectum, and another variety which opens externally, while a complete fistula opens upon both the mucous membrane and skin surfaces. Complicated and complete fistula? usually have one internal opening and several external openings more or less widely scattered over the buttocks and perineum. If the case be one of internal blind fistula it will be necessary to make it complete by making an opening into it from the skin surface. If the blind fistula, however, is of the external va- riety, having no internal opening, it will not be necessary to 358 ORIFIG1AL SURGERY. render it complete, as it can be treated easily and successfully without disturbing either the mucous membrane or the sphinc- ter muscles, as will be readily understood in the light of the operations yet to be described. If the case is a complicated, complete fistula, having one internal opening and several external openings, the methods of procedure which we are about to describe should be ap- plied to the main track of the fistula, which starts from the in- ternal opening and the various branches which open upon the skin surface at some distance from the anus can be dilated, curetted, and tubed or packed, and easily cured after the main track is satisfactorily dealt with. The internal openings of all forms of fistulae are almost invariably to be found between the two sphincters ani, about half an inch from the margins of the anus. They are usually located laterally, but may occur anteriorly or posteriorly. As the treatment is practically the same in all cases their loca- tion is a matter of surgical indifference. A description of the manner in which complete rectal fistulae, which is the simplest variety, are to be treated will be an adequate guide for the treatment of all other forms of fistulae. The first method to be considered is one which will be welcomed by those who are averse to the employment of the knife. It is as follows : A grooved director is entered at the external opening of the fistula, passed along its track, and carried through its in- ternal opening in the bowel, when the end of the instrument meets the finger of the operator, by means of which it is dragged downward, brought out of the anus, pushed well through the fistulous track, so that its point can rest upon the opposite buttocks. This stretches the tissues tightly across the grooved director and changes the direction of the track from a perpendicular to a horizontal one, making it superficial and easy of manipulation. A sharp-pointed probe is now made to pierce the skin at a point equally distant from the anus with the external opening and an inch distant from it laterally, whichever way is most convenient, and carried straight through the intervening tissues until its point can be made to emerge at the internal opening of the fistula at the side of the ORIFIC1AL SURGERY. 359 grooved director. The sharp-pointed probe should be fur- nished with an eyelet at its blunt extremity, which should be threaded with platinum wire. Three or four inches of the wire are now to be drawn through the internal opening of the fis- tula, after which the probe is to be carried along the groove of the director until its point appears at the external opening of the fistula. The grooved director can then be withdrawn and traction made upon the probe, dragging the wire after it. In this manner a piece of platinum wire will be carried around a triangular piece of the tissue, whose apex is the internal opening of the fistula, whose base is in the inch of integument which marks the distance between the external opening of the fistula and the point at which the probe was at first entered, and whose sides are formed, one by the fistulous track itself and the other by the track made by the probe as it found its way to the internal opening of the fistula. Both ends of the platinum wire are now to be attached to a cautery battery, the current turned on, and the triangular tissue embraced by the wire is to be severed by the cautery. This proceeding pro- duces a conical-shaped wound, whose apex is the internal opening of the fistula and whose base is at the skin surface. While tenacula are holding apart the lips of the wound, the cavity is to be packed with iodoform gauze, which is to be untouched for two or three days, after which it is to be packed daily until the wound is so filled by granulations as to be no longer a cavity and the cicatrization of its surface is all that remains to be accomplished. A second method, which is also successful, may be de- scribed as follows : After administering the pruning and di- lating which the other rectal conditions present call for, the track is to be laid open, severing completely the mucous mem- brane, skin and muscular structure covering the track just as in the old way of operating. But instead of leaving the track to granulate from the bottom as in the old operation it is to be seized by tenacula and carefully dissected out, after which the wound is to be closed by sutures, the muscle or muscles should be stitched together by a No. 3 catgut and the skin surface co- apted by a sub-cutaneous sewing. The . wound should bo 360 ORIFIC'IAL SURGERY. cleansed and a dry dressing applied, which should be renewed every day. The paroxysms of coughing which the patient un- dergoes are liable to tear the tissues apart and interfere with the healing by first intention in a large number of cases, al- though it is by no means a universal experience, and sometimes it is necessary to apply stitches a second and even a third time in order to secure a satisfactory union of the tissues. For this reason the following operation is by all means to be preferred and, from the ease with which it can be accomplished and the success which invariably attends it, it is by all means the most satisfactory operation yet devised for the cure of rectal fistula in pulmonary tuberculosis. The external sphincter is a flat muscle, varying in width from one-half to an inch, and completely surrounding the anus. Its fibres are interwoven anteriorly and posteriorly. The external opening of a fistula is usually at the very outer mar- gin of this muscle. A circular cut is to be made along the out- er margin of the muscle, splitting the external opening of the fistula which must occupy the centre of the incision. The cut is to be continued downward deeply into the tissues, splitting the fistulous track throughout its entire length as far as its internal opening. As the fistulous track passes behind the ex- ternal sphincter muscle, the incision enables the operator to push the muscles aside, thereby exposing his field of operation perfectly without doing the slightest injury to the muscle it- self. The lips of the wound are now to be held apart by T- forceps applied on either side, the two halves of the track are to be seized by tenacula, and dissected away by scissors or knife, after which the wound is to be closed by catgut sutures. Before the closure of the wound it is well to expose the in- ternal opening and either dissect away its margin by the aid of tenaculum and scissors, or cauterize it. One stitch within the anus should be enough to completely close the internal opening. After the wound has been closed dry dressings are to be applied and the patient placed in bed. As the wound is not within the grip of either sphincter muscle it readily heals and all trace of the operation soon passes away. ORIFICIAL SURGERY. 361 CHAPTER XLV. RECTAL FISSURES. E. N. CHANEY, M. D. A rectal fissure may result from an ulcer, or from a lacer- ation of the walls of the rectum while at stool. It differs from an ulcer, in that an ulcer involves a smaller amount of tissue; if it increases in depth, passes through the mucous membrane and attacks the muscle, we call it a fissure ; if pus exists in a perceptible quantity, it is an abscess; if its penetration is extensive it forms a fistula. A painless fissure frequently occurs unknown to the pa- tient. At times there will be a little tenderness and hemor- rhage while at stool, but no pain this usually occurs in peo- ple whose vital forces work harmoniously. The fissure being caused by a sharp cutting portion of stool, will, if the system is in good healing condition, incite no more ulceratiou and pain than if the same abrasion occurred on the exterior, but if a rectal fissure takes place within a per- son whose vital forces are at variance with nature, he will un- doubtedly become desperate ; and the attending physician may possibly be induced to consider a list of remedies from aconite to zincum before relief will be found. On the other hand, you may anesthetize, cauterize, dilate, divide or excise the fissure, and still have trouble, sooner or later, unless the assistance of the indicated remedy be accepted. If the fissure assumes a painless character, rectal dilata- tion every other day, to a degree that will not irritate the le- sion, should be employed. A daily cleansing by a two-ounce enema of some good an- tiseptic lotion will be necessary. Peroxide of hydrogen, salt, listerine and similar preparations will be effective. Occasion- ally patients will be susceptible to a few of these combinations, 362 ORIFIG1AL SURGERY. which will demand special care on the part of the physician to prevent drug pathogenesis taking place through the local treatment. The cleansing should be followed by a lubricating oint- ment of calendula, or any medicine noted for its healing qual- ity. Among them probably the most popular is orificial car- bolized vaseline : I White vaseline 1 Ib. Paraffin % Ib. Carbolic acid 8 m. Melt and stir till cool M. Apply with a salve injector, but do not allow it to engage the sphincters ani ; simply the anal verge ; then force the vase- line up into the rectum. This treatment will be sufficient to heal not only the painless fissures, but also any existing ulcers. If the fissure is irritable, a 2 per cent, solution of cocaine with 1 per cent, of phenol in distilled water may be required to partially anesthetize the raw surface, which is excruciat- ingly painful when simply touched. Dilatation should be the first procedure, in order to relieve the impeded circulation of the congested sphincters; also to provide free drainage and increase the calibre of the bowel to facilitate the making of applications to the wound. Excessive dilatation should not be resorted to at any time, as it is liable to result in proctitis. Neither should a blunt dilator, or one having blades be used ; nor any other instrument possessing features that will irritate the wound ; for they will increase the trouble rather than alleviate it. A long, pointed aluminum instrument, well heated and lu- bricated with orificial vaseline, I consider most effectual for this line of work. In regard to the frequency of the treatments, the temper- ament of the case must decide. In some cases they may be given every day; in others, every other day or once a week. The dressing and care should be the same as for painless fis- sure until complete dilatation is accomplished and the sore is opened to its depth; then treat the same as you would an ex- ORIFICIAL SURGERY. 363 ternal wound. Swab it out with a solution causing a slight ir- ritation, such as pyrozone, or peroxide of hydrogen full strength, or a 1 per cent, solution of argentum nitricum, or any non-toxic preparation that will induce granulation. Our object to fill the wound from the bottom to a level with the walls of the rectum, that nature may extend over it a new mucous membrane. The applications should never be strong enough to cauter- ize ; as the burned tissue would remain as a scab on the wound, sometimes for months, and before healing was completed, an evacuation of the bowel would carry away the protecting crust and again establish the fissure, much to the discomfort of the patient. At the same time cauterization either by chem- icals or electricity, usually culminate in cicatricial tissue which destroys the secretory functions of the mucous membrane. Our largest and most irritable fissures appear after an operation for piles or ulcerations, by the incision method, when the after dilatation and surgical dressings have been neglected. The reason for this is that the operator must dip into the mus- cular tissue, in order to remove all diseased tissues lying be- low the mucous membrane. Frequently operators prefer to coapt the edges of the fissure with a suture instead of using the above method. This may allow it to heal by first intention, if successfully performed; and the patient would experience relief for months and maybe for years; but the work has re- duced the caliber of the sphincters ani, thereby insuring a return of a similar malady at the same site or some other por- tion of the rectal wall, with less provocation than formerly. Some may claim that filling up the wound with granula- tions will press upon the terminal nerve fibers and benumb them; this will be impossible if complete dilatation be main- tained while the process of repair is in progress. Granulations will cover the exposed nerves as well as if done by coapting the edges of the wound; that is, as far as hampering nerves and exciting reflex symptoms is concerned. In fact, it will produce no more trouble than circumcision or an unrepaired perineum, involving the same amount of tissue. 364 ORIFIG1AL SURGERY. The irritation or prostration of a nerve is caused by a wound being involved with inflammation and suppuration or impingement by adhesions and cicatricial tissue. In treating a case of fissure by gentle dilatation, it pro- vides ample time to thoroughly execute the work and the pa- tient has been relieved constitutionally as well as locally. Auxiliary measures aside from the orifieial work and home- opathic remedy may be found in the hygienic and dietetic care to relieve portal and mesenteric congestion, also with oste- opathy and heat to assist in equalizing the general circulation. The remedies most frequently indicated for fissure will be found in a list ordinarily used for pelvic congestion, indi- gestion, biliousness, and catarrhal troubles. In selecting a remedy, however, allow yourself to be guid- ed by the peculiar constitutional symptoms rather than by the local indications. This might be illustrated by a single case. An allopathic physician, about a year and a half ago, con- sulted me in regard to a fissured rectum of several years' standing. He received gentle dilatation and surgical care as de- scribed in the above; administered nux vomica, arsenicum, and sulphur in different potencies, as the local symptoms would indicate. Improvement continued for three T veeks, when the days that he received dilatation he would experience an unbearable cutting pain from midnight until morning. All the palli- atives found in a drug store wouM probably have been in- sufficient to give him relief sooner. At least he tried them for six hours, because not homeopathy, but my homeopathy failed. These pandemonium exhibitions took place about three times, when an ulcer developed on his nose beneath the bow of his gold spectacles. As the ulcer was prone to appear every few weeks for years, I concluded that over-sensitiveness to the action of gold was with him an idiosyncrasy. This with his despondency, diarrhea, rectal fissure, and ulceration were suf- ficient indications for aurum metallicum, one-thousandth po- tency; of which he received three powders; one every twelve OBIFIC1AL SUEGERY. 365 hours. By this time we had opened the fissure about half way, and ever after the dilating went on with but little discom- fort. The ulcer on his nose was healed in a few days and the fissure in a few weeks. About two months later, the ulcer on his nose returned; but the fissure remained quiescent. We repeated the aurum metallicum . and the ulcer again disap- peared quickly, and has not returned. I have learned recently that the patient gained thirty pounds in weight during the past year. CHAPTER XLVI. DISEASES OF THE RECTUM AND SIGMOID. C. A. PAULY, M. D. The neurologists of today feel that the discovery of the neuron theory has opened the way for a more comprehensive investigation of mental and nervous diseases. The rectal specialists feel that the discovery of auto-in- fection from the intestinal canal has opened the way for the in- vestigation of many diseases, the pathology being obscure at present. The progress in bacteriology and physiological chem- istry has gone far to demonstrate that most of the processes of disease in general are due to toxic substances in one form or another. The poisons found generated in the intestinal canal are the result of chemical putrefaction or fermentative changes, or the action of bacteria. We may have auto-infection from any part of the intestinal canal. It is claimed, however, that the seat of infection is more frequently in the descending colon, sigmoid and rectum. The peristaltic action of the colon is very sluggish, and the sigmoid being the most constricted part, obstruction in the form of impaction often takes place. If the impaction is permitted to remain any length of time, the fecal matter is relieved of its watery elements, a solid mass remaining, from which putrefaction takes place, afford- 366 OBIFIC1AL SURGERY. ing a rich field for the multiplication of septic muco-organisms and their products. These organisms, with their ptomains, are taken up by the circulation and lymphatics and carried to the different parts of the body, causing a systemic infection. Such diseases as gout, rheumatism, diabetes, chorea, chlorosis, uremia, asthma and the different skin diseases may be generated in the intestinal canal. Constipation, compli- cated by impaction, is the most frequent cause of auto-infec- tion. Fecal toxemia manifests itself by the patient complain- ing of headache, dizziness, loss of appetite, palpitation, indi- gestion, etc.; the circulation is impaired; pulse may be full and slow, or rapid and feeble ; heart excitable, violent palpita- tion; patient is drowsy, feels sleepy, yet rolls and tosses all night, rising in the morning feeling weak and exhausted ; the skin has an unhealthy color, looks yellow or muddy. Some of the patients suffering with fecal toxemia look not unlike a per- son with a malignant growth. Constipation and impaction are also factors in the patho- logical changes that take place in the rectum and sigmoid. By the constant irritation of the confined fecal matter the mu- cous lining becomes inflamed and denuded. Ulceration fol- lows, and by the aid of diarrhea, a prominent symptom of ul- ceration, the fecal mass is liquified, and its poisonous elements are introduced into the circulation through the exposed sur- face of the mucosa. Ulceration and stricture of the sigmoid form a good culture medium for muco-organisms, and favor putrefaction and fermentation. As a result, more poisons are generated and absorbed than nature can take care of, the sys tern becomes saturated, and the skin presents the sallow ap- pearance which is usually present with ulcer of the colon. Many of the mental and nervous diseases in the form of acute insanities are due to gastro-intestinal disorders. If we can keep the stomach and intestines in a state of functional activ- ity and healthfulness, the majority of cases of nervous dis- orders can be cured. Melancholia is sometimes induced by auto-intoxication, the result of an impacted colon or sigmoid. When the impaction has been removed, the melancholia is re- lieved. ORIFIC1AL SURGERY. 367 It has been tersely said: "No class of diseases is of more importance to the general practitioner than those occurring in and around the sigmoid, rectum and anus." Mr. Allingham says: "Diseases of the rectum are among the most common that affect civilized humanity." While the rectum and sigmoid are not the seat of all the ills of the body, yet a person suffering with some constitu- tional trouble, and who at the same time has a pathological condition in the rectum, need not expect to get well until the rectum has been cured. We all know the peculiarity of the nerve supply to the rectum and anus. Many neuroses have their origin in these parts, in the form of chorea, hysteria and neurasthenia. In cases of epilepsy, the convulsive attacks are kept at longer intervals by keeping the sigmoid and rectum free from imperfection. Violent cases of mania which have developed suddenly, the result of prolonged constipation, have been restored to sanity by emptying the colon. Fortunately the intoxication had not lasted long enough to impair the in- tegrity of the nerve cells. I suppose the neuron theory is cor- rect, but a better understanding of the pathogenesis of ner- vous and mental diseases can be obtained by studying the brain and nervous system, not separately, but along with other or- gans of the body, becoming more familiar with the pathologi- cal processes that operate on the whole organism. You are, perhaps, more familiar with the diseases and their treatment in and about the rectum than diseases of the sigmoid. Very lit- tle has been written on sigmoidal troubles. They have been generally considered along with diseases of the colon. From the structure and physiological action of the sigmoid, it is more liable to pathological changes that do not happen higher up in the bowels, and it is possible for it to be the seat of ob- scure diseases that are not recognized. We are satisfied that chronic diarrhea and dysentery often have their origin at the sigmoid instead of higher in the colon. The various pathological changes found at the sigmoid are congestion, inflammation, ulceration, stricture and can- cer. It is often difficult to diagnose just what the condition is. The symptoms are misleading; diarrhea is most frequent, 368 ORIFICIAL SURGERY. yet constipation may be one of the leading symptoms. There are symptoms of intense backaches, pain in the left iliac re- gion, across the abdomen down the left thigh, in the bladder, uterus and prostate. Reflex symptoms are nausea and spas- modic cough. The character of the fecal evacuation is the most positive symptom. The physician must examine the feces to determine the nature of the trouble. He cannot depend solely on the description given by the patient. If the discharges con- tain a great deal of mucous and no pus there will be a con- gestion of the mucous lining, and possibly the beginning of in- flammation. If there is pus and blood in the evacuations you may expect the presence of an ulcer somewhere in the largo intestine, and if an ocular examination shows the rectum to be free from disease, the chances are the ulcer will be at the sig- moid. If there is no history of specific or malignant disease these symptoms will be of great help in the diagnosis of con- gestion, inflammation and ulceration. In the treatment of diseases at the rectum and sigmoid the best results are obtained by strict asepsis, and the use of antiseptics and healing applications. You must not only de- stroy the ptomains and toxines that cause auto-infection, but restore the functional activity and remove all pathological con- ditions of the colon. In chronic cases of long standing stringy mucus and pus are often present in the stools. No cure can be accomplished before the lining of the intestine is freed from the unhealthy muco-pus. We should begin the treatment by giving an aper- ient of some kind to thoroughly wash out the bowels from above. The wash-out should be followed by the colon douche. A rectal tube with syringe attachment will answer. The rectal tube should be carried into the sigmoid and a half gallon of hot water medicated with boracic acid pumped into the colon. This treatment should be given once every twenty-four hours for a week ; by that time the sigmoid will be aseptic and ready for a healing application. Fluid hydrastis is good. One or two drams in two ounces of hot water is carried into the flexure through the rectal tube. Have the injection given just be- fore retiring, and if the fluid can be retained all night it is OBIFIC1AL SURGERY. 369 better for the patient. Another good prescription, used in the same manner, is distilled hammelis and fluid calendula equal parts. While using these prescriptions have the colon cleansed twice a week with hot water and boracic acid to keep the parts aseptic. A mixture of almond oil 1 pint, iodoform 8 grains, sub- nitrate bismuth 1 dram (Mathews), is both soothing and heal- ing. Use at bedtime. Stricture of the rectum and sigmoid in most cases is the result of syphilis or cancer. Some relief may be received by the use of bougies, and the local applications just mentioned. Sooner or later surgical procedure will be called for, and by the aid of surgery only temporary relief can be expected. If impaction of the sigmoid cannot be relieved with injections and the scoop, laparotomy may be necessary for the removal of the impacted mass. While treating these diseases a soft diet may be prescribed oysters, milk, broths, soft-boiled eggs, small amount of bread, and a very little of meats. For in- ternal medication, arsenicum, ingluvin, subnitrate bismuth, salol, the mercuries, the iodides, the carbons and the different forms of diastase have their places in the treatment of diseases of the rectum and sigmoid. CHAPTER XL VII. SIGMOID CATARRH IN WOMEN. CORA SMITH EATON, M. D. Last September at Dr. Pratt 's clinic in orificial surgery the subject of chronic constipation and its cure received an extended discussion. It is the gleanings from this discussion with my own modifications which constitute the line of treat- ment I have been following in the last eight months. My cases of sigmoid catarrh have numbered about twenty. The ma- jority of these were suffering from constipation, a few from chronic diarrhea ; in other words, the dry catarrh is more com- 370 ORIFIGIAL SURGERY. mon than the moist variety. The results in all have been ex- cellent and in some simply phenomenal. The theory of the treatment is this: First. To cleanse the bowel of the superficial coat of mu- cus by large colon flushings at home. Second. By a medicated irrigation at the office, into which an electric current is turned to loosen a deeper layer of mu- cus and also to stimplate the paralyzed muscular coat of the bowel. Third. After this double cleansing and stimulation has been accomplished to inject a medicated oil as high as possible into the bowel, to act in the double capacity of still further loosening the crust of old mucus deposited and to heal the dis- eased mucus surface. Fourth. To assist the total results by every means con- stitutional and systemic, as internal medicines and central faradization. Before this treatment is attempted every organic trouble should be relieved, such as lacerations, pockets, papillae, ad- hesions to clitoris, etc. Special attention should be given to the spine to make sure it is straight. Some of these cases are oc- casioned by paralysis of the intestinal nerves following a cur- vature. To complete the cure requires from one to six months. The treatment should be given every second day at first, then every third or seventh day as the case progresses. In the in- terval between treatments the patient should each day take a large colon flushing to wash away the loosened mucus and that which has been forming during the last twenty-four hours. If the patient is too weak to endure the flushings daily, or if there is a daily stool without them, there may be used instead of the flushings merely four ounces of sweet oil, medicated or not, injected into the rectum in the knee-chest position. This position is retained until the oil has run up into the large bowel. It will then in all probability be held until the bowel movement takes place, unless there is such a clogging of the sigmoid with mucus that nothing can pass without an enema. When the patient comes to the office she is supposed to have cleansed the bowel with from four to twenty quarts of ORIFIC1AL SURGERY. 371 water, taken in the knee-chest position until the water comes back free from mucus. She is put upon the table with the Kelly pad under her. Cole's sigmoid irrigator is passed into the bowel full length and through this is injected from a foun- tain syringe two quarts of water medicated with two teaspoon- fuls of Kennedy's White Finns Canadensis and two teaspoon- fuls of salt. Of course any other medications can be used, such as hammelis, hydrastis, calendula, etc. After the two quarts of water have run into ihe bowel, I disconnect the syringe tubing from the Cole's irrigator and connect the irrigator with one pole of the battery. The other pole is placed on the abdomen. The current used is the pri- mary farad ic interrupted, and is continued for ten minutes. The irrigator is then withdrawn and the patient is allowed to pass the water that was in the bowel, much of which will pass from the bladder, so quickly is it absorbed into the circula- tion and excreted by the kidneys. We have had a few cases where the sigmoid was so swollen and coated that not even the finger could enter, and the irri- gator could not be passed till treatment had relieved this practical stricture. In these cases we fill the lower bowel with medicated water through a rectal tube instead of the irrigator and give the electricity with one pad under the lumbo-dorcal region and one over the abdomen, while the water is in the bowel. In the constipation cases the large flakes and crusts of hardened mucus which come away under treatment are start- ling both as to thickness and quantity. It is not uncommon for a patient to pass after the electric treatment, a double handful of mucus looking like shredded codfish. Sometimes flecks of blood show where scabs formed over ulcers. This mu- cus and blood gradually decreases until only fresh mucus, like uncooked white of egg appears, such as is the normal intes- tinal lubricant. After the water has come away the patient is put on the table again in the knee-chest position and a long colon tube is passed full length ; through this is injected by a hard rubber piston syringe four ounces of oil medicated with oil of tar, 372 ORIFIG1AL SURGERY. eucalyptus or hydrastis. The tube is cautiously withdrawn and the patient remains in the knee-chest position for ten minutes to help the oil stay where it is needed. We have lately found we get almost if not quite as good results, with far less trouble to ourselves and less discomfort to the patient, by giving the oil simply into the rectum and having the position retained for ten or fifteen minutes. Some- times it is a terrible trial to pass the tube as it kinks in the sigmoid or else hurts the patient unconscionably. After the pa- tient has passed the water and before we give the oil we fre- quently have her lie on a flat electrode and take a spinal sec- ondary faradic cupping. It is a very fine stimulus to the bow- el nerves which are given off from the spine. Besides that, it starts up contractions in the bowel sufficient to help expel any water which may remain. In the preparation which they make at home, we have them medicate the last two quarts with some of the medicines I have named as using at the of- fice. The remedies used by mouth are most frequent hamam. Ix, napthalin 2x, sabad. 3x, and a combination tablet consisting of pepsin, nux vom. and carbo veg. to be taken before and after meals. This treatment has served to clear up for us so many ob- scure cases that we no longer grudge the time and effort re- quired to follow it. CHAPTER XL VIII. "THE SIGMOID." G. E. COGSWELL, M. D. That we live by reason of the sympathetic nerve is a fact so well established that to attempt to prove it is entirely un- necessary. Any irritation of this nerve whereby it is weakened and its power wasted, is sufficient to account for many, if not most, of the so-called chronic ailments, by whatever name ORIFICIAL SURGERY. 373 known. While this is true, it is not always easy to tell the pre- cise spot where this irritation is located, nor having found the place, is it always easy to remove it. Again, when there has been all-around work done, we find there is a slow reaction and reproduction of the local irritation which calls for repeated removals, ere the patient has fully recovered. From this it would seem as if there were some irritation other than what appeared on the surface, and some other treatment called for before the cure can be made permanent; some irritation of an obscure kind that at first escaped notice, but still persists in keeping up the nerve waste so that its functions are interfered with, thus continuing the reflex condition. One of the particular locations for these obscure irrita- tions is the sigmoid flexure of the bowel. For the reason that it lies so high up in the pelvis, and so entirely behind the blad- der and uterus, having but few symptoms peculiarly its own, but usually manifesting its discomfiture by reflex symptoms, it is often overlooked and neglected, and the trouble, if left to itself, may compel the patient to succumb, the victim of our neglect. The sigmoid flexure of the bow T el is the narrowest part of the descending colon. It is situated in the left iliac fossa, com- mencing from the termination of the descending colon at the margin of the crest of the ileum and ending in the rectum op- posite the left sacroiliac symphysis. It curves in the first place inward across the psoas muscle; it then descends vertically along the left wall of the pelvis, and finally again passes in- ward to the left sacro-iliac joint where it becomes the rectum. It is retained in position by the loose folds of the peritoneum % the sigmoid-mesocolon ; it is in relation in front with the small intestines and the abdominal parietes. Treves defines the sigmoid flexure as that portion of the large bowel from the psoas muscle to the third sacral vertebra. He includes therefore and properly in the sigmoid flexure the first part of the rectum as it is usually denominated; it lies not in the left ilias fossa but in the pelvis. It is not S-shaped but is a large loop 171^ inches long and shaped more like the Greek letter Omega, or an inverted U, the top of the loop 374 ORIFIG1AL SUEGERY. sometimes even touching the right side of the pelvis. Such in brief is the description we have in Gray's Anatomy of that portion of the alimentary canal that plays so important a part in the treatment of chronic cases by orificial methods. To me the sigmoid is the door through which success has been reached, and without which failure must have been met. A fact to remember in connection with this part of the in- testinal tract is its location and the part it is called upon to do in maintaining the body in a state of health. Where the sigmoid ends and the rectum begins is an ac- cumulation of muscular fibers known as the sphincter of 'Bierne, which narrows the intestine, making it almost the in- ner door to the rectum, and preventing the escape of the fecal matter into the lower bowel until the mass shall have ac- cumulated in the colon in sufficient quantities, that by passing, the outer door or external sphincter, it shall, by dilation, flush the entire capillary circulation of the whole body. It is, therefore, the repository, so to speak, of the waste products of the food, and ofttimes becomes very tolerant of these accumulations, as well as diseased conditions arising therefrom. It is supplied with nerves from the same ganglia as the uterus and prostate, the rectum and bladder, and is in so close relation to these parts that it is very easy to under- stand how irritation at these points may produce trouble at the sigmoid, which, having but few sensory nerves, can only express its disconfiture in the way of perverted function 01* re- flex condition. Because of the obscurity of the part and the absence of pain, it is too often overlooked in diagnosing a diseased condi- tion ; but the close relations existing between the sigmoid and stomach, the lungs and thyroid gland, as well as the uterus, bladder and rectum, give it an important place in perfecting our diagnosis of any obstinate chronic condition, and they will not become chronic if not obstinate. In the normal condition the process of digestion and as- similation, as well as the elimination of the waste products of the food and tissue, is carried on without our being conscious of it, so that we find but few nerves of sensation after we leave OEIFIO1AL SURGERY. 375 the surface; and what is true in the general sense is also true at the sigmoid flexure. Hence, pain becomes a very unreliable symptom from which to tell where the trouble is; in fact, a patient's sensations are of but little account in making a di- agnosis, or locating the irritation that is responsible for the nerve waste that has resulted in the impairment of the health. It is to the local irritation and to the objective symptoms that we must look for the causes that are active in keeping up the irritation. We start with the thought, if one is sick some- thing is the matter, or rather, there must be a cause; that cause is nerve waste which may be at the sigmoid as well as at the orifices of the body. Any of the more serious chronic troubles, such as con- sumption, paralysis, rheumatism, or the much abused com- plaint, indigestion, may all have their start at the sigmoid, and will remain until that part of the intestinal tract is freed from its irritation and the contraction of its sphincter. We may clear the rectum of its pockets and papillae, hem- orrhoids and fissures, or whatever form of irritation found there; we may remove from the sexual system everything that causes nerve waste; we may loosen the hood of the cli- toris, and liberate it from its long captivity, according to the most approved orificial method; we may clip the frenum, en- large the meatus, dilate the urethra and circumcise the fore- skin, and still find that the same trouble exists and is doing business at the old stand, as one important part, the sigmoid, has been overlooked. This is but following out the orificial idea that all of the orifices must be free from irritation and easily dilatable, for the sphincter of O'Beirne is but the sentinel guarding the out- let of the sigmoid and is subject to the same constriction as the other sphincter, and must be treated in much the same way, by thorough dilatation and the removal of the offending portion. That we can have irritation here, and not at the lower opening of the bowel, as a primary condition, is a question ; but that we do have irritations at the sigmoid in connection with those at the other orifices, and that they can continue af- 376 ORIFICIAL SURGERY. ter the other irritations have been removed, is no longer a question, but an established fact, and one that we must take into consideration in those obstinate cases that manifest so strong a tendency to return after they have once been ordered off the premises. We must still carry out the orificial thought: all nerve waste must be stopped, so that all the sympathetic nerve power shall be used in carrying on the nutrition of the body, and not be spent in building up a diseased condition. The means suggested for the treatment of the sigmoid have been many, and it seems to me that we have yet to find the ideal one. Many times it is difficult to reach the point of ir- ritation owing to the constriction, which must first be dilated ; again, a too redundant tissue and a relaxed condition of the mucous membrane is an obstacle in the way; however, in re- peated and persistent effort it can usually be accomplished. The conditions here, unlike the lower orifices, cannot al- ways be removed at one sitting, but must be repeated until by reaction the parts have been brought to a normal condition. In those cases that do not react well after an operation, or fail to manifest the improvement expected, you will prob- ably have some trouble at this point; it is this class of cases that I shall offer as an excuse for this paper. It is not my purpose to give in detail the cases only so far as the treatment of the sigmoid is concerned, but I wish to state at the beginning that in most of the cases that have trouble at the sigmoid you will find more or less irritation at the lower orifices, which precedes the trouble higher up in the bowel; hence the preliminary orificial work is necessary to obtain the best results. On the other hand, there are many cases that have received all-round orificial work, the results of which have not been satisfactory, and in such cases the fault many times will lie at the sigmoid flexure, which will need special treatment for complete success. The following will illustrate some of the means used in the successful treatment of those cases which otherwise would have been failures. ORIFIC1AL SURGEBY. 377 CASE 1. Mrs. M., aged 65. Paralysis of the lower ex- tremeties, torpor of the digestion, laceration of the cervix, and hemorrhoids; seemingly a typical case for orificial work. After the operation, which afforded some relief, the bowels were still inactive, with a tendency to dropsy. Dilatation, colon flushing, and careful prescribing alike were ineffectual; a thorough dilatation of the sigmoid, with an injection of lin- seed oil and hydrastis for a few weeks, effected a cure. CASE 2. Mrs. P., aged 56. Epilepsy ; all-round work gave but little benefit, but the continued use for two months, of the large rectal bougies with the injection of oil and cascara, the wool tampon medicated with boro-glyceride and oil, introduced in the sigmoid, massage over the abdomen and daily anoint- ing with olive oil has given the most help ; in this case, when- ever there seemed to be more sluggishness of the bowels, there would be an attack, but the use of the long rectal tube with oil would stop the trouble. CASE 3. Mr. B., aged 40. A supposed case of cancer of the stomach. The local trouble was rectal fistula, which was operated on about a year prior to my seeing the case. This operation gave relief for about three months, when all the old symptoms returned with greater force. At the examination there was but little local trouble. Thorough dilatation, mas- sage, electricity and colon flushing, as well as smoothing up of the lower orfices, gave no relief. A Cole's irrigator, passed with difficulty, brought away a quantity of mucus, and the continued use of the irrigator, followed with the larger rectal tube and medicated oil for a few weeks, brought on reaction, and the patient has recovered his normal health. This was a case that had been given much morphine, and the trouble at the sigmoid was largely due to this fact. It has been my observation that in morphine subjects there will be more or less trouble at this point, owing to the fact that the constipation due to the drug will many times cause the irritation and constriction of the sigmoid, ami to thoroughly overcome the habit it must receive the attention it needs. In this case we found that as the waste of the bowels passed down to this point there would be the uneasiness felt 378 ORIFIC1AL SURGERY. at the stomach and the right side of the abdomen, assimilating almost an appendicitis, but every time after using the large rectal tube and relieving the sigmoid, there would be a relief from all these other symptoms. CASE 4. Mrs. P., aged 58. After thorough all-round work for laceration, adherent hood, pus pockets around the meatus, piles, pockets and papillae of the rectum, still continued to have high fever, cough, night sweats, feet bloated, loss of appetite, and at times diarrhea and constipation; it was thought to be a clear case of tuberculosis. For several months after the op- eration these symptoms continued; the cough, which was spas- modic, now became constant, and could only be relieved by a rectal suppository of cocaine, boracic acid and cocoa butter; massage, electricity, baths, and the combined prescribing of several physicians, the patient gradually sinking under the disease. There was no soreness over the lungs, no cavity, but little expectoration, complete loss of appetite, great dryness of the mucous surfaces, and but little thirst. The bowels were flat, and percussion and palpitation gave no soreness nor any indication of trouble. The sphincters were dilated without any reaction following; the patient very anemic, but the high temperature continued. On passing the Cole's irrigator, and throwing up four ounces of cottonseed oil and glycerine, there was nearly a pint of pus brought away. The colon flushing had been used faithfully several times prior, which failed to move the bowels. After the discharge of pus the fever seemed to abate. I now attempted to pass the large rectal tube into the sigmoid, and I w r ish to state that at the time of the operation, when the patient was under an anesthetic, there was little or no trouble in dilating the sigmoid, both with a Pratt sigmoid speculum and the large rectal tube, but now I found a great deal of trouble in getting the large tube through the sphinc- ter of O'Beirne. It was accomplished in the following man- ner: First, by throwing into the rectum about two ounces of oil, then introducing the tube as far as it would go, taking care that the end entered the lower curve, then by adding a little more oil, thus forcing the bowel open just ahead of the ORIFIC1AL SURGERY. 379 tube, and so alternating by using the oil and forcing the tube up, we finally succeeded in passing the tube into the sigmoid, then using from four to six ounces of oil and phytolacca. I use the oil instead of the water because it gives better results and the tube passes more easily. The mucus in this case was almost a cast of the bowels, somewhat like the membrane from a diphtheritic throat. This was continued twice or three times a week, as the patient could stand it, for four or five weeks, with the result of lessening the fever, increasing the appetite and emeliorating the cough. One fact in the case was, almost every time after using the large tube there would be a hoarseness not unlike that consequent on a recent cold; it would last from twelve to twenty-four hours, when it would subside without any treatment. The case has gone on to com- plete recovery, and I believe but for the persistent use of the rectal tube introduced into the sigmoid it must have been re- corded as a failure. Now a word as to the medicines used in the sigmoid. I have used sweet oil, linseed oil, cotton-seed oil and lard, melted vaseline and glycerine ; my preference without special indication is for cotton-seed oil. To this is added such reme- dies as hydrastis, phytolacca, calendula, hamamelis, cascara, sulphate of magnesia, boracic acid, glycerine and peroxide of hydrogen. In one case of hemorrhage I found great benefit from cotton-seed oil used through a Cole's irrigator. In closing, just a word about the colon douche. It has been my experience that the too frequent douching has rather increased the constipation than lessened it ; for a few times much good may be done by using from three to five quarts of salt water, forcing it well up into the colon; but this should not be used too frequently or continued too long or it will cause a loss of tone instead of increasing peristalsis. Neither should the water be too hot unless it be a case of diarrhea, when the hotter the water the better, up to the point of tol- eration. In obstinate constipation with extreme sluggishness and loss of peristaltic action, the water may be used almost cold but should not be used oftener than once a week or ten 380 ORIPIC1AL SURGERY. days. Its effect may be increased by adding a small cup of common salt and two or three ounces of glycerine. In the diarrhea of typhoid fever and cholera infantum much good may be done by the use of the colon douche with hot water and milk, but the quantity must be as large as can be borne and not used too often. CHAPTER XLIX. NON-MALIGNANT DISEASES OF THE UPPER RECTAL POUCH AND SIGMOID FLEXURE, AND AN IM- PROVED METHOD OF TREATMENT. E. Z. COLE. M. D. Of late years much has been written upon diseases of the rectum and the lower orifices of the body, but little has been said of the non-malignant diseases of the upper rectal pouch and the sigmoid flexure, and their treatment. I mention the two because it is almost impossible to separate them, they be- ing generously supplied with sympathetic nerve tissue and being a continuation of the same mucous surface; and as a rule when we find a diseased condition of the one, we will find the other affected. And many of the local and reflex symp- toms are similar. In my own experience in orificial work, no class of cases has given me so much trouble as those suffering from obscure diseases of the sigmoid I found them hard to make out and still harder to treat. It took me some little time to realize the fact that a diseased condition of the lower bowel is almost in- variably accompanied by trouble higher up. If the one is treat- ed and the other overlooked your patient will not make the progress that you desire. The first one to call my attention to this fact was the late Dr. Geo. A. Hall. It was my privilege to receive much private instruction from him upon this subject, and also to attend his lectures upon rectal surgery. Many of you have ORIFIC1AL SURGERY. 381 doubtless read his lecture in the February number of the Journal of Orificial Surgery, and will remember his question : "Why do not all of our patients receive like benefit from ori- ficial treatment?" And his answer to the same: "It is due to the fact that the pathological changes involving the rectum and sigmoid have been overlooked." His descriptive symptoms of proctitis are so character- istic of the local and reflex symptoms that I have observed in some sigmoidal troubles, that I cannot do better than to give them here. He says: "The patient will not as a rule complain of pain in the rectal district, but will complain of pain in the back of the head and in the dorsal region, pain in the occiput extending around to the forehead, attacks of dizziness, verti- go, pain in the lumbar and sacral region extending down the thighs, a sense of numbness and disability of the limbs, consti- pation of long standing, irregular action of the heart, violent palpitation awaking him from sleep, dyspepsia and feeble di- gestion, asthma or harassing cough, and pain in the inguinal region, in the female often mistaken for ovarian irritation. The once amiable disposition has become perverted, the pa- tient feels irritable, peevish, despondent, apprehensive and is usually more or less emaciated. Now, you may have one or more of the symptoms which I have described, in any given case. There may exist only one ; that may be simply nausea and vomiting when first rising in the morning; or there may be simply an unpleasant feeling in the head, with loss of memory. ' ' I will add that if the trouble be localized in the sigmoid, there will frequently be colicky pains in the stomach and bowels, a great amount of flatus, constipation or diarrhoea, and straining at stool ; but the greatest pain is as a rule just be- fore going to stool, at the moment the feces pass through the sigmoid flexure. In the female the mucous surface is sometimes so sensi- tive right back of the uterus as to give rise to the belief that the pain is in the uterus and ovary, and these organs are con- sequently subjected to an undue amount of unnecessary at- tention. 382 ORIFIG1AL SURGERY. I am firmly convinced that the primary cause of inflamma- tion of the flexure is constipation. Considering the physiology of the act of defecation, O'Beirne says, "If the calls of nature are not heeded, the fecal mass is lifted back into the sigmoid flexure and there remains until the next effort is made." Dur- ing this time, of course the watery constituent of the mass is reabsorbed and the remainder is left in a hardened condition. What could be the source of greater mechanical irritation than this? Is it any wonder then that a congestion, an inflammation and lastly an ulceration could occur? When we take into consideration the fact that putrefact- ive changes must have been going on while this mass was re- tained in the sigmoid, we can readily understand that septic organisms must pass into the circulation. Dr. Mathews thinks the dark color, emaciation, sweats, etc., that are frequently observed in persons suffering from the constipated habit, are due to a species of sepsis or so-called blood-poison. Hence the importance of keeping the sigmoid clear, whatever the condition of your patient may be other- wise. Always investigate the upper part of the rectal pouch and the sigmoid when you are examining and doing orificial work for a case. You will never regret the extra pains taken, and will, in many cases, be gratified with the results of this plan of procedure. The trouble that I experienced in carrying out Dr. Hall's plan of treatment, was that there was no proper instrument for reaching and treating the sigmoid. He used his long double curved forceps, holding a pledget of cotton saturated with carbolated or borated glycerine, etc., to swab out and medicate this region. But this was a very dif- ficult and imperfect way of doing the work. One objection to this method of treating was that patients could not carry it on by themselves, as it required an ex- perienced operator to use the forceps safely. I felt that if some method could be devised by which the sigmoid could be reached easily and safely, and by which ORIFICIAL SURGERY. 383 fluids could be used instead of swabbing with pledgets of cot- ton, then patients could carry out the plan of treatment at home. Another objection that I wished to overcome was, that in the majority of the cases we were swabbing out a sigmoid loaded with fecal matter, mucus, etc., which, of course, pre- vented thorough work. In my efforts to overcome these difficulties, I devised this little instrument which I call a Sigmoid Irrigator. It is a hol- low tube, taking the natural curves of the lower bowel and has a bulbous end which is perforated for the passage of fluids. This little device has given me greater satisfaction and has yielded better results than any one instrument I have ever possessed, because it has made the sigmoid as accessible to diagnosis and treatment as the rectum. With this all accumulations can be thoroughly washed out of the sigmoid and descending colon before any medica- tion is used. After a thorough washing out, from one to four ounces of whatever medication you wish can usually be re- tained in the sigmoid from a half an hour to several hours. In the congestive, inflammatory, and catarrhal conditions, or where they have gone on to ulceration discharging daily large quantities of viscid mucus, sometimes even pus I find that a thorough use of three or four quarts of very hot water fol- lowed by the proper medication will speedily clear up these conditions. For washing out the sigmoid always use boiled water, but it is best never to use water alone. A little salt, oil, glycerine, milk or starch can be put in the water, any one of which will render it less irritating. I have sometimes found that the indicated remedy may be used advantageously as a medication in the sigmoid; but we frequently have to perscribe for the pathological conditions which we know to exist and not for symptoms alone, and I have found the following useful in these conditions, carbolated or borated glycerine or oil. One ounce fluid hydrastis to one pint of olive or almond oil. Solution of bismuth and hydrastis, hammelis, pinus can- 384 ORIPIG1AL SURGERY. adensis, listerine, tar water, all in about the same propor- tions will be found good remedies. There are also such remedies as: Tannic acid 5 to 10 gr. to oz. Sulphate zinc 5 gr. to oz. Eucalyptus oil 5 gtts. to oz. lodoform or Boracic acid 5 to 10 gr. to oz. These can be used in olive oil, glycerine or water, ac- cording to the nature of the medicament, and from one to four fluid ounces can be retained in the sigmoid. The treatment should be made every other day, but later every third day. Do not expect good results from any treatment unless the sig- moid has been thoroughly washed out before it is medicated. For carrying out Dr. Terry's plan of treating appendi- citis with oil, you will see that this instrument fulfills every requirement. It places the oil in the ilio-caecal region quickly and safely, and would, I believe if used in time, render sur- gical interference unnecessary in many cases. SECTION VI. The Male Sexual Organs, OBIFIG1AL SURGERY. 387 CHAPTER L. SOME POINTS CONCERNING THE ANATOMY AND PHYSIOLOGY OF THE MALE SEXUAL ORGANS. E. H. PRATT, M. D. A foreskin of proper length reaches no farther than the point of the glans penis, leaving this part continually exposed. Upon retraction it exercises no compression whatever upon the glans, and when completely retracted does not in the slightest degree constrict the penis. A normal frgenum is of such length that when the foreskin is forcibly retracted it does not manifest even the slightest tendency to depress the point of the glans penis. A normal meatus urinarius is readily dilatable to the full calibre of the urethra. The color of the apex of the glans and the membrane lining the meatus is an index of the condition of the prostatic inch, as the extremeties of any canal are so sympathetically associated as to flush and pale simultaneously. A bleached, pinched, anaemic condition of the point of the penis means atropy of the prostate. A dark red, patulous meatus urinarius indicates prostatic congestion of the passive variety. A bright red, swollen meatus means an acutely congested and irritable prostate. A dark red, swollen and patulous meatus means prostatic hpyer- tropy. A physician who is capable of judging of the condition of the stomach and liver from the appearance of the tongue, is also capable, after a little experience and observation, of diagnosing prostatic conditions from the appearance of the orifice of the urethra. A normal prostate gland resembles in size and form a horse chestnut, and its outlines can be distinctly felt through the rectum. It should be firm in texture, and should present a well-defined groove upon its under surface, dividing it into 388 OEIFIC1AL SURGERY. two well marked lateral lobes. The urethra passes through the gland, and this portion of it is about an inch or an inch and a quarter in length. The prostatic gland in the male corresponds to the uterus in the female, and is supplied by the corresponding pencil of TAKEN FROM WEISSE'S ANATOMY sympathetic nerve fibres. Therefore, when in a pathological state, it is capable of instituting all the reflex disturbances and symptoms in the male which uterine pathology can induce in the female. Functional derangement of the stomach, pain in the top of the head, asthma, paralysis, acne, nervousness, spinal irrita- tion, etc., can all be induced by the morbid condition of the prostate gland, just as a similar state of symptoms in the gen- ORIFIG1AL SURGERY. 389 tier sex may obtain their explanation in morbid conditions of the uterus. The sexual tone prescribes the conditions of peristalsis generally, including capillary activity, and prostatic conditions determine sexual tone. In other language, the prostate gland is the key to male sexual force. It is the great sexual nerve center, and dominates sexual activity and power. It is the central office of the sexual telephonic system, and its authority is supreme in the sexual domain. Messages issuing from this spot control sexual conditions. 7?- TAKEN FROM FLINT'S PHYSIOLOGY. a, vas deferens: 6, seminal vesicle: c, ejaculatory duct: d, termination of the ejaculatory duct: e. opening of the prostatic utricle: /, g, voru montanum; h. I, prostate. TAKEN FROM FOSTER'S PHYSIOLOGY. 1, the urinary bladder; 2, the longi- tudinal layer of muscular fibres; 3, the prostate gland; 4, membranous portion of the urethra; 5, the ureters: 6, blood vessels; 7, left; 8, right vas deferens: 9, left seminal vesicle in its natural position; 10, ductus ejaculatorius of the left side traversing the prostate gland; 11, right seminal vesicle injected and unravelled ; 12, 13, blind pouches of vesi- culae; 14, right ductus ejaculatorius traversing the prostate. The prostatic inch of the urethra is, therefore, a spot of supreme importance in the sexual domain. Health in this part means normal sexuality and its attendant blessings; while pathology here involves confusion and abnormal states of all the sexual organs and its systemic consequences. As rays of light diverge in every direction from a lumi- nous body, so do the powers of sexual commerce start from the 390 ORIPIC1AL SURGERY. prostatic urethra and spread in various directions up into the prostate itself, by means of the prostatic ducts ; to the vesiculae seminales and testicles by way of the vasa deferentia ; into the bladder by way of the os vesi- cae, and to the point of the glans penis by way of the out- going urethra. The prostate gland is thus seen to be an organ of profound interest to the orificial surgeon. Messages of health, and sug- gestions of disease in all parts of the sexual apparatus reach their destination by way of the prostatic inch. The orificial principle, that the irritation of an organ starts at its mouth, is universally true throughout the human econ- omy. Applied to the prostatic inch, it means that the condi- tion of the testicles depends on the condition of the mouths of the ejaculatory ducts in the prostatic inch. Applied to the bladder, it means that the con- dition of the bladder depends upon the os vesicae. Applied to the prostatic itself, it means that its state of health responds to the conditions of the orifices of the prostatic ducts as they open into the prostatic urethra. As sexuality, and through this the sympathetic nerve force, is the great motive power of the world, that has won the great battles, solved the great problems, amassed the great fortunes, composed the great music, and, indeed, is responsible ORIFIC1AL SURGERY. 391 for the great progress of civilization in the history of the race ; and as the prostatic inch is the key to sexual conditions, the causes which operate to disorganize it, and the remedies which are efficacious in restoring it to a healthful state, deserve the careful and continued consideration of the medical fraternity. All the knowledge which we possess of hypergesthesia and hypertrophy, anaesthesia and atrophy, and their vari- ous causes, will find a fertile field for application in the prostatic inch. We must familiarize ourselves with the anatomy, physiology, and the pathology of this part, as well as with effective means of relief, in order to keep the machinery of life in proper balance for the purposes of our existence. Sexual conclitons fluctuate our hope, our cour- age, our affections, our will-power, and our intelligence more than those of any other part of our human structure. It must remain for a later article in this series to con- sider the causes of prostatic pathology and its cure ; the pres- ent object being simply to call attention to the importance of maintaining a healthy condition of the prostatic inch of the urethra, in order to furnish an adequate supply of nerve force for the continuance of a vigorous peristaltic power in the va- rious tubular structures of the body, by means of which all the activities of our physical natures are carried on. The teachings of the orifieial philosophy are so plain, practical and effective that they are bound to revolutionize the entire treatment of chronic diseases in the male as well as in the female organizations. As the importance of the part becomes better appreciated, as a knowledge of reflexes and metastasis of irritation and congestion become more thorough- ly discussed and better understood, the prostatic inch will cease to be so commonly neglected, present surgical measures will be speedily replaced by superior ones, and the longevity of human life will be correspondingly increased. When once the great truth is thoroughly and universally recognized, that normal sexual organs are an essential to normal activities throughout the entire body, doctors will begin to apply what they know about atrophy and hypertrophy, about anaesthesia 392 ORIFIC1AL SURGERY. and hypergesthesia, to the sexual organs as well as the rest of the body. Sexual nerve waste is very commonly painless and speaks mainly in the language of disturbed function. Doctors will cease to regard seminal losses as normal, because they will be able to cure them. They will cease to ignore the mass of universally prevailing conditions of perverted sexual tenden- cies, and by means of the present or better orificial methods re- deem the race from its present pitiable condition of sexual servitude. To refresh the memory of our readers upon the anatomy of the male sexual organs, although our present purpose is not to present in this article a complete anatomical sketch of them, herewith are presented a few cuts "illustrating the mutual re- lations of the various organs which compose the sexual appar- atus. CHAPTER LI. CIRCUMCISION. E. H. PRATT, M. D. Sexuality is chiefly responsible for all that is -good, great, grand and progressive in the evolution of mankind. Sensu- ality is chiefly responsible for all that is mean, morbid and con- temptible in human history. Sexuality has been the chief pro- pelling power in the erection of churches and cathedrals, school houses and libraries, in the construction of steamboats, rail- ways and telegraph and telephone wires; its purity and vigor have had to do with the best books, the grandest music, the greatest essays and poems and all practical inventions that mart the progress of the race. The enervating influence of sensuality has dimmed the noble inspirations, blunted the fine sensibilities, paralyzed the worthy efforts and polluted the health and vigor of its numberless victims. Sexualit.y is a grand and God-given inspiration, purifying and elevating in its tendencies. Sensuality is a God-forsaken, mildewing af- ORIFIC1AL SURGERY. 393 fliction that blights everything and everybody with whom it comes in contact. From a doctor's standpoint sexuality is an expression of bodily health, while sensuality is an ex- pression of bodily disease. There are some in our profession who are charitable enough for the frailities of humanity to construe them in the light of morbid conditions. It is not nat- ural to limp, or wheeze, or cough or cry; it is no more natural to lie, or steal, or commit adultery. All deformities of mind or matter have their incipient suggestion in bodily infirmities. If this position is tenable or even partially so, it becomes an important matter to examine each body carefully to ascertain its deviations from normal standards of perfection. If the male sexual organs of mankind were subjected to a critical examination with the idea of judging of their approach to an ideal standard of perfection, the number which would pass muster as perfectly normal in every particular would be so few as to be a startling disclosure of the true source of a very large percentage of the weaknesses and sicknesses of hu- manity; for sexual abnormalities predispose to sensuality and its various and disastrous sequences. They are perpetual sources of temptation, nerve waste and disaster while they are permitted to remain uncorrected. They are usually a pain- less affliction and consequently all the more subtle in their mischief. Our ideals are the composites of our knowledge and experience, and in deciding between what is normal and what is morbid in the conformation of the male sexual or- gans, the decision will depend upon the standard of excellence which each physician or surgeon has established for himself. In discussing this subject I can only speak of my personal standard of excellence and preferred methods for the correc- tion of the various forms of deviation from it, expecting that many of the readers of the Journal differ from me more or less radically. The most frequent and I believe most important sexual abnormality in the male sex is exhibited in the confor- mation of the foreskin. An ideal foreskin, measured by the standard which I have long since adopted, loosely covers the corona glandis and upper half of the glans penis, and retracts 394 ORIFIG1AL SURGERY. easily and without compression of the glans or constriction of the corpus immediately above it. Upon extreme retraction of the foreskin there is no adhesion to the glans or its corona and no tendency of the fraenum to depress the point of the penis. The foreskin which completely covers the glans penis while in a relaxed state of the organ is too long. One which compresses it snugly upon retraction is too tight. One that depresses the penis upon retraction has too short a fraenum. The commonest deformity is where the foreskin is too long, or, in other words, redundant. The nude figures of ancient statuary and the nude paintings by the recognized masters almost invariably illus- trate this type of malformation and also prove it to be so com- mon as to be considered by the uninitiated as normal. The practice of circumcision received a perceptible blow at the recent World's Exhibition in Chicago. The numerous nude paintings and statuary there exhibited were not discussed in this particular, but they were observed and the sightseers, not allowing for the fact that a good artist was probably a poor doctor, accepted the published deformity as a standard of ex- cellence. It will take much education and discussion to cor- rect the wrong impression concerning this subject which has thus quietly, but at the same time effectually, been made. After an unusually extended and careful study of this whole subject, with an ambition to be extremely conservative, I regard a redundant foreskin as inimical to the health and happiness of its possessor regardless of his age or apparent condition. To illustrate the influence which an enlongated and adherent foreskin has upon the nutrition of the body, I beg to submit for the consideration of the readers of the Jour- nal one of the many cases which led me to realize that our nutrition and the funtional activity of all our organs are un- der the control of the sympathetic nerve, and that the fore- skin which is supplied by the same nerve exercises a wonder- ful influence over all the bodily suggestions and conditions. More than thirty years ago I was summoned to inspect the con- dition of a child who was evidently suffering from marasmus. It was about nine months old and at that time weighed one ORIFIG1AL SUBGEEY. 395 pound less than at three months of age. It was emaciated to an extreme degree, had no appetite, was frequently afflicted with nausea and had never enjoyed a good night's sleep or a single meal. It was not teething and appeared to be well formed except that its entire body had an extremely hungry FIG. l. look. Its bowels were regular and its urine apparently nor- mal. A few prescriptions checked the nausea but did not in- crease the appetite or relieve the restlessness, wakefulness and fretfulness, and a change of climate was ordered and secured. After three months' absence from home I was again called to inspect its condition and was much alarmed at the state in which I found it. Its condition of malnutrition had increased rather than diminished and it was becoming dropsical in its little feet and lower limbs. Counsel was called, its gums were lanced, drugs were administered, its appetite was tempted by a change of food, but all to no avail. The dropsical condition continued until the lower half of the child was badly swollen. At my request the infant was stripped and I gave it a careful examination from head to foot. I found nothing to criticize except a redundant and adherent foreskin. Not realizing at the time, as I have since been compelled to, the numerous and serious pranks which this condition can play with a human 396 ORIFIC1AL SURGERY. body, I did not consider the condition of the foreskin at all re- sponsible for the lowered vitality of the child ; but not knowing what else to do, I advised the mother to permit me to slit the foreskin along the dorsum and loosen its attachment to the glans. The mother gave her consent and the task was easily and quickly accomplished. Imagine my astonishment as well as satisfaction at the sequel. That night it slept without wak- ing, for the first time in its life. The next morning it was hungry. Within twenty-four hours the dropsical condition began to pass away, and by the end of a week had entirely disappeared and the child was dismissed as cured, the mother having received instructions to separate the lips of the wound daily to prevent a return of the condition. Two weeks later the mother in a state of frenzy presented herself at my office, begging me to visit her child once more, as it was dying. She was so beside herself that she could not describe the child's condition, and I could not imagine what unhappy change had set in. I shall never forget the picture which greeted my eyes as I entered the room where the little sufferer lay in his moth- er's lap. The dropsy had returned, but, instead of attacking the lower half of the body, had taken the form of hydrocepha- lus. Water had accumulated in the subaraclmoid space to ORIFIG'IAL SURGERY. 397 such an extent that the frontal bones were forced prominently beyond the eyebrows, causing the eyes to appear as deeply receding. The entire circumference of the head was greatly increased and it was so heavy that the child could no longer support it by its slender neck. Remembering my recent ex- perience, I asked the mother if she had separated the lips of the wound daily as I requested. She said she had. I asked to examine the condition and was refused permission. Recog- nizing that the mother was so beside herself as to be irre- sponsible for her actions, I insisted upon making an examina- tion and did so. I found that the mother had failed in her efforts to keep the lips of the wound apart and that the mar- gins of the foreskin had reunited. Sending the mother from the room and summoning the nurse, I then circumcised the child and afterwards gave my personal attention to the wound until it had healed satisfactorily and was capable of free and easy retraction beyond the corona of the glans. The relief, I am delighted to say, did not come too late. Slowly the water about the brain was absorbed, the head diminished in size and in two weeks the condition of hydrocephalus had disappeared and the child was once more dismissed as cured. For many years I was continuued as the family physician, but never had 398 ORIFIGTAL SURGERY. occasion to prescribe for the baby again for he was the perfect picture of health. I met the father fourteen years later and he informed me that the child had never seen a sick day since and was then grown into a robust and healthy young lad. I have previously described this case, but it is so apropos in the present connection, and it presents such a remarkable illustration of the action of the foreskin over the nutrition of the body, that I feel confident that the readers will pardon my making use of it in this article. There are many ways of performing circumcision, but it would be a waste of time to record them in the present con- nection. The operation which I shall now describe is so easy of FIG. 4. accomplishment, so mathematically exact in its application to all cases and so thoroughly satisfactory as to supplant all oth- ers in my estimation. It is the product of an extended experi- ence with this operation, based upon a suggestion which was made to me by Dr. J. M. Walker, of Denver. Dr. Walker in circumcising children found that by the aid of a double uter- ine tenaculum he could seize the opposite margins of the fore- skin and produce sufficient tension to enable him to amputate the foreskin at any desirable point. As my practice called upon me to circumcise adults as well as children, I found the ORIFIG1AL SURGERY. 399 double tenaculum insufficient for the purpose and so made use of two separate tenacula and a pair of T forceps to ac- complish the same purpose. The fraenum is first to be tested by practicing extreme retraction of the foreskin. If too short it is to be severed. The meatus is then to be examined and if too narrow is to be en- larged at its lower extremity. The foreskin is then to be re- placed in its normal position. Searching its lower border for the point at which the mucous membrane which lines the foreskin becomes continuous with the integument which cov- ers it, a Pratt tenaculum is made to transfix it on the under FIG. 5. side. The instrument is now passed to the hands of an assist- ant and, while sufficient traction is being exercised to straight- en the tissues, another tenaculum is inserted directly opposite at the margin of the foreskin. While the assistant is render- ing the foreskin tense by means of these tenacula in such man- ner as to give its opening the appearance of a long narrow slit extending at right angles to the direction of the organ, the intervening margins of the foreskin are secured in the grip of a T forceps midway between the tenacula. (Fig. 1.) The tissues are to be held tense by traction upon the tenacula and T forceps; the mucous membrane lining the foreskin, by its 400 ORIFIGIAL SURGERY. attachment to the corona, limits the possibilities of tension so that there is no danger of stretching the tissues too far. The operator can now easily locate with the thumb and finger of one hand the position of the point of the glans penis. A sharp, narrow-bladed scalpel is now made to pierce the foreskin be- neath the attachment of the T forceps on a level with the point of the glans penis. (Fig. 2.) The cutting edge of the knife is to be turned toward the under side of the organ and the lower half of the foreskin severed on a line parallel with its free margin. (Fig. 3.) A pair of scissors is now employed to amputate the remaining half. (Fig. 4.) In doing so the scissors are opened and, starting from the upper edge of the wound made by the introduction of the scalpel, the foreskin is to be severed from below upward in a line not parallel with the margin of the foreskin as was practiced with the lower half, but curving upward and backward at an angle sufficient to make the upper angle of the amputation on a level with the edge of the corona. This is practically removing a V- shaped piece from the dorsum of the foreskin. The severed margins of the skin and mucous membrane are now to be su- tured by interrupted catgut sutures, after which another cat- gut suture is to be employed to close the amputated foreskin over the point of the glans. (Fig. 5.) The object of this last procedure is to hold the foreskin moderately tense over the glans while the raw surfaces are agglutinating: otherwise erections, which are liable to supervene from the presence of stitches, would cause the foreskin to retract back of the glans, and either interfere with the healing of the wound or ensure its healing in a thickened ring of tissue which would remain permanently retracted about the margin of the corona. Many surgeons prefer to amputate the entire foreskin, thus leaving the glans and corona permanently exposed. This I believe to be unnecessary and much prefer securing the ideal result out- lined earlier in the present article, namely, a foreskin which is worn, when the organ is relaxed, in a manner which covers the corona and the upper half of the glans, leaving merely the apex and lower half exposed. As the sutures employed are catgut they will not require removal. ORIFICIAL SURGERY. 401 In cases where adhesions between the foreskin and glans are encountered, these should be broken up before circumcis- ion is performed. Subsequent to the operation in such cases, the adhesions between the glans and prepuce will reform; but, after the severed margins of the mucous membrane and skin are well united, they can easily be broken up and kept from uniting by daily anointing with cold cream or carbolated vaseline. Circumcision is practiced by some surgeons under the action of cocaine hypodermically employed, but as cocaine pre- disposes to hemorrhage, interferes with the healing and its employment hypodermically is accompanied with more or less danger, it seems to me preferable to perform the operation under the action of an anaesthetic, a mixture of ether and chloroform being my choice for grown people and chloroform for children. CHAPTER LII. CIRCUMCISION. T. E. COSTAIN, M. D. This subject was assigned me by the secretary, and al- though it involves the consideration of the entire sexual sys- tem from an orificial standpoint, I shall endeavor to adhere to my text as nearly as possible. Before taking up the consideration of operative proced- ure, let us first consider the anatomical and physiological re- lation and nerve supply of the foreskin to the adjacent struc- tures and through them to the entire economy. The nerve mechanism of the foreskin in male and female is so closely connected and intertwined with that of its adja- cent tissue as to bring these parts in close communication. The sympathetic nerves extensively supply the erectile tissue of the foreskin and glans penis in the male and the glans cli- toridis with its surrounding structure in the female. LL-t*L r 01- 402 ORIFIGLAL SURGERY. The erectile tissue possesses rhythmical action, besides being supplied with nerves from the lumbar plexus (gentio- crural) and the sacral plexus (pudendal and internal pubic). This latter chiefly supplies the glans penis or glans clitoridis with large branches terminating with tactile or genital cor- puscles. The mechanism of these nerves associates the geni- tals with certain muscles and overlying skin. These parts are closely associated by the sympathetic nerve with all the pelvic and abdominal viscera. The cerebro-spinal nerves supply the skin and muscles associated with the genitals and the skin of the adjacent organs is closely associated with these parts branches coming from the same nerve trunk. What affects the periphery of one affects that of the other. Both must be nor- mal or reflexes will arise. By means of the pudic nerve and small sciatic the skin and muscles of the vulva, perineum and anus are brought into harmonious relation with the gluteal muscles (of coition) and skin over them. The numerous reflexes in the pelvic region will bear close observation in their relation to each other. You have all ob- served the retention of urine after an operation on the rectum, and it has frequently been demonstrated in this clinic that putting a forceps on the foreskin will cause defecation. These reflexes may be of sympathetic or cerebrospinal origin to the various centers or may originate over one and terminate over the other, so closely associated are these parts. In view of all this, let us consider the foreskin itself for a moment. It must extend no farther than the point of the glans penis; it must be perfectly free from adhesion to the glans and its corona; form no constriction upon the glans it- self; should be retracted freely and easily without pinching, and should be free from thickening around its margin. The deviations from this standard will require surgical attention, not only because of the local abnormalities, but for the addi- tional reasons which can readily be seen by tracing the ner- vous mechanism of these parts with the adjacent organs. A foreskin protruding beyond the glans, no matter how free from constrictions, is too long and should always be am- [T/v f iG37G iG ORIFIC1AL SURGERY. 403 putated. The results will be gratifying and always beneficial. If constricted and too long, the amputation should be carried well over the dorsum to relieve the constriction at the same time. If constricted and the length about normal, it should be slit along the dorsum sufficiently to relieve the abnormal contraction. Should a rim of thickening be observed around the margin, amputation of this band will be your only means of causing the parts to present a normal appearance and re- move the constant irritation produced on the sensitive termi- nal endings of the nerve fibers. As to the method of circumcision, you are all familiar with one or more ways to accomplish the object sought. My own preference is the method used by Professor Pratt in the clinics you have just witnessed. Let us now consider the object of this work, in addition to the local comfort and the relief of local abnormalities, as we consider them to be. Experience has taught me that much of the disease and weakness, mental, moral and physical, of both sexes, may be prevented or relieved by proper attention to the hygiene and the correction of pathological lesions of the sexual system, both of male and female. Those fortunate beings who have been free from sexual irritations will un- doubtedly be found by investigation to be the perfect physical and mental types of manhood or womanhood of our race. On the other hand, you will find the weak, puny and sickly speci- mens in those who have lacked control of the sexual organs. The question goes beyond this, however, for we find in mere infants the results of past generations, and every obstetrician who fails to examine the foreskin of the boy and girl at birth submits them in many cases to disease and nervous phenome- na as a handicap to their physical and mental development at the very outset of their existence, and even life itself becomes extinct from a lack of proper attention to these parts. It is not the experience of one, but of many, that when children fret, seem irritated and cry constantly, or may have rachitis, hydrocephalus, lack of mental or physical develop- ment, or many other conditions of childhood too numerous to 404 ORIFIG1AL SURGERY. mention, that these conditions can be relieved almost at once by breaking up adhesions of foreskin and glans or by circum- cision. These experiences are so common to the observant physician in childhood that it seems a pity that recognition of these facts should not be carried to the relief of the boy or girl, the man or woman. Fully as brilliant results can be accomplished by the doctor who will bring to his aid the re- lieving of the nerve terminals in the later stages of human de- velopment. Let us now consider the sexual apparatus in the sexes as a whole and discover, if possible, the connection between the foreskin and the adjacent structures in the male. The same nerve supplies the foreskin, urethra, prostate, ejaculatory ducts and bladder, and in the female the nerves of the hood of the clitoris are only branches of the same nerves supplying the urethra, bladder, vagina, uterus, tubes, ovaries and rectum. If then we have pathological lesions of the foreskin, what an enormous amount of damage to the health of the human body can be going on all the time through reflexes to these various parts, and even through them to the great center of life itself, the solar plexus, by failing to recognize the necessity of the proper hygienic or surgical remedial measures to the foreskin. CHAPTER LIII. LESIONS ARISING FROM CONTRACTED PREPUCE- TWENTY CONSECUTIVE ILLUSTRATIVE CASES. J. W. MEANS, M. D. The time-honored custom of the Jewish people of circum- cising all males within eight days after birth, had not only a moral and religious significance, but is based upon a principle more scientific than this age of self-worship is willing to con- cede. Centuries have passed away since the origin of this cus- tom. In fact, it might be termed one of the lost arts, and not ORlFIClAL SURGERY. 405 until the last generation have we become cognizant of the im- portant facts and great possibilities underlying the seeming insignificant operation of removing a contracted prepuce. The present age has an exaggerated estimate of our achievements. Wendell Phillips says : ' ' We seem to think that knowledge, whether it will die with us or not, certainly began with us." That the operation of circumcision, as performed before the Christian era, was based upon a knowledge of reflexew manifested in the human system, and not upon a mere cus- tom, is evident to all who care to investigate the status of hu- man intelligence at that early period. While the idea that only custom prompted the operation is in harmony with our self-conceit, it is not doing justice to a once intellectual people, whose achievements in some of the sciences and arts, at least, make this age pale with insignifi- cance in comparison. The object of this brief recapitulation is to call your atten- tion to a few cases of reflex troubles resulting from contrac- tion of the prepuce. While this subject may be considered commonplace, and somewhat foreign to the bureau in which it appears, yet it is within the possibilities of some of our more astute symptoma- tologists to effect a cure of this condition with drugs alone. While I admire the acumen of certain prescribers, and ac- knowledge the spirit-like power attributable to drugs in restor ing the equilibrium of the body, I prefer the scapel as the remedy "par excellence" in the treatment of reflex disorders arising from contracted prepuce. I have selected twenty consecutive cases occurring in my practice during the last two years. In these cases there was a general abnormal condition manifested in all, but, to be move specific, the age and particular lesion for which treatment was given is hereto appended. In the first group of three, whose ages were respectively 30, 22 and 18 years, each had a well marked case of Acne Vul- garis. Removed contracted prepuce of each with the local 406 ORIFIC1AL SURGERY. anaesthesia of cocaine, and a full-sized metallic sound was in- troduced into the urethra beyond the prastrate gland. Com- plete cure within one month following. In the second group, in which we find five, aged respect- ively 13, 10, 8, 6 and 5 years, we have in all Nocturnal Enure- sis, for which affliction the numerously indicated remedies were applied without avail; marked elongation and hyper- trophy of the prepuce existed in the two oldest cases. After circumcision, complete and immediate relief in each case, ex- cept the oldest of the group, 13 years, chronic cystitis had been induced, and only after persistent treatment did he fully re- cover. In addition to nocturnal enuresis, in a child six years old I found inco-ordination and tremor choreaic movements of the lower limbs, simulating spinal sclerosis so closely that it had been diagnosed by a leading physician of our city to be the latter disease, and pronounced incurable. Three months af- ter circumcision the child was entirely well, and showed no traces of the once formidable disease. In the third group we have twelve of the twenty cases re- ported, aged from five to one and a half years. All these cases had obstinate diarrhea, malnutrition, slow dentition : two with occasional spasms. While the operation for phymosis was per- formed on all these cases, the indicated remedy, based upon the totality of symptoms as manifested in the peculiar charac- terestics of the stool, and general appearance, was persistently followed. One striking case of perpetial contraction, interfering with the whole assimilative process and intellectual develop- ment, was in a case of five years old that had been treated by physicians of all schools of medicine for malnutrition. At the age of two years the child was bright and healthful, nothing unusual in manner or size; at five years of age it was an im- becile, could not walk or talk, weighed less than at two years of age, and presented a pitiable condition, with scarcely a ray of hope for its recovery. On examining the child I found hypertrophied prepuce, extending fully one inch beyond the glans penis. Circumcision was immediately performed, and ORIFICIAL SURGERY. 40? one year later the child was a hearty, robust boy, intelligent, mentally active, yet unable to pronounce a word. Here we have a case of aphasia, arising from neglect on the part of both parents and physician to discover in time the abnormal condition so as to arrest the terrible consequence resulting from the contracted prepuce. The reflex troubles arising from this lesion alone are le- gion, and the crowded almshouses and asylums are testimonials to this fact. CHAPTER LIV. THE MALE MEATUS AND URETHRA. E. H. PRATT, M. D. Upon examining the male meatus in a large percentage of cases it will be found of much smaller calibre than the urethra beyond it. For those who have not sufficient confidence in their own judgment as to what constitutes a normal meatus I would suggest the employment of the Otis bulb graded sounds, of which the following cut is an illustration, as a means of ar- riving at a satisfactory conclusion. The meatus should be di- latable to the extent of the urethra so that in passing in or withdrawing a bulbous instrument which fits the urethra snug- ly, no considerable resistance should be met with at the meatus. When obstruction at this point is noticeable the meatus should be enlarged to a sufficient extent to permit the free and unobstructed passage of the bulb into the urethra, meaning, of course, a bulb of sufficient size to fit the urethra snugly. It is a simple matter to enlarge the meatus. For this pur- pose a bistoury or a pair of scissors may be employed, making the cut always on the under side. In many cases the narrow- ing of the urethra will be found due to a thin membrane which constricts the meatus at its lower fourchette, and in most cases the severing of this membrane furnishes sufficient en- 408 ORIFIC1AL SURGERY. largement. Occasionally, however, the cut must be made fur- ther back, severing a part of the corpus spongiosum which sometimes marks the seat of the strictured condition. It is possible to make the cut too generous, as the entire severing of this thickened part of the urethra in some cases de- stroys virility, induces inconvenience in urinating and might interfere with conception as it detracts from ejectile force. Personally I have never found it necessary to completely sever this thickened part of the corpus sporigiosum although I have frequently found it necessary to sever it in part, preferring to secure the desired calibre of the urethra partly by dilatation if necessary. After the meatus has been severed it invariably shows a marked disposition to close again, so that the ad- vantage can only be maintained by daily spreading the lips of the meatus until the wounded surfaces have cicatriced. [Dr. Pratt now prevents adhesion and closing by taking a stitch with small catgut through each wounded surface, bringing the lining of the urethra and the covering of the glans together. This does away with the necessity of daily spreading the meatus. Editor. ] THE FR^ENUM. To the median line of the under side of the glans penis is attached a narrow strip of membrane which at the outer ex- tremity reaches as far as the poterior fourchette of the meat- us and at the other extremity splits into two crura which di- verge and become continuous with the margin of the foreskin on each side. Another way to describe it would be to say that, after the foreskin had been constructed around the glans penis, the lower edge of it was gathered up and fastened to the under surface of the glans penis as far as the meatus so as to constitute a fraenum or bit, one margin of which was free and the other margin continuous with the under surface of the glans. ORIFIG1AL SURGERY. 409 The possession of a fraenum is not an abnormality, but on the contrary is well nigh universal. But it is often found in what we have now learned to consider an abnormal condition. The test for the proper length of the frgenum is retraction of the foreskin. When upon extreme retraction of the foreskin the frgenum is so short as to depress the point of the glans penis, it is now considered by those who are best posted on the subject to be abnormally short and should be severed. A sat- isfactory manner of accomplishing this is as follows: While the fraenum is made tense by retracting the fore- skin and pushing the point of the penis backward, one blade of a pair of scissors or the point of a scalpel is pressed against the fraenum upon one side, the instrument being held at right angles to the penis. Before the cut is made the handle of the cutting instrument should be carried either to the right or left sufficiently to avoid the danger of cutting too deeply and wounding the urethra. It is always desirable to avoid wound- ing the artery of the fraenum if possible, although this is some- times unavoidable and is not a serious accident when it oc- curs. In infants the fraenum is so delicate in structure as to resemble tissue paper and can be sufficiently broken by bend- ing the glans penis as far as possible backward with the thumbs, thus tearing the delicate membrane. It is well, how- ever, to nick the margin of the fraenum before breaking its base so as to insure the tear taking place at a desirable point. The part of the fraenum which still clings to the glans penis is now to be clipped away with the scissors. Occasionally cases will be encountered in which the retraction of the fore- skin will depress the glans penis and yet the fraenum be en- tirely absent. This is due to an abnormal shortening of the corpus spongiosum which can be remedied by nicking its sur- face and bending the glans penis backward with the thumbs. Great care is necessary in such cases to avoid snipping or lac- erating the urethra. The surgeon can judge of the thickness of the part by passing the sound and examining the tissues over it. The condition of the meatus and fraenum has more to do with the habits and consequent happiness and health of men than has been heretofore appreciated, and the correction of 410 ORIFICIAL SURGERY. malformations of these parts will do much toward the eradica- tion of lustful tendencies, while they will not interfere with the employment of legitimate sexual sentiments and powers. While the wound occasioned by the severing of the fraenum is healing, the foreskin should be retracted daily so as to pre- vent a recurrence of the trouble. THE URETHRA. There is little of importance to the orificialist in the male urethra after the proper condition of the meatus has been se- cured until the prastatic portion is reached. Strictures of the urethra between these two points are common and are either spasmodic or organic. The spasmodic strictures are almost in- variably reflected from difficulties at either the extremity of the penis or the rectum, and their cure is assured by the re- moval of their cause. Organic strictures are a product of venereal disease and do not call for consideration in the pres- ent article. This subject has been exhaustively treated in so many standard publications that I will respectively refer the reader to them for its consideration. The patients to whom orificial treatment is applicable are not merely those who have been punished by their morbid propensities by syphilis and gonorrhea and their sequals, nor those who suffer from night losses, or who have practiced or are practicing masturbation, or who are in the habit of indulging in excessive intercourse, legitimate (so-called), or otherwise, for orificial effects can be attained in the various forms of chronic disease in men of the most correct habits and apparently normal sexual condi- tion. All chronic conditions, both local and general, are sub- jects for orificial work; however, we will give a brief con- sideration to the more important local as well as general con- ditions from the orificial standpoint. [This language may be misleading^ if not carefully noted, by imply- ing that orificial treatment offers no relief to those with incorrect habits and abnormal seual conditions. We are sure the author did not in- tend to convey this impression. Orificial surgery offers the most potent and permanent relief to the libidinous individual who masturbates or in- dulges in excessive venery. It changes 'his focus of attention; it breaks the shackles of passion and makes the slave a free man; the fire which is consuming the building is confined and controlled to its intended uses; ORIFIG1AL SURGERY. 411 it leads from the hard, rugged road of the transgressor to green pastures beside the still waters. Relieving impingement of sympathetic nerve terminals in the lower openings of the body sends a message over the life-wires to the sanctum sanctorium of the soul that may be transmitted to the shores of eternity. Editor.] First, then, a brief word about strictures. They usually occur in the body of the urethra, between the glans and the prostate. Attention to the urethra itself, either by the employ- ment of dilatation or the urethrotome, is not sufficient for their cure. The extremity of the penis must be put in proper con- diticm and rectal abnormalities, which will always be found accompanying these troubles, must be corrected in order to secure rapid, satisfactory and permanent results. Many spe- cialists, who have given their undivided attention to the ureth- ra, have ignored the influence of rectal conditions upon this part and are consequently abusing it beyond its deserts. I believe that urethrotomy is almost never necessary if due respect is paid to orificial principles when treating urethral strictures. It was while handling an extensive surgical clinic, replete with gonorrhea and all its stages and sequences, that the orificial philosophy was born. The difficulties encountered in curing gleet and urethral strictures, and the fact that these difficulties vanished as soon as orificial principles were applied to them, had much to do with the earlier development of the thought, which, of course, was soon found to be ef- ficacious, not only in curing pelvic troubles, but in general dis- orders of the system as well. After a stricture has been thoroughly and persistently di- lated until all raw surfaces have healed, the reason of its re- turn, which almost invariably occurs later on, is not to be found at the seat of the stricture, but in some form of orificial irritation. As soon as the rectum and extremity of the penis are placed in proper condition and the urethra once thor- oughly relieved, the stricture will permanently disappear with- out the employment of the urethrotome or even electricity. 412 ORIFIG1AL SURGERY. CHAPTER LV. THE USE OF MALE SOUNDS. E. H. PRATT, M. D. In skillful hands urethral sounds are invaluable in the treatment of all forms of chronic disease to which men are liable. If employed awkwardly or unadvisedly they are dan- gerous instruments. Their usefulness is confined almost en- tirely to chronic conditions either local or general. If em- ployed in acute cases they are liable to induce serious aggra- vations. For many generations urethral sounds have been em- ployed for the cure of gleet and stricture. But this has been the limitation of their use until the development of the ori- ficial philosophy. It is now found that in addition to what they can accomplish in local troubles resulting from gonor- rhoea and its sequences they are indispensable in the cure of seminal losses and impotency, and have a wide range of use- fulness in the treatment not only of reflex troubles but in all other chronic affections of men which require a stimulus of the sympathetic nerve to awaken reactive power. Skillful handling of the instruments can only be acquired by a knowledge of the proper manner of their introduction and by frequent practice. The adaptation of their use in the various forms of chronic disease in which they are serviceable is an art, in the practice of which some general directions may be helpful but nothing but an extensive experience can ever develop correct judgment. In selecting a set of sounds, those are better which taper slightly at the tip, and they should be carefully graded so that the small end of each sound is a trifle smaller than the largest diameter of the preceding sound. If this suggestion be followed it is not necessary for an operator to possess each number, the sizes increasing by one and a half numbers being adequate for all purposes. No steel sounds under No. 10 are desirable, as in cases where smaller numbers are required ORIFIO1AL SURGERY. 413 urethral bougies are safer. Over-distension of the urethra is harmful. It is both unnecessary and undesirable, and con- sequently no number higher than a No. 18, English scale, will be needed. Over-dilatation of the urethra is liable to induce enuresis and impotency, and the full benefit of the instrument can be obtained without running the risk of over-distension. The following cut illustrates a form of instrument devised by the author. These double sounds are fully as serviceable as the single ones, are a saving in both number and conse- quently expense and weight. They are best made of steel, for although they can be made of rubber or aluminum and thus made lighter, this is by no means a desirable object. The questions of importance are: First. How properly to introduce a sound? Second. How long to hold it in position? Third. How often to employ it or them? Fourth. Should they be used hot or cold? Fifth. How long is their use to be continued? Although each case must be individualized, nevertheless some general rules covering these points will be found service- able. The sound is to be lubricated with a fine quality of toilet soap. Soap is the best lubricant because it not only renders the instrument sufficiently slippery, but favors the removal of mucus so frequently encountered in the urethra as the sound is withdrawn. It is harmful to use vaseline because it is in- soluble in urine and some of it is liable to remain in the blad- der and along the urethra and become a nest for the develop- ment of germs. Post mortem examinations have frequently revealed large accumulations of vaseline in the bladder, which had become rancid and acted as a source of vesical irritation. 414 OBIF1C1AL SURGERY. There is no objection to the use of olive oil, except that its use does not favor the extraction of the mucous. Soap, being en- tirely unobjectionable in every particular and being the most cleanly of lubricants, is preferable. First. The proper manner of introduction. Standing upon the right side of the patient as he lies in the recumbent position, the operator holds the lubricated sound in his left hand in such a manner that the back of his hand rests upon the patient's abdomen and the instrument extends across the palm. The penis is then to be carefully drawn over the sound, which is now gradually lowered until the instrument is hori- zontal with the hand of the operator. As the sound is now carefully raised it is also carried downward as nearly as pos- sible by its own weight, as no force is ever to be employed in the manipulation of the instrument. Where the penis is ex- ceedingly flaccid, as it frequently is in the aged, it should be kept in a condition of tension by the right hand which seizes the organ on either side just back of the glans penis. The in- strument is made then to continue its course until it is carried slightly beyond the point where it is at right angles to the body, and will consent to remain in this position after all ef- fort employed in its introduction is withdrawn. When in this position the tip of the sound will have passed the os vesica? and have entered the bladder. Care must be exercised to avoid the impinging upon the inner surface of the bladder with the point of the instrument, as perforations are possible and in- flammatory action of the vesicus could easily be induced by sound bruise. The urethra is frequently bruised at the en- trance of its membranous portion by failure to follow the canal accurately, and the sound may not reach the prostatic inch, which should be its destination, if its introduction is not made complete. As the sound enters the bladder, if the patient is not under an anesthetic and the parts are normally sensitive, a sensation of passing water will be experienced by the pa- tient and be an indication to the operator that the neck of the bladder has been effectually entered and a satisfactory in- troduction has been accomplished. OKIFIC'IAL SURGERY. 415 Second. How long shall it be permitted to remain in situ? The length of time which the instrument should be permitted to remain will vary with the different eases, from the mere in- troduction and immediate removal up to an hour or perhaps even two hours, according to the torpidity of the case and the degree of reaction desired. If the urethra is hyperesthetic its immediate removal after it has been successfully passed is demanded. If the case be one of impotence or seminal losses, or one in which reactive power is at low ebb and considerable sympathetic stimulus is demanded, it should be held in posi- tion for at least ten or fifteen minutes at the first sitting. If upon its removal strings of mucus are found clinging to its surface, it should be cleaned, again lubricated, and again passed and withdrawn until mucus fails to appear upon its surface. This may require two or three introductions or it may require a dozen. The urethra is first cleared of mucus by the aid of medium sizes, both the larger and smaller ones of- ten proving ineffectual in bringing it away. As soon as mucus begins to appear upon the sound, the same sound should be used until the mucus has disappeared before passing on to the employment of a larger size. In attempting to pass a sound in case of stricture, where it is impossible to effect an introduction, the urethra should be thoroughly dilated as far as the strictured point, after which an entrance of the smaller sizes can be much more readily effected. As reaction, either general or local, is the object of the use of the instrument, the length of time for leaving the sound in required for this pur- pose is to be sought for, always being careful to underdo. A singular experience, furnished by a case of paralysis some years ago, gave the writer a valuable point as to the length of time a sound might be left in the urethra in desper- ate cases. The patient, who had been paralyzed for ten years, applied for relief. He had but partial use of his lower limbs and no control of either urine or feces. Orificial worK was performed upon him twice, at intervals of one year, without effect. He wrote for further instructions, and was advised to pass a sound upon himself at bedtime, and allow the instru- ment to remain in position for half an hour. He attempted to 416 ORIFIG1AL SURGERY. follow the instructions, but before the half hour expired dropped off to sleep, leaving the sound in position, having propped it in such a manner that it was retained in place with- out the use of his hands. Being tired he slept soundly and awoke in the morning, eight hours later, much shocked and chagrined to find that he had not stirred in the night, and that the sound was as he had left it when dropping to sleep. He removed it, but although being a physician he did not re- alize that he had induced a severe shock to the urinary tract and his system in general, and that it would be necessary for him to exercise extreme caution to escape severe consequences. He dressed himself and took a long ride into the country. By the time he arrived at his destination, however, he was taken with a severe chill and was too ill to return home. Suppression of the urine supervened, extreme congestion of the kidneys followed, and for forty-eight hours his life was despaired of. The first discharge from the urethra was a little blood, then a few drops of urine ; finally the flow was re-established and in a short time he made rapid convalescense. Much to his gratification he found that he had not gone through his ex- perience without benefit. He had been wearing a urinal for many years, but found to his delight that now the paralysis of the bladder was completely cured and he was able to evacu- ate the bladder voluntarily and normally in every way. The cure of the paralysis remained permanent, and not till the cure was effected did the doctor inform me of his carelessness. He has since had occasion to laugh at the experience as the final result was satisfactory. In reflecting upon this case the writer speedily reali/cd that he had not been using the sounds to their possibilities of usefulness, as it had been his custom previously to withdraw the sound after letting it remain in position a short time. Along this same line are satisfactory results obtained from the use of uterine stems in cases where the mere dilatation of the organ produces no satisfactory results. In bad cases of constipation and catarrh of the sigmoid much benefit can be derived from packing the sigmoid and permitting the pack- ORIFIC1AL SURGERY. 417 ing to remain for twenty-four or forty-eight hours, or even longer, until a sufficient degree of reaction has supervened. This is the only case in which the writer has known a sound to be left in position for eight hours in succession; and although the reaction was satisfactory, it was a dangerous proceeding. It is perfectly proper for a surgeon to decide the length of time a sound is to be left in position by the require- ments of the case, which can only be ascertained by repeated trials at longer or shorter intervals until symptoms of satis- factory reaction begin to manifest themselves. Third. How often shall the sound be employed? Never oftener than twice a week and more frequently but once in one or two weeks, and in many cases once in from one to three months will meet the requirements of the case. When reaction is once aroused the sounds are to be employed at only long intervals and for a short duration of time, to avoid the dis- asters of their over-use. In cases of seminal losses and im- potency the point of reaction is not so quickly reached and consequently the use of sounds will be demanded at short in- tervals and it will be necessary to protract their stay in the bladder beyond what will be required where the sexual or- gans are in a fairly normal condition and they are to be em- ployed for a stimulating effect upon the various organs and tissues of the body remote from the pelvis: It is a fine point to determine just when reaction is secured and the use of the instrument is to be abandoned. Increased irritability of the urethra, improvement in the color and tonicity of the organs themselves, and the effect produced upon the general health of the patient, can alone determine this point. When the use of the instrument produces an aching sensation of the perineum or a hyperesthesia of the testicles or backache or chilly sen- sations, it must be taken for granted that its use is to be abandoned or at least be materially lessened in frequency. Fourth. Should they be used hot or cold? If for merely the local purpose of relieving strictures or curing gleet, they should be used hot. But where they are used to re-establish sexual tonicity, or as a general sympathetic tonic, they had 418 ORIFIC1AL SURGERY. better be used both hot and cold. The heated sound is first to be passed and permitted to remain a long or short period ac- cording to circumstances, and after its removal the same is to be passed cold, but should remain in position no longer than thirty seconds or one minute at most. Immediately after the removal of the cold sound and indeed it is a good rule to fol- low universally after the passage of sounds the point of the penis should be held in warm water for five minutes three or four times a day, until all traces of a smarting or burning sen- sation in passing water have disappeared. Fifth. How long is their use to be continued? There is such a thing as a "sound habit." It is very easy to continue the use of the sound to the harm of the patient, and the prac- tice had much better be under-done than over-done. In em- ploying them for the restoration of sexual tonicity their over- use would tend to destroy what little sexual power still re- mained. In cases of atony of the bladder and weakness of the accelerator urinae, evidenced by difficulty in voiding urine, the small size of the stream and dribbling of urine at the close of the effort, too prolonged and frequent use of the sounds is liable to precipitate the case into one of complete paralysis instead of restoring the weakened muscles to their proper tone. Metaphorically speaking, they are edged tools, and while handled with discretion they are of incalculable benefit in the treatment of all forms of chronic diseases, both local and gen- eral, of the male sex ; if injudiciously or awkwardly employed they are equally productive of mischief. CHAPTER LVI. DISEASES OF THE PROSTATE. E. H. PRATT, M. D. Prostatic afflictions are liable to be overlooked, especially in their earlier stages, by both the laity and the profession. They are overlooked by the laity because they are seldom pain- ful, and the disorders of bodily functions which may fairly be OBIPICl'AL SURGERY. 419 attributed to them are usually referred to other causes. They are liable to be overlooked by the medical profession for three reasons: First, doctors are seldom good anatomists or physi- ologists, do not appreciate the unity of the human body nor take into consideration the complicated working of its varied machinery; second, because physical examination when form- ing a diagnosis is imperfect, due partly to the fact that in the answers given by the patient to the doctor's questions no im- pression is conveyed of the existence of prostatic trouble simply because many of its forms are painless; and, third, many forms of prostatic trouble are liable to escape detection even upon what is commonly considered a local examination. The laity are excusable for their medical mistakes and ignor- ance, but the profession must be able to go beyond the physi- cal expression of disease, wherever located, and unearth its cause. When this practice becomes a habit and a more thor- ough education furnishes people with medical men who are better equipped for their calling, conditions of the prostate will assume an importance in medical considerations which they have long deserved and never yet enjoyed. In estimating the degree of attention which prostatic troubles may legitimately claim in deliberations which have for their object the prevention and cure of human suffering, we must bear in mind that sympathetic nerve power and reactive power are synonymous terms. Sympathetic force is the steam which propels the entire enginery of the body. When it is abundant peristalses are vigorous, capillary circulation is nor- mal, and health prevails throughout the various tissues. When it is deficient peristalses become sluggish, effete matter is un- duly retained, fresh material is insufficiently supplied, capil- lary circulation is irregular and inadequate to the renewal and purification of the tissues, blood stasis results in whatever part of the body is used most or is weakest by nature, and pathology finds its incipiency. This sympathetic power upon which all bodily activity de- pends is the nerve force which sustains the prostate and its be- longings, and prostatic troubles, by draining this nerve force prodigally, reduce the general sympathetic nerve power and 420 ORIFIGTAL SURGERY. consequently the tonicity of the entire body, permitting it to be the unfortunate prey of whatever opposing forces it encoun- ters. On account of the nerve exhaustion which prostatic dif- ficulties accomplish, they are prone to be one of the primary causes of all forms of chronic disorder. Skin troubles, mu- cous membrane troubles, head, thoracic and abdominal diffi- culties in fact, the entire list of chronic diseases may find at least a part of their explanation in nerve waste incurred by prostatic illness, which has been going on continuously until it has exhausted the reactive power of the body, but so silently as to escape the attention of both patient and doctor. It must be remembered also that the irritation of an organ starts at its mouth, and that when the prostate is clogged and its functions perverted it involves the disorder of all organs whose mouths empty into the prostatic inch ; from above is the blad- der with its renal appendages, from below comes the urethra, and in its centre are found the ejaculatory ducts, which are in the outer openings of the vesiculae seminales and vasa defer- entia, and also the prostatic ducts themselves. The prostatic inch is thus seen to be the central telephone office for the male pelvis, and its influence is as wide as sexuality and the urinary functions, for which the part stands. The disease forms which the prostate takes on when its circulation has been sufficiently impeded and protracted are similar to those suffered by other parts of the body. They can be malignant or benign; then can be atrophied or hyper- trophied. Malignant disease of the prostate is fortunately a very rare affection, but when it is once well established it is practically an incurable trouble. Excision of the prostate is not a success; castration will only check the progress of the disease, it will not exterminate it; perineal section is but a temporary makeshift, and there is very little hope from internal medication. The profession has very little to offer for the relief of cancer of the prostate. Some slight satisfaction can be obtained by the use of sounds, electricity, massage, rectal work, cold water and internal medi- cation. Every measure which tends to improve the capillary ORIFIG1AL SURGERY. 421 circulation of the prostate will prolong the fight for life, but the battle will ultimately be lost. Benign affections of the prostate are to be counted among the commonest afflictions to which men are liable. Tumors, either cystic or fibrous, are very rare, and need not be sep- arately considered, as their removal is impracticable except in rare cases, and the measures for relief are similar to those which are effectual in the two commoner forms of prostatic pathology, namely, atrophy and hypertrophy. One word about fibroid tumors of the prostate. If the middle lobe be enlarged and project into the bladder like a rhinocerous horn, producing painful and frequent micturition, it is possible by suprapubic cystotomy to successfully excise the offending growth. It is not a bad plan in such cases to practice perinea! section at the same time, so that the up- per opening in the bladder can be closed and drainage secured at the same time. Occasionally a fibroid growth will project toward the rectum from one of the lateral lobes of the pros- tate, or it sometimes happens that the middle lobe enlarges in this direction instead of toward the bladder. Where the tumor is not too sessile it can be successfully removed by an operation from below. A horseshoe incision is to be made around the anus parallel with the outer border of the external sphincter. The sphincter is to be dissected from the bed of areolar tissue upon which it rests and turned toward the anus, but not injured. The rectum is then to be dissected loose from the under surface of the prostate and the tumor removed. The disturbed tissues are then to be carefully replaced and stitched into position. Atrophy and hypertrophy of the prostate, however, are the conditions which will by far the most frequently apply for relief. Of these two conditions, hypertrophy of the prostate has received a fair share of the professional attention which it deserves because of the urinary disturbances which are in- duced by it. But atrophy of the prostate, although perhaps the commonest form of pathology which the prostate takes on, and of sufficient consequence in chronic diseases of men to handicap recovery in the cases in which it is a factor, is almost 422 ORIFIC1AL SURGERY. invariably overlooked, as the patient has no symptoms, except possibly that of impotency, which would lead the doctor to suspect its existence and suggest an examination of the condi- tion of the prostate. It is not a common practice for physi- cians to examine the condition of the prostate unless some in- dications of prostatic trouble can first be discovered by inter- rogating the patient. Atrophy, however, is a more profound pathology than hypertrophy, and a much more obstinate af- fection to cure ; at the same time when it exists it is a matter of vital importance that the condition should be corrected if possible. Atrophy of the prostate is a frequent precursor of tuberculosis, bone disease, spinal cord affections, paresis, and chronic abscesses in various parts of the body. In studying the treatment of atrophy and hypertrophy of the prostate it is important to remember one fact concerning the sympathetic nerve distribution of the pelvis, and that is that the genito-urinary organs are supplied by pencils of sym- pathetic plexuses of nerves, which are common in their ori- gin at the sympathetic nerve centres, but are exceedingly va- ried in their distribution. As the brotherhood of nerves which supply the bladder, testicles, urethra and prostate spring from the same nervous centre, the various parts of the male sexual and urinary systems are in such close sympathy that the irri- tation of any terminal nerve fibre supplying these parts may express its distress in, first functional derangement, and af- terward organic pathology of any of the parts supplied by other branches of the same pencil of nerves. I mean by that that a narrow meatus, a shortened frgenum and narrow or elongated foreskin may induce prostatic congestion, or starva- tion, may cause prostatic hyperesthesia or anesthesia, accord- ing to the general tendencies of the patient. The influence which the rectum exercises over prostatic conditions must al- ways be borne in mind, for the outlets of the body which serve for the exit of the solid and liquid excretions are also in close sympathy, and usually enjoy both sickness and health in common. The first important step, therefore, in the cure of either atrophy or hypertrophy of the prostate is to institute a careful examination of the condition of the parts at the ex- ORIFIGIAL SURGERY. 423 tremity of the penis and in the rectum. If the meatus is too narrow it should be slit ; if the condition is one of hyperspadias the canal should be reproduced ; if the f raenum is so short as to depress the point of the penis upon extreme retraction of the foreskin it should be clipped and the extremity of the penis liberated ; if the opening in the foreskin be too small, the fore- skin itself being of normal length, it should be slit along the dorsum sufficiently to give perfect freedom of motion without constricting the glaiis penis. The slit in such cases should be carried as high as the corona glandis. Where the fore- skin is too long, even if it is not too narrow, it should be amputated, not by the old method which removed the en- tire foreskin, for this does not seem to be necessary, but suf- ficient to relieve the redundancy of tissue, so that in a relaxed condition of the organ the corona and upper one-half of the glans is covered, leaving only the lower one-half exposed. Urethral sounds should be passed, using soap as a lubricant, because by this means the urethra can be relieved of any ca- tarrhal discharge which it might contain, and may be safely dilated in most cases to No. 16 or 18, English scale. Great care should be taken not to over-dilate the prostate, as it is not uncommon to induce enuresis by the use of sounds, es- pecially in those well advanced in life, and also because the prostate is somewhat friable and over-dilatation is liable to lacerate it, leaving a raw surface for the absorption of septic material. Slight rupture of the prostate, caused by the care- less use of sounds, is a common cause for the urethral fever which so often follows their use. Whatever form of rectal pathology is encountered should be corrected, be it hemor- rhoids, fistulas, pockets and papillae, ulcers or fissures, or, as is sometimes the case, merely stenosis. There is a very close nervous connection between the sig- moid flexure of the colon and the prostatic inch, and many cases of prostatic trouble defy cure simply because of an ir- ritable condition of the sigmoid flexure of the colon, which has been overlooked and is an active agent in sustaining the pro- static irritation. 424 OElPIClAL SURGERY, A single treatment under an anesthetic which carries out all of these suggestions is frequently sufficient to effect a speedy and radical cure of an enlarged prostate, although in most cases the subsequent and periodic use of sounds and the employment of sigmoid and rectal treatments at stated inter- vals aie required to reduce the gland to its normal size. In the employment of sounds it is better to use them heat- ed in irritable, hyperesthetic and spasmodic conditions of the prostate and urethra, whereas cold sounds are better in cases requiring tonic measures. In cases exhibiting irritable ten- dencies if sounds are employed they should be immediately removed after their introduction. But where the parts are pale, anemic, more or less anesthetic, and therefore calling for stimulating treatment after a sound has been introduced, it may be held carefully in position for ten, fifteen or twenty minutes, or even half an hour, and in rare cases one or two hours. It is better to underdo than overdo their use, and con- sequently the length of time for a sound to be left in position can only be ascertained by a thorough acquaintance with the case under treatment. Where the prostate is not only enlarged but irritable, the use of rectal plugs, so constructed that they may be heated by a stream of hot water, is invaluable, and may be employed daily for a short time if necessary, although once or twice a week is usually as frequently as they can be employed to ad- vantage. Electric currents can be used in the urethra and rendered serviceable in reducing or developing a prostate, ac- cording to its condition, by means of insulated urethral tips, upon the same principle that similar conditions are acted upon by electrical treatments in other parts of the body, the gal- vanic current aiding absorption, while the faradic is service- able in strengthening the weakened muscles found in atonic conditions. It is always well after passing sounds to imme- diately hold the point of the penis in hot water for one or two minutes so as to favor a prompt reaction. Massage of the prostate is serviceable in both atrophy and hypertrophy, but is to be employed with extreme caution as a slight bruising of the prostate from careless massage is a frequent source ORIFIC1AL SURGERY. 425 of cystitis and also orchitis. It should not be employed often- er than once or twice a week, and even then with extreme caution. Water may be employed to great advantage in all forms of prostatic pathology. It is of some service in some cases employed in the rectum, either in the form of frequently re- peated injections in small quantities, either medicated or plain and hot, or for the purpose of securing dry heat by the aid of a rectal plug. And in the urethra it is often serviceable for purposes of irrigation, especially in enlargement of the pros- tate where there is residual urine. But its greatest service is in its use externally. There is no more refreshing, invigorat- ing or curative measure known to doctors than the skillful use of water applied to the base of the body. If the prostate is in an irritable condition it can be employed either as a hot sitz bath or while the patient is placed in the lithotomy position by means of a pitcher of hot water poured over the genital or- gans, perineum and buttocks. Where a tonic effect is desired the water should be used cold. If the patient is very weak the action of the cold can be secured by first douching the parts by means of a pitcher of very hot water and immediately fol- lowing this with a pitcher of ice water. The parts can then be dried and the patient either dressed or put into bed as de- sired. If the patient be strong enough to react spontaneously from the use of cold the hot water had better not be em- ployed, and for such cases a sitz bath of cold water will be found very satisfactory. This should be of only one or two minutes' duration, and should be taken at bedtime, after which the patient should get into bed immediately without drying himself. A sitz path, which includes the lower half of the body and the lower extremeties, is still more serviceable for those who are sufficiently vigorous to establish a satisfac- tory reaction. In some cases this can be borne only every other day, while a few can stand a daily treatment of this kind to advantage. So much for physics. And now for a briefer word upon a still more important consideration in the treatment of pro- static cases. As the body is but the crystallized life, so its diseases are but the result of unfortunate mental and emo- 426 ORIFICTAL SURGERY. tional habits. The use of the handkerchief does not cure the catarrh, and the removal of disease products in the prostatic region by surgical, medical or hygienic means is mere patch- work and but temporizing with decay unless the habits of thought and feeling which have permitted the prostatic disin- tegration to take place be also reconstructed and turned into healthier channels of activity. In medical writings it is customary to confine the atten- tion to the mere physical forms of disease, ignoring the part which internal forces play in their establishment. But the time has now come when we should no longer be guilty of so serious an omission, for as the whole body is but the crystal- lization of its internal life, it stands to reason that any attempt to effect a permanent cure by physical agencies alone is but born of ignorance and fostered by professional habit. In this day of freedom we must emancipate ourselves from the thral- dom of preconceived notions and refuse longer to be handi- capped by the narrow-minded precepts formulated by those who are spiritually blind. Our mission is to cure the sick, and this can only be done by a re-establishment of order in men- tal and emotional habits as well as in physical functions. The whole man is our patient, and mere physical consideration is not adequate to the cure of morbid physical conditions, espe- cially of the prostate. My paper is already of sufficient length for the present occasion, and the theme now broached is of such importance that I shall make no effort to do more than merely record my hearty appreciation of the important bearings which the life of the body has upon the body itself. The cure of love which has been sick, even unto lust, in all forms of prostatic derange- ment both functional and chronic, is a sufficient theme in it- self for an extensive paper which should be written and I promise you shall be written in the near future. When lust has consumed the sexual organs it is because love has been sick, and the relief from lust and its ravages lies in the re-establish- ment of love in all the strength of its natural prerogative. There is a thoroughly accurate, effective and scientific way of ORIFIG1AL SURGERY. 427 accomplishing this magical transformation in human emotions ; and although the present is not the time for its consideration I should be untrue to this society, to the subject under dis- cussion, and to myself if while discussing the subject from a material standpoint I should not also recognize that the cure of prostatic difficulties involves mental and emotional trans- formations as well as physical patchwork. SECTION VII. The Female Sexual Organs. ORIFIG1AL SURGERY. 431 CHAPTER LVIL SOME POINTS CONCERNING THE ANATOMY AND PHYSIOLOGY OF THE FEMALE ORGANS. E. H. PRATT, M. D. The nervous supply of the clitoris and its hood, in the female, corresponds with that of the point of the penis and the foreskin in the male. The nerves which furnish the labia minora are the same which, in the male, supply the scrotum. The nerves which are distributed to the ovaries and Fallopian tubes in the female, are the same ones which, in the male, go to the testicles; while the nervous distribution to the uterus corresponds to those which are distributed to the prostate gland. In the male, the urinary and sexual organs are so inter- mingled that the first inch of the urethra, which carries the urine from the bladder, passes directly through the prostate gland, which is the great nerve centre for the male sexual or- gans. In the female, the sexual and urinary tracts are divorced, the female urethra being short and uncomplicated by any di- rect connection with the uterus. The nervous connection, however, remains the same ; and as prostatic conditions affect the condition of the bladder and urethra, and are reflected at the end of the penis, where they can be more or less correctly interpreted, so uterine conditions, especially those at the in- ternal os, may express themselves in bladder and urethral language. Idiopathic cystitis and urethritis in the female are rare affections. Reflected troubles, however, from uterine pathol- ogy are exceedingly common. In the male, bladder and ureth- ral troubles usually begin with some form of prostatic derange- ment, and the cure of the one involves attention to the other. In the female, vesicular and urethral difficulties can scarcely be cured without respecting the association which exists be- tween the uterus, clitoris, hymen and urethra. 432 ORIFIGIAL SURGERY. Of course, in both sexes, it is necessary to remember that nature's philosophy is orificial, and that the lower openings of the body are mutually interested in each other's welfare. It is impossible to maintain normal urethral and sexual condi- tions in either sex when rectal pathology is present; and it is also impossible to maintain a rectum in a normal state so long as the sexual and urethral abnormalities remain uncor- rected. Never forgetting, therefore, that the pelvic organs are supplied by a pencil of sympathetic nerve filaments, so inti- mately associated that the condition of one of them influences, and oftentimes expresses itself by means of any or all of the other filaments, let us consider a few points in the anatomy and physiology of the individual organs of the female sexual system. The same points, which were observed in reference to the foreskin of the penis, apply to the hood of the clitoris. The normal hood exposes the point of the clitoris, is readily re- tracted, and does not bind, either when pendant or retracted. If enlongated or hypertrophied, it should be amputated; ifc atrophied and stenosed, it calls for a mere slitting along the dorsum to relieve the abnormal tension. The hood of the clitoris differs from the foreskin in one respect, that it does not completely surround the clitoris, simply covering the clitoris like a gabled roof. As the point of the penis is the most sensitive spot of the male sexual organs, so the clitoris acts in a like capacity for the female sexual or- gans. An adhesion of the hood of the clitoris to the clitoris is as mischievous in the female economy as the adhesion of the foreskin to the glans penis is in the male. It is exceedingly common to find the hood of the clitoris adherent to the clitoris and confining smegma which has been unmolested for a lifetime, even in subjects well along in years. When one thinks of the convulsions, the dropsies, the epilep- sies, the paralyses, the insomnia, the dyspepsia, the eczema, the strabismus, the kidney troubles, and the immorality which date their beginnings from abnormalities of the foreskin, and realize that the clitoris and its hood are supplied by identically OKIFICIAL SURGERY. 433 the same set of nerves, subject to the same laws of action and reaction, and that abnormalities of the hood of the clitoris are as mischievous as those of the foreskin; and realize, also, FIG. l. FIG. 2. K TAKEN FROM AM. JOURNAL OF OBSTETRICS. Fig. 1. Miss A. Prepuce firmly adherent to glans, allowing only the tip of the glans to protrude, and imprisoning small, hard particles of smegma. Fig. 2. Miss A. Prepuce stripped from glans. Fro. 3. Fro. 4. Fig. 3. Miss B. A deceptive case. Glans apparently free on casual Inspection, but its base tightly adherent with prepuce, and inspissated smegma retained. Prep- uce drawn up as far as possible. Fig. 4. Miss B. Adhesions separated and prepuce drawn up. that doctors have for generations completely ignored the part ; it is easy to understand why the true history of the treatment of diseases of women is marred by the record of so many fail- 434 ORIFICIAL SURGERY. ures; the chlorosis and the insanity, the organic derangements and the susceptibility, the various forms of mal-nutrition, and the mental and moral eccentricities of the gentler sex are eas- ily understood. The miseries that have been entailed upon the females of our race by what doctors have not done, in the way of simply removing all forms of irritation from the cli- toris and its hood, if written, would make a long and mourn- ful page in medical history. Many years ago, the French doctors recognized the cli- toris as a source of nerve waste in women. Their measures for relief were so radical as to do serious harm instead of the good intended. In cases where the condition of the clitoris was recognized as a source of irritation, they were in the habit of amputating the labia minora, the hood of the clitoris, and the clitoris itself. If they had practiced the same philosophy upon the male sex, for the relief of troubles which arose from the irritation of the foreskin, they would have amputated the penis and scrotum as well. The result of their severe work was not only a relief from the abnormal irritation which they sought to cure, but also from all normal sexual instincts, and was so frequently followed by insanity, that the question of the practice was subject for legislative action, and the ampu- tation of the pudenda was forbidden by law, making one of the most painful pages in the history of French legislation. It is no more necessary to amputate a normal clitoris than it is a normal penis ; and it is quite as essential for the mainte- nance of female health to secure and maintain in normal con- dition the hood of the clitoris, as it is essential for male health to secure and preserve a normal condition of the foreskin. Although in the present article, it is not intended to pre- sent the subject of treatment, it might be well to mention in the present connection that in amputating the hood of the clitoris, it should not be done too closely; sufficient room should be left to admit the stitching of the membrane which lines the hood to the skin which covers it, so that when the parts heal the clitoris will not be unduly bound down by cicatricial formations. ORIFIClAL SURGERY. 43? Nature is consistent in her building of the human house, and seems to distribute individual characteristics with equal generosity in parts which are closely associated in function. I mean that those which present hypertrophy of the hood of the clitoris, will be equally generous with the tissue about the orifice of the vagina, in the structure of the uterus, and in the construction of the rectum. The cases, therefore, which call for a removal of the hood of the clitoris, will frequently demand considerable trimming of the urethra and hymen, present a hypertrophied cervix and body of the uterus, and also more or less redundancy of tissue in the rectum. Those which are atrophied in one of these parts are more or less atrophied in the others. The cases which pre- sent a fringe of papillary elongations about the urethra and on the inner margins of the hymen, will also be furnished with uterine granulations and rectal pockets or papillae, or both, just as though an abnormal condition of one of these parts had been contagious and imprinted its characteristics on all the others. If the orifice of the vagina and the cervix uteri are in a normal condition, the stretch of vagina which connects them will also be normal. But when pathology has enthroned it- self at the two extremities of this canal, the canal itself often- times suffers throughout its entire extent. A normal vagina is perfectly smooth, dilatable, but neither baggy nor cavernous, moistened with a proper amount of mu- cus ,but not to the extent of deserving the title of leucorrhoea. When the passages from the uterine cavity have been ex- coriating, especially in cases which present fringe-like ex- crescences about the hymen and the urethra, and have re- mained uncorrected for a considerable length of time, the whole vagina becomes abnormally congested and frequently presents an abnormal development of the papillae of its mucous membrane, which oftentimes becomes so rough and hard as to present the roughened appearance and feel of a fish's maw. This condition is sometimes so extreme as to call for the use of the curette and scissors over more or less of the entire surface 438 ORlFIGlAL StJBGERY. of the vagina. Dilatation, proper medication, and completed orificial work are sufficient to restore the mucous membrane to its normal velvety texture. The external os uteri should point slightly backwards, present the same color as the vaginal mucous membrane, and be patulous and dilatable to pass from a No. 9~y 2 to 14, English FIG. 7. FIG. 8 TAKEN FROM LUSK. Fig. 7, 1, cavity of the body ; 2, lateral wall; 3. superior wall; 4.4. cornua; 5, os intern um; 6, cavity of the cervix ; 7, arbor vitae of the cervix; 8, os internum; 9, 9, vagina. Fig. 8. 1, body; 2, 2, angles; 3, cervix; 4, site of os internum; 5. vaginal portion of the cervix; i>, external os: 7, 7, vagina. scale, uterine sound without resistance. The deviations from this standard, like those of the other parts under considera- tion, are those of atrophy and hypertrophy, hyperaesthesia and anaesthesia in their various forms and degrees of manifesta- tion. The external appearance of the cervix uteri, however, may be normal in every particular and still enclose in its grasp mischievous forms of pathology in the mucous membrane lin- ing its canal ; so that an examination of the uterus is not com- plete without a thorough exploration of its cavity, perfectly regardless of its position and external appearance. ORlFIClAL SURGERY. 438 The internal os is the lower opening of the uterus proper, and is guarded by circular fibres of the body of the uterus. Its tissues are independent of those of the cervix. The cervix is attached by muscular and aerolar fibres to the body of the uterus after the manner that the basket of a balloon is at- tached to its gas bag by the series of ropes which pass around the outside of the balloon. The internal os is the last gateway which guards the cradle of the race, and is consequently the most vital point of the female sexual system. It is the great nervous centre which dominates, more than any other one spot, the condition of the entire female sexual apparatus. The messages from this cen- tral office pass upward to the uterine cavity, and outward to the Fallopian tubes, with their fimbriated extremities ana the ovaries. They pass downward and fluctuate the condition of the cervical canal and the external os. Their influence extends still farther by means of other terminal nerve fibres, and af- fects the condition of the orifice of the urethra and the puden- da in all its parts, including the clitoris. They also have di- rect telephonic communication with the sigmoid flexure of the colon, and with the last inch of the rectum. Above all other questions, therefore, in the economy of the female sexual organs, is, what is the state of the internal os uteri ? Is it stenosed or too patulous, is it hypertrophied or atrophied, is it hypergesthetic or anaesthetic, is it free or choked by undue flexion of the organ forward or backward? It is the most fixed part of the utrerus, and circulating about it are the largest nerve trunks and the largest lymphatics. It is the great commercial center of sexual activity, and upon its health or disease depends the female harmony and discord. The last orifices in this line of investigation are the uter- ine orifices of the Fallopian tubes. Health of these openings means normal Fallopian tubes and ovaries. The converse of this is also true, that morbid states of ovary and Fallopian tubes have their incipiency in pathological states of these openings. When these openings have undergone pathological changes, the measures which establish a healthy endometrium 440 ORIFIG1AL SURGERY. generally are about all that can be relied upon to exterminate it. The curette, the douche, the packing, electricity, dilatation, and internal medication in addition to the effects which can be produced by attention to the other terminal nerve fibres of FIG. 9. FROM AMERICAN TEXT-BOOK OF SUKGEKV. Diagrammatic Sagittal Section of the Female Pelvis: U, uterus; E, Rectum; S symphysis; P, perineal body ; B is beneath bladder. This is the position of the uterus when the bladder is almost empty. the genitalia, together with what may be obtained from cor- rect habits of thinking and feeling, constitute the various means of relief which the profession has to offer for disordered conditions of the internal openings of the Fallopian tubes. If tubular and ovarian pathology has been well established and too far advanced to react from these measures, the case ORIFIG1AL SURGERY. 441 has gone beyond the reach of orificial work, and appeals as a last resort to the laparotomist. It may strike some thoughtful reader as incongruous, in an article which essays the mention of a few anatomical and physiological facts about the female sexual organs, to occupy so much space with the deviations from the normal standards of excellence in these parts, rather than being content with purely anatomical and physiological considerations. The fact of the matter is, that should one enter upon a search for nor- mal conditions of the sexual organs of the female, the chances are that one will almost always encounter pathology instead of anatomy; and that, consequently, physiological processes are as disordered and sick as the anatomical conditions which shape them. This is true even with the apparent specimens of health that are proud of their independence of the medical fraternity. Professional cannibals are a savage looking race; pro- fessional shepherds have crystallized their habitual kindness into features which tell their own story of gentleness and ten- derness. There are intellectual races and savage races, there are musical races and warlike races, and in every race the in- ternal life is so stamped on the external as to leave its im- print indelibly impressed into the forms of flesh ; but there is one element of human nature possessed by all races of men which has made discordant music upon the harp of life through all history. Distorted sexual appetites have tinctured human love with its perversion of lust during all the preceding ages, until the unwritten history of the inner lives of men would make the largest and most melancholy library on earth. I said unwritten history. To those who can read the rocks, the evolution of the earth is a plain page, for the story of animal and vegetable life is crystallized into them; and to those who can correctly interpret the human body and its crystallized forms, which are but the imprint of generations of living, the history of man's inner life is readily interpreted. Passions of all kinds, when they have become perpetual habits through succeeding generations, invariably clothe them- selves in bodily forms of expression ; and, judged by this 442 ORIPIC1AL SURGERY. standard, the female sexual organs (and the male as well) tell a sad story of perverted sexual emotions. Undoubtedly, the abnormal physical conditions which we inherit, and which are encountered in almost every human being, react upon the na- ture of the individual and prescribe its tendencies to develop- ment. Only when such abnormalities are removed and the forms are restored to their ideal condition, can we hope for that immunity from temptation that is essential to true health and happiness. Orificial work will be necessitated for both sexes through many generations to secure for mankind the inheritance of their untarnished birthright, which gives them sexuality and not sensuality, which inspires them with love, but does not consume them with lust. It is said concerning dogs that if the tails of both sexes be amputated close to the body through sev- eral generations, it will result in a tailless species. If Moses had prescribed the amputation of the hood of the clitoris as well as the removal of the foreskins for the Jews, they would undoubtedly by this time have had the qualities which, crys- tallized, produce these formations, so thoroughly eradicated from their natures that the forms themselves would have dis- appeared, and the Jews to-day would be born without fore- skins and without hoods to the clitoris. It is not uncommon, I am told, even as it is, with the practice of circumcision con- fined to one sex, to encounter Jewish male children who are born without a foreskin. I do not pretend to say that an ideal condition of the sexual organs involves an absence of foreskin or the hood of the clitoris. The abnormal states of humanity have existed so long that pathology has become anatomy and distorted func- tions have become physiology and sickness seems to be the normal state of the human race ; and it will be difficult to de- cide upon the true standard of ideal excellence. The present state of these organs as found, however, is so extremely and evidently abnormal, that a systematic and persistent attack upon the present abnormalities which prevail is unquestion- ably not only advisable but exceedingly desirable. From re- sults obtained in the practice of orificial surgery, we simply ORIFICIALi SURGERY. 443 444 ORIPIC1AL SURGERY. know that the putting of these parts in better form does con- serve the power of the sympathetic nerve, does remove ab- normal sexual inclinations, does free the individual from un- happy emotional suggestions, does liberate the soul from its thraldom of unholy desire, does economize nerve force, and does increase thereby the general re-active power of the sys- tem ; thus securing for it increased peristaltic actions through- out the body, thus enabling it, when its functions are disor- dered, and when it is staggering under pathological loads, to regain its equilibrium, and enjoy once more the harmony and pleasure of normal bodily functions in general and in detail. From this it would appear that the hopes of the race for emancipation from sin as well as from sickness will find their main reliance in orificial surgery. Sexual abnormalities have failed to receive their due meed of attention at the hands of the profession, because as they were extravagant of sympathetic power rather than cerebro- spinal, they did not appeal to the consciousness of patients. The cuts which are dispersed throughout the present arti- cle are introduced simply to refresh the minds of the readers on the anatomy of the parts discussed and to ensure a clear understanding of what has been written. CHAPTER LVIII. TERMINAL NERVES OP THE SYMPATHETIC AND THEIR TROUBLES AS A FACTOR IN PELVIC INFLAMMA- TIONS AND OTHER DISORDERS OF WOMEN. E. H. PRATT, M. D. The physiological world has long been deeply concerned about the two nervous systems, the cerebro-spinal and sympa- thetic, and interest in the subject is increasing. Many prob- lems in connection with the study still remain unsolved, and yet there is much knowledge upon the subject which is now well established. In a general anaylsis of our human organ- ORIFIC1AL SURGERY. 445 ization no one will question that it possesses a conscious and an unconscious part. The conscious part is perpetually in evidence, sensing in manners peculiar to itself its surrounding panorama of other existences and conditions and directing the activities of the body so far as it can control them according- ly. No one can question the fact that the physical habitation of the conscious human being is the cerebro-spinal system, which consists of the brain, spinal cord, and their afferent and efferent nerves. But there is also, as everyone knows, an un- conscious or sub-conscious part of us, whose earthly abiding place is unquestionably in the sympathetic system of nerves, which consist of ganglia of gray matter and of afferent and efferent nervous cords connected therewith. Our conscious selves are more or less intelligent and ra- tional; our unconscious selves are automatic and more or less mechanical in their activities. Between these two forms of us there is a very close relationship, whether viewed physically or physiologically. And yet, while they have much in com- mon, each has spheres of operation perfectly independent of the other. It is perfectly natural that the conscious part of us and its earthly house, the cerebro-spinal system, should have monopolized the lion's share of attention and consideration in the deliberations of medical men, for by nature it is con- spicuous and self-assertive, and how we feel or sense ourselves to be, is easily taken to be synonymous with how we are. For in this world of signs, appearances are perpetually parading themselves as realities. But our unconscious part, whose physical lodging-place is the sympathetic nerve, is, especially of late years, assum- ing its proper position of importance because we now realize how much it has to do with the formation of our physical his- tory. The sympathetic nerve as a factor in health and in dis- ease is now beginning to receive scientific consideration in the etiology and treatment of all the various forms of devia- tions from health to which physical man is prone. There is a book recently published by Dr. Byron Robinson, of Chicago, upon the sympathetic nerve. The book is called "The Abdominal Brain and Automatic Visceral Ganglia." Per- 446 ORIF1C1AL SURGERY. mit me to quote briefly from a page of this book a few sentences bearing upon the mutual relationships and functions of the two nervous systems. On page 8 Dr. Robinson states that ' ' The ce- rebro-spinal nerves together perform the animal functions which prove us to be feeling and thinking and willing beings." That is, the physical products of cerebro-spinal activity are purely conscious products. We think, we feel, we decide, we will, and then we become. It is quite evident from this that all products of our conscious living not only require correction when they become unsatisfactory, but that radical work in- volves education as well, for habits of thought and feeling can be corrected by education and by education only, here being unquestionably the legitimate field for suggestive therapeutics. Immediately following the sentence quoted occurs the fol- lowing paragraph : ' ' The ganglionic system of nerves, with the abdominal brain as their central organ, performs the vital functions which are independent of mind and present to .us the idea of life. The sympathetic system of nerves presides over the viscera over secretion, nutrition, gestation, expulsion, respiration, and circulation over sub-conscious phenomena." In other words, growth and repair are all dominated by the sympathetic nerve. To a disturbed and inadequate supply of nerve force must all deviations from the health standard be attributed, and to this same power must all remedial measures for their effectiveness appeal. As Dr. Robinson's position is merely that which is uni- versally recognized by all prominent anatomists and physiolo- gists, it certainly behooves us as physical tinkers of this watch of time, the human body, to bear in mind the construction of its machinery, and in inaugurating curative measures have due respect to the waste and repair of the sympathetic nerve. The existence of pelvic pathology, in common with physical disorders of the general system wherever located, implies, therefore, a deranged, depleted, or otherwise disturbed sympa- thetic nerve force. Our work of physical adjustment and re- lief is consequently incomplete unless the sympathetic dis- turbances which were their first cause be sought for and cor- rected as far as possible. OBIFIG1AL SURGERY. 447 With this fact in mind, let us briefly consider the waste and repair of sympathetic nerve. First, the waste. Sympa- thetic nerve force is usually wasted or its rhythm disturbed in either one of three ways: First, by undue terminal nerve impingement ; second, by excessive and unremitting demands upon the sympathetic nerve supply to the involuntary mus- cles; third, by impingement or undue pressure of the sympa- thetic nerve trunks themselves. First: Undue terminal nerve impingement. In consid- ering this point, it is well to remember that the sympathetic nerve supplies an apparatus, not by a single nerve trunk, but by a pencil of nerves proceeding from a common source, and that impingement of any one of the terminal nerve fibres, by disorganizing the sympathetic harmony at the nerve center, can throw into disordered operation any or all of the other fibres proceeding from the same source. Gynecologists will be specially interested in the pencil of nerves which supplies the pelvic organs of women. From the same nerve centers plexuses of the sympathetic pass to the ovaries, to the fallopian tubes, to the uterus, to the vagina, to the vulva, to the bladder, to the urethra, to the clitoris, and to the rectum, thus associating all these parts in close sympa- thetic relation. Impingement of the terminal nerve fibres which pass to the ovaries may take place in either of two ways: First, ci- catricial contraction of roughened apertures occasioned by the discharge of the ovum in the tunic of the ovary. Most of the scars thus produced are harmless, but occasionally the mar- gins of the wound do not heal symmetrically and the conse- quent impingement and strangulation of tissue ensues. It is not at all uncommon to encounter spots of hardened cicatricial tissue in one or more places upon one or both ovaries. Second : The impingement of terminal nerve fibres supply- ing the ovaries occurs when ovaries are imbedded in inflamma- tory products. These inflammatory products are cicatricial formations and like other scars contract with increasing grip as the months and years go by. Atrophy of the involved ovary ensues, but so long as its terminal nerve fibres are not com- 448 ORIFIC1AL SURGERY. pletely destroyed, their incarceration in the steadily tighten- ing vice of cicatricial tissue is a prolific source of sympathetic nerve waste, although almost universally overlooked and ig- nored. Ovarian tumors in themselves are not seriously detri- mental to health, but cicatrix-entangled, and consequently pinched ovaries are conditions of more serious import. Sympathetic plexuses supplying the fallopian tube may be disturbed in their functions by inflammatory adhesions be- tween the fimbrias at the other extremity of the tube. It is not uncommon to encounter tubes that have been entirely closed at their outer extremity by inflammatory processes, and impingement of terminal nerve fibres of the sympathetic en- sue as a consequence. Congestion and inflammation of the lin- ing of the tube, and also pyosalpinx, frequently press unduly upon the nervous filaments distributed upon the surface of the membrane lining the tube. The uterine orifice of the fal- lopian tube may become excoriated and the terminal nerve fibres distributed to this point may be unduly squeezed by prolonged contraction of the muscular fibres which surround it. Impingement of terminal nerve fibres of the sympathetic supplying the lining of the uterus may be occasioned by clonic uterine contractions induced by corporeal endometritis and by intrauterine and intramural fibroids. But the greatest nerve center of the uterus, and the one most liable to injury, is the internal os, which is formed by circular fibres belonging to the body of the uterus. Flexions of the uterus have their bend at this point, and in this way impinge terminal fibres, and this being the narrowest point of the uterine cavity it suffers most in cases of endometritis, and is apt to escape the attention of the gynecologist because of its concealed position. But sten- osis, partial or complete, of the internal os uetri is a common source of sympathetic nerve waste in women and more pro- lific of mischief than is credited to it. The terminal nerve fibres of the sympathetic plexuses supplying the cervix uteri are liable to suffer impingement in two ways. First, by stenosis, and second, in cases of prolap- sus uteri by impingement against the perineum. OEIFIG1AL SURGERY. 449 Impingement of the vaginal nerves occurs most frequent- ly at the two extremities of the vagina. In cases of vaginismus the nerves supplying the entire length of the vagina are in- volved. An excoriating leucorrhea confined to the upper part of the vagina is a frequent occurrance. The mucous mem- brane ultimately becomes denuded of its epithelial layer and the vaginal sulcus surrounding the cervix in the course of time becomes completely obliterated by the adhesions of the vagina to the outer surfaces of the cervix. The cervix no lon- ger protrudes into the vagina, and upon examination seems to entirely disappear. The adhesions of these surfaces, however, produce unremitting impingement of terminal nerve fibres, and of course are depleting and mischievous. In the older text- books it is common to meet with descriptions of uterine condi- tions in elderly ladies in which the cervix is referred to as having been completely absorbed. The large majority of cases are undoubtedly those in which the upper part of the vagina has first become excoriated and afterwards adhered to the cervix, so that while the cervix in reality is of customary length it nevertheless seems to have disappeared from the va- ginal canal. This condition is always harmful, and yet is sel- dom deemed worthy of mention by practical gynecologists. Impingement of the terminal nerve fibres of the sympa- thetic at the lower end of the vagina is of frequent occurrence in young women and girls, being due to muscular contractions at the os vaginae induced by irritable conditions of the hymen. Terminal nerve fibres distributed to the lining of the blad- der are seldom disturbed except in cases of calculi or of cys- titis, and when tumors press upon the bladder. Terminal nerve fibres of the sympathetic supplying the mu- cous membrane lining the female urethra seldom suffer im- pingement except at their extremities. Excoriations of the os vesicae serve to induce it at the upper end of the urethra by reason of the undue tension of the sphincter vesicae. Carun- culae and hypertrophied papillary and glandular growths about the orifice of the urethra frequently occasion terminal nerve impingement at the lower opening of the urethra. 450 ORIFIC1AL SURGERY. The plexuses of sympathetic nerve fibres supplying the clitoris and its hood are more numerous in proportion to the size of the organ than those supplying any other organ in the body. Adhesion of the hood of the clitoris to the clitoris induces impingement of the terminal nerve fibres of the sym- pathetic supplying this part because the clitoris is constructed of erectile tissue, and as it fluctuates in size it pulls and presses upon the adhesions spasmodically and irregularly. And as such adhesions tend to undue sensitiveness and excitability of the part they are exceedingly prone to seriously disturb a normal sexual rhythm and are a prolific source of over-sen- sitiveness and its attendant train of unhappy consequences in all the other parts of the female sexual apparatus and also of the rectum. The terminal nerve fibres of the rectum suffer impinge- ment in either hyperesthetic or anesthetic conditions of its mucous lining. In hyperesthetic conditions the entire mucous membrane is unduly pinched by excessive and continuous squeezing of its muscular coat, which is excited to over-activity as a result of the nerves supplying the mucous lining, and in an anesthetic condition of these nerves their terminals are more or less constantly impinged upon by the presence of large masses of fecal matter which the insensibility of the mucous lining of the rectum permits to be retained. Prolapsed ovaries, fibroids growing from the posterior surface of the uterus and pressure from the fundus of the uterus itself in conditions of retroflexion and retroversion also compress the sympathetic terminals of the rectum by holding the walls of this tube in too snug a coaptation. The terminal nerve fibres supplying the lowest inch of the rectum suffer impingement more frequently than those dis- tributed to its upper part. This is because, first it is the most dependent part of the rectum ; second, it is the narrowest, most constricted part : third, in consequence of the first and second reasons it is the part most prone to congestion, to laceration, to excoriation, to bruises, to pathological products of various kinds; and fourth and last, because the circular band of in- voluntary muscular fibres surrounding this part are more nu- ORIFIG1AL SURGERY. 451 merous and more powerful than in any other part of the reetum and consequently are capable of a severer impingement of the sympathetic terminals distributed to the mucous membrane lining it when, responsive to the automatic stimulus of the sym- pathetic nerve which supplies them as well as their lining, they are held in clonic spasm. Such in brief are the various ways in which sympathetic nerve force can be wasted or disturbed by undue impingement of its terminal nerve fibres. The second method of sympathetic nerve waste or dis- turbance is by excessive and unremitting demands upon the sympathetic nerve supply to involuntary muscles. The sym- pathetic nervous system, like the cerebro-spinal, has its af- ferent and efferent nerves. Its afferent nerves, which corre- spond to the sensory fibres of the cerebro-spinal system, are those which are employed for surface distribution, and these we have just considered. They merely convey messages from periphery to center. The efferent nerves of the sympathetic correspond to the motor nerves of the cerebro-spinal, and are distributed to the involuntary muscles. There is a coat of in- voluntary muscular fibres surrounding the fallopian tubes, the uterus is constructed of involuntary muscular fibres, the vagina is surrounded by a coat of involuntary muscular fibres, the bladder and urethra are similarly provided, the blood ves- sels and lymphatics are wrapped by a coat of involuntary muscular fibres, as is also the rectum. It costs steam to run an engine, it costs electric force to telephone or telegraph, or to heat or to light, and it taxes nervous centers to induce mus- cular action. The voluntary muscles are supplied by the cerebro-spina] system, and their constant activity during waking hours is so exhausting as to demand that a third of our time shall be spent in sleep for recuperative purposes. The action of the in- voluntary muscles, however, is presided over not by the ce- rebro-spinal, but by the sympathetic nerve. And so essential to our existance is its continuous and rhythmic operation that this system is never permitted to be off duty from the begin- ning of life to its close. For legitimate muscular activity on E 01-" 452 ORIFIG1AL SURGERY. the part of the involuntary muscular fibres the sympathetic nerve force is ample for a century run. But if in response to afferent disturbance the efferent or draining forces are un- duly taxed, sympathetic exhaustion supervenes, and if contin- ued is followed by its long train of first congestion, then dis- turbed function and imperfect renewal of bodily tissues, then retarded removal of debris, and finally the establishment of every possible variety of pathology, after which comes prema- ture bodily dissolution. The operation of the sympathetic nerve is rhythmic and automatic. Activity of afferent nerves involves activity of efferent nerves. That is, a disturbance of any surface supplied by sympathetic nerve fibres invariably induces muscular ac- tivity of the involuntary type at some associated part. If the irritation be transitory in its nature the stimulated muscular activity will be likewise transitory in its operation. But if it be of a chronic nature the muscular activity will be corre- spondingly prolonged. In this way does terminal nerve irri- tation induce sympathetic exhaustion, not only by impinge- ment, but also by unremitting demands upon the sympathetic nerve supply to the involved muscles. The third way in which sympathetic nerve force is wasted, as mentioned, is by impingement or undue pressure of the sym- pathetic nerve trunks themselves. Such impingement may be occasioned by misplaced organs, by tumors, or by deep lacera- tions and subsequent cicatrical formations involving nerve trunks in their grasp. Retroflexion and retroversion of the uterus injure not only the terminal nerve fibres of the sympa- thetic, which are distributed to the lining of the rectum but also the large bundles of plexuses surrounding the rectum it- self, and lying between the rectum and the sacrum. The same is true when enlarged prolapsed ovaries, fibroid growths, ac- cumulations of pus or serous fluid are lodged in Douglas cul- de-sac. In prolapsus of the rectum, in cystocele, in rectocle, and in procidentia the sympathetic exhaustion which ensues is due to the excessive tension upon the nerve trunks of the sym- pathetic. ORIFIG1AL SURQEBY. 453 In these various ways is the strength of the gentler sex unobtrusively, because unconsciously, sapped. The sympa- thetic nerve speaks not to womankind except in the language of function, and appeals to her consciousness only as disturbed functions or their pathological sequences obtrude themselves upon the attention of her cerebro-spinal organization. But if the self-consciousness of a woman is not appealed to, her vital force can be spent unobtrusively until death ensues as a conse- quence and the real cause of her premature departure may com- pletely escape detection. So much for the sympathetic nerve waste. The repair of the sympathetic nerve needs but little atten- tion if its waste be stopped. Local feeding of accessible parts governed by sympathetic nerves, electricity, massage, internal and external medication are all of remedial value, and above all are regular and helpful automatic habits essential to sym- pathetic vigor. When women come to us for medical advice they have become aware of some form of physical or mental derangement, and they are seeking relief from some conscious distress. But in reality every trouble which they suffer, what- ever form their complaint may take on, has its real beginning in a silent, unconscious, yet nevertheless actual distress and embarrassment of the sympathetic nerve. "We must remem- ber that the sympathetic nerve force controls the circulation, nutrition, function and repair of each and all of the organs of the female pelvis, and these have no other reliable and con- tinuous source of nerve supply. When its rhythm and har- monious operations are undisturbed by undue impingement of its terminals or plexuses, or by exhaustion from exorbitant de- mands made by undue and prolonged tension of involuntary muscular fibres, there is sufficient vitality or reactive power to ward off disease and maintain health in any and all of the pelvic organs. But to embarrass or in any way disarrange the vital power which denominates the pelvic conditions of woman is to inaugurate serious pathological transformations which invariably have their beginnings in disturbed functions and congestions, and in due time passes on to inflammations, ab- scesses, tumors, cancers, and every other possible variety of 454 ORIFIG1AL SURGERY. pathological crystallization. Thus do the consuming fires of the female pelvis, whose ashes take on different shapes and are known to us by different names, and which have been so ably considered, have their incipiency in sympathetic nerve waste. Let us by all means make women comfortable. But while we remove her tumors, evacuate her abscesses, allay her inflamma- tions, and correct her displacements, let us at the same time bear in mind that our pelvic work to be effective, complete, per- manent, satisfactory, rational, must also include all possible considerations relating to the waste and repair of the sympa- thetic nerve. CHAPTER LIX. DILATATION OF THE VULVA, VAGINA AND UTERUS. E. H. PRATT, M. D. In these parts, as elsewhere, dilatation is a serviceable measure, both in abnormal conditions of contraction and in abnormal conditions of relaxation. In other words, it is good for hypergesthetic and also for anaesthetic states ; it is good for spasmodic conditions, and for paralytic ones. Spasmodic con- ditions of the vulva, vagina and uterus are most frequently met with in unmarried women and those of the married who have never borne children. Abnormal relaxation of the same organs is a common condition in sclerotic and tubercular sub- jects, and as a post-parturition state. These parts of the female sexual apparatus are so closelr associated in function and in construction that conditions of tension or relaxation in one part are common to them all. Con- sequently they must be treated in common, and they will con- valesce simultaneously. Protracted irritability of the vulva, which expresses itself in a spasmodic action of the sphincter muscle guarding this opening, frequently is furnished with a hymen which presents upon its margin numerous papillary growths, giving the margin of the hymen the appearance of ORIFIG1AL SURGERY. 455 a fringe. In such patients, a similar condition may be observed about the orifice of the urethra, and in examining the rectum I have usually found papillae; if not papillae, there will al- most invariably be encountered a marked development of rectal pockets. In such cases, the entire hymen is to be trimmed away, as is also the roughened margin of the urethra, and the vulva and urethra thoroughly dilated. The latter can be nicely dilated with the uterine graded sounds. A good dilator for the vulva or the vagina is the rectal bivalve speculum. In employing the instrument, dilatation should be prac- ticed intermittently and gradually, so as to secure a proper degree of dilatation without rupturing the perineum. Irritability of the vagina, if sufficiently protracted, fre- quently develops the papillary layer of the mucous membrane which lines this tube, transforming it from the smooth velvety surface which it should present to a rough, fibrinous, horny structure, entirely devoid of all resemblance to a mucous mem- brane, and inducing vaginismus. Wherever the vagina is thus roughened, it should be thor- oughly curetted, and its undue tension overcome by means of the rectal bivalve. Here, again, care must be exercised not to rupture the vaginal walls, as such an accident would have a tendency to aggravate rather than to relieve the vaginismus. Occasionally, in cases of uterine catarrh, where the dis- charge is of an acrid nature, the vagina in the neighborhood of the internal os becomes excoriated, swollen, and finally strictured. I can recall several cases in my professional ex- perience in which the stricture at this point has been so com- plete as to entirely obscure the view of the uterus, and give the parts the appearance upon a mere casual examination, of a case devoid of a uterus. Bimanual examination, however, would soon dispel this illusion, and disclose a uterus of normal size hidden above the stricture. In such cases it was impossi- ble to overcome the stricture without considerable laceration of the vaginal walls which required subsequent daily packing of antiseptic wool to secure a restoration to a normal size. In vaginismus, it is often necessary to repeat thorough dilatation under an anaesthetic two or three times at long in- 456 ORIFIC1AL SURGERY. tervals, or to insert and inflate a long, rubber, air pessary, to be worn at the discretion of the physician. A chronic irritability of the endometrium is also product- ive of irregular growths upon its surface. These growths are usually known as granulations. Their texture is prescribed by that of the uterus itself. When that organ is tough and fibrinous in its nature, the granulations will be correspondingly firm, and are removed with difficulty even with a sharp curette. Where, however, the uterus is soft and friable, its granulations will be correspondingly tender ; and in scraping them off great care must be exercised not to curette away the uterine tissue. Either condition can induce uterine stenosis, which may confine itself to the cervical canal, the internal os, or to the entire uterine cavity. The latter is an exceptional condition, irritability of the lining of the uterus being usually expressed by a spasmodic state of its gate-ways. Uterine stenosis may be accompanied or not with some form of flexion. The catarrhal condition which occasions it may be, as catarrhal affections of any other mucous surface, either of the atrophic, dry form, or of the hypertrophic or moist type. The same treatment is applicable to both forms of pathology. In practicing dilatation of the uterus, which is the only satisfactory remedy in such cases, the first treatment should be a thorough one and under an anaesthetic. It is best accom- plished by means of the graded sounds, which the following il- lustrates. Sea-tangle, sponge and other uterine tests have long since been abandoned by progressive gynaecologists, as they are prone to inaugurate septic conditions. The objection to valvu- lar dilators is their tendency to bruise or tear. In this, as in all other surgical procedures, the nearer we approach the pro- cess of nature the more satisfactory are the results. When na- ture dilates the uterine cavity she does it thoroughly and by OEIFIC1AL SURGERY. 457 a round body, which impinges with equal force around the en- tire circumference of her gate-ways. In employing the graded sounds for uterine dilatation, they can be introduced quite rapidly until a size is reached which meets with considerable resistance. From this point the succeeding sizes should be partially entered and removed al- ternately, so that the tissues are stretched intermittently and gradually, thus avoiding danger of laceration. Successive and increasing sizes should be passed until all resistance at the in- ternal os is so completely overcome that no more resistance is felt at this point than is offered along the rest of the uterine canal, the sounds always being carried as far as the fundus. In conditions of atrophy of the uterus, especially in women past the menopause, great care must be exercised to avoid puncturing the fundus of the organ. This has happened three times in my personal experience, but I am pleased to report that in none of the cases was it followed by unpleasant conse- quences. Should such an accident happen, all subsequent di- latation must be confined entirely to the cervical canal and in- ternal os, and under no circumstances must any liquid be in- jected into the uterine cavity. After dilatation of the uterus has been completed to a sat- isfactory extent, the cavity may be thoroughly curetted, swabbed out, and had better be packed. There are three favorite locations for the appearance of granulations in the uterine cavity ; one just above the internal os, and one at each uterine opening of the Fallopian tubes. It is not uncommon, however, to find the entire uterine cavity covered with granulations requiring the curetting of the en- tire surface. The curved curette is serviceable in scraping the horns of the uterus, while the straight one is more serviceable for removing the granulations at the fundus on the anterior and posterior uterine surfaces and about the upper margin of the internal os. As the curette acts as a douche as well as a curette, the granulations are washed out of the uterine cavity by the instrument, so that the completion of the curetting is signaled by the disappearance of the granulations by the re- 458 ORIFIC1AL SURGERY. turning stream. While curetting it is well to hold the uterus firmly in position by either the single or double tenaculum. [Better use guy ropes. Ed.] The solution employed in thus douching the uterine cavity may vary according to the preference of the operator. Per- sonally, I am in the habit of employing bichloride of mercury, 1-4000. I have never seen any harm come from the injection of this fluid; perhaps because I am very careful never to per- mit any of the fluid to be retained in the uterine cavity. As soon as the curetting is completed, I am in the habit of packing the uterus with antiseptically prepared candle- wicking. The candle-wicking is boiled one hour in bichloride solution, 1-2000, and then for an hour in sterilized water. Af- ter this it is kept wrapped in sterilized gauze and used dry. For packing purposes, the uterine dressing forceps, will be found satisfactory. [Prepared and sold under the name of "Cordine." Ed.] The candle-wicking is doubled, the forceps seize the wicking at this point and carry it to the fundus. The forceps are then loosened, partially removed, and made to seize the wicking again, and once more introduced well into the uterine cavity. This pro- cess is followed until the entire cavity is packed snugly. If there be any oozing resulting from the curetting, this first packing is to be left in position for a few minutes and then removed, and another packing introduced. This process is repeated until all oozing has ceased and the uterine cavity is thoroughly dry. The wicking can then be severed, a piece of silk thread fastened to its outer extremity, which is pushed well into the vagina. If the uterus be an irritable one, it may be well to leave the packing in position for a few hours only. If, however, it be atrophied and indolent, it may be left un- molested for from two to four days, according to the amount of reaction desired. After the removal of the packing it is well to thoroughly douche the vagina with sterilized water or boracic acid and sterilized water. Only in exceptional cases will it be found necessary to douche the uterine cavity itself, as the uterus is supposed to be in an aseptic condition after the completion of the work, and the manipulation necessary ORIFIGTAL SURGERY. 459 to introduce a uterine douche involves more or less trauma- tism at a time when the uterus is sensitive, and might be the means of setting up inflammatory action. In extreme cases of stenosis, especially in atrophied con- ditions, even dilating, curetting and packing are not sufficient to restore the organ to a normal state; but it will be neces- sary to follow this first operation with repeated dilatations, which may be done without an anaesthetic, at intervals ranging from once a week to once in two or three months, according to the reaction instituted. The secondary dilatations need not be carried to the full limit of the first one. In some cases it will be found necessary to go still further and introduce a uterine stem, to be worn for a few weeks or even a few months, until satisfactory results are obtained. The following cuts illustrate the forms of stem-pessary which have been favorites with me, either of which I can rec- ommend in such cases. After the first thorough treatment under an anaesthetic it is well to leave the uterus unmolested, except as it may be affected by vaginal douches or tampons, if necessary, so long as the case continues to improve. But if, after a time, im- provement ceases, or if there has been no apparent satisfac- tory reaction from the work, a secondary thorough treatment under an anaesthetic man be called for. It need not surprise the operator in employing the cur- ette at this second sitting to bring away another crop of gran- ulations. Whether these secondary granulations are a second growth, or merely those which were not removed at first treat- ment, is difficult to decide, but nevertheless, in spite of the most thorough work, it will oftentimes be found necessary to submit a uterus to several curettings before the uterine gran- ulations can be effectually and completely removed or ex- terminated. 460 ORIFIG1AL SURGERY. Catarrhal conditions are difficult to exterminate from a mucous surface. Aurists have a hard struggle, and often an unsuccessful one, with catarrhal conditions of the middle ear. Nasal catarrh is likewise usually a troublesome affection. Ca- tarrh of the sigmoid and rectum is frequently overlooked, and even when it is not, yields only to persistent and protracted after-treatment, although the orificial work has been thor- oughly done and satisfactorily finished. Vaginal catarrh, and also catarrh of the bladder are equally obstinate affections, and when the uterine cavity has been once infected by this poison it is no less obstinate than when it attacks other mu- cous membranes of the body. But it can be overcome by pa- tient and persistent effort. The treatment which we have outlined is the only one in which we have ever found any satisfaction in combating this common and obstinate affection. There is little danger when practicing uterine dilata- tion in over-doing it at the time of the first thorough treat- ment or operation, if sufficient care be exercised not to tear the uterine tissues. But there is danger in employing subse- quent dilatations too frequently. The only rule which we are able to suggest at the present time which can be safely fol- lowed in all cases, is the rule which will apply equally to all sphincter-guarded openings; namely, to repeat dilatations un- til signs of reaction begin to manifest themselves. The points to be observed in deciding this question are the color of the lower extremity of the mucous membrane as it appears in the field of the speculum, its sensitiveness as it is demonstrated in the passing of sounds, and the marked increase or diminu- tion, as the case may be, in the amount of the vaginal dis- charge. Examinations may be made at regular intervals of longer or shorter periods, at the discretion of the operator when the reaction, which has been instituted, has ceased. If the case is not convalescent, dilatation by hot or cold sounds, intra-uterine douches, or the employment of a stem-pessary may be resorted to to stimulate the case to an increased ef- fort at repair. By following these suggestions, never forget- ting that cases must be individualized, hypertrophy can be re- ORIFIG1AL SUROERY. 461 duced and atrophy cured. Dilatation alone is not a panacea for abnormal degrees of tension of either the vulva, urethra, vagina, or uterus; but it is a necessary part of all successful treatment of the diseases to which these parts are prone. Operative procedures will next claim our attention. In the great majority of cases, it will be found most satisfactory to do thorough all-round orificial work at the time of the first operation. In such cases it is well to do what work is neces- sary upon the sexual organs first, reserving attention to the rectum as the last part of the work to be done. But in cases which, in the estimation of the surgeon, are too delicate to rally properly from so severe a nervous shock as the complete work implies, or where so much repair is needed that it is injudicious to accomplish it all at a single sitting, and where, consequently, a choice must be made as to which of the lower openings of the body had better be attacked first, it will be found advisable to operate upon the rectum first and reserve for a subsequent sitting the repair which the sexual organs may call for. CHAPTER LX. THE CERVIX UTERI. E. H. PRATT, M. D. Sometimes it is too long, and sometimes too short. Some- times too cone shaped, and sometimes too club shaped. Some- times too red, and sometimes too pale. Sometimes hypertro- phied, and sometimes atrophied. Sometimes its mouth is too large, and sometimes too small. It is sometimes in a hyper- aesthetic, and sometimes in an anaesthetic state. In other words, it shares with the rest of the body all the possibilities of pathological variety. The ideal cervix is exceptional in the cases which apply to doctors for the relief of chronic suffering. The cervix is so distinct an organization from the body of the uterus ner- 462 OKIFIG1AL SURGERY. vously, as to almost deserve the distinction of being consid- ered a separate organ. It is to the body of the uterus just about what the basket of a balloon is to the balloon itself. It is a very highly organized structure, and its condition has much to do with the health and happiness of its possessor. It prescribes more of the smiles and tears of a woman's life than is usually appreciated. It colors her landscape with roseate hues, or darkens it with clouds, according to its condition. It not only influences the body of the uterus, and through this the fallopian tubes and ovaries, but its telephone wires stretch out and beyond to every nook and cranny of the female or- ganization. As an individual structure it has not been suf- ficiently studied. If its mouth has been too small it has been simply incised. If it were too large, even to the point of in- ducing extreme ec.tropium of the membrane which lines its canal, it was seldom considered important to reduce it to proper dimensions by surgical procedure, except as it could be done by the application of some form of cautery. The condition of the terminal nerve fibers at its extremity as a factor in health and disease has never been studied to any pur- pose whatsoever except by orificial surgeons, and even we have not completed our studies in this direction. How often do we find in our work cases which appear to have no cervix whatsoever, but which upon examination are found to possess one of normal length, the apparent deficiency being caused by adhesive inflammation between the upper part of the va- gina and the outer surface of the cervix, to such an extent that the sulcus around the cervix had entirely disappeared. What a state of irritability and distress the terminal fibers of these surfaces have passed through to have caused this ad- hesive inflammation. How pinched they must have been by the contracting cicatricial tissue. What nerve waste must have been occasioned by this long and tedious process. And yet who has thought of its importance or the means of relief? So frequently in examining the uteri of insane girls have I found the entire lower end of the cervix denuded of its epi- thelial layer and presenting what is commonly called a straw- berry erosion, varying in size from a dime to a quarter of a OEIFIG1AL SUEGEBY. 463 dollar, that I am satisfied that it is by far the more common form of the cervix possessed by this unfortunate class of cases. This is the condition for which the sovereign remedy used to be some form of caustic, nitrate of silver, sulphate of copper, carbolic acid, the actual cautery, or some other vio- lently destructive agent. Repeated treatments of this severe nature would finally produce an eschar, which would destroy the inflamed appearance, but would contract upon the sensi- tive nerve fibers and do all the more mischief. So that while it improved the appearance of the end of the cervix, the treat- ment almost invariably proved detrimental to the general health of the patient. More of hysteria, undue emotional ten- dencies, irritability and irregularities generally of the female constitution, are due to morbid conditions of the end of the cervix uteri than the most of us have yet dreamed. Sometimes it is situated high in the pelvis, and its irritable nerve fibers, gripped unduly by the spasmodic condition of the circular fibers of the upper part of the vagina, as in cases of vaginis- mus, and sometimes the sick organ is prolapsed sufficiently to compel the sick cervix to rest upon the perineal body, chafing against its surface not only with every step, but also with every sneeze, every cough, every burst of laughter, every sob, yes, and every breath. As to treatment for morbid conditions of the cervix, the same principles must prevail as apply to the orifice of the urethra, the orifice of the vulva, or the last inch of the rectum. Dilatation, heat and cold, local applications, either soothing or stimulating according to circumstances, and electricity, all have their use and should be given a fair trial where patho- logical conditions are encountered. But when their effect ap- pears to be merely temporary and the case is stubborn, there is a sovereign remedy for cervical pathology which should never be forgotten, namely, amputation of the cervix ; not of the entire cervix so much as the removal of a mere slice of the lower extremity, so as to dispense with the diseased terminal nerve fibers which penetrate its surface. The action of the American operation is no more mar- velous and satisfactory than is the amputation of the cervix 464 OBIFIC1AL SURGERY. in cases to which it is applicable. It is not a serious operation, is apparently harmless in every respect, and is so frequently really serviceable that when its importance is once fully re- alized by the profession, there is some slight danger that it may be practiced unnecessarily. This fear, however, must not deter us from its proper employment. Amputation of the cervix does not interfere with the ability to bear children, and, if it should be done a few times unnecessarily, it is an apparently harmless mistake. It would be a difficult matter to lay down a rule which would be a sure guide as to the necessity for the operation, except, perhaps, the rule which it has been found well to follow with reference to the American operation. There are two classes of cases to which it would be applicable: Severe cases of hypertrophy, especially when accompanied by cystic degeneration and ec- tropium, with erosion and pinching; and atrophied conditions accompanying deep-seated reflex conditions, especially abnor- mal mental and emotional states of a persistent and depress- ing nature. Between these two extremes are the medium cases of moderate degrees of pathology and the simpler form of reflexes that can be relieved by the higher measures of local attention to the part; never overlooking the fact that needed rectal work must always be accomplished, and that the clitoris, urethra, vulva, and sometimes the labia minora must be restored to normal conditions before satisfactory results from the local attention to the cervix can be secured. In amputating the cervix the entire uterus should first be dilated, curetted and packed. Guy ropes should then be in- serted in the very tip of the cervix in front and behind, and tenacula transfix the end of the cervix laterally from the canal outward and be held apart so as render the external os ob- long laterally. A pair of sharp-pointed scissors should now be employed to divide the mucous membrane around the cer- vix just above the line of demarcation between the healthy and morbid structures. The amputation of the mucous membrane should be carried completely around the cervix, after which a pair of heavy scissors, their blades resting in the line of the amputation of the mucous membrane, can be closed down and ORIFIC1AL SURGERY. 465 made to amputate the cervix evenly and to the extent desired by the operator. A V-shaped piece, with the apex pointing upward, can now be taken from the cervical lining on either side, according to the redundancy and flabbiness of the tissue. Care should be taken to make the ends in this mucous mem- brane very straight and regular, and to leave the strip in front and behind in as perfect a condition as possible and about a quarter of an inch in width. A silver stitch may then be taken in front and behind, coapting the cervical lining with the sev- ered margins of the vaginal mucous membrane. Side stitches can then be inserted, usually two on each side. The packing can now be removed and the operation is complete so far as the cervix is concerned. But of course, the other orifices must be examined at the same sitting, leaving the rectum to the last, as the handling of this part flushes the capillaries and re- lieves the congestion resulting from the previous work. The stitches may be removed on the ninth day, as in case of lacera- tion of the cervix. There is no more satisfactory operation in the entire cur- riculum of orificial surgery than amputation of the cervix, when the ease is properly selected and the operation is well performed. In cases which have a tendency to retroflexion or retroversion, it is not advisable unless a radical operation for the correction of these conditions be performed at the same sitting. It is often desirable to couple this operation with that for laceration of the cervix, it being absolutely essential to the health of the woman to be free from all forms of cervical pathology. When this, with the other forms of ordinary orificial work, fail to produce a satisfactory result in the treatment of diseases of women, it will be in those cases that demand hyste- rectomy and oophorectomy. 466 ORIFIC1AL SURGERY. CHAPTER LXI. IMPROVED TECHNIQUE IN VAGINAL HYSTERECTOMY. E. H. PRATT, M. D. First of all the patient should be properly prepared for the work. If the tissues of the vagina are in fairly good condition this may be accomplished in two or three days, but if they are anemic and atrophied, and especially if they show a tendency to ecchymosis under manipulation, fully a month should be devoted to local feeding previous to the operation. This can be accomplished by injections twice a day of a table- spoonful of bovinine, holding the solution in the vagina by means of a plug of cotton inserted in the vulva. The immediate preparation of the patient should consist, as in other cases of vaginal hysterectomy, in a thorough evacu- ation of the bowels, a careful scouring and shaving of the vul- va, a thorough cleansing of the vagina with soapsuds, followed by such antiseptic solutions as are favored, and dilatation, curetting and packing of the uterus itself. In some delicate cases the expansion of the uterus seems to exercise such an effect upon the vitality of the patient that dilatation must be dispensed with, and so of course also the packing. The preparations having been completed, two guy ropes are inserted into the lower extremity of the cervix, one an- terior and the other posterior. While an assistant is exposing the cervix by the aid of a broad-bladed Sims speculum pos- teriorly and a retractor in front, the operator seizes the two guy ropes in one hand and with the other, by means of a sharp- pointed pair of scissors, severs the mucous membrane of the vagina at a variable distance from the extremity of the cervix. If the cervix is long the amputation may be made well up, but otherwise, especially in those cases where adhesive inflamma- tion in the sulcus about the cervix have resulted in adhesions between the mucous membrane which covers the cervix and OBIFIC1AL SURGERY. 467 that which covers the upper part of the vagina, so that the cervix itself appears to be excluded from the vagina, great care must be taken to make the amputation close to the cervi- cal margin especially in front, in order to avoid wounding the bladder, which in such cases is dragged downward and will be found in close proximity to the lower end of the anterior lip of the cervix. In thus separating the walls of the vagina, if the end of the cervix is small the opening can be increased in size by am- putating the mucous membrane well up on the cervix poster- iorly. As soon as the mucous membrane is cut through the scissors may be laid aside, unless the operator prefers to con- tinue their use, and the spud end of a hysterectomy knife em- ployed to peel back the tissues from the cervix. Beginning this dissection in front, a hole is made through the areolar tissue in front of the cervix by means of a spud, perhaps an inch in depth. The spud is then removed, and the instrument is reversed, a hysterectomy knife entering the hole made by the spud, and the tissues carefully separated on the other side of the hole as far as the lateral margins of the cer- vix, care being taken to make the dissection as close as possi- ble to the cervical tissues. This process is repeated behind the cervix, after which a double tenaculum is employed to seize the cervix on one side close to the severed margins of the mucous membrane. By means of this instrument the neck of the uterus can be drawn sideways by one of the assistants, while the surgeon by means of the hysterectomy knife, em- ployed under the guidance of a thumb and finger of the hand which is free, dissects away the tissues from the side of the cervix until the dissection has been carried to a level with that accomplished anteriorly and posteriorly. The double tenacu- lum is then removed, and made to perform a similar service around the other side, and the process of dissection employed also upon this side as upon the other. The dissection has now been made evenly around the cervix as far as the neighborhood of the internal os. The operator is now ready to enter the peritoneal cavity. It matters little whether he accomplishes this in front or be- 468 ORIFIC1AL SURGERY. hind. As the anterior cul-de-sac of the peritonium where it is deflected from the anterior surface of the bladder is per- haps easiest of access, the entrance is usually made in front. To accomplish this the spud is employed until the folded mar- gin of the peritoneum is reached. There is no difficulty in settling this point, as the peritoneum is not easily detached from its attachment to the anterior surface of the uterus. By making the dissection upward while the operator is hugging the anterior surface of the uterus as soon as the instrument reaches the folded margin of the peritoneum it readily slips beyond the fold, which is then brought into view. If the operator is not satisfied by ocular inspection, by inserting his finger in the hole made by the spud he can readily detect that the peritoneum is folded upon itself in the upper part of the wound, and by employing a tenaculum while his fingers are still inserted in the upper part of the wound he can seize the rounded margin of the peritoneum, draw it well into view, and with a hysterectomy knife or scissors he will be able with- out difficulty to make a small opening into the peritoneal cavity. With a T-forceps he now seizes the severed margin of the peritoneum just as it is deflected over the bladder, and dragging it well into view it is well to stitch this free margin of the peritoneum to the severed margin of the vagina, plac- ing the stitch in the median line in front to act as a guy rope. Although this stitch is a temporary one it is serviceable in keeping the wounded surface covered and in placing the mar- gin of the peritoneum always at the command of the operator. Passing this guy rope to the hands of an assistant, an in- dex finger of the operator is inserted into the opening and the finger flexed to one side. A hysterectomy knife is now passed along the finger, between it and the body of the uterus, and made to enlarge the opening in the peritoneum, first in one side and then in the other, as far as the sides of the uterus. Great care must be taken in making these cuts to hug the uterus closely in the dissection, otherwise the point of the knife will wound the uterine artery. A double tenaculum is now embedded in the posterior surface of the cervix, and while by means of this instrument an assistant brings the field well ORtPIClAL SUROERY. 469 into view, the peritoneum is entered posteriorly in the same manner as was accomplished in front. In handling the tissues back of the cervix it will be fre- quently observed that the breathing of the patient is inter- fered with and the anesthetic should be suspended for the time being. After the peritoneum has been opened in front and be- hind, the tenaculum is again employed laterally and the dis- section of the broad ligament from the side of the uterus is made first on one side and then on the other, carrying the dis- section always close to the uterine tissue. The guide to the closeness of the dissection may either be made by the free hand of the operator or a tenaculum inserted in such manner as to hold the tissues tense during the dissection. In making the lateral dissections there is always more or less danger of wounding the uterine artery, which lies embed- ded in the areolar tissues close to the lateral margins of the uterus. If through careless dissection this vessel be wounded it should be immediately seized by a pair of artery forceps and secured by ligature, or simply be retained in the grasp of the forceps, to be secured subsequently by the continuous suture which closes the wound, as the operator may elect. In a careful dissection the artery is not wounded, and conse- quently requires no ligature. In case the vessel is wounded and the surgeon prefers to apply a ligature immediately this should be done not by simply tying a ligature around the tis- sues as they are grasped by forceps, but by passing a thread beneath the artery by means of a needle and then tying the knot. With this precaution there is no danger of the slip- ping of the ligature. The ligature should always be of catgut. By continuing the dissection upward, on first one side and then the other in the manner described, the uterus can be removed without wounding either the uterine artery or dis- turbing the positions of the ovaries and tubes, the fallopian tubes and the ligaments of the ovaries being severed close to the body of the uterus. This is also the better plan to be pur- sued where adhesive inflammation has rendered the uterus 470 ORIFIG1AL SURGERY. fixed in its position. It obviates all possibility of wounding either rectum, bladder, uterus, intestines, or omentum, and accomplishes satisfactorily the extirpation of the organ. When the organ is movable however and where it is de- termined to remove the tubes and ovaries as well, as soon as the openings in the peritoneum in front and behind are accom- plished and the dissection of the broad ligaments from the uterus is made and the dissection carried well up 011 the body of the uterus, the packing is removed from the cavity and com- plete version of the uterus is accomplished, either anteriorly or posteriorly as the operator may choose or the case demand. Where there have been adhesions along the entire body of the uterus posteriorly, binding it closely to the rectum, the index finger of the operator can be carried through the an- terior opening in the peritoneal cavity and by crowding it well over the fundus and down into Douglas cul-de-sac these can be readily broken up. Under ordinary circumstances the organs will be found easier of manipulation if the version is made through the an- terior opening in the peritoneal cavity rather than the pos- terior. To accomplish this, while the guy ropes are dragging the uterus well down a double tenaculum may be inserted into the body of the uterus. Tension upon the guy ropes is now suspended and traction made upon the double tenaculum. As the upper part of the body of the uterus is brought into view it is seized by another double tenaculum, traction upon which will expose still more of its upper surface into which another double tenaculum is thrust. Climbing the anterior surface of the uterus in this way the fundus is finally reached and dragged down to the peritoneal opening. On either side of it will be found the margins of the broad ligaments containing the fallopian tubes, and if the ovaries are not adherent, these also will appear in the field. Sometime when the mesentery is very long it, or knots of the small intestine, will also appear in the field. The speculum should now be removed and the double vulsellum applied to the fundus of the uterus, by means of ORIPIC1AL SURGERY. 471 which one of the assistants can hold the fundus downward while the operator proceeds with the removal of the tubes and ovaries. If the intestines or omentum obstruct the view they are to be held back by a tampon inserted into the opening, to which a string has been attached, and to this a pair of artery forceps, to ensure its not being forgotten before the wound is closed. In cases where the tension upon the tissues is great and the uterus is not easily dragged downward, it is well to split the organ in an antero-posterior direction. This never causes hemorrhage of consequence as the uterus is not a bloody organ, and as it enlarges the field of operation it is many times a con- venient resort. When the ovaries are found to be adherent the adhesions are to be broken up by the index finger inserted through the wound. It is sometimes necessary to dig them out of a mass of inflamed tissue, but their removal in such cases is all the more important as the squeezing of the ovaries by inflamma- tory products is in itself a great source in many cases of de- pression of the vitality of the patient. In removing the ovaries and tubes where the tissues are sufficiently lax it is well to accomplish this from above down- ward, which can be done as follows : The fimbriated extremity of the fallopian tube is seized with one pair of T-forceps and the ovary with another; both forceps are then placed in the palm of one of the hands of the operator, while the index fin- ger of the same hand is passed into the cul-de-sac between them. The end of a long piece of No. 2 catgut is then fastened into the folds of the broad ligament beyond the point where the dissection is to begin. By means of a pair of blunt-pointed scissors the fallopian tube is severed from its attachment to the broad ligament, as is also the ovary and its ligament. If in this dissection the peritoneum is severed close to the tube and the ligament no hemorrhage will be encountered. The dissection should be carried as far as the lateral margin of the uterus. The continuous suture already started should now be made to approximate the margins of the wounded 472 ORIFIG1AL SURGERY. peritoneum in such manner that the two wounded surfaces are turned toward each other and nothing but a narrow seam along the free margins of the peritoneum marks the situation once occupied by the fallopian tube and the ovary and liga- ment. The other side is to be treated in a similar manner, af- ter which the broad ligaments on either side are to be severed with a pair of blunt-pointed scissors, care being taken to make the dissection close to the side of the uterus so as to avoid wounding the uterine artery. The same service is accom- plished upon the opposite side, when the specimen will be in the hands of the operator and all that remains to be accom- plished is the closure of the wound. The operator now has at his command the two long cat- gut threads already mentioned. By means of one of these the broad ligaments are stitched together, thus cutting the circu- lar opening at the vault of the vagina into two smaller circles. The thread employed to coapt the sides of the broad ligament may now be carried around the anterior or smaller circle, while the remaining thread may be made to constrict the pos- terior or larger of the circular openings. Of course if any sponges have been inserted into the ab- dominal cavity they should be removed before the puckering strings around these two small openings are drawn together. It is also well before closing the posterior opening to give Douglas cul-de-sac a thorough sponging in order to remove all blood clots that may have accumulated during the opera- tion. After these small openings have been closed either of the threads can be employed to close the wound in the vagina. In accomplishing this it is better to do sub-mucous work, as there is no tension upon the wound and but little force is re- quired to hold the parts in apposition. The seam which closes the vagina may extend in either an antero-posterior direction or from side to side, as the operator may fancy. When the seam is half way completed it is well to make a knot of the two threads employed in the operation, so as to hold the broad ligament in close coaptation with the vault of the vagina to prevent the formation of hematoceles. Either thread may be ORIFIC1AL SURGEKY. 473 used to complete the closure of the wound. When the ex- tremity of the wound is arrived at the thread may be either tied or made to transfix the mucous membrane of the vagina half an inch from the margin of the wound, and its extremity secured by the application of one or two perforated shot. Throughout the operation it is well to use pitchers of hot water freely and repeatedly, to clear the field of blood clots for purposes of cleanliness. The wound is then dressed ac- cording to the notions of the surgeon, either with or without tampon, with or without medication, as he may elect. Most cases heal by first intention and are uneventful re- coveries. Where the tissue has been poor, however, its bruis- ing may involve more or less breaking down of tissue and the subsequent formation of a small abscess in the areolar tissue and necessitate the reopening of the wound with a pair of forceps for its evacuation. In such cases the wound should be dressed daily until it is thoroughly healed. The ordinary time for confinement to bed is two weeks. In cases of cancer, where the cervix has been destroyed and the upper extremity of the vagina is infected, the guy ropes are to be placed half an inch beyond the ulcerated mar- gin and the dissection carried on as already described. In vaginal hysterectomy for fibroids in most cases it will be necessary to split the uterus in an anterior-posterior direc- tion and remove the fibroids as they are encountered. Large sized ovarian tumors can also be removed by the vaginal route if their contents be first evacuated and after- ward the sac dissected away after the manner of removal of the ovaries of smaller size. I am thoroughly persuaded that if the cases are carefully selected and the operation well timed and performed, and the subsequent treatment skillfully handled, the operation should never be fatal. The operation is practically devoid of risk to life. 474 OKIFIC1AL SURGERY. CHAPTER LXIi. VAGINAL HYSTERECTOMY. FRANCIS D. HOLBROOK, M. D. The point has been settled that conditions of the ovaries and tubes necessitating removal warrant the extirpation of the uterus as well. If the removal of these organs is neces- sary, choice must be made between the abdominal or vaginal route, or combination of the two. Notwithstanding the great progress which has been made in laparotomies in the past few years, no fair-minded person will question the statement that opening the abdomen by laparotomy is fraught with a good deal of anxiety to the conscientious and conservative surgeon. Shock is more pronounced, drainage not so good, recoveries are not so rapid from an abdominal hysterectomy as is usual with the vaginal method. Where it is possible and the opera- tion is advisable, vaginal hysterectomy is far superior in the estimation of the writer. Tumors of the uterus or appendages weighing three and four pounds have been removed by way of the vagina, showing that this route is wide in its possibilities. Deciding then for the vaginal method, we have four rec- ognized procedures, and to show the superiority of one over the others is the aim of this paper. I call attention to the clamp, the ligature, the actual cautery, and the pratt method. Dangers arising from the clamp, the ligature and the cautery method are many, some of which are impossible, and others ex- ceedingly rare by the Pratt method. I have had the pleasure of assisting the originator of this method in two hundred or more hysterectomies, and have performed, personally, the operation without a death in forty-four consecutive instances. Some of the dangers following total extirpation of the uterus are as follows: Intestinal obstruction caused by the gut adhering to margins of wound or being included in the clamp or ligature. These conditions have not been recognized in time to correct and have proved fatal. Peritonitis is fre- ORIFIC1AL SURGERY. 475 05 to P HI d a child of sickly sentimentality or religious fanaticism, but is thoroughly scientific and practical, and the results already achieved are so pronounced that its students are enthusiastic in its praise. The God worshipped by the new school is spirit, but He is not regarded as a being en- dowed with ordinary human qualities to be moved by prayers and entreaties, or angered by abuse or neglect on the part of his creatures, but is simply the great law-giver whose opera- tions among men are carried on only by means of universally prevailing principles of cause and effect, as mathematically exact in matters of mind and morals as in physics ; nay, more than this, instituting and directing all physical phenomena through the agency of indwelling forces. The stud}- of these forces, and the means of making prac- tical application of them in all the affairs of everyday life, is the work which they have laid out for themselves. They be- lieve that the essentials of all true religions are identical. But instead of being matters of mere tradition or sentimentality or superstition they regard them as nothing more or less than laws of spiritual physiology, a life according to which secures health, and a life in violation of which invites and explains disease. Now, while everybody admits the existence of thoughts and emotions, these are commonly considered very vapory and unsubstantial entities, and but few people as yet realize that mind .is a substantial reality, is, indeed, the molten sub- stance out of which all material shapes are cast. But such ORIFIC1AL SURGERY. 511 is, nevertheless, the case. And with a knowledge of this great fact, it is found to be no longer necessary to leave the mis- chief of the world brewing at its fountain head, and for re- lief be satisfied with mere scurrying about in a vain effort to exterminate the consuming fires of life by simply clearing away the smoke and ashes. Mind has always been conscious of its superiority to mat- ter; indeed, has held the entire material world to be its le- gitimate playground. It could always, through its material expression, build houses and tear them down again. It could always sing songs, write books, make speeches, wage war, raise crops, breed stock, tame forests, direct the evolutions of plant and animal life, transform minerals to its purposes, construct factories and make water run them, could paint and carve, could touch solids as with magic wand and turn them into liquids, touch liquids and transform them into gases, confine gases and convert them into power, harness the power and command it for all forms of destructive and constructive purposes. It has constructed gigantic microscopes for the more careful study of the stars, and smaller ones with which to observe the infinitesimal form of physical creation. Nor is mind yet satisfied, but is pushing its conquest still further in hopes of enabling men to fly through the air like birds and to swim under the water like fish, and is am- bitious to regulate the course of the winds, the fall of the rain, and the dashing of the waves. No surface of land or water is too broad to be traversed and to be strung with talking wires, no mountain is too high, no depth too low for explora- tion. No climate is too hot; none too cold to limit investigation. Mind, ever active, ever expanding, ever inventive, ever irre- pressible, ever aggressive, ever ambitious. God-born and God- like mind has thus come down into time and space and turned the whole world into a mere workshop for the kindergarten ex- ercises necessary to its own evolution. From the God mind has emanated the great hidden forces through whose creative ener- gies physical existence has been accomplished and continuous- ly sustained. From the human mind has come the energy and intelligence by which the virgin creations of the God mind 512 ORIFIG1AL SURGERY. have been reshaped and adapted to human wants and neces- sities, the results being harmonious and healthful just in pro- portion as man has been able and willing to think God's thoughts after Him, and discordant and disease-breeding, and consequently short-lived, to the exact extent to which man has ignorantly or willfully differed from his maker. God's love has found one form of physical expression in heat. Man's ingenuity enables him to extract this heat from numberless sources and employ it to his liking. By its use he can hatch eggs and sprout seeds, can cook, dissolve, melt or burn, and consume as he may elect. God's truth has been crystallized into raindrops so abundantly as to furnish all creation with an ample supply of water for all possible pur- poses. Man's intelligence can employ it for purposes of con- struction or destruction, as he will. It is the same with all created things. The whole God-made world is placed at man's disposal, and by his knowledge of its laws of construction and sustenance he can build up or tear down to his liking, thus being able out of the big world which furnishes him the crude material to secure the luxuries and necessities with which to endow a private habitation suitable for his occupancy. As the soul of God has clothed itself in the material universe, so has the soul of man, which is itself, like the rest of creation, God- made, taken on the material shape which constitutes its house of matter, in the health, comfort and prosperity of which we are so deeply interested. No attempt will be made to present an argument adapted to the annihilation of the philosophy which holds to a ma- terialistic causation of creation. Those who look upon mind as merely the result of brain chemistry, and explain in all species of activity upon incomprehensible conceptions of mo- lecular affinities, are at perfect liberty to stand on their heads and see things upside down, to mistake the outside for the in- side, the effects of things for their causes, the creatures for the creator, to their hearts' content. It is useless to discuss light with the blind. It is taken for granted that most of us are probably already persuaded that it is the man who weaves the garments of flesh with which he is enveloped. OEIPIC1AL SURGERY. 513 The burden of my song is to direct your attention to this great fact, and to the resulting fact of the dominating influ- ence which the soul wields in all forms of bodily expression, be it those of health or disease. As students of medicine, we are ambitious to fit ourselves for satisfactory service to whom- soever may be our patrons. This involves our ability to eradi- cate disease and establish health. We must, therefore, neces- sarily be interested in anything that will render us valuable assistance in this great errand of mercy. Now, if we once be- come fully persuaded that the mental world is the birthplace of every form of physical expression, and if we further learn that the conditions of this same world are subject to our dic- tation, we will no longer confine our studies to the surface of things, to the mere appearances which are discernible by sense perception in either our diagnoses or remedies, but gladly avail ourselves of whatever help the powers of mind may be able to furnish us in the prosecution of our lifework. Theo- retically, the new departure, which does not consist in the mere recognition of the spiritual causation of things, for that philosophy is as old as the race, but in the recognition of the fact that thoughts are things and can be effectively employed under all circumstances to transform bodily conditions, may seem sufficiently plausible. But how much in it is really of practical importance in the healing of the sick? Can mental states in reality be so manipulated as to shape physical condi- tions? If so, are they all-sufficient for remedial purposes, and is our present equipment of hard-earned medical lore an un- necessary investment and incumbrance? Or, by the acquisi- tion of mental science, will we simply add another valuable remedy to our list of remedial agents, which appears to be not yet quite long enough for the complete subjugation and eradi- cation of human diseases? These are burning questions of the hour, and are of pro- found interest not only to the laity, but, from the necessities of the situation, to doctors as well. They are serious ques- tions for the laity, for while people entertain great respect and appreciation for the indefatigable labors and faithful ser- vices of the medical advisers who have presided at their birth, 514 ORIFIC1AL SURGERY. and tended them in sickness, and advised them in matters per- taining to bodily prosperity, all along through life's journey, they are also aware of the limitations of professional possi- bilities at present attained, and keenly feel the need of more substantial help from their infirmities than doctors have as yet been able to furnish them. The natural tendency of all evolution is toward higher forms of life, and especially in times of distress, when human help proves unavailing and mortal doctors fail, man instinc- tively searches for his God. It is the fallibility of physical help that has instituted the search for a higher means of relief from which more effective and satisfactory results may be realized. From this search has come the discovery of the mental causa- tion of both "health and disease, and the necessity of suggestive therapeutics in the accomplishment of radical cures in all cases of sickness. The laity have already found such sub- stantial relief that their sympathies are strongly in favor of the practice of mental healing wherever it may prove of prac- tical service. At the same time their love and respect for their long-timed and faithful servants, the doctors, and the consciousness that they may still have need of their services in such cases as prove intractable to mental treatment, makes them hesitate in their endorsement of the new form of treat- ment without the consent and endorsement of the doctors themselves. The doctors are deeply concerned, for if there is anything of practical service to humanity in the employment of psychic forces in the cure of disease, they will be only too glad to avail themselves of its helpfulness. The only question with them is one of utility. They are loath to give their en- dorsement to any system of healing until its virtues have be- come well established, for they are naturally anxious that their professional opinion shall be so well founded as to secure their being sustained by the issue of events. They are willing to concede the unlimited influence of mind over matter in ex- ceptional cases, and to give due credit to all well-authenti- cated instances of mental healing. But the failures of mental practice are still too common, and most of the reports of cures said to be effected are entirely too unreliable to deserve con- ORIFICIAL SURGERY. 515 sideration. In determining the exact value of mental thera- peutics in the treatment of disease, there is one position which they will, therefore, in all fairness be able to sustain, and that is that the condition of the patient, both before and after treatment, shall be estimated by the same standards of diag- nosis as are employed in passing judgment upon their own work. It must not be forgotten that this estimate includes both objective and subjective symptoms. The subjective symptoms, which are merely matters of self-conscionsness on the part of the patient, by no means furnish reliable testi- mony as to the presence or absence of morbid physical condi- tions. Only by a careful invoice of objective bodily phe- nomena as well both before and after treatment, determined by universally recognized means of physical diagnosis, can an adequate record be obtained of what has and what has not been accomplished. In this respect the laity are weak, and their testimony as to the practical value of all remedial meas- ures is perfectly unreliable. They may claim to have been cured of consumption, of cancer, of tumors, of paralysis, or of other troubles, but they are not sufficiently familiar with the characteristics of any form of disease to be able to state, with any degree of reliability, the real nature of the trouble for which they were treated, or whether or not a cure has really been effected. It is a singular fact that mental healers do not seem to realize that the evidences of their work are furnished them only by sense uneducated itself, and when employed with unpracticed and uneducated faculties it is very liable to be erroneous. The diagnosis of disease can only be made by those who are thoroughly educated and skilled in its characteristics. So that the only testimony as to what has been cured and what has not by mental healing would naturally be the testi- mony of the medical experts themselves. Bodily sensations may be changed by suggestive measures, but this does not necessarily involve a change in existing pathology. Mere im- pressions and self-told tales by patients themselves are per- fectly valueless from a scientific standpoint, although an im- proved state of bodily sensations and physical comfort may 516 ORIFICIAL SURGERY. allure and deceive those who are uneducated in correct meth- ods of diagnosing physical conditions. The difference between the conscious and unconscious mind should not be overlooked or ignored. The subjective part of human suffering can undoubtedly be reached by sug- gestive therapeutics, as this is merely a matter of self-con- sciousness. It is said that the human mind can entertain but one idea and its associate ideas at the same time. Now, the sick who are constantly complaining of some form of discom- fort are universally illogical in the selection of the idea which they consent to entertain. In matters outside of themselves they are sensible enough in their pursuits to give their atten- tion to and direct their footsteps in the pursuit of whatever may be the object of their desires. Perhaps they have lost something. It takes no doctor to convince them that the way to find it is to hunt for it, and to the neglect of everything else the energies of their mind and body, and sometimes those of t^eir friends, are at once enlisted in the search for the lost. But in matters of bodily economy they are so singularly il- logical as to completely ignore this very common sense pro- ceeding. If they have lost their health and become conscious of any variety of distress in consequence, instead of focusing their powers of mind on the health which they have lost and confining their attention to what should be the legitimate ob- ject of their search until they have again secured it, they in- variably proceed to take an invoice of every ache and pain which invites their attention; and, as their sufferings increase under the stimulation of their search for why should they not find what they look for they enlist the services of others about them, doctors and nurses included, to help them in giv- ing attention to the very thing which they do not want, name- ly, the discomfort which has come upon them. Now, it is im- possible to push and pull at the same moment. Neither can one take hold and let go at the same moment. Nor can one look east and west with the same glance. And while one's mind is steadily held upon the contemplation of health, it can- not in the same instant be occupied with considerations of sickness, so that if a suggestion of what is desirable can be ORIFIG1AL SURGERY. 517 firmly grasped by the mind of the patient, he will necessarily lose consciousness of everything that is undesirable, and his former pain will pass away, for in all cases pain and discom- fort of all kinds are mere matters of attention and recogni- tion. To illustrate to what extent mental concentration shapes history, listen for a moment to the narration of two simple incidents of comparatively recent occurrence. A resident of one of the suburbs of Chicago, having a fondness for animals, secured a fine kennel of dogs, consisting of three fox terriers, two greyhounds, two St. Bernard pups, weighing 150 pounds apiece, and a beautiful collie. There was no cat on the premises, but it was the fault of the dogs, for they had no respect for cats and considered them merely as their legitimate prey. It was the delight of the greyhounds to tree them in their morning excursions with whatever equipages were in use, while it seemed to furnish keen de- light to the fox terriers to tear them to pieces whenever the opportunity presented itself. The good-natured St. Bernards and the friendly collie expressed their good-fellowship with the other dogs by simply joining in any cat-hunt which they might institute. On a beautiful Sunday morning, when all of the dogs were assembled in the carriage part of the barn, patiently waiting for something worthy of their attention to present itself, an innocent-minded, simple-hearted, inoffensive two- thirds grown kitten, leisurely entered the open door and ap- proached the dogs with the intention of joining their company. It chanced that the kitten had not been raised among her kind, but had been in constant association since her babyhood with a company of friendly dogs, among whom her lot had been cast. Dogs! why, she just loved dogs! Dogs were her friends; and she seemed pleased at this new opportunity of demonstrating her friendliness for them. Before the dogs had time to recover from their astonishment at the audacity of the new arrival in their midst, the little thing walked right up to one of the big St. Bernards and began to rub her side against the big legs of the animal and give expression to her friendly sentiments in true cat fashion. The greyhounds, 518 ORIFICIAL SURGERY. whose experience with cats had always been in the chase, with the cats in the lead, pricked up their ears and patiently waited for the kitten to start on the run, holding themselves ready to take after it. The kitten, receiving no attention from the St. Bernard, observed the expectant attitude of the grey- hounds, but misinterpreted their hostile intentions for playful- ness, so that instead of running from them it began to walk toward them. Having heretofore merely chased cats, and be- ing entirely unaccustomed to facing them, they did not know what to make of the new situation in which they were placed, and as the kitten did not seem to be afraid of them they be- came afraid of the kitten, and backed away as fast as they were approached. By this time the three fox-terriers had closed around the poor little kitten from behind, and were about to pounce upon it when they were observed by the in- truder. Recognizing in dogs no sentiment but friendliness, and with its little cat mind thoroughly imbued with the spirit of good-fellowship, the little trustful kitten stopped following the greyhounds and, while the interested collie stood patiently waiting for the excitement to begin, in a spirit of playfulness turned its attention to the fox terriers. These cat-destroyers were so dumbfounded at the audacity of the kitten that be- fore they had time to recover from their surprise the kitten began playing with them in a most cordial manner. The contagion of good will which the kitten brought with it completely overcame all opposite sentiments in the breasts of every member of this pack of cat hunters, and the kitten was duly initiated into their good graces and permanently es- tablished as one of their fast friends. Cats suffered and died at the hands of these dogs afterwards as they had done be- fore, but this specimen of the feline tribe was an exception, and was always welcome and safe in their midst. Upon the morning of its introduction to them, if a single suspicion of distrust or fear had entered the mind of the kitten, if a single hair along its spine had become erect, or its tail grown one bit larger, if it had spit just once, or expressed the slightest trace of antagonism to the dogs in any form of cat language, that Sunday morning would have been its last on earth. But ORIFIC1AL SURGERY. 519 its implicit trust in the honorable intentions of dog nature and its fidelity to its memory of all the good things it knew about dogs, saved its life and made playmates of beasts to whom friendly sentiments toward cats were a new sensation. In the next incident the dominant idea was not so happily chosen. The night was dark. One of the professors of this college was driving his faithful horse north on Racine ave- nue. As the sides of the street were rough and there were no cars in sight, the horse was driven for a short distance along the car tracks, and just as the doctor was approaching the corner of Fullerton avenue, and before he had time to guide the horse to the side of the street, an approaching cable car, with its headlight glaring in front of it, turned the corner and bore down upon him. The light immediately attracted the attention of the horse, which, instead of obeying its master and dragging him out of harm's way, suddenly stopped right in the middle of the track, not from malice (for the horse was not a balky one), but simply because its gaze was so thor- oughly fixed by the headlight of the approaching train that it lost all conscionsness of everything else. The doctor used the whip freely and shouted with all his might, but the horse was too thoroughly occupied with his new concept to heed his mas- ter's voice or his blows. With cruel speed on came the train, but the horse, unmoved by any sense of danger or by the ap- peals of his master, stood motionless on the tracks over which the train must pass. The gripman appreciated the situation too late to prevent a collision. There was a heavy thud, the doctor, badly shaken up, was entangled in the ruins of his phaeton, and the horse was killed by the shock, dying as the victim of an unfortunate concentration of attention to an approaching danger. Had it given heed to its master's bid- ding, instead of surrendering to its fears, the catastrophe would have been averted. These two incidents illustrate the power of an idea for good or for harm; and, although they occurred in animals, the principle involved in the incidents operates with equal force in human experience. "As a man thinketh in his heart so is he." Whatever idea succeeds in establishing a dominat- 520 OBlFICIAL SURGERY. ing influence in the mind of man at any time dictates the di- rection of his self-consciousness and makes good or bad his- tory, according to its quality. For this reason the conscious mind is a fertile field for the practice of suggestive therapeu- tics. And when it becomes universally recognized that joys and sorrows, and pleasures and pain, and happiness and mis- ery, and delights and tribulations, and all other states of self- consciousness are matters merely of attention and cultivation, there will be less pride in suffering and more in enjoying, less sympathy for the sick and more appreciation for the healthy. The physical world appears at first thought to be one great accumulation of fixed facts, which we may all enjoy or suffer in common, but in reality there are as many physical worlds on our small planet as there are people who cling to its surface, for all the world there is, to any living being, is merely the world of his own self-consciousness; and as no two individuals are alike in their observations and mental photo- graphs of things, so there are no two world pictures which are identical. There is no light for those who are blind, there is no sound for those who are deaf, there is no odor for those who have no sense of smell, there is no flavor for those who are devoid of the sense of taste, and there is no contact with anything on earth to those who are without the sense of touch. Those who have neither sight, nor hearing, nor smell, nor taste, nor touch are practically dead, so far as earthly existence is concerned, and for them there is no physical world. But the power to ob- serve, through the various senses, does not lie in the physical organs themselves, but in the faculties which created these organs; and as they operate merely under the stimulus of at- tention, or suggestion, if you will, all the material world that exists for any one of us is merely the one which we have pho- tographed through our various senses. This fact gives great variety to the material worlds as they exist for each one of us ; indeed, makes them as numerous as mankind itself. For some, it is a place of sickness, and suffering, and disappointment, and anguish, and failure, and death. For others, it is bright, beau- tiful, radiant, glorious, delightful. For some, it is a hard world ORIFIC1AL SURGERY. 521 of stern necessity, furnishing nothing but an eternal grind for something to eat, something to wear, and a place in which to sleep. For others, it is a land of wealth, and prosperity, and beauty, and happiness. Some would like to remain here al- ways, while for some it is but a waiting-station, where they are trying to kill time until summoned by the inevitable course of events to leave it. In view of this situation, it is a matter of extreme im- portance what photographs we take with our various facili- ties, what pictures of things about us we make and hang on memory's walls. Our tastes and inclinations are clearly dem- onstrated by the collection which we accumulate. Seek and ye shall find, knock and it shall be opened unto you, are sayings wonderfully broad in their scope of application, for they ap- ply to all the details of every-day life. How important it is, then, for us to seek for the desirable and to withdraw our at- tention from the undesirable ; to be guided in our observations by hope and trust, and refuse to recognize the things we fear and wish to avoid ! Any one who has ever ridden a bicycle ap- preciates the importance of this suggestion, for concentrated attention upon an obstruction which a rider may be nearing invites a collision. The unfortunates of life are merely those who are perpetually taking headers upon the undesirable, sim- ply because they fail to recognize this universally prevailing principle of human progress that we approach and are more or less influenced by the objects of our attention. To seek what one wants seems a mere matter of common sense, for how shall we find what we do not look for? We can never find health by hunting for disease. There is all the difference in the world between helping the Lord and fighting the devil. By the one act we are ushered into the heaven of our satisfaction, and by the other into the hell of our disappointment. The psychic factor dominates, indeed includes, the faculty of observation, and therefore acts for the great unerring power as a producer of concepts, whose accumulation makes each in- dividual world picture. There is no pain, no disease, no death to him who fails to recognize them, and much of the confusion in the debates constantly arising concerning material entities, 522 OKIFIC1AL SURGERY. has its origin merely in unequal observation. We know that our various physical faculties are many times more or less de- fective. Our eyes frequently mislead us as to the size, shape and color of things. Our ears sometimes trick us with false re- ports concerning what is heard, and our other organs of special sense are fully as prone as these to bear false witness. Like other telephones our organs of sense will sometimes get out of order. Nevertheless, we have standard tests by which to gauge the condition of our organs and correct all deviations from a normal. So that for all practical purposes the testimony of our senses is reliable, the difference between the impressions received being due, not to our physical organs, but to the dif- ferent objects for which they are employed. This fact gives great variety of opinion as to the physical entities, and at the same time may cause some one to wonder why it is that physi- cal creations seem so fixed and substantial. There is a reason for this, and it lies in the kinship of mankind and the conse- quent common directions in which the powers of observation are directed. The thought is perhaps best expressed in that thrilling, heart-warming, sustaining and harmonizing sentence so often quoted, "The fatherhood of God and the brotherhood of man. ' ' What is common to us all we recognize and seem to understand, and consequently believe in. Experiences of an individual, when unique and unheard of, are credited as mere fancies, perhaps because they are such, and perhaps because their strangeness prevents their recognition as possible veri- ties. But as all our world pictures are furnished by our physi- cal senses, these are our sole reliance for all we know, not only of life and of health, but also of disease, of remedies, of cures, and of death. Whatever changes our self-consciousness, there- fore, changes our knowledge of things. We are always more or less open to suggestion, so that whatever is able to secure our attention is registered as knowledge. External objects can do this, and those whose attention is dedicated to the signs of things merely are especially and constantly susceptible to any- thing and everything that appeals to the senses. For this rea- son, physical measures can be employed as means of diversion, ORIFIG1AL SURGERY. 523 and consequent cure; for the cure of pain lies in its forget- fulness. Now, the question of importance to us is, can internal forces, all of which consist of some varieties of thought and feeling, do the same thing ? Let us particularize so as to more fully appreciate the meaning and application of the question before us. Ether or chloroform can completely destroy con- sciousness without depriving the body of its sustaining life. Can suggestion do as much? Yes, it can; and many a capital operation has already been painlessly performed under the in- fluence of steady and intense suggestion. There are drugs which will allay pain, some of them acting generally by be- numbing all sensibility of the body, such as morphine, codine, phenacetine, etc., others acting specifically, as ipecac for nau- sea, colocynth for abdominal cramps, doscorea for bilious colic, digitalis for palpitation of the heart, belladonna for headache, bryoma for pleuritic pains, etc. Now, have drlugs in both their general and specific actions upon bodily conditions their sug- gestive counterparts? Most certainly they have, especially in people who can surrender themselves to their operation, for the success of suggestion depends to a great extent upon the power of mental concentration. Instances of this are so fre- quent as of necessity to be more or less frequently observed by all of us. Drugs can allay fever, although they frequently fail, possibly because poorly selected. The record of the action of mental forces clearly demonstrates that they also can allay fevers and subdue inflammations. Indeed, if one but reflects upon the matter, it is the play of disordered psychic forces that produces confusion among the tissues of the body and makes fever possible. One cannot blister or inflame a corpse, and nothing but the element of life can produce such bodily con- sternation as to inflame tissues, either generally or locally. Now if psychic forces can induce fever, and if it is possible to con- trol their action to one's liking, they should in all reason be equally efficacious in resolving inflammations and subduing fevers. In this way we might go on indefinitely through a long list of human ailments of which the body is conscious, and still 524 ORIFIG1AL SURGERY. further emphasize the fact that the cure of conscious ailments among human sufferers is in all cases accomplished by a re- adjustment of indwelling forces, whether the remedy employed be a drug or a thought. The comparative merits of the two forms of treatment is too extensive a subject for considera- tion this evening. As truth, however, is never inconsistent with itself, it is safe to conclude that the various measures, be they physical or mental, which have been found beneficial in any form of sickness will not quarrel, and there is no reason why it should not be as legitimate medical practice to think away dis- ease as to exterminate it by drug action, and where either alone may prove insufficient to employ both methods at the same time. But what of the unconscious mind and its more serious troubles of organized pathology? Suggestion may divert the attention of the conscious part of a sufferer until its spell serves as an anodyne and allays pain, relieves the superficial symp- toms of disease, and corrects the various forms of functional derangements. But can the soul in its innermost depths be so stirred and purged of its impurities, inherited and acquired, as to dissolve, disintegrate, and remove all physical traces of a well recognized serious malady, so that when the case is sub- jected to the standard tests of physical exploration, a radical cure can be truthfully pronounced to have been effected? Can the intellectual and emotional nature of one whose system has taken on the physical expression of cancer, consumption, syphilis, scrofula, rheumatic gout, or any of the deep-seated constitutional maladies usually so fatal in their results, be so tuned to harmonious and health-giving action by processes of suggestion as to restore physical perfection and completely eliminate the deadly poisons and all traces of their existence from the tissues of the body? Can mental healing reach the children ? Can it cure the insane ? It is not so important that the simpler, more superficial maladies which afflict the human race should be provided with a new form of treatment, how- ever successful it may be, for the measures already at the com- mand of the medical profession are quite serviceable and sat- isfactory in these types of disease. But where more light is needed and additional help wanted is in the cases for which ORIFIG1AL SURGERY. 525 at present there appears to be no adequate form of relief. Can the sins of omission and commission, which must be deep-seated to have resulted so disastrously, be so thoroughly erased from the pages of the book of life, which is but another name for the unconscious mind, as to reinvigorate the entire physical or- ganization and materially extend its period of earthly experi- ence? As the body is but the effect, of which the indwelling life or spirit is the cause, whatever condition it may display must of necessity stand for soul habits or realities. A careful analy- sis of the spiritual organization of man resolves it into two primal elements, namely, thoughts and emotions; and if mis- chief of any type whatsoever appears in bodily expression, it must be the fault of either the head or the heart. The specific cause of the difficulty may prove difficult to trace in any given case, for the depths of life are fathomless and dark, and diffi- cult of exploration. But of one thing we can be certain, that the hope for a radical cure of physical pathology lies in the di- rection of soul purification. We want so much that proves to be bad for us, and our wits are so thoroughly dedicated to the service of our heart's desires, that we can scarcely hope to ef- fect radical cures of constitutional maladies by physical meas- ures alone. The axe must be laid at the root of the tree, which means that the mistakes and errors of the inner life must be reached and corrected before complete healing is secured. So let us extend a hearty welcome to all forms of sub- stantial progress. Doctors in general may be a little appre- hensive that their equipment of physical knowledge and para- phernalia for the treatment of disease may lose 'their due ap- preciation, and their prospects for useful and successful lives be thus seriously injured. But there is really no occasion for alarm in this direction : for truth, when once born into the world, is never lost, and all that has proved serviceable in their work will always be needed so long as the conditions which call for it prevail. There is such a thing as thought-transference or telepathy. Its operation is more rapid than light or electricity, or any other force of which we have any knowledge. Unconsciously, 526 ORIFIC'IAL SURGERY. it is in active operation at all times and among all people, but its existence is usually unrecognized, and although a few prac- ticed experts have been able in some cases to make practical use of this power for definite purposes of communication, nev- ertheless the science of conscious thought-talking is certainly in its infancy. Should it, however, finally become developed and be available for everyday use, would it necessarily para- lyze the business of the great ocean cables of the world or dis- pense with the telegraph or telephone wires? The invention of wire-talking has by no means dispensed with written com- munications, and lip service and the mail service of every country is still thriving, and private and public oratory seem just as necessary as a means of communication as ever. Analagous to these same lines of progress has been the growth and development of medical practice. The new light which has evidently come into the entire world is flooding the practice of medicine as it is all the other activities and occu- pations of men. The psychic factor at last demands recognition, study and appreciation. Nevertheless, the enjoyment of health as well as the affliction of sickness is almost universally ascribed to external conditions. The environment of the individual is held by almost everybody as responsible for whatever develop- ments occur in the history of physical existence: whereas in all cases it is not what happens, but the interpretation of what happens that is responsible for history. The challenge to be sick, with visible excuse, lies everywhere about us at all times. The acceptance of the challenge, the surrender to its influence, lies purely with the conditions of the individual at all times. The element of susceptibility seems to have been overlooked by professional diagnosticians, notwithstanding the fact that under identically the same conditions no two individuals mani- fest the same inclinations or secure the same results. No ade- quate explanation has ever been offered for the great fact that what is one man's meat is another man's poison. But disease, like health, is not from without, but from within, and this unconsidered element of susceptibility, the personal and yet unconscious interpretation of the incidents OBIFIC1AL SURGERY. 527 and accidents of time, which alone is responsible for the history of every event which is etched into bodily expression, is at last looming into importance, and demonstrating the necessity of suggestive therapeutics as a long-needed supplement to physical medicine. The phrase, supplement to physical medicine, is used ad- visedly. For, whereas, the order of creation is unquestionably from within outward, our knowledge of it must always proceed from without inward. We undoubtedly came from an unsensed shore. But all the knowledge of that shore which we can ob- tain in this world will be by means of knowledge furnished us by the senses themselves, and while we linger on earth we will never be able to dispense with their services. We obtain a knowledge of the letters of the alphabet from the picture-blocks of childhood, and, although later on we learn to spell out the whole dictionary of words in which are crystallized all the knowledge of this world or the next which we ever come to possess, we never forget our letters, nor can we dispense with them. We may acquire other means of communication, may talk by sounds or signs, or even by thought transference, but written language, with its familiar words and more familiar letters, will be a human necessity throughout all time. As well, there can be no lasting science in metaphysics which does not rest as a basis upon correct principles of physics. This is a sweeping proposition, and true in its every possible application. Bringing it home to the subject under discussion tonight, we are forced to the conclusion that, although a human soul is undoubtedly the active force which has constructed, from materials furnished by the earth, every human form that has ever been projected into the realm of time and space, and al- though the soul continues as the active agent of continued earthly existence and is responsible for every form of it, be it that of health of disease, nevertheless there can be no accurate knowledge of soul-formation, of soul-physiology, or of soul- pathology, or no specific and enduring form of soul-medica- tion or soul-treatment that does not issue from corresponding 528 ORIFICIAL SURGERY. physical knowledge. And just so long as the alphabet of our childhood will be needed in the language of the race, without regard to the degree of wisdom to which it may ultimately at- tain, so will every well-established fact known to the physical practice of medicine be always retained as a necessary basis for whatever knowledge of the higher medicine may ultimately come into our possession. For this reason, practitioners of physical medicine must of necessity become the most scientific and successful spiritual practitioners of the future, and the greater and more accurate their knowledge of the human body and its operations, and of the various physical measures found useful in accomplishing physical repairs, the more accurate, detailed and, consequently, serviceable may their knowledge of spiritual conditions and new remedies become. For the present, it but remains to remind those who seem imbued with the desire to ignore all physical knowledge in their search for the underlying principles of truth which are expected to be a panacea for human ills, that when in any of our processes of evolution we retire completely from the ac- cumulated facts of sense perception as a basis of scientific work, we at the same time effect our complete exit from earth and leave our physical world behind us, in which case the search for healing truths will be no longer necessary, for then, we arp told, "there shall be no more sickness nor death, neither sorrow nor crying, for the former things are passed away." In the meantime, let us go on with our medical studies, let us learn all we can of physical aids to the cure of disease. It requires a thorough knowledge of arithmetic and algebra and geometry and trigonometry to fit one for the study of as- tronomy. But without a knowledge of astronomy, our train- ing in mathematics is incomplete. So, in addition to our physical knowledge, let us welcome the new light which is come into the world. It is the astronomy of our medical math- ematics. There is nothing whatever incompatible in the vari- ous forms of healing. In man perfect health reigns only when the objective and the subjective mind, or the internal and the ORIFIG1AL SURGERY. 529 external, are adjusted to harmonious operation; so, too, will doctors become true healers of diseases only when mental and physical healing become embodied in a single system of active, everyday practice. CHAPTER LXVIII. MENTAL HEALING. E. H. PRATT, M. D. Shall we ignore it, condemn it, tolerate it, or make use of it and add it to our already long list of legitimate remedial measures ? We cannot afford to ignore it, for too large a number of patrons are deeply interested in it and will not permit it to remain unnoticed. We cannot condemn it, for although its sins of omission are great, our own shortcomings unfit us for the task even if it were otherwise possible of accomplishment. And then, too, its claims for recognition, like our own, are based upon what it has done and not upon what it has failed to do. As to its toleration, this will not be a matter of choice with us for it has evidently come to stay, and its friends and advo- cates and defenders are too great and too enthusiastic a host to be downed by any action, however concerted, upon our part. It is certainly old enough to be entitled to recognition, for mental healing has been employed for the cure of the sick from a time so long ago as to be completely lost in the vista of the centuries. Its special claim to recognition in our own time lies in the fact that it now claims to be established upon a scientific basis and is no longer a mere superstition, a senti- ment, a religious fanaticism. To be sure, there is still a sect of faith healers who are as unscientific in their methods as they are uncertain in their results. But since the time when Swedenborg spoke of human beings as possessed of an internal and external, and especially after his analysis was copied by the Christian Scientists, only named differently, being referred 530 OKIFIC'IAL SURGERY. to as the personality and the individuality, and by Hudson in his "Law of Psychic Phenomena," the same distinction being kept up under still different titles, namely, the objective and the subjective minds, observation, reason and experiment have been furnished with a substantial basis for their operations not previously enjoyed, and the claim of mental healing as a scientific means of cure can by no means be considered as absurd. Many of the inconsistencies constantly encountered in any individual experience between mental and physical condi- tions, and the confusion occasioned by observing the great dis- crepancies between mental fancies and physical facts can be readily accounted for and explained by recalling the double nature of man, whether considered physically or mentally. Physically, the nervous system which dominates nutrition, which builds up and tears down tissues, which presides over functions, which blesses with health or afflcts with disease, which ignites inflammations and which extinguishes their fires, which is responsible in fact for all bodily normalities and abnormalities, is the sympathetic. Its activity is steady and unremitting in its operation from birth to death, through wak- ing and through sleeping, through work and through play, through calms and through storms, through sickness and through health. The action upon the organism of the cerebro- spinal system is intermittent, erratic, and for the sole purpose of adjusting the individual to its liking with reference to its environment. By its various senses it warns the body of its dangers and cognizes its delights. By the voluntary muscular system, which it dominates, it moves the body about to its liking, orders its footsteps, prescribes its work and its rest, its smiles and its tears, and in every way dominates its volun- tary activities. But there it stops. It can blush or pale a face, or prescribe bodily tasks or pastimes, or work it or rest it, but it cannot nourish it. The cerebro-spinal system can neither digest, circulate, nor appropriate food nor dispose of the debris from the wear and tear of tissues, except secondarily as it is able to obtain the co-operation of the sympathetic sys- ORIFIC1AL SURGERY. 531 tern, which fortunately for mankind, has a mind of its own and is not at all times and in all places at the mercy of the ce- rebro-spinal activities. The mind, or indwelling spirit, which animates the sym- pathetic nervous system, is unquestionably the subjective mind of Hudson, the individuality of the Christian Scientists, or the internal of Swedenborg, while the soul of the cerebro-spinal system or its vitalizing principle is the objective mind of Hud- son, the personality of the Christian Scientists, or the external of Swedenborg. The two natures of man, the external and in- ternal, or the personality and the individuality, or the ob- jective and subjective, or whatever else they be termed, are always more or less at variance in every human being. And hence the incongruities which are constantly arising between the fancies of the external, the personal, the objective which habitates the cerebro-spinal system, and the internal, indi- vidual or subjective, which has its dwelling place and finds its bodily expression through the sympathetic. This is why in serious illness many times the faith and trust deeply implanted in the sympathetic nerve may serve to effect a restoration to health in spite of the fact that the ce- rebro-spinal organization is thoroughly impregnated with the fear of perpetual illness or speedy death ; or, on the other hand, how a deep-seated conviction that the end has come, when op- erating through the sympathetic nerve, can bring to an untime- ly end all the activities of the body, and prescribe death in spite of all the hopes, aspirations and expectations entertained by the spirit of the cerebro-spinal nervous system. In other words, it is our book of life, the" unconscious, the involuntary, internal, personal, subjective part of us that holds our keep- ing in its hands, and prescribes for us our days and conditions, that registers our histories and unfolds our prophecies. A persistent or determined belief or desire on the part of the indwelling vitality of the cerebro-spinal system may, and undoubtedly many times does, influence the course of action of the sympathetic nerve, and in such cases can affect the deep issues of health and disease, life and death. But not necessar- ily so. For our judgments, which belong to the one, and our 532 ORIFIG1AL SURGERY. intuitions, which characterize the other, are by no means in agreement, however fierce the struggle for supremacy. Women sometimes have a mind of their own, even if they are married, and the sympathetic nerve, which stands for the feminine ele- ments of the individual, can cling so closely to its faith in how things should be, and how they will be, in spite of all the per- suasive eloquence of the more wilful nature which finds ex- pression through the cerebro-spinal system as to exercise de- cisive action in all measures of bodily economy. They say that women rule the world. Be this as it may, it is certain that in the personal economy of every human being the sympathetic nerve, which contains the internal, individual, subjective, in- tuitive, or womanly, part of man, most emphatically runs the bodily household. Her plans may be wrecked, her activities disturbed by the lordly cerebro-spinal, but she has a mind of her own, and she carries her point. But it is the separate and distinct characteristics of these two parts of our nature that so often saves us or ruins us in spite of ourselves. The cerebro- spinal system may fear indigestion, but the sympathetic system will scout the idea, and take care of a good dinner. The ce- rebro-spinal system may violate any one or all of the ten com- mandments to the point of bodily annihilation if it had the say in the matter, while the sympathetic nerve may calmly and quietly follow a more practical career, and shield the general household from the danger that otherwise would follow it. Or the judgment of the cerebro-spinal system may in all sincerity of purpose issue bodily decrees, which may be easily set at naught by an opinionated intuitional sympathetic. It is only united households which stand. And it is only where judg- ment and intuition agree that fancies will conform to facts, and hopes and fears, and all thoughts and emotions in all their varieties find accurate expression in physical conditions. In all bodily repair, therefore, this double organization of man must constantly be borne in mind, and when the measures employed are mental or physical they can only secure perma- nency of results as they are able to influence the action of the sympathetic nerve. ORIFIG1AL SURGERY. 533 That mental forces are capable of exercising action, suf- ficiently deep-seated to affect the intuitional part of man's nature which presides over his functions and nutritions, has now been demonstrated so plainly and repeatedly that any one who is at all open to conviction may easily become persuaded of the fact by carefully conducted investigation. In this great fact mental healing finds its excuse for existence and for recog- nition, and also justifies its claim of a scientific basis of opera- tion, for all cures, be they accomplished through physics or metaphysics, are universally effected through the agency of the blood vessels, under the immediate command of whatever in- fluences the sympathetic nervous S3 r stem to action. Truth is never inconsistent with itself, whatever be the plane of its manifestation. College-bred men do not necessar- ily make poor farmers, culture is not inconsistent with good carpenter work, religion need not incapacitate a day laborer for his toil, and a recognition of the value of psychic forces in curing disease by no means depreciates the value of drags and scalpels. Physics and metaphysics are not rivals; but when rightly interpreted are mutually helpful to each other. Doc- tors, perhaps, have been heretofore too materialistic in their ardent search for helps for human ills ; and, on the other hand, mental healers have made strenuous efforts to ignore physical aid. Thus each class of workers has done more or less in- justice to the other class, and established an unwholesome ri- valry between measures which should act in harmony. The soul and the body should not quarrel, neither should mental and physical healing; but the scope of each should be care- fully considered and discussed, and each given its proper field of operation, as only by their co-operation can humanity ever enjoy emancipation from its ills. Both air and soil are essential to the growth of trees and plants, and roots and branches are not rivals but mutual helps in plant development. In a like manner should physics and metaphysics be mutu- ally helpful. Any system of cure that ignores the factor which the soul life of the patient plays in the problem of disease is too superficial and elementary to be permanently, and in many 534 ORIFIC1AL SURGERY. cases even temporarily effective. On the other hand a system of healing based purely upon suggestion, if solely relied upon in active practice would soon find itself so burdened with sins of omission as to speedily bring it into well deserved dis- repute. While the letter alone kills in the practice of medicine as elsewhere the disembodied spirit is too ghostly for earthly purposes. The letter must contain the spirit, and at the same time the spirit must rest in the letter to be of practical service to mankind. Abuse of any organ of the body may institute pathological changes too deep-seated for a change of habits to efface. Nevertheless to ascribe all diseases to physical causes in this age of enlightenment is both illogical and childish. The psychic factor demands and must receive recognition. On the other hand physical agencies are helps that mankind will never be able to ignore. Both mind and matter are God-made and law-governed, and are so closely intertwined as to be perfectly inseparable in all forms of bodily activity, be it in health or disease. The logical sequence is plain. If both mental and physical forces are operative in the production of disease their combined action is called for in its cure. The senseless rivalry between legitimate curative agencies should be speedily cried down. Prejudice, bigotry and intolerance have lived long enough. The harm which they have already accomplished to humanity is incalculable, and there is now a crying need for a broader philanthropy more in keeping with the free spirit of the age. Whatever will heal the sick should concern doctors, be it men- tal or physical ; and the efficacy of mental healing, properly and scientifically applied, especially when used in conjunction with well directed physical measures, it seems to us has now been so thoroughly established as to entitle it to recognition as a worthy, accurate, scientific and desirable aid in the heal- ing of the sick. It belongs on our list of legitimate remedial measures, and its study should be prosecuted with the thor- oughness and vigor which characterizes all our investigations. In their struggles with disease and death doctors have al- ways had a hard time of it. Their victories have been fre- quent enough to keep their consciences fairly clear, so that ORIFICIAL SURGERY. 535 the poor living which the world has given them has seemed to them well earned. But so many times their cures have been merely temporary, and so often they could not cure at all but only palliate, and besides this, the fact that the great volume of sickness is practically undiminished, and that nearly all the deaths in the world, even from a doctor's standpoint, are pre- mature, in spite of the long-drawn battle which has lasted through all time, keeps them constantly on the alert for still more effective weapons of warfare. Doctors are hard, consci- entious students, and are constantly endeavoring to improve their methods, and are always willing to endorse and make use of any measure of true merit that will render valuable service in either curing or preventing disease, and just as soon as they are persuaded that suggestive therapeutics has an available and reliable healing power they will be only too glad to give it their hearty support and encouragement, and make use of it for all it is worth. The advocates of mental healing should be patient for recognition. A too ready acceptance of every measure which presumes to healing power is by no means desirable, and true conservatism on the part of the guardians of the public health is the only safe policy for the people, because otherwise quack- ery and humbuggery would be rampant and lead to endless confusion and disappointment, while on the other hand any measure of true merit can well afford to wait patiently and undergo a sufficiently long and severe test at the hands of competent judges before receiving whatever recognition its real value entitles it to. So many cure-alls have been tried and found wanting, so many theories have been so auspiciously in- augurated and have so ignominiously failed to fulfill their promises of relief, that every new cry of lo, here ! and lo, there ! is naturally looked upon with suspicion, and only upon the presentation of proper credentials does any measure become entitled to even a trial of its merits. The credentials of mental healing, however, are all right. Its processes are rational, its frequent cures have demon- strated beyond the possibility of a doubt its practicality and efficiency. But its failures are likewise numerous, and it has 536 ORIFIG1AL SURGERY. already done much mischief, being guilty, like all other reme- dial measures that have ultimately come into lasting favor, of many sins of both omission and commission, so that while it has already passed into quite universal recognition as a power there remains yet to be defined its legitimate sphere of appli- cation and its limitations. In speaking of mental healing as a means of cure we by no means wish to imply that there is one well defined and universally accepted method of applying mental forces as a remedial agent. Doctors of all descriptions are quite univer- sally celebrated for their differences of opinion, and mental healers are by no means less distinguished in this respect than those who rely solely upon so-called physical measures. For the purpose of the present consideration we wish simply to recognize the fact that the power of mind to dominate mat- ter for both weal and woe has now been so well established as to deserve universal recognition at the hands of the medical profession, and to outline as well as we are able what seems to us, for the present at least, its legitimate field of application. All phenomena which we call facts, because we can prove their existence by sense perception, are beyond all question simply the products of forces. The forces themselves we can neither hear, see, smell, taste nor touch. The harmonious opera- tion of forces which we call health is by no means a naked re- ality, but appeals to our consciousness only through the sym- metrical forms which it takes on. The discordant operation of indwelling forces which alone constitutes disease is equally hid- den from sense perception, which is able to recognize merely its ill-shapen results. Both health and disease are therefore as incapable of diagnosis by physical means as is gravity, elec- tricity and every other power. Those who have heretofore fancied that they could de- tect the presence or absence of either health or disease in its incipiency must correct their impressions. Only by their fruits are they subject to our ordinary means of diagnosis. We know that whatever man has invented or constructed in the physical world has been accomplished by the combined action of his thoughts and feelings. What he wanted has in- ORIFICIAL SURGERY. 537 variably been his motive power, and what he thought has un- der all circumstances furnished it shape. The heads and hearts have thus fathered and mothered every creation of man. Such is likewise the universal plan of all creation. God's love, clothed with his wisdom, has brought everything that is into existence. All the products of God's creation are pro- nounced by the Creator himself, not merely in his written word but in the very fact that he created them, to be good. Both his love and his wisdom must therefore be infinitely good and infinitely true, as their combined operation is infinitely perfect. If the loves and the thoughts of man are equally respon- sible for all that he is and becomes and accomplishes, and if the results are unsatisfactory, the real fault must lie with what he feels or what he thinks. If he were equally pure-hearted and clear-headed with the God who made him and sustains him, all his works would be correspondingly perfect. His health would be perpetual and disease would be unknown. In search- ing for the causes of disease, therefore, in their incipiency, we must inquire into his affections and interrogate his mental op- erations. In both God and man, love is life, and truth is its form. In God we can only presume that his love, which is in- finite, is pure and unselfish, and bestowed in all its fullness up- on his entire creation. He must love it for its own sake, and his sole source of satisfaction must be in giving. His infinite wisdom must be co-equal with his love and unerring in its op- eration. With him there can be no sin, sickness, or death. In man, love may be of two kinds a love of God and man's neigh- bor, or a love of self. His thoughts can be true and logical, or false and inconsistent. Love of God and the neighbor, united with true thinking, never made anybody sick. Such a result would be perfectly incongruous with such a cause. All sick- ness, therefore, must result from some form of selfishness mar- ried to some type of falsity. The radical cure of disease, there- fore, involves his being shorn of selfishness and established in the habits of correct thinking. And is this not the true scope of mental healing? 538 ORIFIC1AL SURGEKV. In a good many cases, when the causes of disease have been removed, the disastrous effects, which may have gone no further than mere functional derangements, will speedily dis- appear. And in such eases mental therapeutics should furnish ample remedial measures. At other times, however, where dis- ease has passed the boundary lines of mere functional derange- ments, and reached the stage of more or less tangible physical pathology, the establishment of correct habits of thinking and feeling will scarcely be able to undo the mischief already ac- complished until the time comes when mental forces become sufficiently powerful to raise the dead. And in all such in- stances mental healing will have found its limitations, and will feel the need of so-called physical means to supplement its op- erations. Doctors need not become apprehensive at the pros- pect of the inauguration of this premeditated attempt to eradi- cate disease by attacking it at its incipiency, nor let their scal- pels get rusty, nor burn up their splints and bandages, nor empty their bottles, for some little time to come, for humanity has erred so continuously and so extensively that even if it should become universally christianized in the true and heal- ing sense of the term, the particles of humanity that have al- ready become so thoroughly dead as to be beyond resurrection, would still keep the so-called physical doctors busy for a long time with all their implements for molecular grave digging in the occupation of giving the various products of destruction a decent burial. The present scope of mental healing, it seems to us, therefore, is the eradication from the human heart of selfishness and of falsity, and its present limitations we would define to be the boundary lines, which we are willing to con- fess are more or less indefinite, between functional derange- ments and organic pathology. Mental and physical healers have not the slightest occasion, therefore, to be jealous of one another, but on the contrary should join their forces in a com- bined attack upon sickness and death, each having a task suf- ficiently arduous to satisfy all laudable ambitions for work and usefulness in the interesting pursuit of the health and happiness and longevity of the human race. ORIFIG1AL SURGERY. 539 If mental therapeutics can purify the wicked hearts and straighten out the tangled brains of men; if it can purge hu- manity of its selfishness and inaugurate correct thinking, no honorable minded practitioner of medicine would interfere with its labors, but on the contrary bid it a hearty Godspeed and aid it in its work in every possible manner. The only ob- jection which can reasonably be raised to the employment of mental therapeutics is the ambition of too optimistic healers to dispense entirely in all cases of disease with every form of physical aid, and court responsibilities which they are, as yet at least, unfitted to bear, and which are sure, therefore, to visit upon their heads such serious sins of omission and commission as to bring their cause, which is really a worthy one and ca- pable of much good if prosecuted with a safe conservatism, in- to well-earned disrepute. A case in point will perhaps fur- nish an illustration that will ensure a correct interpretation of our position. A man of much worth to the community in which he lived, and between fifty and sixty years of age, had been for many years suffering from severe attacks of asthma, accompanying a chronic bronchitis which he had long kept at bay by re- peated vacations. Being of a skeptical turn of mind as to the efficiency of doctors, in his case at least, he had refused their assistance and struggled on as best he could with his malady. His good wife a few years since became a convert to what is known as Christian Science, accepting the extreme type which denies the efficacy in disease of all physical remedies. This little family was an illustration of the homely saying that "a prophet is not without honor save in his own country." The sick man, skeptical concerning doctors, was equally skeptical concerning the doctrine of mental healing, so that the frequent pleadings of his wife to accept her extreme views on mental therapeutics were steadily resisted, although he occasionally submitted to so-called treatments, and as he often thought with benefit. His case happened to be one of a type in which surgical measures are uniformly efficacious, and but for his skepticism his cure at any time could have been easily ef- fected by the aid of a little perfectly safe and harmless sur- 540 ORIFIG1AL SURGERY. gery. But while his fear of doctors was great his fear of sur- geons was still greater, and he resolved to die rather than sub- mit to their suggestions and procedures. In the course of time his malady gradually sapped his vitality until his flesh wasted to an extreme degree, his heart became strained and diseased by over-exertion, dropsical tendencies began to manifest them- selves in his feet and ankles, and his breathing was so labored that he was unable to lie down or sleep more than an hour or two in the twenty-four even in a sitting posture; when his asthmatic paroxysms of coughing would seize him, he would grow so purple in the face that it seemed to his watchers that each attack would end the struggle. He at last became per- suaded that his end was near, and yet he was not willing to die, so finally surrendered. It was to a doctor, however, and not a Christian Scientist. But his surrender was complete. He mastered his worst fears and summoned a surgeon. The case was an extreme one, having been neglected so long, but the surgeon had the courage of his convictions and, furnished with ample means for resuscitation, placed the sufferer under an anesthetic and proceeded with the operation, which, had it been accomplished years before, would have undoubtedly ef- fected a speedy cure of his distressing malady. As it was the patient behaved so badly under the anesthetic that only a part of the work could be accomplished, but enough, however, to give substantial relief. In a short time sleep came to the tired eyelids, the asthmatic attacks were less severe and frequent, the appetite returned, the heart's action became stronger and more regular, the swelling of the feet disappeared, and the pa- tient became sufficiently convalescent to visit the doctor at his office. The recovery of the case seemed almost like a resur- rection. But now comes the pitiful part of the history. The com- pletion of the surgical work, which was left in an unfinished state, was deemed necessary by the surgeon to ensure a per- manency of results. The patient, however, had not been com- pletely cured of his fear of the surgeon's knife, and as the wife again put in her plea for the employment of mental heal- ing in the case, the surgeon, who was in sympathy with the OEIFIC1AL SURGEEY. 541 employment of mental therapeutics when practiced with proper limitations, was glad to accept the assistance of the wife, through whom by means of her Christian Science accomplish- ments he hoped to succeed in reassuring his patient sufficiently to be permitted to complete his work and finish the cure of the case. Imagine his disgust, however, when the patient, who had been so marvelously rescued by physical measures, sur- rendered himself completely to the care of a Christian Scien- tist who considered it her first duty to undermine the trustful confidence of the patient which the surgeon had honorably won. She demanded that he should rely solely upon her ef- forts and completely throw aside all physical crutches of whatever type. She was not willing to recognize the efficacy of any form of physical measures and demanded his complete surrender to her keeping. The responsibility, great as it was, was placed in her hands and the surgeon never saw his dear friend and patient again. Inside of a month's time, owing un- questionably to the uncompleted state of the physical work, a relapse ensued and the metaphysician proved unworthy the tre- mendous responsibility she had invited and accepted. A brief death notice in a morning paper told the interested and de- feated surgeon that while one poor misguided, unfortunate man, a valued citizen and friend, had passed to his grave pre- maturely, there was still living a woman equally poor, unfortu- nate and misguided, who had already done much mischief by her dangerous fanaticism, and who would probably do still more if suitable opportunities presented themselves unless re- morse for her uncalled-for interference and its disastrous re- sults opened her eyes to the error of her ways, a consumma- tion devoutly to be wished for but scarcely to be expected. There is one thought which should cure extremists of the folly of fanaticism in the direction of mental healing, and that is that if mind is God-made so is matter, or what we call matter, and when beneficial effects beyond all question can be had by material agencies, it is not only irrational, but in responsible cases, like the one just detailed, positively criminal to eschew their help. All things work together for good, and mental therapeutics and all the physical helps of the doctor's art are 542 ORIFIG1AL SURGERY. by no means incongruous, but, on the other hand, are mutually helpful. Those who give their exclusive attention to the study of mental healing will have ample opportunity for the exercise of all their powers in the eradication of selfishness and ignor- ance from mankind, and in doing so they will undoubtedly make many cures and relieve much suffering. For that task they are well fitted, and in that labor they will not be handi- capped or interfered with by any doctor who has the good of humanity at heart, who will only be too ready to join their ranks and help them. There is no condition of health or disease in which the element of fear does not do serious mischief. Let suggestion be aimed at it until every vestige of it is destroyed. There is no condition of health or disease in which jealousy is not harm- ful. Let it be suggested out of existence by all means as speedily as possible. There is no condition of health or disease to which greed is not so extremely detrimental that it deserves the earnest consideration of all mental healers. It is a com- mon as well as grievous fault. There is no condition of health or disease in which sensuality, in all its types, is not only dis- graceful but also disastrous. Suggestive therapeutics is es- pecially fitted to cope with it, and a warfare of extermination should be at once inaugurated. There is no condition of health or disease in which hatred is not a dangerous attribute. Let it be marked by psychic specialists for complete extinction. There is no condition of health or disease that worry does not disturb and damage. Let wholesome thought currents be directed against it until it is annihilated. Let mental healers attack insincerity, distrust, infidelity, skepticism, and ignorance, and all errors of the heart and mistakes of the head, until every thrill of selfishness is extracted from the hearts, and every false thought or suggestion is swept from the brains of men. Disease will then unquestionably be antidoted at its source, and although all its effects will not immediately pass away punish- ment will be lessened, and the physical aid furnished mankind by its able and hard-working corps of medical experts will be more rapid in its action and permanent in its effects. In the meantime mental healers should not antagonize the medical ORIFJC'IAL SURGERY. 543 profession by courting responsibilities beyond their ability to successfully cope with and foolishly deny the efficacy of well- established lines of cure, which, while they are limited in their usefulness to be sure, are still invaluable helps to humanity in times of need. "Let all things work together for good." CHAPTER LXIX. SUGGESTIVE THERAPEUTICS IN THE TREATMENT OF CHRONIC CASES ; OR AS AN AID TO ORIFICIAL SURGERY. C. T. HOOD, M. D. At the request of your secretary, and at the solicitation of our mutual friend, Professor Pratt, I have written this short paper on Suggestive Therapeutics, in the hope that perhaps a few ideas might be presented that would be of some service to you in the treatment of chronic diseases. It is not intended at this time to enter into any scientific discussion, or present any scientific basis for suggestive thera- peutics. It is taken for granted that all of you, or at least all who will participate in the discussion of this paper, admit the so-called hypnotic state, or suggestive state. Nothing will be said in regard to the induction of the so-called hypnotic state, or the modus operandi necessary. It is intended in this paper simply to discuss suggestion in its relation to the production and relief and therapeutic application in chronic diseases. If we reiterate some things that are familiar to you all in order that we may have somewhat of a practical basis upon which to begin work, the only excuse we offer is that truth cannot be too often told. It is generally admitted today, by scientific men as well as neurologists, that the human mind is aduality ; that it consists of the objective, or conscious, mind, and the subjective, or un- conscious, mind. That the objective mind is the ego, the self, the so-called will of the individual ; that it presides over the 544 ORIFiClAL SURGERY. voluntary acts of the human body; that being the will, it is like all other parts of the human body that are under control of the will or the voluntary parts it requires sleep for its re- cuperation. The objective mind has a certain amount of con- trol over the subjective mind, but it only exerts this control while it, the objective mind, is in activity. The objective mind, while it usually acts upon reason, in very many instances it acts upon suggestion. The more enfeebled the will or the ob- jective mind is, the more readily will it accept suggestions and act upon them. These thoughts are of importance to a logical understanding of what we are about to present. The subjective mind is of a very different character. It presides over the involuntary parts of the body; its action is upon digestion, upon absorption and assimilation, and excre- tion and secretion ; upon the circulation of the blood ; the flow of the lymph ; osmosis and endosmosis, and even the chemical action that takes place in the cells is to a certain extent under the control of the subjective mind. The subjective mind differs also from the objective mind in that it never acts upon reason or by reason, but always acts by suggestion and suggestion alone. The odor of something cooking produces a flow of saliva ; the sight of something good to eat causes the saliva to flow ; the presence of food in the stomach causes gastric juice to be secreted. The presence of materials in the intestinal canal causes peristaltic action. The presence of blood with its floating material in the kidney caus- es the excretion and secretion of urine. And so through the entire apparently complex, yet simple process of normal physi- ology. Yet these things are but the result of suggestions con- veyed to the subjective mind. I am well aware that this is taking rather a broad stand, but I do not at this time care to go into the discussion of this part of the subject. However, scientific investigation and careful experimenting have dem- onstrated and I think it can be shown to any candid mind that these are facts. Admitting them, we have, then two propositions for discussion in accordance with our subject. First. What part does suggestion play in the production of chronic diseased conditions? ORIFIG1AL SURGERY. 545 Perhaps we had better leave out that word diseased, and say, What part has suggestion in the production of chronic conditions ? First, then, what part does the objective mind take in the production of chronic conditions? Keeping in mind the fact that the objective mind usually acts upon reason, but that it frequently accepts suggestions, it is easy to understand how suggestions to the objective mind that certain parts of the body are ill; that a kidney is dis- eased ; that a liver is diseased ; that digestion is abnormal ; that nervous prostration is, or has, come with all its train of symp- toms, and the objective mind by-and-by accepts the suggestion that there is a diseased condition. It accepts this suggestion to such an extent that it begins by degrees to impress the sug- gestion upon the subjective mind. The subjective mind, acting upon suggestion and suggestion alone, soon accepts the fact that digestion is disordered ; that the activity of the bowels is abnor- mal ; that pain in such and such localities actually exists. The result is a chronic condition that may eventually result in a true pathological condition, because the subjective mind con- trolling the circulation of the blood can in time bring about pathological conditions. Examples of these conditions are, I am sure, familiar to you all. Second. What part does the subjective mind play in the production of chronic conditions? Remembering that the subjective mind acts upon sug- gestion and suggestion alone, it is easy to understand how peripheral irritations and actual pathological conditions can by suggestion bring about through the unconscious or sub- jective mind chronic conditions, and for that matter, many acute conditions. Then remembering that the subjective mind has the power, while the objective mind is asleep, of imprinting upon the objective mind suggestions that it, the subjective mind, has accepted, so that in time the objective mind accepts the suggestion given it by the subjective mind that the body is diseased, and the individual himself, by his own reasoning, believes that he is sick. These being facts, which I think you will all admit, what part has suggestion in the treatment of 54 OBIFIC1AL SURGERY. chronic conditions? Or how can it be of assistance to the ori- ficial surgeon in the treatment of this large class of cases! First, through the objective mind. As it is always best to individualize our cases it is particularly true when we wish to take advantage of the power of suggestion. A case falls into the hands of a physician, and the question is, how to man- age it. A careful study of the case will determine how much of the diseased condition, or perhaps, better, how many of the symptoms complained of are the result of suggestion alone. If the physician can confidently state to that patient, "Here is the seat of your trouble ; by the removal of this difficulty your recovery is assured and a perfect restoration to health will fol- low; if he can convince the objective mind of his patient that that is the cause and that its removal will bring health, and the objective mind of the patient will accept that suggestion and imprint it upon the unconscious mind that presides over the nutrition of the body, then in all probability, the removal of that so-called cause will result in a restoration to health. If on the other hand, there are peripheral irritations or actual pathological conditions present that have been the cause in the first place of the suggestions that have resulted in the chronic invalidism, it will be necessary to remove those local irritations. Not only that, but the objective mind as well must receive the suggestion, not only from the subjective mind, but from without, and be convinced that health will result before it will take place. This is why failure results many times when excellent work has been done. How then can we make a prac- tical application of these facts in our work? When a case presents itself to you, be very emphatic in what you can do. It is not to be, "I think this will help you," or "I believe this will do you good," but "I know, I am posi- tive that this will do what I say it will." After the work is done many times the results are not all that you expected ; not all that your patient expected, and after-work is necessary; further dilatation ; further douches ; electricity ; massage, Swedish movement; osteopathy, and even Christian Science. Yes, I am sure that some of you have had cases in which all these things have been tried, and the Materia Medica gone ORIFIGIAL SURGERY. 547 through with from A to Z, and your patient still not well. Why ? Well, I can tell you some reasons : You did not take time enough in the preparation of that case. You should have treated it for weeks or months. If it was a lacerated cervix, you should have treated it; if it was a diseased rectum, you should have treated it. In fact, if it was any condition, you should have taken time in preparing your patient. You forgot that the objective mind had accepted the suggestion of disease, and you did not sufficiently eradicate that suggestion by putting in the suggestion of health ; so when normal physiological conditions were restored as perfectly as possible, the objective mind still clung to its suggestion of disease. Then, another reason: After the work was done the suggestion was not all eradicated, and you said, "Well, elec- tricity will fix you all right now; that's all you need; it will cure your dyspepsia ; it will make you sleep ; it will make you eat ; it will make your bowels act ; in fact, it will finish the thing up," but it didn't. Why? If you think that you can eradi- cate a whole score of suggestions that have found lodgment in the human mind by one little suggestion, you are mistaken. But had you suggested to that patient, "Electricity will help the action of your bowels, it will help you to sleep, ' ' and stuck to those two things, it would have accomplished them. And so with massage, osteopathy, Christian Science and drugs. Had you picked out one, or at most two, suggestions to be removed by the new thought, the object would have been accomplished. I do not think it best to occupy any more of your time in the presentation of this subject. Now after the paper has been read, I am sure that a great many of you are saying to yourselves, "Why, that's what we do every day; there is nothing new in that: that's old." Yes, we realize that ; in fact there is nothing new under the sun, but did you appreciate it when you did it? Did you do it thoughtfully? Did you intend to do it? Were you thinking about it when you did it? That's the point. In other words, did you appreciate, and do you appreciate what part sugges- tion plays in the production of chronic ailments? If we have given you a few ideas, or presented some old thoughts in a lit- 548 ORIFIG1AL SURGERY. tie different dress so that they may be of some practical serv- ice to you, our time has been well spent. But in the future, watch your opportunity and study the power of suggestion. You will be astonished, as I have been, at the results at- tainable. [The first thing necessary in the practical application of therapeutic suggestion is, as Dr. Pratt has taught, to clean up your self live, breathe and BE what you wish to photograph upon the subconscious being of your patient. You can't wash soiled spots from white linen with dirty water; you can't paint a house white with drab paint; you can't show a bright light through a greasy smoked globe. You must take the beam out of your own eye, then you can see clearly to remove the mote from your brother's eye. Not an easy task. However, we can, on occasions and for awhile, attain this state of purity; by strenuous efforts we can climb to this high terrace. Even if we fall back the effort can be repeated, for the view and tho glory are well worth while. The best time is when your patient is under the anesthetic. The cerebro-spinal man is asleep. The father, boss of the fam- ily, is quieted put out of the way for the time being. Some men are so noisy, domineering and meddlesome that the over- worked, timid, tired, sick wife has no opportunity to listen to or talk with another while he is present. Now with this pre- sumptuous lord tucked under the blanket of slumber, we can sit down and in a quiet but forceful heart-to-heart talk, give this discouraged, cringing woman some wholesome advice. In operating have a definite purpose in your mind : not simply to do good bodily repairing, but remember you are at the threshold of the inner sanctuary; you are touching the life-wires of the soul; you are fingering the strings on the sacred harp of life; you are on holy ground and your shoes of sensuality and impurity must be removed. Then we are ready to marry mind and matter; then we can enter the foun- tains of the deep, and replace hatred with love, fear with trust, discouragement with hope, jealousy with confidence, and disease with health. Editor.] SECTION IX. Chronic Diseases and Functional Disturbances ORIFIC1AL SURGERY. CHAPTER LXX. LOWERED VITALITY. H. B. BEEBE, M. D. What means this term and how it is to be overcome? The life and vigor of an organized body depends upon the physiological functions, the aggregate of vital actions, the amount of tissue resistance of that organism. Lowered vitality is simply a lack or loss of normal tissue resistance. When the physiology of an organism is impaired we have pathology. So-called functional diseases cannot long remain without resultant structural change in some part or parts of the body. The diseased anatomy may be remote from the functional manifestations. Pathology is sick physiology resulting in diseased anatomy. Pathological processes are il- lustrations of preverted nutrition, physiological vital action out of its course, all embodied in the term lowered vitality. The sole object of the physician and surgeon by his vari- ous modes of treatment is to improve nutrition, re-establish healthy physiological functions, elevate vitality and correct morbid anatomy, that the normal process of repair and waste may go on undisturbed. When this equilibrium is lost some- thing is wrong; to restore it is to cure the patient whatever and wherever the disease may be. That we are not always able to do this none will deny, and as to how it is done when we do succeed there are various ways. It is quite well settled that Nature is the successful doctor and her efforts to do this work are great. All we can do is to assist. Her powers are not inexhaustible and at times she will fail when but little aid is needed. This is more true in chronic diseases where she needs special assistance, as her reparative powers are more taxed in chronic troubles. The majority of acute diseases are self-limited, and if the reactive powers are good, recovery is to be expected where ordinary care and proper therapeutic means are used. If the 552 OBlFIClAL SURGEBY. life force the vis a tergo be weak, the trouble continues till we have chronic disease affecting the weaker parts of the body. Of the many measures resorted to in establishing this lowered vitality to a normal standard, it is not always easy to determine which is best. We should first and always try the simplest and mildest conservative methods. Look well to the hygiene, regimen and sanitary requirements of our patient. If these measures alone will cure, well and good ; if not, add to these resources other agents, indicated drug remedies, hydro- pathic applications, electricity, massage, psychological thera- peutics and numerous other agents well known to the skilled physician. Any of these measures may do harm when not properly applied. Individualization is always to be considered. Seldom can two patients be treated alike. Conservative means are first to be thought of. Let surgery be used only as a der- nier resort. When it is necessary be not slow to use it. Many of the valuable agents used by the profession in their early application were loudly condemned, until their true merits were established. They were often used by incompe- tent and unprincipled charlatans to the injury of the patient, as well as that of the worthy advocate. It is but a few years since that that very potent agent, electricity, so valuable a therapeutic remedy, was considered of little or no value in dis- ease, by the rank and file of our profession. All of these agents have their proper use in correcting lowered vitality, when rightly understood. Quackery has injured the reputation of valuable measures for treating diseases. There is no other opportunity where the impostor can so easily dupe his vic- tims as with the suffering invalid. Because a method has been badly handled it must not be discarded. Remember: "In cer- tis unitas ; in d\ibiis libertas ; in omnibus charitas. ' ' Twenty years ago, the late Dr. Beard went before the British Medical Association and demonstrated some of the phe- nomena of hypnotism. He was insulted and practically mob- bed by Drs. Crichton, Brown, Donkin and others for his pains. At the recent meeting of the association a committee appointed for the purpose, reported that they have satisfied themselves >",'/ JiSU i A -: r, n r. ORIFIG1AL SURGERY. 553 of the genuineness of the phenomena and of the therapeutic value of the method. The same may be said of another method lately used to arouse lowered vitality, and brought before a similar body in 1886, the oldest national medical association in this country. The first production on orificial philosophy presented to the American Institute at Saratoga, was far from favorably re- ceived. The author, too, like Dr. Beard, was insulted and practically mobbed, for his sincerity in advocating views of which he had no doubt. A self-constituted committee of those present was there appointed to investigate the merits of so ab- surd a doctrine. In this case it did not take ten years for the committee to bring in a similar report to that of the British Medical Association, as the late meeting at Washington cer- tainly proved. The difference in time may have been due in a measure, to the way in which the Americans do things when compared with our British brethren. The crank who pre- sented the paper six years before, then unsupported, had in- stead of the little handful of disgusted listeners, a large audi- ence mostly far differently impressed. Many of them, leaders in the profession, had tried the new agent and were only too anxious to confirm its merits. There were none who publicly opposed it as at the first meeting. It has become a well established fact that orificial treat- ment will arouse sleepy, dormant life force to a normal stand- ard after other well-known agents have failed. It is another potent agent in the physician's armamentarium. The successful specialist, the author of the new measure, is usually dubbed a "crank," chiefly because he advocates advanced ideas or original thoughts. Some one has said: ' ' One of the most unfortunate attributes of man is his apparent unwillingness to be unlike other men," his seeming dislike of originality so far as he himself is concerned, and his sheep-like acquiescence in the doing of others. There never yet was what the world calls a crank who was not a man of originality of character, of intelligence, a man who was literally one of the cranks that are instrumental in the onward movement of the world. Julius Caesar, Napoleon, George Washington, Carlyle, 554 ORIFIG1AL SURGERY. Bismarck, were all cranks. He who does his own thinking ana who acts for himself, based upon his own individuality, is what we understand the word "crank" to mean. The orificialist is not the narrow-minded, one-idea person some would have us think. To meet success in this practice is to be conservative, to carefully individualize the cases, to look well to the vis medicatriv naturoe. Try all measures to assist Nature, give her every chance. Do not treat the orifices alone because there is some visible local trouble, but treat the pa- tient, the vital forces, by handling the great organic nervous system by way of the orifices. The orificialist is a neurologist, his investigation is the study of reflexes, and while his studies usually refer to the lower orifices of the body, they do not al- ways, for there are reflexes from the upper orifices demanding attention at the same time we are treating the lower openings of the body. Of the eight medical colleges announcing pro- fessors of orificial surgery in their catalogues, several of them state that there will be a special course under this professor on diseases of the rectum. They do not seem to realize that while rectal treatment is orificial treatment, orificial treatment is far from being rectal treatment alone. Said announcement might just as well state that this professor will give a special course on uterine diseases or on the genito-urinary organs. This chair is not filled creditably until the lecturer treats his sub- ject from the standpoint of the neurologist. But some orthodox or skeptical doctor asks: "Why not try it as so many have done and furnished as proof, living, healthy subjects who had been long suffering invalids? Yes." he says, "but I have seen it tried and it did not do iV." Does anyone say that there are not cases beyond control of any and all means? What is claimed is that it will bring reparative processes in many cases, often where everything else has failed, if the treatment be skillfully and thoroughly applied. Because all methods fail in some cases, none would think of abandoning everything. The work of the true orificialist continues after that of the general surgeon ceases. The general surgeon treats orificial diseases for their local manifestations. The orificialist does this ORIFIG1AL SURGERY. 555 and also in addition, by his work, expects to arouse the low- ered vitality to a healthy physiological standard, and thereby give nature a better chance to cure the patient. The average general surgeon he who does major surgical work dislikes orificial work, because there is not enough cutting with it. Its methods are entirely too mild, simple and conservative. Much of the treatment is not surgery. For this reason I have never been satisfied with the term orificial surgery, preferring to call it orificial methods. Many times the best results are attained without the loss of blood. It is certainly very appropriately termed conservative treatment. We believe, in fact we know, that orificial treatment carried to completion will prevent the necessity, oftentimes, of major surgical work. Give it a thor- ough, impartial trial, you who have not already done so. CHAPTER LXXI. FUNCTIONAL DISTURBANCE AND MENTAL CONDI- TIONS IN CHRONIC DISEASES. E. P. NOTREBE, M. D. The simplest forms of functional disturbance, such as in- digestion, constipation, headaches, fluttering heart are but the prodromes of the more serious forms of the so-called diseases, such as chronic skin lesions or eczema, dropsy, asthma, par- alysis, etc. ; while the simple forms of mental disturbance, as impatience, dissatisfaction, fear, worry, anger, distrust or reck- lessness lead to the symptoms of the so-called diseases neu- rasthenia, insomnia, epilepsy, melancholia insanity and imbe- cility. They are all the perversions of health and results of disease. The mental symptoms are looked upon as the peculiarities of an individual until they are more grave then they are re- garded as sin. We have been taught to look upon sin as dis- graceful and deserving the punishment of law, but taught to excuse disease with pity and to encourage it to weakness and 556 ORIFIC1AL SURGERY. death, with gratification of every childish want. We should be taught to be ashamed of disease, as it is the result of a trans- gressed law and the greatest cause of sin. Then we should be charitable with the symptoms and frailties of others in sin, for they are crippled and weak in both mind and body and need laws of body, health and better spiritual thoughts and feelings. The human body is simply a piece of machinery, more perfect than any that has ever been made. In treating it we should look upon it as composed of individual parts, each part having a special work to do and each part deserving a certain amount of protection and respect. When we fail to give these parts this protection and respect, we will have in this ma- chinery a disturbance in action and work and a detrimental change in its products and their uses. In a successful manufacturing plant we will have special parts and individuals given special attention and respect. We will have a chief engineer to supervise the whole machinery and see that a good machinist keeps the bands and wheels properly connected and in good running order. We will have a carpenter to see that the building is protected and repaired with proper material; we will have good, earnest and faith- ful laborers to handle the material, carry away the waste and store away the products, and these specialized if the work de- mands. We will also have a man of principle, a man of action, a man of brain, a man of feeling, as general manager of this business. This man should see that his chief engineer is pro- vided for, that he attends to his duties and is protected, in or- der that he may not become weak, diseased and negligent, al- lowing the machinery to become irregular in action and dis- connected and run to extremes, nervousness, an explosion, par- alysis and death. The laborers should be guided, favored and protected in order that their energies should equal the capacity. If these elements are kept in harmony the then manufactured products will be good in quality and sufficient in quantity to please and bring a smile and ease of action to the general manager so OKIFIG1AL SUBGERY. 557 that he can turn over a surplus to the owners that will please and bring a smile and ease to their souls, that will return a good support and continuance to the business. We would call this a beautiful work, something worthy of attention and interest. In the human body we can have this condition or we can have explosion, paralysis, and death. In our search for and preservation of health we should give every tissue in the body the responsibility, protection and respect of a specialist, these specialists having in common one end the production of the elements necessary to health. The nerves are made up of special cells whose properties are sen- sitiveness and action. The special cells of contractility make muscle tissue. The special sells of secretion make the secre- tory system. The special cells of reproduction make the repro- ductive apparatus. The bony cells make the bone tissue for the support of the body, etc. All of these may be managed, supported and protected in order that they can attend to their duties. In the nervous systems we have as the chief engineer the abdominal brain, and his machinist, the cervical, hypogastric and other plexuses; the general manager is the brain and spinal cord. The important laborers of the body machine are under the control mainly of the chief engineer or the sympathetic ner- vous system, and comprise the heart, lungs, stomach, liver, kid- neys, intestinal tract and all other functional organs of the body. These parts or laborers must take in, prepare and give food products to the tissues and dispose of the waste. It is among the laborers that we usually find troubles that cause disturbance throughout the plant or body and we should give them attention, for when the laborers become weak the source of revenue becomes disturbed and sometimes so embarrassed that there is a failure. We as physicians should be good machinists, good car- penters and good general managers and should have and use the privilege of closely examining the body from head to foot and should know what nerves control organs and from where an organ gets its commands and how much it should work and 558 OBIFIC1AL SURGERY. how much it should rest. Then we will probably be able to tell a patient more of his condition than he himself knows and be of some benefit to him. Nervous cases have many symptoms in common, such as indigestion, constipation, headache, liver, kidney, bladder, heart, lung, throat and skin troubles, and in fact all degrees of disturbances of the functions of the vital organs. They can find their cases exactly depicted in any newspaper almanac or descriptive book of diseases. This means something, and these invalids are not very much mistaken, and we should stop to find the cause of all these troubles, for we can detect symptoms ad infinitum and to deal with them is like picking the leaves off a tree to kill it. Let us use the same common sense in de- tecting and adjusting the friction of the body that we would in a manufacturing plant or business. In that business we would first go to the two main heads, the general manager and the chief engineer, to determine what is wrong for all com- mands should originate with them. Is your general manager on a drunk ? If so, their will be immediate trouble unless the engineer is sober and at his post. Is the engineer disturbed? If so, there is immediate danger. Unless these two commanders are right, the business is in dan- ger, and if one is continually wrong the house must fall, or from bad commands we will have bad work from the laborers and hence bad results. The sympathetic nervous system is the great commander through its centers (namely: the solar, cer- vical and hypogastric plexuses) of all the vital organs; and the reason that chronic cases have disturbance of the func- tions of all these organs is that the centers that send cords to those organs and control their action entirely by commands are disturbed, and it is natural, since there is no shut-off from those centers that every organ should be aroused when the centers are irritated. Then when the sympathetic nerve cen- ters are irritated there will be an irritation of every vital or- gan in the body and a consequent disturbance in its action and it will only be a question of endurance as to which organ will become tired, weak or diseased first: and the one that shows ORIFIC1AL SURGERY. 559 this influence the most is the organ that the patient usually thinks is diseased. The solar plexus or abdominal brain when disturbed rings up "Mr. Heart" and tells him to get on extra duty. It says the same to lungs, liver, kidneys, stomach, bowels or secretory and circulatory cells throughout the body. They all do extra duty, but like many other individuals with individual rights, after a time extra duty becomes tiresome and, like individuals still, if they get no rest they become impatient; and still if no rest comes they become dissatisfied with their master; and still if no rest they become disgruntled and irritable, and then after pleading, if there is no rest, there will be a struggle, an explosion, disease and death. Vital organs and tissues are. simply individual laborers making up the whole body, its products and expressions, and as these vital organs or tissues act so the man will act. Instead of the surface man being responsible he is simply the product of inner forces. A weak muscular man means that the mus- cles are not properly fed and cared for. A weak bony man means that the bony individual is neglected. A weak mucous membrane man means that his tissue is starved and neglected. A weak skin man means that there is starvation in his house and a weak nervous man means that there is starvation and neglect there, too. When the weak muscular man is despondent and wishes something done we encourage him immediately and say, "Why, you just need food and all will be well soon." Food is the essential for health and happiness to nervous tissue, to mucous membrane tissue, to skin tissue and to bony tissue and to all tissues alike and they also will improve by its supply ; then in order to cure chronic conditions of mucous membrane, as catarrh, in order to cure chronic conditions of skin and nerves why not pursue the same common sense course and expect the same results as we would in muscular weak- ness, for these tissues are subject to the same laws of life and healthy action ? We must see to the food supply in order to have health and all that goes with it. The sympathetic nervous centers command all the food preparers and carriers of the tissues ; they send cords that con- 560 OBIFIG1AL SURGERY. nect with gland cells or agents in the stomach that control di- gestion there; they send cords that connect with gland cells in the bowels that control digestion and excretion there ; they send cords that connect with gland cells or agents in the liver that control its labor; they send cords that connect with cells or age'nts in the kidneys and control their work; they send cords that connect with cells or agents in the heart that give it force to carry food; they send cords that connect with agents in the lungs that control the fuel of the machinery. If this system is disturbed it will then cause irregularity and weak- ness of stomach and bowel digestion, or indigestion, disturb- ance of liver, kidneys, skin, lungs and the heart and blood ves- sels, the railroad system or carriers of the food. Tissues are just like we are: Let the laborer be deficient in making food products, then add to that a disturbance in the railroad system that will not carry what we might have, and imagine our actions ; and stand the nervous system by our side under similar conditions and see its actions. First, we would both see that food supply was getting scarce; next we would think that the railroads were irregular in running, and we might not get just what we needed at the right time. This knowledge would arouse interest, we would become a little anxious, and begin to accelerate our efforts to lay up, but if with the acceleration we still gained nothing, but were losing, we would become restless and overworked and tired, then we would begin to draw on what we had reserved, and if we did not have enough we would call on some one else. If we failed we would become weak, grow impatient, distrustful and irritable, and would worry and lose sleep, and at last become desperate. The tension would be so great that there would be an explosion and we would go mad, or else the weakness would be so great that paralysis or death would ensue. Remove the cause of disturbance of food laborers, make food, and feed this man, and he will gradually recover from that wild state to a sane, stout man. Remove the cause of ir- ritation to the nerve food laborers, turn them loose and feed the nerve, and that insane, weak nerve will become strong and calm again. OEIFICTAL SURGERY. 561 The peculiarity of a weak thing is its susceptibility of being moved or impressed, and a weak person is a nervous per- son, for weakness makes the nerves susceptible to action, and their thoughts are numerous; they want to talk a great deal, they see things quickly ; and, while weakness is a hindrance to most forces, it acts as an accelerator to thought forces, for thought is simply the result of irritation of brain cells arousing them to action. You never thought of a man unless you saw him, heard of him, or by some of the senses had an irritation of him. It does not rob God nor interfere with his divine prin- ciples for us to know thought laws any more than to know the laws of gravitation. This knowledge should make us more grateful, more trustful, more hopeful, and more confiding in such a Creator a Creator who has given us individuality, a Creator who has given us force, a Creator who has given us such sensitive means to thoughts and feelings, and has given us a crowning purpose for which the right use of thought laws was intended. Our discovery and understanding of orificial laws should not cause us to rob and depreciate its founder, E. H. Pratt. He owes us nothing, but we owe it all to him, more than money can pay. But he has given us an insight to better principles of thought and feeling, and through their coin he can be rewarded. Thought forces, like all other forces, can be used for destruction as well as construction, are sub- ject to bad as well as good impressions, and should be handled with care. To illustrate the breaking down of special tissues I report the following cases: Case 1. Most prominent symptoms: insanity and emaci- ation. Unmarried woman 30 years old, family history good. She had been treated for ten to twelve years for chronic indi- gestion, constipation and nervousness. Her insanity dates back about three to five years. Did not care for detailed his- tory of the case, thinking it would not give the cause, as par- ents usually attribute such troubles to a fall, fright, taking cold or something of the kind which has very little to do with the real cause. By symptomatic examination could see every organ in her body was weak ; weight about 65 pounds, when 562 ORIFIG1AL SURGERY. she should have weighed 120 to 130. Examination of body re- vealed clitoris completely covered and hood adherent; hymen and vagina in chronic granular, ulcerated condition; mouth and neck of uterus eroded, soft and friable with granula- tions; chronic endometritis and uterus without tone. Rectum full of ulcerated pockets and papillae and in a state of granular degeneration. Lower bowel was so dead and dry that fecal lumps adhered to the walls as though baked. All her mucous membranes were in a catarrhal condition. Like all such cases she was intense in her desires and suspicions. She had only one or two thoughts and used them incessantly day and night. She was as troublesome as a case of this kind could be. Operation consisted in freeing the clitoris; clipping, trim- ming and curetting hymen and vagina ; dilating, curetting and amputating neck of uterus; slit operation on rectum after in- troducing wool plug saturated with balsam of Peru and Pond's extract, which was left in for four days. She was so uncontrol- lable that it was necessary to chloroform her to keep her quiet and treat her for two or three weeks, as morphia, sul- fonal, chloral, etc., had no effect. She did not seem to change until the third week when she had two or three hard chills and fever, which was caused by the secretions being aroused; tem- perature ran up to 105. After the fever abated she began to notice, you could attract her attention and she would obey. About this time she complained of pain in the limbs and head and would grunt when she seemed to suffer. Up to this time there had been no expression of what would usually give pain to any one. This is a common condition of insane cases. In her case the brain gave way before any of the other organs, from starvation, and she became insane. It might as well have been her lungs causing consumption or her kidneys or heart or liver causing dropsy. It is now five weeks since she left the sanitarium and she comes in twice a week for treatment. She is gaming rapidly in flesh, and while she has, of course, nerv- ous thoughts and wants, she is rational and takes care of her- self without being watched. All the abnormal conditions of her nervous system must be eliminated by time, strength and growth, and her mind become healthy. ORIFIC1AL SURGERY. 563 Case 2. Prominent symptom, dropsy. Heart, lungs, kid- neys and liver all appeared to be so disturbed that it seemed they must be broken down in tissue. Considered the case en- tirely hopeless; in fact regretted her coming to me for treat- ment. After explaining to her her condition she was willing to take the one chance, though it seemed small. There was so much heart and lung trouble that she had not been able to lie down for weeks and only slept one to two hours in twenty- four, and that was broken rest, as she had an almost incessant cough. On examination I found Skene's glands enlarged until some were 1% to 2 inches deep and the tissue all around the meatus was so hyperplastic that it seemed cicatricial. The cervix had a bilateral laceration and the rectum was studded with piles, pockets and papillae. I knew she could stand no operation in her present con- dition, so began preparatory treatment by rectal dilatation and heart stimulants, strophanthus and cactina. In about ten days I considered her circulation much improved and removed by tapping about three gallons of serum, repeated the tapping twice, removing in all seven gallons. In two weeks from time she came to the sanitarium I removed piles, pockets and papil- lae, cut out Skene's glands and hyperplastic tissue. Operation lasted one hour and a half. Patient has been in comparative ease since, sleeps all night, lies on her back comfortably. Ex- pect to repair lacerated cervix in a short time. Wishing to give credit where it is due I will say I was much encouraged by the assistance of Dr. Warden, whose thorough confidence in and knowledge of the work relieved me from all anxiety in the management of the anesthetic. But for this and my knowledge of the effect on heart and lungs of rec- tal dilatation I would no more have put that woman on the operating table than I would have shot her. Case 3. Invalid, asthma for five years. Had been wheeled in invalid's chair and carried in husband's arms for five years; was thought to be in last stages of consumption, life wretched and hope about gone. All that was left of her was a small bundle of extreme, petulant, sickly wants. She had been a 564 ORIFIG1AL SURGERY. belle in looks and merriment, but, oh, what a change! She was so distorted that one could not begin to please. Even her husband, who was as loyal and attentive as the name can im- ply, could not satisfy her in the smallest particular. If he handed her a glass of water it was too little, too much, too hot, too cold, or he did not come quickly enough or was too quick, etc. Examination showed the lungs and heart weak and dis- turbed in action, but not diseased in tissue any more than the irritation of bronchial tubes in asthma. Clitoris completely covered and hood adherent; meatus fiery red, with irritation; Skene's glands enlarged, numerous and loaded with pus; bi- lateral laceration of cervix and chronic endometritis. Rectum pinched and last inch badly diseased with hemorrhoids, pock- ets and papillae. Did all-around work as indicated, and in twenty-four hours asthma relaxed and she had no more attacks for about six days, when the rectum began to pinch and she suffered all night with asthma. I asked her why she did not have me called, and she said she did not think I could do anything for the asthma. I dilated the rectum, and in a few minutes she was relieved. But she still clung to her asthma inhaler that had been by her bedside for years and it was months before she would leave it at home. In three weeks she was up and began to walk, and in five weeks could enjoy a lively buggy ride. She then went home and had a slight return of asthma with other complaints, and I had her come back. The rectum seemed in good condition, the uterus was much improved and I could not understand why she had asthma. Was treating her with elec- tricity, and noticed that the meatus was still irritated ; applied the negative galvanic current and that night she had a very severe attack of asthma. As this irritation was removed she became better and better until the asthma is about forgotten, together with other morbid symptoms, and she is getting back her former good qualities and there is happiness in that home. Case 4. Most prominent symptoms, skin lesion and dropsy. A young lady fourteen years old. She had an eruption over the entire body, and lower limbs were in a chronic condition ORtFIGlAL SURGERY. 565 of ulceration from three inches above knees to feet, and had been so for several years. She had been treated for varicose ulcers of legs for nine years. The rest of the body was patched with pimples and old sores. Her feet and limbs were much swollen, she was troubled with incessant itching, and could not sleep more than two or three hours in twenty-four. Physicians had told parents that nothing could be done, and when they spoke of having her operated on they said it would be brutal to think of giving her an anesthetic ; it would kill her instantly, but she could not be cured with medicines, as she had been under constant treatment for nine years, was rapidly growing worse and it seemed she could not live long. The parents thought it was death anyway and decided on an operation. Examination revealed clitoris completely covered and rec- tum studded with pockets and papillae. Four days after clip- ping the hood and freeing the clitoris and doing the slit opera- tion the pimples and sores began to disappear. In three weeks after operation her whole body was perfectly smooth with the exception of a few pimples on her face; the varicose ulcers on legs were completely well. She went home and her physician said the eruption just happened to get better I had done nothing. In four months her first menstrual period appeared and immediately the eruption re-appeared, though not severe. I had paid no attention to vagina and uterus, thinking she was young and would have no trouble there, but my work was not complete. I had not removed all irritation. I am surprised at her improvement, for on closer examination found the hymen very irritable, uterus retroverted and endometrium very much inflamed. After removal of these conditions by operation and after-treatment with electricity, the young lady is well, has a beautiful complexion, has grown much and gained forty pounds in one year. 566 ORIFIC1AL SURGERY. CHAPTER LXXII. INSOMNIA; ITS RELIEF BY ORIFICIAL METHODS. I* C. GROSVENOR. M. D. Case 1. A college graduate pursuing an advanced course of study across the water became gradually the victim of in- somnia. Bright, ambitious, and hopeful in his efforts to better pre- pare himself for a college chair of Modern Languages, he felt this handicap keenly. As I had been his medical friend during his college course, he naturally turned to me for advice. At my suggestion he came home for treatment, as the dis- tinguished surgeon across the water had not yet learned the new philosophy. He was placed in the Lincoln Park Sani- tarium, where dilatation of the lower orifices, circumcision and thorough rectal work were done. In four weeks he recrossed the ocean, completed his course of study, and has for one year filled an important po- sition in an educational institution. Not only was his sleepless- ness completely cured, but he claims that his mental grasp and power of continued thought are greatly improved. His friends, too, notice his cool, quiet, self-contained manner with its sug- gestions of reserved power in place of the former nervous unrest. Case 2. An old gentleman who could not sleep after 2 o'clock in the morning was much improved by rectal work and the occasional use of the rectal plug. Case 3. A little boy in one of our best families suffered from insomnia and made night a terror to his family. He was thin, spare, capricious in appetite, and of little comfort to the home circle. Circumcision (of which we found great need) changed the whole character of the boy, so much so that on a recent visit the mother said to me, "Tell your son (Dr. Wallace Grosvenor who performed the operation^ ORIFICIAL SURGERY. 567 that the boy gained fifteen pounds in weight since the opera- tion, eats a whole spring chicken for his dinner, and is now always happy." The father, a man of affairs, asked in a quiet way "if that operation would do as much for him as it had for the boy." The fact that insomnia is the high road to insanity, and that a very large proportion of these cases may be relieved by orificial methods, is my excuse for presenting this brief paper before this honorable body of distinguished surgeons. Dr. Dill : For five years prior to April, 1893, I was a con- stant sufferer from insomnia for the remainder of the night from about 1 o'clock, and. I am here as a living monument to the results of the orificial philosophy at the hands of Dr. Pratt. He did all-round work on me and made a new man out of me. I feel better now than I have for twenty years. Dr. Curryer: I am a comparative novice in this, but I want to relate one case of insomnia. I had a patient who had been unable to sleep for months, and they said they really thought the woman was going to lose her mind. I made ar- rangements to go to her house, and took a friend along to ad- minister the anesthetic. Stretched the rectum, found a papilla a quarter of an inch long, and one or two pockets; gave a thorough dilatation and left her. The second day the friend at whose house she was staying came to me and said: "We are scared about your patient." I said, "Why, what way?" He said, "We gave her her supper and she slept all that night the operation was performed on Sunday and all day Mon- day, only arousing her to feed her, and she slept till Tuesday, and we think she's going to die." I said, "Let her sleep, and she'll waken all right." The operation was better than morphine. 568 ORIFIGTAL SURGERY. CHAPTER LXXIII. FUNCTIONAL INSANITY. H. P. SKILES. A. M.. M. D. Before reading my paper I wish to quote from Dr. Spitzka's work on insanity, page 97. Speaking of the morbid anatomy of recent mania, he says: "In not a single accurately studied case has a characteristic lesion of the essential mental apparatus been found, nor has any doubtful appearance of any kind been discovered that has not been found in lesser degree, in sane persons also. The same author, in quoting from M en- del, says: "From all this I draw the conclusion that mania is a disease whose patho-anatomical basis we have thus far not been able to discover in the brain. ' ' The terms "mental diseases" and "diseases of the brain" are considered synonymous, since it is supposed that the mind is located in the brain. Accepting this as true, we naturally divide mental dis- eases into two classes, viz.: organic, where there is an organic change in the brain; and functional, where the morbid symp- toms are apparently from the brain, but are rea\ly produced by some other cause. It is the latter class of which I wish to speak in this paper. Ordinary cases of aberration come under the notice of every physician, in general practice, and are produced in va- rious degrees by any of the acute diseases, varying in severity according to the temperament of the patient. These, excepting in very rare instances, pass away as the disease subsides with- out any special treatment with reference to the mental condi- tion, but those whose minds have been turned, without acute sickness or from no apparent cause claim our attention at the present time. In this day, when insanity is on the increase, it is fitting for us to inquire whether there is not some way to prevent this ORIFICIAL SURGERY. 569 terrible disease, and whether we, as physicians, are not in a, measure responsible for permitting it. Usually cases of func- tional insanity are hurried off to the asylum where, with hun- dreds of others as miserable, they are confined, not as a rule for their cure, but that they may be detained. These institutions are in a great measure detention hos- pitals. In the treatment of insane cases it is very important that we should pay attention to the smallest details in the symptoms of the patient ; not only that we may choose the proper remedy, but that we may find the cause of the abnormal condition. I take it that there is no class of diseases that requires closer observation than insanity. Patients -suffering from this disease recover in exactly the reverse order from that in which they were attacked, experi- encing the same delusions and aberrations, though of shorter duration. If there is obtained a clear and complete history of the case from the time of his first attack, stating the different phases of his mania in the exact order in which they occurred, you can tell exactly whether or not he is improving and how near he is to a normal condition. This is a great satisfaction to anyone watching the grad- ual return of health. Considering that they are hyperaes- thetic in every particular, it seems to me that all local treat- ment should be given while under the influence of an anaes- thetic, and for these cases I prefer chloroform. For the same reason, while they are not considered re- sponsible, they do know a great deal more than people give them credit for, and our motive should be to accomplish the restoration with as little shock to the abnormally sensitive or- ganization as possible. Again in regard to deceiving insane patients, great care must be observed. This should never be done by the physi- cian or attendant, no matter what others may do. Even in the matter of putting medicine in food, it may cause a great deal of trouble, for they are just as sensitive to taste and smell as they are to pain and are sure to discover it. 570 ORIFIC1AL SURGERY. The character of the attendant may to some seem of little importance, yet an attendant may, by a word, do more harm than a physician can do good in many days. He should be controlled by the same gentle, yet firm and fearless spirit that the physician is, and must be in harmony with him. The physician must have complete control of his patient, from the beginning of his care until recovery is complete. It is the climax of all diseases. To thus lead a patient for weeks and months, to complete and perfect liberty of thought and action, so that he who was once a raving maniac, is again a sentient being, is a work worthy of the deepest thought and greatest effort. The satisfaction derived from thus lifting one from misery indescribable, and restoring him to his family and friends, is sweet and deep. I wish to give a few cases to illustrate. Case 1. Was taken from a private asylum in July, 1887. She had been insane for twenty years, according to the records of the court. Sixty-two years of age, mother of a large family. At times she was vicious, restless, talking a great deal, sleeping from one to two hours per night, swearing a greater part of the night, and was considered beyond all help by the learned superintendent, he saying that her physical condition was perfect, that her condition was the effect of a diseased brain. The next day under chloroform, I made an examination, not of the brain, but to find if there was not other cause that had produced her mania. She knew enough to tell me that she was burning up right down through her body and that she vomited a great deal. My examination revealed a retroflexed uterus, slightly lacerated, a prolapsed rectum exposing about two inches of the mucous membrane. This portion of the rectum was ampu- tated and the patient put to bed. She improved so much in sleep that at the end of the first ten days she was sleeping most of the night, in spite of the ORIFICIAL SURGERY. 571 fact that with our facilities we were unable to keep her in bed longer than a few hours after the operation. At the end of three weeks her husband met me as I made my morning call and said he was much encouraged, that his wife was going back over the road she came. The first noticed when she lost her reason that she found fault with her husband and his people, and from this became very violent and was adjudged insane. Next, she thought everything had a bad odor, and then that everything was poi- son, food, ornaments, pictures, etc. At last she saw floating through the air, parts of the bodies of friends and children and she would converse with them. This stage continued until about three weeks after the operation when she began to talk about the poison, until finally she spoke only of the poison that surrounded her. This remained for some time when it was dropped for the odors that seemed to her to permeate everything. Finally came the "tug of war." The vials of wrath that had been stored up for twenty years against her husband and his people were poured out. This lasted about ten days when she became quiet and peaceable most of the time. It has now been nearly five years since she had any treat- ment and she has had no attendant. The retroversion I was unable to cure and she is, of course, nervous and easily ex- cited. She is at liberty to go and come as she wishes, goes out calling and to church. Principal remedy, arsenicum. Case 2. In January of 1888 I was called to see Mrs. P., 22 years of age, married, one baby 17 months old. I found her violently insane with a temperature of 104 degrees, requiring three persons to keep her from throwing herself from a second story window. There was an abscess in the left breast, as the exciting cause of the fever and delirium. The abscess was opened and in a few days the fever was controlled, but the delirium re- mained, requiring constant attention and vigilance to keep her under control. I informed the friends that it was my opinion that there was some trouble with the uterus. 572 ORIFIG1AL SURGERY. Under chloroform, an examination revealed sub-involution of the uterus, the depth of which was eight inches and retro- verted. Secale was ordered three times a day in small doses. Cer- vix was dilated and uterus replaced. It was with great difficulty that she was fed enough to sustain her. I informed the friends that she would not improve men- tally until the uterus regained its normal condition. This was accomplished by treating under chloroform every ten days or two weeks for two and one-half months, after which she made a rapid and perfect recovery, and has re- mained in perfect health since. Beside secale, aconite and belladonna were used accord- ing to their indications. Case 3. Mr. A., aged 62, was brought to me November 1st, 1891. He had been ailing for two years or more. Could not even tell his name or place of residence. He had been a man of more than ordinary intellect ; an ex- member of the legislature of Kansas. He was cyanotic in the extreme, lips, finger nails, etc., blue, so much so that I was afraid to give him an anaesthetic. I put him into bed and waited two days to see if there might be some improvement from rest. As none came, I began the treatment with a great deal of trepidation. Keeping him under the influence of chloroform only for a few minutes, I dilated the rectum and passed sounds in ureth- ra. Reaction was good; hot applications were applied locally for three hours, with good effect. At the end of that time, in accordance with the desire of the patient, they were discon- tinued, which we soon found was a great mistake. In two hours he had a chill and collapse. Aconite every few minutes and the hot applications again restored him. From this he improved rapidly. At the end of a week he was again treated. Beside his mental trouble, he had a sloughing heel which also improved as the circulation was improved. ORIFIGTAL SURGERY. 573 His aberrations were reproduced in exactly the reverse order, as we learned from the son's statement which we re- ceived at the end of the second week. At the close of five weeks he was taken home in his right mind. I would state here that, as a rule, it takes from two to lour months to permanently relieve one of these cases. Aconite, nux vom., aloes and arsenicum were the remedies used. Prin- cipally, aloes. Case 4. Mrs. R., aged 27, was seen the latter part of March, 1891, and I found the following history. She had undergone an operation for lacerated cervix, and after she began to convalesce, showed signs of insanity. This increased until she had to be kept with an attendant continu- ally. After having her under remedies for several days, I put her under chloroform and dilated the cervix and also the rec- tum thoroughly, as I found it was ulcerated. There was no improvement in her mental condition and for several weeks I tried keeping her quiet and giving remedies. It was all of no avail. She became more violent until we were finally obliged to restrain her by force. On July 15th, I reopened the cervix and removed the cicatricial tissue and again replaced the sutures for its repair. From this treatment her improvement was gradual and com- plete. It was more than two months before I removed the sutures. She has remained in good health since. Case 5. Mrs. H., aged 32, the mother of four children, had been ailing several years. I was called the last of March, 1892. Found her suffering from melancholia, being able to talk with a great deal of difficulty and very much frightened. This was the most severe and stubborn case in regard to taking any kind of nourishment that I have ever seen. For five weeks we were compelled to feed her by means of a tube. She would not even take a swallow of water. On examination we found the cervix was lacerated, the vagina eczematos and the rectum ulcerated. April 1st, under chloroform, I dilated cervix curetted with cotton, also treated ulcers of rectum by dilatation. 574 ORIFIC1AL SURGERY. From this we had some general improvement so that on May 15th, operated for lacerated cervix. Mental condition so bad that we were unable to keep any clothing on, excepting a night dress of ducking. June 15th, under chloroform, I found a severe impaction above the rectum which was relieved by hand. From this date, improvement was marked and very rapid. Early in July she was able to go out, and by July 15th I was able to pronounce her in perfect health ; she has been able to take charge of her household better than she has done for years. I might continue to recite cases, but these are enough to illustrate what has been done and what may be done again. It also shows that every one of these cases might have been prevented very much easier than they were cured. [It will be observed that these cases were treated a score or more years ago. Since then many advances have been made in the orificial thought and new methods of its application dis- covered. I am sure all these cases would have improved much more rapidly under all-round orificial surgery as it is done to- day. There was more or less gross pathology manifested in each case which received attention, but the clitoris was ig- nored ; only the gross pathological condition of the rectum cor- rected ; the meatus, prepuce and frenum not mentioned. Dr. Skiles has given us a valuable chapter, which is worthy of careful reading, and the cases reported show the marvelous results of this work in this gloomy field of mental stubble. If doctors could only be brought to a realization of the great potency of this measure in curing functional insanity, what a wonderful benediction it would bestow upon humanity! It would enter many homes as a welcome guest, bringing sunshine and laughter where gloom and tears abide. Our insane asy- lums, now full to overflowing, and are only places where these unfortunate beings are restrained, clothed and fed, could be relieved of three-fourths of their inmates, sent home clothed in their right minds, and nine-tenths of those being sent there could be kept at home by preventive measures. Editor.] OKIFIGTAL SURGERY. 575 CHAPTER LXXIV. NEURASTHENIA. C. E. SAWYER, M. D. Neurasthenia is a chronic functional disease of the nerv- ous system with deficient nerve force and a constant liability to exhaustion. There are two types of the disorder anemic and hyper- emic. In the anemic type there is a disposition to apathy, dull- ness and listlessness, accompanied with a general appearance of mal-nutrition. In the hyperemic variety the chief mani- festations are those of excitement, nervousness and constant unrest, while the general appearance may not indicate other than a favorable physical condition. In each class, however, we find the same general symptoms. They all live in a state of nervous bankruptcy and, unaided, become hopeless invalids, sooner or later surrendering the citadel of their existence to some intercurrent disease, which the inroads of neurasthenia have made accessable. Neurasthenia may originate from some emotional strain or mental depression involving a constant irritation of the feel- ings. It may also arise from poor hygienic surroundings and improper diet. Not infrequently acute diseases lapse into just such conditions. Many people unknowingly live in a state of nervous extravagance which when comparatively well they manage to support without any appreciable effect, but when the overdraft of some apparently slight acute disease is made upon their vital bank account they are never able to recover. In my personal experience, nine-tenths of all cases, both male and female, are reflex, and ninety per cent, of these arise from some sexual, generative or rectal disorder. In symptomatology there is no other disease so replete. Chief among them are sleeplessness, dizziness, weakness, numbness, ringing and roaring in the ears, floating specks be- 576 ORIFIdAL SURGERY. fore the eyes, cold hands and feet, irritability, petulance, im- patience, uncertainty of conduct, morbid fears and vain im- aginings. Neurasthenics are dejected, melancholy, despondent and distrustful. Having tried the young doctor, the old doctor, the specialist, the quack, and the patent medicine vender alike without relief, they have lost confidence in things both human and supernatural. Having lost control of the balance wheel of their nervous machine, they become a source of discomfort to their family and a burden to themselves and friends; they are afloat on a rough and dangerous sea without compass or rudder to guide them. Their condition is a pitiable one indeed. Every community has them, every physician sees them. They are chronic invalids found in the homes of the rich and poor alike. They are the most abused, neglected and maltreated class of individuals on earth. Their neighbors accuse them of being hysterical and their physician, unless he be an observing man and awake to the necessities of suffering humanity, con- soles himself with the thought that their condition is only imaginary. These charges may be true, but I do not believe this vast army of complainers are so from choice and without cause. The following cases illustrate the two types of the disorder and the line of treatment that my experience has found most useful. Miss H., aged 20 years, blonde. Family history, fairly good. At the age of fifteen years had an attack of remittent fever, from which lapsed into one of anemic neurasthenia, re- maining bedridden for five years, two years of which she was swung in a hammock night and day. Every one was excluded from her apartments but her at- tendants. At times the faintest ray of light, the slightest noise would make her so nervous as to require hours of soothing to overcome its effect. For days and nights together she would not sleep one hour out of the twenty-four. At my first visit I found her bathed with perspiration, her hands and feet cold, her face pale, her expression drawn and ORIFIGIAL SURGERY. 577 distressed, her teeth decaying, her hair short and stubby, her muscles soft and flabby. She could not raise her head to take a drink of water without help. Her pulse rate was 120 beats per minute, her bowels were constipated and her menses suppressed. Her whole appear- ance was that of general anemia. Her family physician, with whom I was called in consulta- tion, assured me that he had exhausted every remedy in the Materia Medica in his efforts to afford relief. [This patient was taken from her home and for four months Dr. Sawyer assiduously tried medication, mental impressions and electricity, with but little if any benefit. The following year she was placed in his sanitarium and a physical examination made which was heretofore denied. Following he relates her con- dition and treatment. Editor.] All of the pelvic viscera were engorged. The os uteri was but a pin hole, and the sphincters were all tight and un- yielding. I at once did forcible dilatation, and in less than forty- eight hours the outpouring of vital force had ceased. The victim of reflex irritation was released from her thraldom. All that remained necessary to complete her cure was to afford her every opportunity of regaining strength, which we did by bringing to bear the same influences that had failed the year before, and in less than two months she was discharged a well woman. Mr. C., aged 55 years; married, farmer. Was attacked with la grippe. After the acute symptoms had subsided, he continued poorly. [Here the doctor relates the development of the neuras- thenic condition. How the patient became restless, walking the floor for hours, like a caged hyena, .then dejected and depressed; grew steadily worse, threatening his own life, as well as that of others. How for six weeks he left no means untried in the way of medication and saw his patient growing desperately worse. Editor.] Physical examination revealed tight sphincters, with two irritable pile tumors, feur large pockets and an enlarged pros- tate. Under ether I did the slit operation, remove dthe pock- ets and dilated the urethra. 578 ORIFIGTAL SURGERY. On the eighth day following the operation I began massage and general Faradisation. Today he is a well man. I do not cite these cases because I cured them, for any progressive physician could have done the same, but rather to show the necessity of seeking diligently for the cause, and when once found thoroughly and unhesitatingly removing it. Most cases of neurasthenia are curable, but there is a time when they have crossed the border line and succor comes too late. This is when the nerve centers have been starved so long that atrophic changes have taken place in them. CHAPTER LXXV. CHRONIC CONSTIPATION. T. E. COSTAIN, M. D. Anatomically considered, all the functional activities are presided over by the sympathetic nerve mainly, although the communicating rami in the cervical and sacral regions may play an important part both directly and reflexly. Constipation itself being merely a symptom of a neurotic condition, the cause of this trouble must be looked for in a general or local neurosis. Constipation essentially belongs among the affections of the sympathetic nerve, due to a loss of tone, or lowered vi- tality of this nerve, the causes of which are many: brain or spinal cord lesions, improper or irregular diet, alcoholism, sex- ual excesses, pathological conditions, such as hemorrhoids, pockets, papillae, fissures or fistulae disturbing the anal sphinc- ters. Chronic constipation depends on perverted action of the muscular coat of the intestines presided over by Auerbach's plexus, or may be due to a prolonged spasm of the sphincter muscles which are supplied by both cerebro-spinal and sympa- thetic. Physiology teaches us that immediately after the ex- pulsion of feces the sphincter muscles contract vigorously and remain so for some time. This is due to the irritation of the ORIFIG1AL SURGERY. 579 nerve terminals. How much more contraction, then, do we have when pathological lesions of the rectum serve to con- stantly irritate these nerve terminals, producing an almost con- stant spasm of the sphincter muscles. The nervous manifesta- tions ruling the small intestines differ somewhat from those of the large, the nerves ruling the small intestines acting more vigorously and with greater rapidity, while the nerves of the large intestines act slower. The slower action is due to the inferior mesenteric plexus. We find in the walls of the intes- tines plexuses known as Meissner's, which control the secre- tion of the mucous membrane, and Auerbach's, which control the muscular action. Both these plexuses are a part of the sympathetic nerve and controlled by that nerve, so that a weakened sympathetic means a perverted muscular action or secretion due to a lack of nerve force. Especially is this true of the part supplied by the inferior mesenteric plexus, the action of this nerve nominally being slow, and it supplies that part of the large intestines where the fecal masses lie after most of the moisture has been removed. The function of Meissner's plexus being to preside over the mucosa with its numerous glands, if perverted, the feces cake and often adhere to the walls of the intestines, further pre- venting peristalsis. In this way it is often possible by a subse- quent hyperesthetic state of this same plexus to bring on a diarrhoea, and the patient still remain constipated, because all the fecal mass does not come away. Perverted functional activity of either Auerbach's or Meissner's plexus can be the cause of either a ptomaine or toxin poison of the system. The bacteria normally found in the intestines by an excess of culture media may multiply rapidly, and, nature's sentinels being a little sleepy, allow them full play at their dangerous work of poisoning the system, and un- less these sentinels suddenly wake up to their sense of duty, material damage to the system is apt to result. Cases of this kind, where the temperature and pulse have been abnormally high and all the symptoms of typhoid state seemed present, but which all vanished in from one to three days, have come to my notice. 580 ORIFIG1AL SUKGERY. Structural changes in the brain and spinal cord can re- flexly produce all of these same conditions, but are at all times obvious, and temporary expedients often have to be resorted to, to overcome these conditions, because to cure them under these circumstances the cause must first be removed. Where the sympathetic is the cause, the conditions which have pro- duced the loss of this power must be attacked in order that a permanent cure may result. The predisposing causes having been removed, a perma- nent cure cannot always be had unless the existing causes are carefully treated; this means to secure a better peristaltic action or an increased secretion of the intestines, especially the left half of the colon, sigmoid and rectum, where the feces normally lie, and which is presided over by the inferior me- senteric plexus. To accomplish this the diet must be cor- rected and a diet given which shall have a larger amount of waste product to act as a stimulus to peristaltic movement. The solids and fluids play an important part in the forma- tion of the stool. Water is one of the best adjuvants. A glass of warm water with a little salt taken on rising is often found to be of great value. Regular habits, too, play an important part and patients should always be instructed to go to stool regularly every morning after breakfast, as the warm contents of the stomach at that time aid in increasing peristalsis. Hy- gienic conditions should be regulated; a salt brine bath with a vigorous rub following, stimulates the circulation and is of value. Exercise, too, is a valuable aid. A study of the sympa- thetic nerve must after all be your chief reliance. How can it be stimulated to an increased action in order that it may meet its daily demands. Massage, pressure or vibratory movements of the solar, hypogastric or pelvic plexus give a direct stimu- lus and bring to life the vitality of the branches which control peristalsis. Hydro-therapy or, better still, hydro-electro- therapy, also gives you another means by which a direct stimulus can be given to the nerves governing that part of the intestine most often involved. The indicated remedy should ORIFIG1AL SURGERY. 581 not be overlooked before or during this treatment. So many remedies are indicated in constipation that I shall refrain from naming any of them; suffice to say, don't neglect them if you want to cure your patient. CHAPTER LXXVI. CONSTIPATION AND DIARRHEA AS A NEUROSIS; TREATMENT FROM AN ORIPICIAL STANDPOINT. J. W. MEANS, M. D. Constipation is originally from the Latin Con, meaning together, and stipare, to fill up. Diarrhea is a word derived from the Greek, meaning to flow through. Osier defines constipation as retention of feces from any cause, diarrhea as catarrhal enteritis. The definitions given in the text books are superficial and meaningless dealing with results rather than causes. Upon what do the phenomena known in common parlance as diar- rhea and constipation depend? First, we have central or peripheral irritation in diarrhea, and central or peripheral paralysis in constipation. When central in either case the term chronic is usually applied ; when peripheral, the term acute is used. Chronic conditions are deep- seated, more obscure and hard to cure; while acute states are usually self-limited and induced by local causes. In a broad sense constipation is that condition arising from a sub-normal state of the nerves supplying the mucous membrane of the di- gestive tract, inducing partial or complete paralysis. Diar- rhea is a super-normal action of the same nerves supplying the mucous membrane of the same organs. So in either condition the great organic nervous system is at fault, and to restore it to its normal state is the object of treatment. Chronic diarrhea and chronic constipation cannot be cured or materially benefited, unless the nervous system sup- plying the capillaries of the mucous membrane of the bowels be 582 ORIFIC1AL SURGERY. restored to a state of normality. In fact the nerve-centers are the magazines of the body and the slender fibers leading there- from are the avenues through which impressions are transmit- ted. The great central ganglion located in the calvarium domi- nates the minor centers. They are held in subjection by cen- tripetal force as the sun controls the planets of the solar sys- tem. Impressions made upon the nerves of special sense affect the salivary and gastric secretions ; sight, smell, taste and even thought of food stimulate the flow of saliva. A change in tem- perature, fright, change in constitution of the intestinal se- cretions, will produce diarrhea or constipation. Congestion of the solar plexus either as a result of blows on the abdomen, or from iodopathic causes, has often been found associated with excessive diarrhea. The abdominal brain stands as a monitor of the visceral functions. The sphincter muscles are kept in a state of tonic contraction by a nerve- center situated in the lumbar portion of the spinal cord. In short, both above-named diseases are dependent upon the ab- normal action of the sympathetic nervous system. Health is the result of the harmonious action of the functions of the body. Hence to be in perfect health, the brain situated at the top of the spinal cord must receive from its subordinates healthful impressions not only healthful impressions, but there must be intervals of complete rest. The constant nag- ging and appeals of an irritated nerve for help, exhausts the humor and vital power of the imperial dictator, when a general deterioration of the whole nervous system follows. The rhyth- mic action of the once harmonious network of delicate nerve filaments no longer exists and neuralgia, dyspepsias, headaches, indigestions, in fact disorder reigns supreme, until relief by mechanical or medicinal means is found. What have we done to alleviate these common but in- tractable disorders? The materialist turns to the pharmacopea, and there se- lects the most powerful astringents or cathartics and dopes his patient therewith. He so abuses nature with his so-called remedies that she, with indignation, arouses her latent ener- ORmOLAL SURGERY. 583 gies to throw off the intruder, and in so doing reinvigorates the whole economy so that health is restored in many cases. The ccm. theorist after exhausting the catechism and very often his patient with his interminable array of technical in- terrogatories, adroitly passes beneath the organ of olfaction an uncorked vial from which emanates double distilled, dyna- mized wrath, which grapples with the monster disease so deftly yet so heroically that the sentinels of the central ganglia are not aware of the great intestinal struggle going on. Time is a great factor with both these experimenters. The former has the experience of 2,000 years behind him. The latter has the reserved powers of nature to aid him which he incorrectly interprets as dynamic drug action. What treatment should be adopted? First, dilate the rectum once a week with a Pratt dilator. This had better be done without an anesthetic as the shock in- cident to the use of the dilator without an anesthetic is more profound than with an anesthetic. In my opinion there is no shock without sensation. When the sensibilities are benumbed with powerful anesthetics, the beneficial effects arising from dilatation of the sphincters are local only. The nervous fila- ments need coaxing instead of such sudden forcing as is usually used, and the whole system gains more from gentle and persist- ent effort than from one mad rush like a torrent down a moun- tain side. I care not whether it be constipation or diarrhea, dilatation will in chronic cases do more to re-establish the tonicity of the ganglionic nervous system supplying the in- testinal tract, than any other method known. There are adju- vants useful and needed in many cases, but these when used alone fail to meet the demands of the healing art. Flushing the bowels has its advantages and its disadvantages, but when used in conjunction with dilatation great benefit is derived. Not only is it necessary to dilate the sphincter ani muscles, but a large per cent, of the lesions under consideration are a result of narrowing of the sigmoid flexure, hence dilatation of that region is necessary. Statistics show that 87 per cent, of what have been termed chronic and incurable cases, by all or- 584 ORIFIC1AL StTRGEBY. dinary methods, are so materially improved that the term cured is applicable. Second, circumcision. In cases of marasmus in children, clipping the foreskin often completely cures a long standing diarrhea. In twenty-four operations for circumcision at least 50 per cent, of these cases had diarrhea, all of which were cured. Don't understand me to say that dilatation and circum- cision are the only methods to be adopted, but I wish to empha- size this one point: Pay special attention to the sympathetic nervous system and relieve all impingements of the terminal nerve filaments. CHAPTER LXXVII. CONSTIPATION. B. E. DAWSON, M. D. Observation and study of this subject have convinced me that it has not received the attention at the hands of the prac- tician that its importance demands. Many of us are not only guilty of the sin of omission against this functional disturb- ance, but our treatment is injurious. It is useless to enumerate the train of evils following or accompanying constipation ; we are all familiar with them. A moment's reflection brings them before us in such a view as to plainly spell disaster and confusion among the viseral mem- bers of the family of our patient's body. A physician who prescribes a cathartic, laxative, or medi- cation of any kind upon the diagnosis of constipation by the patient, is unworthy the name. He is stepping down in line with the quack and patent medicine vender, much lower than the old woman who mothers and doctors the neighbors with her "yarbs" and teas. A case of constipation imperatively demands a searching, thorough examination from the upper to the lower openings of ORIFIGIAL SURGERY. 585 the body. The diagnosis is not simply to ascertain how often or how seldom the evacuation of feces takes place. There are numerous other concomitants which should be searched out and placed in the column before adding up to get the sum total. Not only the physical examination is required, but every chapter, paragraph, line and word in the history of the case must be closely studied. Keep before you all the time that constipation is a neurosis of the fecal reservoir under the domain of the sympathetic system. The fecal reservoir left half of the transverse colon, descending colon, sigmoid and rectum presided over by the inferior mesenteric ganglion, must be considered by a study of its several elements. Its mucous, muscular and serous coats ; its blood and nerve supply. We must also remember there is a four-fold function, presided over by the sympathetic, making a factor involved in constipation, not to be ignored. We have sensation, peristalsis, secretion and absorption; any one or all of the members of this quartet may be at fault. As the four strings of a violin must be tuned in harmony to avoid discord, so must these four be and remain in harmony. A free flow of fresh blood supply to the bowel wall is necessary to the perfect work of this quartet. A deficient supply of blood could slow peristalsis or check secretion when constipation will result an index finger pointing toward the line of treatment need- ed. A good pure blood stream is the agent that removes path- ology of any form when it can be removed. Its absence invites pathological conditions. The menstrual flow often so entices the blood from the colon as to cause defective peristalsis and produce constipation as a concomitant; so with chronic con- gestion or inflammation of the sexual organs. New brides fre- quently are constipated from the same cause. Close, persistant attention to the circulation is called for in diagnosing and treating constipation, as one of its most important factors. Ev- ery etiological factor should be sought out and all properly put together in order to spell "constipation," as it is in this indi- vidual. A deficient heptic or pancreatic secretion may with- draw the normal excitement from the ganglia and result in constipation. A very frequent cause of constipation is catarrh 586 ORIFIG1AL SURGERY. of the mucous coat of the colon, pointing to the secretory nerves, also the motor. Here we frequently find diarrhea and constipation alternating. A small fissure may induce constipa- tion by checking the regular habit of going to stool. Habit is often a prominent element in the etiological basis. Excessive mental work and deficient physical activity should not escape our scrutiny. Irregular habits of eating, work or sleep must be looked after, the general health and conditions of mind not neglected. The neurasthenic, hysteric, neurotic, idiotic are troubled usually with constipation. Diet is next to blood as an influence in regulating the bowels. It may often cause or cure this common complaint. In regard to treatment it is near impossible to give a line of treatment as each case must be treated to meet the indica- tions. The treatment must be based on the etiology which re- quires the finest talent to diagnose. Orificial treatment will nearly always be called for, but must be followed by judicious after-treatment. Colonic flushings, medicated or plain, re- peated dilatation, proper medication, correct habits and food must all receive attention. Massage, electricity and proper ex- ercise are useful in many cases. A regular hour for stool is of great importance. Plenty of water at stated intervals is of much value. Constipation can be cured. CHAPTER LXXVIII. EPILEPSY TREATED ORIPICIALL.Y EUG. HUBBELL, M. D. In presenting this paper to the association, it is not to set forth an array of successes in the treatment of the perplexing disease, "epilepsy;" but to report, as well, my failures, believ- ing it is a duty we owe to each other to report our failures as well as our successes and hoping that others may make similar reports on the result of orificial methods in the treatment of this disease so that in the near future statistics can be prepared ORIFIGTAL SURGERY. 587 giving an accurate percentage of epilepsies cured, and also the forms that are most amenable to orificial methods. Some cures have been reported, but we are lacking in sufficient data to es- tablish beyond doubt its efficiency. The accumulated work of this association should form very reliable data, if it could be collected. While my work has been limited I hope that others will be influenced to make more complete and extended reports. The first case under consideration occurred seven years ago, while the others have been within the past two years. Case 1. B. G., has had epileptic seizures since three months of age. Nervous ancestry on father's side, but no epi- lepsy. When one month of age nurse used glass syringe to give enema, which caused much screaming and hemorrhage from rectum, examination showed the point of syringe was broken. When I first saw him would have two to four attacks a day, then go two or three days without any, had all the charac- teristics of epilepsy. He was first relieved of twenty-three feet of tape-worm, but this had but little if any effect on the epi- lepsy though it improved his stomach troubles. Examination revealed a large rectal ulcer, genital organs about normal as he had been properly circumcised and dilated; cleansing and cauterizing ulcer caused severe nervous condition to super- vene, followed by one of his seizures. The second treatment caused the same results, but he went a whole month afterward without an attack, parents would not allow any more treat- ments and soon moved away and I lost sight of the case. Re- sult, not cured. Probable cause, the rectal ulcer. Case 2. S. P., male, Oct. 29. Has clear history. Eight arm atrophied from injury at seven months of age. Epilepsy appeared at age of twelve. As a boy used tobacco, smoked cigarettes and masturbated to excess. Seizures every two to four weeks, very severe, causing great prostration for one or two days. Pockets and papillae removed by slit operation, using co- caine. Urethra dilated once every two to four weeks. Sig- moid strictures were overcome by the sigmoid sound, and gal- vanism was used twice a week for two months, then once in a week or two. The attacks grew less severe and further apart 588 ORIFICTAL SURGERY. until the last attack was very light and after an exemption of sixteen weeks. He is still under treatment. Remedies given were nux vomica, eicuta, sulphur and ananthe at different in- tervals. Result, greatly improved. Case 3. Mrs. W., family history very obscure. Has had severe epileptic attacks for four years. Had two or three mis- carriages, and probably illegitimate child at term as examina- tion revealed endometritis, cervical and perineal laceration, hemorrhoids, pockets, etc. All-round work was done, under chloroform anesthesia. Had one attack at next menstrual pe- riod but none since then (Feb. '96.) Had 'some after-treat- ments. Result, apparently cured. Case 4. W. W., boy seven years old, stout, robust, full- blooded, thick pouting lips, ferocious appetite, passes restless nights, starts in his sleep and has enuresis. Began to have epi- leptic attacks when three years of age, mother is a sufferer from the disease. Examination revealed enlongated prepuce, narrow meatus, contracted sphincters, pockets and papillae. All- round work was done last January. Symptoms rather aggra- vated for two or three weeks then slight improvement. In May again passed sounds and dilated rectum, followed by aggrava- tion. Then he began to improve again, but he still has the attacks once a week but not so severe and of shorter dura- tion. Has taken cina followed by bellodonna. Results, about nil. Case 5. Mrs. W., aet 44. Mother of four children, has suf- fered from epileptic attacks since birth of her first child, who is now fourteen years of age. Is the mother of Case 4 with good family history. Has two or three attacks per month. Ex- amination disclosed endocervicitis, retroflexion, bilateral lacer- ation of cervix and severe hemorrhoidal condition of rectum. All-round work was done, including the American operation. Was up in three weeks, but had severe nerve storms and one epileptic seizure during this time, since which time she has had no return of them and has improved in general health. Of the five cases here, two are relieved, one nearly so, and two not benefited or only slightly so. ORIFIC1AL SUEGEEY. 589 The President: What is your pleasure with Dr. Hubbell's paper? Dr. Means : I am glad to know that the doctor wanted to have the case he failed in known, as well as those he succeeded in. With epilepsy I have not been successful. I have succeed- ed in curing the spasm in children by circumcision alone. I had an experience which I shall relate with reference to epilepsy. A young man a year ago applied for relief. I did everything be- fore I tried dilatation ; and after I used dilatation of the ureth- ra and rectum he had two spasms, where before he had one. It continued that way; I operated three times, and every time there were double the number of spasms there were before. I quit. I could see no reason why it did so, but that was the result. Dr. Dunn: I have had just about the same experience with regard to epilepsy. A young man, a student, a man of rather studious habits, was taken with epilepsy and had to leave college. Found him with a long prepuce, an irritated rectum, papillas, and stricture of the urethra ; gave him orificial treatment ; removed the papillas and pockets from the rectum ; dilated the urethra ; made a thorough dilatation of the urethra and did everything that I thought would relieve the tension upon his nervous system, but the result was not satisfactory. His convulsions occurred a little more frequently than they did before, and are continuing up to this date. I have been watching this case to find what I have overlooked. In all probability this epileptic condition is very different from the spasms of children who are suffering from phimosis, and those cases cannot really be called epilepsy. I think those cases that are epileptic originate in the ventricle of the brain; brain trou- ble, and orificial work is not going to remedy the difficulty that is my experience with this epilepsy. Yet I take a case of epilepsy in hand every time I have it, and treat it with the ex- pectation of curing it, if I can relieve the peripheral irritation ; but when it is central I haven't any hopes of relief. Dr. Notrebe : The first case of epilepsy I treated was a young lady of stout build, about 24 or 25 years old, who had epilepsy for several years. She did not seem to be a nervous 590 OKIFIG1AL SUEGEKY. case ; she could control herself, and was in good physical condi- tion. Like the doctor who has just spoken, I had thought epilepsy was due to a brain lesion, and began to study it along that line, at the same time using orificial principles to see if I could break it down. On examining this young lady I found a very irritable hymen, clitoris bound down, endometritis and re- troverted uterus. After the operation she had continued spells of epilepsy, and I think they lasted twenty-four to forty-eight hours ; she would not be free from them more than half an hour at a time, and I began to be alarmed ; I thought she was going to die of epilepsy. I gave her morphine and applied fomenta- tions, and about the third day she became perfectly quiet and relieved, and did well until the stitches and I was just think- ing of that case as the doctor was reporting his knots those knots began to irritate the labia, and she went into those spells again, which became almost continuous for hours. When she came out I asked what was the trouble, and she said something was hurting her ; I removed those knots, applied fomentations, and she immediately became better. This case improved and had no more spells for months. I wasn't satisfied, and I made another examination ; in examining, I irritated the rectum, and she had more spells. I found there were some pockets, so put here on the table and removed them. I think the case has been well since a year ago. I thought then that all cases could be cured. A case was brought to me that had had epilepsy for fif- teen years, and would have from fifteen to thirty attacks a day, having them almost every day, of course sometimes not so severe. I operated and found the same conditions as in the other case, and did about the same work. She was at this time an imbecile. Her mind improved much, and the epileptic spells became better for three or four months, but she had a retro- verted uterus that I couldn't replace it wouldn't stay re- placed any length of time. When Dr. Pratt was in Springfield he operated on her, and removed the uterus and ovaries. She has gained fifteen ar twenty pounds in the last three or four months. Her mind is good. She now does all the work at home ORIFIG1AL SURGERY. 591 and goes everywhere in town that she likes. She has what she calls "sitting-down spells," probably once a week, gets up dazed, but goes on about her business. This case is much im- proved in mind; the greatest improvement is in the mind, and, considering the frequency of the attacks in the beginning and her condition now, she is wonderfully im- proved, but I don't consider her cured, from the simple fact that I believe the lesion is not in the brain, but a brain train- ing, and I don't believe that case will ever be cured, if she is turned loose to those old impressions. I can bring her into a company of people and the excitement will bring on a spell ; I can keep her confidence, and still be in company, and these spells will not occur. I have come to the conclusion that there is a brain training, and unless that is overcome they can't be cured; I think they're like drunkards they can't get over it all at once ; they must be guided and developed, but I believe they can be cured. CHAPTER LXXIX. TREATMENT OP ACNE SIMPLEX IN YOUNG MEN. H. E. BEEBE, M. D. ACNE, ACNE VULGARIS, ACNE DISSEMINATA. Acne simplex is generally regarded as a chronic idiopathic inflammation of the sebaceous glands, in the center of which is a black comedo plug or a pustule. It is frequently compli- cated with other affections of the sebaceous glands, and is re- garded as a very annoying cutaneous disease especially when it appears, as it commonly does, on the face. Much is written concerning its pathology, causes and treat- ment, yet it seems to be understood the curative treatment has been unsatisfactory. There is an artificial acne, due to the external or internal influence of drugs this is not here con- sidered. 592 OBIFIC1AL SURGERY. The causes usually recognized for idiopathic acne are chronic digestive disturbances, anemic and chlorotic conditions and sexual disorders. It is the latter cause and this cause as a basis for suitable treatment that is here emphasized. This, as a cause, until quite recently, has not been sufficiently studied. Acne simplex occurs chiefly during and after puberty, from the fourteenth to the thirtieth year. It is confined to both sexes. The fact that its occurrence at the time of puberty is most common with those addicted to sexual weaknesses and abuses, and that it often appears only during pregnancy, or ceases during that period, and that eunuchs are very rarely subject to it is proof that it has some connection with the genital sphere. That it can be easily cured by proper treatment in this di- rection is another proof. This center in the male is in the pro- static inch of the urethra ; in the female in the uterine cervix. In the large majority of cases of acne simplex, chronic conges- tion can be found in this locality, and proper local treatment of this center in addition to suitable constitutional remedies will cure most cases of this intractable malady. The experience has been mostly with the male sex, yet there is no reason why the opposite sex will not respond equally well to the treatment. Where formerly treatment was futile, during the past two years the same cases of years' standing have been cured. The local treatment consists in the systematic use of steel sounds to overcome the irritation almost invariably found at the prostatic inch of the urethra. In the application of these sounds, always use them sufficiently large to fully distend the entire urethral canal. If sounds of this size are used and the circular muscular fibres of the urethra are thoroughly dilated, you will need have little fear of the much talked of urethral fever. When this does follow, it is certainly due to the use of too small sounds or traumatiam from careless manipulation. The same rules will apply to dilating the uterine cervix. If the circular fibres of the cervix be fully paralyzed thereby giv- ing free vent to all discharges, little danger need be feared. To overcome this local congestion these sounds should be used ORIFIC1AL SURGERY. 593 as often as practicable without producing traumatic irritation. No stereotyped rule can be given for this. Each case must be judged according to the irritation present. It is astonishing what marked improvement is observed in the acne in most cases in a few weeks, no matter how chronic the case be, certainly proving that it is reflex in its origin. It is a line of treatment that cannot help but convince the most skeptical, for it is certainly calculated to cure the majority of these cases when systematically followed. CHAPTER LXXX. SYMPATHETIC VOMITING. W. H. HURT. M. D. To show the power that orificial surgery has in cases of vertigo, nausea and vomiting associated with fomale diseases, I will cite two cases: Mrs. C., aged 22. For the last six months has felt mis- erable and for the last two months compelled to keep her bed most of the time. If she gets up and walks about becomes very dizzy and wants to vomit. The nausea and vomiting with ver- tigo is brought on at once, as soon as she tries to ride in any vehicle. Has sick headache once or twice a week, affecting the left side of the head. No appetite ; bowels obstinately con- stipated ; cannot have a passage from the bowels without tak- ing a cathartic ; so weak can hardly walk. At every menstrual period suffers intensely during the whole period and flows but little. An examination of the rectum showed it extremely sensi- tive, much inflamed, with three large pockets and three papillae. The cervix utri inflamed and a greatly constricted os. The left ovary sensitive on pressure and pains her much at the men- strual period. Operation : Assisted by Dr. W. M. Johnson, the patient was put under chloroform, and the rectum thoroughly dilated, the papillae removed, the pockets curetted and the bowel thor- 594 ORIFIC1AL SURGERY. oughly flushed with carbolized hot water. The cervix uteri dilated with sounds up to No. 27 English scale, then curetted the whole inside of the uterus, using Dr. F. D. Ilolbrook's cu- rette which washes away the debris as fast as it is removed from the surface. The recovery in this case was something marvelous; the next day she was greatly improved, and in one week a well woman. Her vertigo, nausea and vomiting had all gone, and her bowels moved every day perfectly natural, something they had not done in six months without being forced by the use of cathartics. March 8, 1894. Mrs. II., aged 28 years, mother of one child three years old. Always a healthy woman until the birth of her child; has not been well since. The right ovary has pained her almost daily, and has a continued heavy bearing- down pain in the region of the womb, with constant leucor- rhea. For the last eight months has had nausea and vomiting of a very obstinate nature ; has vomited every day and most of the time as often as every hour ; has been compelled to keep her bed for months. Has had seven different physicians. All have diagnosed pregnancy and treated her without the least bene- fit. An examination of the uterus found it greatly enlarged and not pregnant, but a well marked case of subinvolution. The rectum was extremely sensitive and filled with hemor- rhoids. Operation: Assisted by Dr. W. M. Johnson, who, by the way, confirmed my diagnosis that it was a marked case of sub- involution of the womb associated with a very irritable rectum. After the patient was anesthetized the womb was dilated with the Pratt sounds up to No. 27, curetted most thoroughly and washed out with carbolized water. The rectum was dilated and five large hemorrhoids removed, and then well flushed with the carbolized water. I am satisfied that I get much better results in these cases where a large quantity of carbolized water is used during and after the operation, than can be had where the simple dry absorbent cotton is used. The effect of this operation on this poor afflicted woman was something to be proud of. The next day she felt like a ORIFIC1AL SURGERY. 595 new being and in ten days was up and doing her house-work, feeling absolutely well, but still weak. She was kept on dia- lyzed iron, ten drops ter die for four weeks, then discharged cured. She never vomited once after the operation, although the last thing she did before taking the chloroform was to vomit. CHAPTER LXXXI. HICCOUGH CURED. E. H. PRATT, M. D. Mrs. T. was about 42 years of age and in fairly good gen- eral health, being one of those strong wiry natures that seem able to exhibit almost any amount of endurance when called upon to do so a good subject for tetanus or epilepsy. Her distress was hiccough. When she applied for relief she had been suffering for two weeks, growing steadily worse. In that two weeks she had made diligent search for relief elsewhere, first to the drug- stores in her neighborhood and the doctors they recommended, from all of which she obtained neither relief nor encourage- ment. In her desperation, although she was a woman of some means, not knowing what else to do, she made application for admission to Cook County Hospital under the impression that some of the attending men in that great place might be able to handle her case successfully. In that institution, however, she got no further than the examining room. She was told that her case was perfectly incurable, and she might as well pre- pare to die. They informed her that Cook County Hospital was an emergency hospital, and for curable cases only ; that in- curable cases were sent out to Jefferson to the poorhouse, and if she wished they would issue an order for her admission to that institution, remarking at the same time that- her stay there would not be long, as hiccough was always fatal and she would not have long to remain anywhere. She thanked the 596 ORIFIG1AL SURGERY. interne who examined her for his kindness and his opinion, said that she had car fare enough to get home with, and if she was going to die she wouM rather die at home than in the poorhouse. As Cook County Hospital had failed her, she decided to visit the medical colleges in the neighborhood and persevere in her search until some one was found who took a more hopeful view of her case. In pursuance of this resolution she came first to our clinic and was referred to the orificial chair. When she presented herself for examination the habit of hiccough was badly established and accompanied with severe general convulsive movements of her entire body. Although she had applied as a clinical patient she refused to be made a clinic of, and insisted upon the work being done at her own home. As no time was to be lost, the next day she was placed under an anesthetic and subjected to general orificial work, which con- sisted in loosening of the hood of the clitoris, repairing a badly lacerated cervix, and in performing slit work upon the rectum. It should be stated that the laceration of the cervix was an unusual one, presenting a three-cornered tear, the tissues be- tween the tears being hypertrophied and very much hardened, so much so as to suggest a tendency to carcinomatous degenera- tion. The lining of the vagina was pale and leathery. One of the lacerations proved to be very deep, and the cicatricial scar extended for some distance into the body of the uterus. The cicatricial tissue, however, was all carefully removed and the parts of the cervix carefully readjusted and restored to a proper shape. In the rectum there were a few small papilla? and an unusual number of rectal pockets, having also a few very small hemorrhoids. The anal orifice was badly con- tracted and there was evidence of rectal catarrh. The anesthetic employed was chloroform, to the adminis- tration of which she yielded very reluctantly, requiring dou- ble the amount usually needed for anesthesia and taking twice as long as common to succumb to its effects. Further than this, however, her case presented no difficulties whatever, and proved to be eminently satisfactory in every respect. She went to sleep with the hiccough and awoke without it, and although ORIFIC1AL SURGERY. 597 nearly two months have elapsed since the operation, it has never put in an appearance. She already complains of feel- ing better than she has in twenty years, and is deeply grateful for her rescue. Cases of pernicious hiccough are so rare that it seemed important to place this one on record, as it was so eminently successful and bears marked testimony to the wonderful power of orificial work in such cases, and also gives silent testimony of the ignorance of the medical profession generally of one of the most powerful agents for correcting functional disorders at the command of the medical profession. Just because the woman's entire distress seemed to be hiccough, none of the doctors or druggists to whom she applied for relief, not even the interne who had charge of the examining room of Cook County Hospital, thought far enough to consider it possible that some pelvic trouble might furnish a satisfactory explana- tion for the existence of the dread disease known as malig- nant hiccough. And yet this is such a reasonable explanation. Every doctor who has ever had to do with pregnant women knows of the intimate relationship between the uterus and the stomach, for the great majority of pregnant women are trou- bled with morning sickness during the first three months of pregnancy, when it is commonly recognized that the stomach has nothing to do with its own distress, but is suffering from an irritable condition of the pelvic organs. The close relation- ship between the phrenic and pneumogastric nerves and the sympathetic nerve was also completely ignored by those who had the opportunity of examining the case, so that not even rectal troubles were thought of as responsible for the fatal malady. Indeed not a druggist or doctor with whom she came in contact in her whole two weeks' search for relief even thought of, or at least suggested, an examination of the pelvic organs with the view of ascertaining their condition, but sim- ply recognized that hiccough was a fatal trouble, and told the woman that her end was near, and that nothing could be done for her, acknowledging themselves perfectly helpless to com- bat the formidable condition in which she presented herself. It is with no small degree of satisfaction to me, however, that 598 ORIFIC1AL SURGERY. the interne of the institution to which she applied remembered his orificial teachings and was thoughtful enough to give the woman the orificial straw to grasp at, and that she embraced this only opportunity which had been extended to her, and has the satisfaction of securing for her trust and confidence the restoration to health which she was seeking. Orificial work has scored thousands of professional tri- umphs of which it can well be proud, but it is seldom that it has scored one more brilliant and encouraging than it accom- plished in this case of pernicious hiccough. SECTION X. Miscellaneous, V ORIFIC1AL SURGERY. 601 CHAPTER LXXXII. SEXUAL HABITS AND NECESSITIES. E. H. PRATT, M. D. Humanity is naked, therefore it is clothed. It is shame- faced, and hence struts about in assumptions of false pride and dignity. Only a limited number of the organs of the body and a corresponding number of their diseases are recognized and considered fit subjects for public consideration. It is needless to remark as a comment upon this state of things that the un- cleanliness is not on the part of the body or its diseases, but lies in the unworthy conception of the observer. Sexual organs and rectums were constructed by the same God that made eyes, ears, noses and throats, and the human being that sees dirt in the study of any of God's works is sim- ply vulgar and is an unfit condition for scientific investigation. Love is ever respectable ; lust is never so. Sexuality is always a proper subject for consideration; sensuality needs a doctor. Sick hands and feet, livers and stomachs, brains and lungs, and bones and spinal cords have received due consideration at the hands of the medical fraternity, but sick sexual organs and rectal conditions which have long needed a doctor have been seriously neglected. The establishment of the orificial philosophy will correct this unkindness and disrespect to humanity and its God, and the parts which for centuries have been festering under the fig-leaf will receive the consideration of which they have long stood in need, and the prospects for the cure of lust which through all history has been sapping the vitality of humanity are brightening. The fact that what we now know as merely manifestations of ill health have been heretofore known as sins needs to be universally recognized. The tendency to the violation of laws, mental, moral, physical or spiritual, is not a natural one and only occurs when something is wrong. JLLIEG 602 ORIFIC1AL SURGERY. While each organ of the body has its separate functions to perform, and while it possesses its own peculiar characteristics personal to itself, it is at the same time a part of the whole body, partaking of its weakness and of its strength, its sickness and its health, its joys and its sorrows, its poverty and its prosperity, its virtues and its vices, its integrity and its dis- integration. Laws of growth, development, waste and repair, prevail universally throughout the body, and all the organs are loyal subjects in the bodily dominion. A healthy human body is a unity ; it is entirely unconscious of eyes or ears or hands or other organs. Its separate parts are consecrated to the use of the whole, and only as they are put to use is their existence brought into prominence. In consequence of this universal plan of existence, whenever an organ obtrudes itself in an un- called for manner upon the attention of the individual, it loses its harmonious connection with the whole, and something is disturbing it. If it is an organ presided over by the cerebro- spinal system, it usually manifests its disorderly condition by pain or its absence. It is liable to be either hyperesthetic or anesthetic. Eyes become sensitive to light or take on the op- posite condition and become insensitive to it, staring blindly in- to daylight as though it were night. Ears become too sensitive or too obtuse ; and in a similar manner all the cerebro-spinal family report the individual in the language of consciousness, and call for a doctor. Where the disordered organ does not disturb bodily sensations, its appearance gives evidence of its disordered condition. The spot involved is too red or too pale, is too hard or too soft, is too hot or too cold, is too swollen or too sunken. The parts supplied by the sympathetic nerve, however, when they are in trouble, require a finer diagnosti- cian to appreciate their disordered state, and a better doctor for their repair; for unless they enlist the sympathies of the cerebro-spinal system and voice their troubles vicariously, the symptoms of their illness can be interpreted only in the lan- guage of disturbed functions, and their repair involves not only ordinary medical knowledge, but also the application of a good deal of common sense, a quality entirely too little em- ployed in the practice of the healing art. EIJ ORIFIC1AL SURGERY. 603 As the present is the age of the "new woman" for the world at large, in our doctor world it can and will be called the age of the sympathetic, for now that it is at last beginning to dawn upon the medical profession that reactive power and vitality and good capillary circulation and sympathetic power are synonymous terms the sympathetic nerve and its functions are being investigated. Almost every nation has its cult. It selects its hero, and thousands of devotees search public records and private corre- spondence for every item of knowledge that can be obtained of its hero. France has its Napoleon cult, Germany its Bis- marck cult, England its Gladstone and Shakespeare cults, America its Washington and Lincoln cults. The professions, too, have their cults, and in the profession of medicine the com- ing cult, not only for the present time but for all time, is and will be the sympathetic nerve. It is no passing fad, and no mere fashionable study of the day; its importance as a factor in the interpretation and cure of all forms of human ailments has become so permanently conspicuous that the study of the sympathetic nerve can never again be neglected as it has been and pass into obscurity. The plan of construction by which the body is built and maintained has not varied since its cre- ation. All men in all ages have possessed sympathetic nerves and sympathetic nerve force, although it has not been recog- nized as the physical means by which inspiration flows into hu- manity, has propelled the inhabitants of the world through all their coming and their going, through all their pleasures and through all their crime, through all their backsliding and through all their evolutions. But this silent mainspring of life that has run for ages the machinery of every human form that has walked the earth has done its work so silently, so modestly, so unpretentiously, as to almost have escaped observation, per- mitting the reputation for growth and for repair, for health and for sickness, for deatli and for longevity to be ascribed to other portions of the human anatomy. The arrogant, lordly, noisy, presumptuous, self-conscious and presuming cerebro- spiual system has received not only its mean of consideration and appreciation, but has appropriated to itself much of the 604 ORIFIG1AL SURGERY. reputation and attention that has rightfully belonged to the gentler and less obtrusive sympathetic. It has not been fully appreciated until the last decade, indeed is not even now, that upon the integrity of the sympathetic nerve depends the ton- icity and nutrition of the entire body, even of the cerebro- spinal system itself. The result of this misapprehension of the relative importance of the two nervous systems in matters of nutrition from a professional standpoint has been to lead the medical profession into a hare and hound chase after the ef- fects of disorders rather than point them to their causes. That the first cause of chronic diseases of all kinds is a lowering of vitality and insufficient reactive power, a poor circulation, or what is the same thing a wasted sympathetic nerve force you and I well know, and our life work will not be well done until the entire medical profession is thoroughly vaccinated with the thought, so that it can never again ignore the important subject of waste and repair of the sympathetic nerve in the study of physical ailments and their remedies. When this great truth is once thoroughly appreciated, and it is equally under- stood that the entire sexual system of both sexes is operated by sympathetic nerve force, the sexual habits of the race will be subjected to a thorough and scientific scrutiny that they have always needed and never received. The part which lust has played in the degenerate changes of the human body has been amply suggested throughout all the ages, and by those who are wholly ignorant of physical anatomy and physiology; for the proverbial fall of Adam has been universally ascribed by priests and laymen alike to a fond- ness for some form of sexual indulgence, the most insidious and generally prevailing one being that of lust. Lustful pro- pensities have been sufficiently influential in the history of man- kind to vaccinate the entire race with syphilis and its inheri- tances, among whch may be classed many diseases of skin and mucous membrane, brain and spinal cord, and consumption as its descendants; and they have established and maintained all the houses of ill fame, have fathered all illegitimate children, have been responsible for the abortion business, have perpetu- ally ill-mated humanity and in many cases divorced it, have ORIFIGIAL SURGERY. 605 driven women to wine and men to whiskey, have, indeed, caused such widespread havoc with the health and happiness of mankind that it is difficult to say what form of physical, mental and moral mischief may not be explained by them. Be- cause the extravagant expenditure of sexual power is painless, and because it is not understood that this same power is the vital force by which men and women live and work, the medi- cal profession have never realized that the responsibility of purifying the lives of their patrons rested with them. But the time has now come when these catacombs of undermining lustful propensities are to be explored and ventilated, and the great mission of orificial surgery to the world will never have been accomplished until it is demonstrated to all mankind that the eradication of sickness from the face of the earth involves the regeneration of its inhabitants. Lust must die that love may live, sensuality must give place to sexuality, and man's animal propensities must cease their domination and become servants instead of masters. In effecting this emancipation of the race, the orificial philosophy and its methods of application are necessities, and we are here to discuss what remedies and what plans of action are best calculated for the eradication of sensuality. The cure of this disease is not merely to regulate it, not merely to establish habits of outer conduct, but to de- stroy temptation by removing all lustful tendencies. As for sexual necessities, in an ideal state of humanity there is no more need for sexual indulgence, except for the propagation of the species, than there is for tears. When any organ, when its use is not demanded, obtrudes itself upon the consciousness of an individual, it is in a condition of irrita- blty from some physcal cause, and needs to be doctored, and the sexual system is no exception to the rule. Sexual indulg- ence is necessary for the propagation of the species; it is not necessary for either the health or happiness of the individual. But to bear this message to mankind, to educate men and women to a knowledge and practice of this great truth, in other words, to cure the world of lust and stop the great nerve waste which throughout all generations past has silently, in- dustriously and unnoticed, enervated the human race and per- 60S ORIFIC1AL SURGERY. mitted it to be the prey of the varied forms of physical dis- orders known as chronic diseases, is the ultimate goal of the orificial thought; and although the journey is a long and dif- ficult one, it is time we set out on our way. If bed sores can be cured they can be prevented; and if orificial surgery can cure the offscourings of medical practice, the asthmas and rheumatisms and insanities and eczemas and dyspepsias ;mtl consumptions and other forms of previously incurable trou- bles, the same principles applied earlier can prevent them. When we claim that orificial surgery can cure these troubles we are not presenting the subject quite fairly. The proper statement of the case would be that orificial surgery can ren- der their cure possible, for orificial surgery unaided is insuf- ficient for the great work in which it is so helpful. It needs to be supplemented by every other helpful measure that is available; and while orificial work is the chief factor in the remarkable cures which we are all making, we must not neglect to give proper credit to the other measures, which we by no means desire to underestimate. Indeed, it is to some of these other measures I desire to attract your attention today. It goes without saying that the members of the American As- sociation of Orificial Surgeons are already fully alive to the necessity for applying orificial methods to all cases of sexual abnormality. But after this has been accomplished, either by operation or treatment, or both, what next for those cases still remaining uncured, and possibly temporarily aggravated by the work? DRUGS. The emotional sphere of drug action is extensive. Drugs are serviceable in relieving a disposition to cry or to laugh or to be irritable ; they are applicable to hallucinations or to mel- ancholia ; to a condition of fears and apprehensions, as if something would happen; or to attacks of rage or to ten- dencies to murder and suicide. They are equally efficacious in lascivious tendencies. They can take away the appetite for to- bacco or liquor, and also take away the appetite for women, or propensities to masturbation. Drugs are curative. They are ORIFIG1AL SURGERY. 607 invaluable in the treatment of chronic as well as acute cases, and we must still study them. WATER. Water judiciously applied is one of the most helpful of remedial agents in re-establishing physical, mental and moral equilibrium. In chronic cases hot water is seldom needed un- less the patient be very feeble, and its use is needed to ensure a proper degree of reaction after the employment of cold. The most useful forms of applying it are the foot bath, sitz bath, spinal compress, and the shower bath or dip. Cold compresses, general or local, are also serviceable in many cases, but are more difficult of application, and can in most cases be dis- pensed with. When Father Kneipp, of Bavaria, issued to the world his first book, entitled, "My Water Cure," he conferred a benefit of inestimable value upon mankind. The world has bathed and used compresses and drank water from the infancy of the race, but the value of its scientific application in the healing of the sick was not well known. How hungry the world was for the knowledge, however, is evidenced by the fact that in two years' time the aged priest was compelled to issue fifty editions of the work, six thousand in an edition, making a sale of over three hundred thousand copies of his book in the space of two years, an experience entirely unprecedented in medi- cine. Instead of consuming your valuable time today in the consideration of water and its uses for professional purposes, I will earnestly recommend every member of the association to possess themselves, if they have not already done so, of a copy of Father Kneipp 's remarkable production and make use of whatever of his suggestions may strike them as practical and worthy of application. The practice of walking barefooted in the wet grass for ten or fifteen minutes every morning, putting on the stockings and shoes without drying the feet, and then take a brisk walk for ten or fifteen minutes longer for those who are able to do so, and who are so situated as to make it possible, is not only a pleasant diversion, but has a wonderful effect in awakening the sleeping energies of the system and in relieving internal congestions and inflammations, especially of 603 ORIFIC1AL SURGERY. the head and spine. Those who from any cause are unable to avail themselves of this suggestion will be able to obtain a similar benefit from plunging the feet in a pail of cold water and retaining them there from thirty seconds to three or four minutes, one minute usually being long enough. The feet are afterward to be .clothed with stockings and shoes and, when reactive power is poor, each foot can be whirled by an as- sistant, who seizes an ankle in one hand and the toes with the other and thus turns them in a circle, revolving each foot in the neighborhood of 150 times. If the patient is unable to walk his feet should be warmly covered after this exercise un- til reaction has become fairly established. The spinal compress is a valuable adjunct not only in spinal cord and brain affections, but also as a general tonic where increased reactive power is needed. Its tendency is to flush the capillaries, acting almost as quickly and surely as rectal dilatation. In making use of the compress, take a towel folded lengthwise until it is about four inches in width and as long as the spine, saturate it in ice water, wring it out, and apply it the whole length of the spine. It is then to be cov- ered with a folded sheet, and the patient turned on his back and made to lie upon it for half or three-quarters of an hour. After its removal the patient shall still lie upon the back for half an hour longer, until the back is warm. The ice water may be medicated with salt or vinegar or arnica, or whatever drug may please the doctor. These drugs are absorbed by the skin as well as by the mucous membrane, and whatever drug is called for can be used with advantage in connection with the compress. If the patient is a very feeble one, it is often well to rub the spine quickly with alcohol, following this with rub- bing before putting him upon his back again. A pitcher of cold water poured daily over the external sexual system and rectum while the patient is placed across the operating chair and protected by a Kelly apron is another exceedingly valuable measure. A dip in a bath-tub of cold water, or a shower, should not be taken except reaction has been ensured by either a hot bath or a sufficient amount of ex- ercise taken just previously to thoroughly heat the entire body. ORIFIOIAL SURGERY. 609 In entering the water the patient should first step into the tub, then immerse his hands, then the arms, then wash his face, throwing the water with the hand or a large sponge over the front of the body, and then lie down in the water just long enoungh to be completely covered by it. The colder the water the better. Thirty seconds or one minute is ample time to ac- complish this. The patient should be quickly clothed, and in- dulge in sufficient exercise to establish a healthy glow through- out the entire body. The cold dip or the shower bath should not be used in weak persons, as the failure to establish a suf- ficient degree of reaction would be detrimental, and might be dangerous. Beyond these directions you are respectfully re- ferred to Father Kneipp, as his simple and plain presentation of this interesting and important subject seems to be the most condensed and practical yet put in print. PHYSICAL TRAINING. That systematic physical training is capable of rendering valuable aid in the emancipation of the race from the thraldom of disease is unquestionably true. Doctors know it, and the whole world knows it ; and that the world is tired of its weak- ness and of its sickness, and of supporting its doctors for pur- poses of bodily patchwork, and proposes to take the matter as much as possible into its own hands and work out its own sal- vation is clearly demonstrated by the universal movements in the direction of all forms of athletics. Baseball, football, cricket, lawn tennis, bicycle riding, the establishment of multi- tudes of gymnasiums, all speak in no uncertain voice of a pro- found and universal tendency to the re-establishment of true manhood and womanhood. Health, like disease, is contagious, and a vigorous and well-balanced physique is conducive to the establishment and practice of wholesome mental and moral conditions upon which the escape of mankind from the hands of the doctors depends, and to a greater extent than has hith- erto been appreciated. While a human being can continue thinking and feeling in accordance with well-established laws of life, the physical health is assured so that physical training acts first upon the body, and through this upon mental anc| 610 ORIFICTAL SUBGERY. moral processes, which in turn invigorate the body. It does not follow from this that professional athletes are ideal specimens of mental and moral, as well as physical, perfection. On the contrary, they are too frequently examples of very question- able characters ; and no wonder. From an orificial standpoint, they belong to the great class of the untrimmed, and are still in possession of the inherited and acquired forms of local irri- tation. These various forms of irritation the long foreskins, the short fraenums, the narrow meatuses, the pockets and pa- pillae, the fissures and hemorrhoids, the adherent hoods of cli- torises and irritable hymens, and stenosed, catarrhal and dis- placed uteri are perpetually whispering unwholesome sug- gestions, and an increase in physical vigor simply adds ve- hemence to these morbid propensities, instead of serving as an added force in the direction of self-conquest. The acquisition of physical strength is merely the accumulation of power which simply propels one in whatever way he is inclined to go. For this reason one should surely be started in the right direction before the propelling forces of life are greatly increased. Ori- ficial pruning, or at least examination and treatment, if neces- sary, until ideal local conditions are secured and the soul is free from the perpetual suggestions which come from abnormal orifices, is first in order, and then with natural tendencies in the direction of correct living for spiritual health is just as natural as physical health a perfect physical development, such as can be obtained by well-known processes and appli- ances, will simply constitute a strong fortress of defense against the invasion of disease and death. Sexuality is one of God's greatest gifts to man and is essential to human health, happiness and progress. Sensuality is its perversion and coun- terfeit, is fed by morbid physical conditions, and is responsible for so much of the pain and sorrow, and the various forms of sickness known as crimes and all their attendant consequences, to say nothing of the multitudes of physical diseases for which it is responsible, that its cure has become a necessity. To ac- complish this local repair is first demanded, after which must follow the general building up. OEIFICIAL SUEGEEY. 611 HYPNOTISM. An additional power of service in the extermination of sensuality is hypnotism. This statement is based upon the assertions of Dr. Cocke, of Boston, who is not only an experi- enced hypnotist, but an able physician and an honorable man, alive to the weaknesses and necessities of the sick, and intelli- gent in the application of remedies for their relief. He re- ports that it is frequently necessary in the cure of chronic cases to free them from sensual suggestions by which they are beset involuntarily, and that this can be accomplished under hypnotic influence. It would surely interest the profession if Dr. Cocke, or some one equally experienced in this matter, would tell in just what hypnotic state he places his patient when he makes the suggestion which liberates him from the slavery of sensuality. Those who have studied Hudson's book entitled, "The Law of Psychic Phenomena" will remember his clearly expressed analysis of the objective and subjective minds, and his explanation of all hypnotic, somnambulistic and spiritual phenomena, upon the hypothesis that they are merely various forms of subjective activity, attained by securing the quiescence of objective processes. As the objective mind in- habits the cerebro-spinal system and the subjective the sympa- thetic, this simply means that in such conditions the cerebro- spinal ceases to dominate the sympathetic, and the sympathetic is controlled by the cerebro-spinal system of the operator. If this be true the science of hypnotism is yet very young, and we have much to hope from it. Here is a fact, for instance, which may some time be taken advantage of. An anesthetic paralyzes the cerebro-spinal sys- tem much after the same manner as is accomplished by hyp- notism, and in doing this the patient passes through different stages, more or less clearly defined. And as the different stages are almost identical with those secured by hypnotism when carried to the point of complete anesthesia, why should it not be possible, if the patient be taken at the time when the sug- gestions of the operator will be most powerfully felt, to stamp the subjective mind in whatever manner desired. In other 612 ORIF1CIAL SUEGERY. words, would it not be possible to correct sensual propensities when the patient is partially anesthetized with as much cer- tainty and satisfaction as could be secured under the corre- sponding degree of hypnotic sleep. The administration of an anesthetic is beneficial in most forms of chronic diseases, es- pecially of the insane, with whom some form of sensuality is a prevailing factor. May not the application of hypnotic sug- gestion, applied at the stage of anesthesia at which outward im- pressions exert the profoundest influence, prove to be an ad- ditional source of help to mind-bound sufferers? EDUCATION. Education will also be required to lend its aid in the solu- tion of this extensive problem. In this age of individual freedom everybody must know why. No authority is influential in the control of human con- duct without the sanction of a very evident reason, and this fact involves the necessity of a general education in both spir- itual and physical anatomy and physiology. This subject is too broad to be even epitomized in the present connection, and the mere mention of it by title must suffice for our present purpose. But educational forces are at work and the light is dawning, and before the sun sets upon your career and mine, such progress will have been made in the eradication of sensu- ality from mankind as to gladden our hearts at the success of the campaign in which orificial surgeons, from a physical standpoint, are the pioneers. CHAPTER LXXXIII. TISSUE READING FROM AN ORIFICIAL STANDPOINT. E. H. PRATT, M. D. Most of the animals and plants that have lived on the earth have bequeathed their bodies to the winds, waves, and soil, and in these common burial-places all material relics of individuality have been lost. The earth's atmosphere is im- ORIF1CIAL SURGERY. 613 \ pregnated with the gaseous emanations of decomposing forms which life has assumed and afterward abandoned. The waters of the earth contain in solution the soluble elements of dis- integrated shapes. The extensive areas of settled dust that are so widely spread over the surface of the earth stand for the non-volatile, insoluble part of the ashes of the departed. But although the winds and waters and farm-lands are such common graveyards that they tell no tales of individual existence, nevertheless some specimens of almost every form of plant and animal life have been preserved in rock-forma- tions and in coal-fields, so that the science of geology has been able to furnish us with a more or less accurate history of the evolution of life in its various forms as it appeared from time to time on the surface of the earth. It is much the same with the human body. As thoughts and feelings have taken on cell-life and afterward abandoned their habitations, all that is gaseous of these remains has been exhaled by the breath and insensible perspiration. The soluble parts of the dead cells have been washed away by the sweat and the urine, and the non-volatile and insoluble portions of the devitalized cells are carried by the peristalsis of the body into the alvine canal and constitute, with the unabsorbed por- tion of the food, the steady stream of fecal matter which is systematically evacuated throughout the life of the individual. But the gaseous, liquid and solid funeral trains of the body are but poor tale-bearers of the life of the soul. They are but plebian graveyards, whose monuments are so insignificant as to be unsatisfactory for historical purposes. But the various bodily tissues do not always readily yield up their dead, and so many cells of every variety of structure become entangled and petrified in their hard and horny parts that it is quite possible for a careful observer to read in them with more or less accuracy the story of the life whose petrified remains nature has thus carefully preserved. The bones have their story to tell, the arteries and nerves and various internal organs are record sheets which can be read when brought un- der the scrutiny of a trained observer, and the muscles, mucous membranes and skin are equally rich in historical lore. 614 ORIFICIAL SURGERY. For generations doctors have searched the body for spots that were too red or too pale, have felt all over it for places that were too hot or too cold, too hard or too soft, or too prominent or too deficient. They have listened for sounds that are too loud or too faint, or too harsh or too smothered, every one of the deviations from the normal standard, by the aid of whatever sense they were diagnosed, being the result of the more or less extensive accumulation of the body's dead cells. Auscultation, percussion, palpitation, and inspection have done continuous duty throughout the history of medicine in diagnosing and locating the ash-heaps and burial-mounds and funeral-caves into which the body's expiring cells have been carried and deposited by the streams upon whose bosom all bodily commerce is carried on. Even laymen continually employ their powers of observation to tell them whether it is well or ill with the souls about them. The elasticity or steadiness of the gait, the grace or awk- wardness of the general bearing, the sweetness or harshness, the friendliness or the pathos, the bravery or the cowardice, or the cruelty of the voice, and every other fact and circumstance that can be observed by their various senses, are constantly studied to ascertain the state of life or death of their kinsmen. The face, too, is a signboard, which everybody glances at, not only for items of current interest in soul-life, but also for the purpose of historical investigations. Laymen are more or less accomplished tissue readers, and expert phrenologists, physiog- nomists, and palmists find abundant occupation, because by reading the story of the life as it has engraved itself in tissue construction they are able with more or less accuracy to fore- cast the possibilities and probabilities of the future. From what has been ascertained from bodily relics, they can foretell history. There are surface-markings which stand for every va- riety of thoughts and emotions indulged in, and by applying the well-known laws of cause and effect, they are able to con- clude with the certainty of logical deductions what is yet to be expected. But the establishment of the orificial philosophy has in- troduced to the world a new variety of tissue readers, whose OKIFICIAL SUKGERY. 615 achievements promise to be more interesting and important to the race than any of their predecessors. The universal fact that the condition of an organ expresses itself at its mouth furnishes a key to organic history and deep-seated tissue-read- ing by which the book of life can be opened and its pages read with startling fullness and accuracy. Pale mouths tell of cowardice and discouragement and despair, and the consequent hunger and starvation typified by anemia of the organs they serve. Bright red, irritable mouths are the termini of organs that are themselves in an excitable and irritable condition. Dark purple, congested mouths bespeak organs clotted with blood stagnation, implying disturbed functions, which, if con- tinued, inaugurate any of the changes which have their incipi- ency in an engorged condition of stagnant blood. Atrophied mouths guard the entrance to organs which are atrophied, while hypertrophied outlets indicate a hypertrophied condi- tion of the parts they are connected with. There is an exception which is sometimes to be taken to every one of these statements. It is where there has been a metastasis of anemia, or irritability, or congestion, or atrophy, or hypertrophy, from an organ to its mouth. In such cases the condition of the organ is to be read by contraries. The diag- nosis of this condition many times implies a deep appreciation and insight into the underlying principles of action of the indi- vidual, in addition to the employment of every possible means of physical diagnosis. But the greatest service which the orificial philosophy has bestowed upon mankind consists in the impulse which has been given the medical profession to carry into practical applica- tion the knowledge of which it is already possessed concerning the function of the sympathetic nerve. For generations stu- dents of medicine have been taught that the peristalses of the body were accomplished by involuntary muscular fibres under the domination of the sympathetic nerve. And they have been taught also the meaning of peristalsis, and given to understand that all the solids, liquids, and gases of the body are propelled along their various channels from their source to their desti- nation by this action. They have been told also that the sexual 616 ORtFlOlAL SURGERY. organs are responsible to this same nerve for their vitality and the performance of all their functions. But such knowl- edge has not heretofore been taken advantage of, and students of medicine have been told to go the all-important step further and study the waste and repair of the sympathetic nerve as a means of practical importance in the healing of the sick. Knowing the fact that the entire bodily commerce was dependent upon sympathetic nerve force, their sin of omission has been great, for they have concerned themselves, alas ! too little about ways and means of economizing the expenditure of this force, and restoring it when exhausted. Their efforts at bodily patchwork have, therefore, been exceedingly lame and unsatisfactory, and their ability to re-establish the general bodily vigor, so essential to all re-building, has resulted in an ignominious failure. I am well aware of the serious nature of this charge against the medical profession. I have no disposition to be- little them or call them names. I know their labors in the cause of humanity have been indefatigable. I know that they have not only been earnest workers, but honest ones, and although lives have been lost that a greater knowledge than they pos- sessed would have saved, and although sickness still remains a common lot of mankind, while, in a large percentage of cases at least, it is now no longer necessary, the doctor who has not been able to cure his cases throughout all time has suffered more than the cases themselves, and I have no feeling for him but that of the tenderest sympathy and consideration. But, nevertheless, the accusation that the medical profession is der- elict, in this matter of the appreciation of the uses and abuses of the sympathetic nervous force, is true. He has lost his sleep, his rest, his comfort, his peace of mind, as well as of body, and, in most cases, his life. His best service has oftentimes been the poorest appreciated. For his successes he has been poorly paid; for his failures he has been too severely punished. Nev- ertheless he has been illogical, and has not made sufficient use of the knowledge at his command, and the only way in which he can in any degree compensate the world for his great crime of omission will be for him to snap the bands of prejudice that OEIFICIAL SUEGERY. 617 have bound him, break loose from the thraldom of tradition, dispel his fear of so-called authority, cultivate his reason and observation, and stimulate his self-reliance. It is not necessary for him to study harder, but think more; not to accumulate more facts, but to digest those already in his possession. He must cease propagating mere dogmatism and become a logical and consistent free-thinker, fearing not men, but only God and his own conscience, and by living up to the light he has pre- pared himself for the reception of still greater light. In any factory run by the force of steam, a waste of the steam necessarily decreases the power. Steam must not only be manufactured, but it must be boxed, condensed, held tight, so that its power of expansion may be conveyed by pipes to the places where its judicious expenditure will make the wheels go round. In a corresponding manner is the sympathetic nerve force the bodily steam. When its reservoirs leak, its power is correspondingly depleted, and all bodily functions become en- feebled, and if some organs are weaker than the others their action may be completely suspended. The question, then, of properly performing bodily functions of all kinds, is one of vi- tality or sympathetic nerve power. As the history of the cerebro-spinal activity of a person can be read in the tissues of the face, hands and feet, so the history of the sympathetic life of the individual is disclosed to the orificialist without other testimony than is furnished by the pelvic tissues themselves. Pale orifices tell of exhausted energies. Tight ones bespeak a prodigal expenditure of nerve force in sustaining undue muscular tension. Patulous open- ings disclose a lamentable condition of a still further extrava- gance of nerve force, even to the point of nervous bankruptcy. Hypersensitive tissues at the floor of the pelvis mean morbid sensibilities of both mind and body in all forms of their activ- ity, and papillary developments signify that the condition of morbid sensibility has been so long established as to have passed all mere functional derangement to organic pathology. Hyperesthesia and anesthesia of the lower orifices are keys to the condition and conduct of the entire person, and bespeak universally prevailing qualities of habits of thought and feel- 618 ORIF1CIAL SURGERY. ing, interpreting which in the knowledge of the universal law of cause and effect, the past conduct of the person can be read like a history, its present attitude diagnosed with accuracy, and its future, if the conditions remain unchanged, safely prophesied. Hypertrophied tissues of an orifice reveal prodig- iality, and atrophied ones parsimoniousness. So can what is good and what is bad, what is generous and what is stingy, what is honorable and upright and what is disgraceful and scandalous, what is trustworthy and substantial and what is apprehensive and cowardly; and the continuous antitheses in the entire list of human qualities and characteristics be surely and accurately read by an expert observer in the conditions presented by the pelvic organs of the person. It is not always what the surgeon does to the patient, but how the patient be- haves under the treatment, that settles the outcome of surgical procedures, and a careful inspection of the pelvic tissues, by revealing to the surgeon the patient's principles of action, will enable him to prognose the success or failure of his efforts at repair. The index of the state and habits of the life forces in the individual as evidenced by the pelvic tissues is therefore an invaluable means of diagnosis in all surgical procedure. The pelvic tissue reader, however, has one great advantage over other body geologists. His field of observation contains many of the electrical buttons which control the direction of life's energies, and regardless of the conditions encountered, lives can be righted and habits of thought and feeling transformed to the liking of the operator if he is sufficiently skilled in manipulating as well as in reading pelvic organs. There is no part of the human body whose skillful manipu- lation can influence the issues of life and death, with all their varying shades of approach and departure, at all commensu- rate with those of the pelvis, for it is here that sympathetic terminals are accessible, it is here that messages of rebuke or of commendation, of punishment or of encouragement, can be sent tingling to the sympathetic nerve centers, and from these throughout the entire organization of the individual, influenc- ing functions, inspiring emotion, stimulating thought activi- ties, and. distributing whatever messages are sent along the ORIFICIAL SUBGEBY. 619 wires throughout the whole being. Messages from the pelvic outlets touch the heart and brain, and through these the bodily economy, more directly than those received from any other source, for they appeal to the nervous system, which never sleeps, which is the first to be born and the last to die, and in whose keeping rests the issues of life and of sickness, of hap- piness and of misery. Orificial tissue reading is as yet in its infancy. But young as the science is, its permanency and development is ensured by its value, not only as a historian of life, but also as a power in shaping its course. Facts are but the crystallization of forces, and the proposition is universal in its application. It therefore applies to bodily tissues. And by a knowledge of cause and effect the conditions in which organs ar efound stand for indi- vidual characteristics and qualities. They are but habit prod- ucts, and can be easily interpreted by those who have a suf- ficient knowledge of forces and their effects to read these hand- writings of life upon the impressionable walls of time. Because orificial sign-reading furnishes a substantial basis for accurate surgical judgment, it is an art well deserving an extensive cultivation. CHAPTER LXXXIV. PROSTATES AND WOMBS. F. W. MORLEY, M. D. Case 1. During the month of January, Prof. -, aged 68 years, presented himself for treatment for the relief of a slight irritation of the bladder, which necessitated his urinating about every hour or two hours. He declared he was never in better health and spirits and was about to go to a distant city to fill an engagement which took him before the public as well as before large classes of ladies. Tt was on this account that he sought relief from this slight bladder irritation. We are taught that men of his age often yes, always have enlarged 620 ORIFIOIAL SURGEEY. prostates, and that gradual dilatation by means of the passage of graduated steel sounds is "good" for that complaint, so a No. 11 Pratt sound was passed to the prostate, which gave much resistance and pain; and the sound was removed, fol- lowed by a gush of blood. The whole man seemed to have been shocked, and although he said nothing, he looked every- thing. Within two hours he was attacked with violent sci- atica (left), pain running to heel and terminating in outer maleolus where the cellular tissue became very much injected, obliterating all anatomical points. A violent chill of three hours, vomiting, dysuria, every five to fifteen minutes, extreme pallor, in fact the nerves of animal life seemed to have been suddenly paralyzed. He was weak, listless, indifferent, apa- thetic, could scarcely speak above a whisper. This last feature was very marked after recovery was quite well established, and exceedingly annoying, as when in health he has a superb voice. This falling to pieces process went on for several days when re- covery was established, which was slow indeed. After he was able to be about, the frequency of urination was not lessened until 1 had acted upon a suggestion given me by my esteemed friend Dr. Francis D. Holbrook, of Chicago, and given the prostate, which was as large as my fist, a thorough daily mas- sage. From the first the patient was relieved and used to say to me every day, "Doctor, you've hit it this time." Case 2. On the day following the first examination of Prof. - , Miss - - presented herself for the relief of metrorrhagia of ten years' standing. A steel sound, No. 11, was passed with difficulty along the cervico-uterine track ; al- most immediately she screamed with pain in left leg following the course of the sciatic, down to the heel she suffered the most excruciating pain. After a few minutes she got one- quarter grain morphia and went home in a coupe ; had no further trouble except a course of morphia nausea. Case 3. Deacon - , aged 50 (white), contracted gon- orrheal urethritis from undue exposure to the person of one Miss - - (colored). A wild orchitis ensued and the poor old fool suffered intensely, a suffering which his long-drawn- out prayers failed to mitigate. In due time he presented the ORIF1CIAL SURGERY. 621 usual gleety discharge and complained that the bladder was entirely unreliable especially in church. Rectal examination revealed a nodular gland the size of an orange, the left lateral lobe being largest. Massage cured the ' ' everlasting drop, ' ' the irritable bladder, restored him to his church work, and I am told by those in authority that the deacon never prayed bet- ter, his voice never rang out clearer than since he had the grippe (?). SECTION XI. After-Treatment ORIFICIAL SURGERY. 625 CHAPTER LXXXV. IMPORTANCE OF AFTER-TREATMENT IN ORIFICIAL SURGERY. H. A. SHERWOOD, M. D. Probably in no other class of surgical work does the care- ful after-treatment of our cases demand attention for so long a time, as in orificial surgery ; and the neglect of such continued treatment is, undoubtedly, the cause of many failures and dis- appointments to the patient as well as the surgeon. When we stop to consider that in nearly all cases of those who resort to this method, the patient has been a chronic sufferer, has been the rounds among physicians, and tried various methods, it is not strange that continued after-treatment is of vital import- ance, if we are to be successful. This statement is undoubtedly one which will be accepted by you as a body of orificial surgeons, without a dissenting voice. But to impress upon the minds of our patients the ne- cessity of after-treatment, in the way of dilatation of the lower orifices, the use of electricity, massage, hot and cold water, rectal flushings, etc., is a thing not so easily accomplished. It is difficult to make them understand how the use of dilators for the uterus, rectum, and urethra can possibly relieve disor- dered conditions of other parts of the body. This fact was forcibly brought to my mind recently while dilating the lower orifices of an insane man, for whom I had amputated a pendu- lous scrotum and operated for hemorrhoids. He said he did not see how it was going to help his head to have his rectum and urethra stretched twice a week, and he was getting tired of it. I finally compromised matters with him by sending him to Dr. Sawyer's Sanatorium at Marion, Ohio, where I felt sure the orificial methods would be continued in the most thorough manner. It is difficult for a general practitioner, who has a busy practice, to devote the necessary time to the after-treatment 626 ORIFldAL SURGERY. of his orificial cases, and I think it is best, when the patient becomes discouraged, to send him away if possible where he can have the benefit of a change of scenery and the various methods, of local treatment to be found in private hospitals. In my experience the majority of patients think they must notice a marked bhange as soon as the operation is performed ; and when they do not, it is difficult to hold them long enough to follow out the necessary after-treatment. In cases of sexual neurasthenia of young men, I have seldom failed to get satisfactory results in those cases where the patients presented themselves regularly and for a proper length of time, for dilatation after the primary work of cir- cumcision. So marked has been the difference in results be- tween those who did and those who did not follow out the after-treatment, that I have adopted a rule of explaining to each patient the necessity of following up the treatment ; and those who will not promise to do so, I do not urge to be operated. The use of rectal dilators, either with or without hot or cold water, has been practiced and followed by good results in the hands of so many orificial surgeons, that the theory of Dr. Pratt, that this mild form of treatment is applicable to a cer- tain class of weak and nervous persons, who will not submit to more radical measures, is well established. In this class, too, the treatment must be long continued to insure satisfactory results. The point that I wish to make in this brief paper then is, that whatever we do along the line of orificial work must be followed up with the same earnestness of purpose wkich we possess at the time we do the primary work, fully believing that this is the only way to derive the full benefit of orificial work. ORIF1CIAL SURGERY. 667 CHAPTER LXXXVI. AFTER CARE E. Z. COKE, M. D. I have a few suggestions to offer to those who are just be- ginning to do orificial work and to those who have experienced some trouble in obtaining satisfactory results both local and general from the work. It is one thing to do a skillful surgical operation, and it is quite another to have beneficial and satisfactory results follow the operation. I firmly believe that a great deal of the un- favorable criticism we have had to face is largely due to the fact that when we first began the work we did not fully realize the importance of thorough after attention and treatment, and we have had to learn through our own discouragements and failures the necessity of following up these cases to a finish, whether the time required be months or years. After the American and slit operations it is of the greatest importance to follow the case with thorough, careful dilatation, trimming and smoothing (under anaesthesia when necessary) and mas- saging of the parts until healthful functions are restored. While your patient is receiving this care keep the parts clean and use colon flushings daily, or at least every other day. After each flushing medicate the sigmoid and rectum with one or two ounces of olive oil and phenol sodique, in the proportion of one drachm of phenol sodique to one ounce of olive oil. There are a number of other good remedies; with which you are all familiar, but this mixture has given me the best satis- faction of any one remedy. As a rule we always find sigmoidal trouble in these cases, and I keep up this plan of treatment until all tenderness in the region of the sigmoid is gone, and the stools have a natural ap- pearance instead of being a mixture of balls and slimy mucus. You will find that if you neglect to treat the sigmoid you will not cure these cases, and the time to treat them is while you 628 OBIPICIAL SURGERY. have them in bed and under your control. They can easily be taught to follow up this plan of treatment at home. Some of my experience in rectal work has been gained in the Northern Indiana Prison, where I have been consulting physician and surgeon for the past twelve years. The prison hospital is by no means a sanitarium; the surroundings are about as unhygienic as they can be and admit of the possibility of recovery, and if there are any trained nurses in the institu- tion they did not go there voluntarily. Experience has taught me to use fine silk and silk-worm gut in all my work. I have entirely given up the use of catgut in any part that cannot be made absolutely aseptic and kept so. I can then use such local measures as I see fit without danger of the sutures softening and breaking down permitting the tissues to become infected, suppurate and retract. Even where the tissues are very soft from old inflamma- tory action, the silk is more reliable and less likely to pull out. [We now have catgut prepared to last a sufficient number of days for union to take place. Ed.] With the use of a two or four per cent, solution of co- caine, there will be little, if any, pain when the sutures are re- moved. I use hydro-naphthol gauze and powder in place of iodo- f orm (when I have occasion to use this form of dressing) , with just as good results and without the disagreeable features of iodoform. If from any cause the wound breaks down, allowing the mucous membrane to retract sufficient to permit the for- mation of extensive cicatricial tissue in the wound surface, the best plan is to make the wound aseptic, freshen up the sur- face, dissect the mucous membrane free, and then suture as in the first place. This will save you a great deal of time and trouble, and save your patient much pain and inconvenience. In the cervix operation, I always use the silk-worm gut sutures, leaving a long end on each side, which I knot together and lay above the uterus. If the sutures are not suppurating, I prefer to leave them in a few days longer than the prescribed time. When I am ready to remove them I can take hold of these suture ends and draw the uterus down easily, bringing ORIFICIAL SURGERY. 629 the sutures to view and permitting their easy removal without injury to the wound. In these cases where we have had to cut out a great deal of cicatricial tissue, in the way of plugs, the work is bound to be followed by contractions of the organ. When we find our patient beginning to experience a return of the old symptoms, mental and physical, that called for the work in the first place, it is an unfailing sign that she is suffering from these contractions, and we must put the patient under an anaesthetic, dilate the cervix thoroughly, and curette the uterus if necessary. Repeat this whenever the patient appears to be falling back into the old rut. I have had cases which re- quired this to be done on an average of twice a year for over three years before a cheerful, hopeful, mental state and a nor- mal physical condition was assured. Had this not been done, these cases would have been worse off after the operation than before; and would not people have been justified in thinking and saying that the operation was injurious rather than bene- ficial? Even the little operation for phimosis will sometimes be a failure for want of attention afterwards this can also be the case in work upon the clitoris. In closing, I will say, never undertake to do orificial work on any case that you cannot follow to a finish, either personally or through some competent practitioner who is in full sym- pathy with this work. You will then get grand results in cases that would otherwise bring discredit upon our cause. CHAPTER LXXXVII. AFTER-TREATMENT IN ORIFICIAL SURGERY. FRANCIS D. HOLBROOK, M. D. The preparatory and especially the after-treatment in orificial surgery are quite as important as the operation. The American operation, for instance, is the most mechanical and scientific operation for the excision of the last inch of the rec- tum yet devised, and can be made to leave that organ as serv- 630 OK1F1CIAL SURGERY. iceable and unobtrusive as a normal one. Yet how it has been assailed by both profession and laity, because it is not always satisfactory! And why? Because we have not followed the work to a finish. Simply once curetting, packing and doing other orificial work will cure only about fifty per cent, of the cases of dys- menorrhea. They will all be better for a time, but it does not cure. We must handle them again and again to attain the best results; and let me tell you, while you are taking good care of your patient, following up the work already done by good after-treatment, your patient will not want to go off to another doctor, and you can follow your curable cases to a cure. Many cases of locomotor ataxia can be cured, and the ma- jority benefited, not by orificial surgery alone, but with ori- ficial operations and the other methods known to the profes- sion, such as electricity, massage, baths, drugs, etc. With many of our patients the preparatory treatment is the operation, but there is no question but treatment, to get the patient in condition for the surgical work, is of great value. If we are to work upon the uterus, either curette and pack, repair a cervix, perform hysterectomy, or anything in the line of uterine work, and the organ is big and flabby or eroded, a great deal can be done to lessen the size and tone it up, and get it in better condition by douches, tampons, replacing if it be out of place, and attention to the bowel, using either cathartic or enema. When patients come to the hospital, where it is pos- sible for them to be treated a day or two before the operation, we put them through the following course : Give them a thor- ough tub-bath, scrubbing with soap and brush, then a salt glow, an enema of about 15 drops of turpentine to a gallon of water, or use hamamelis, or anything of that kind, and have the bow- els move thoroughly; if a woman, give a vaginal douche, 1 to 4000 bichloride, inject a little bovinine into the vagina to re- move secretions, then irrigate, then equal parts of peroxide and water, and irrigate again; the vagina to be thoroughly dried with gauze sponges. If the cervix be much hypertro- phied, we insert a pledget of cotton saturated with the fol- lowing preparation : ORIFICIAL SUEGERY. 631 Oil Eucalyptus, 2 drachms, Hamamelis, 4 ounces, Glycerine, 4 ounces. You will find that this will reduce the swelling. It is a good plan to put a little vaseline on the tampon to make its removal easy. We repeat this local treatment daily, have the bowels move every day, and continue the use of the tampon for two or three days previous to the operation. The night before the operation the tampon is removed, a douche is given and the vagina packed with iodoform gauze which is removed the morning of the operation. A cathartic should not be given under thirty-six hours before the operation; an anema should not be given on the morning of the operation or immediately before, but one should be given the night before. It is our practice to give a hypodermic of 1-4 grain of morphine and 1-150 of atropine about fifteen minutes before starting the anesthetic for operation as it steadies the heart, takes less anesthetic to hold the patient well under, and when patient awakes after the operation it is as from a sleep rather than in the hysterical condition which is so common with ether or chloroform. [H. M. C. is preferable. Ed.] The immediate after-treatment is much the same in all varieties of the work. For nausea and vomiting immediately following the operation, the less you put into the stomach the quicker relief is obtained. All the drugs in the Materia Medica are sometimes unavailing. Champagne, sherry, inhalation of camphor fumes, vinegar fumes, hot and cold milk, water, cof- fee, tea and a host of other things have all been given with va- riable success. But to cure the vomiting naturally you must reverse the peristalsis, and the quickest measure for that is to get the gases to go down by the use of a catheter in the rectum, or an enema of hot water, six or ten ounces with ten drops of turpentine in it. Dr. Bessey: How soon after the operation? Dr. Holbrook: Immediately after for instance, if your operation is either rectal, cervical, or on the abdomen, and 632 ORIF1CIAL SURGERY. the patient vomits more than ordinarily, and you have tried ice-bags on the throat, had them lie on the back, had them put the head down ,given them morphine, and they still continue to vomit for six or seven hours, I would suggest that you use the catheter insert it in the bowel and you will find it lets off a large quantity of flatus. That relieves for the time being. Should the nausea return then I suggest that you throw hot water, plain or salt, into the bowel which not only reverses the peristalsis but relieves restlessness. Dr. Dunn: How soon would you give a cathartic? Dr. Holbrook: Seldom immediately after the operation as it is weakening. They have got all they can do to revive from the operation. When the nausea and vomiting continue and pain is felt over the abdomen, you should not feel easy about your case until the gases have passed, else you may have peritonitis, and you will check but few cases of well defined peritonitis that follow an operation. If your patient starts in with fever, restlessness and pain, and the gases form, you insert your cath- eter and draw off a little gas, and there still is vomiting ; your case is not in a very good condition, and if you don't relieve it by the milder measures you ought to give a full enema ; I would use two quarts to a gallon of water, have a free passage from the bowel. If you can take them in that stage you can prevent the peritonitis ; but if not, if they go two or three days and the fever gets a hold, tongue a dark color, restless and vomiting, and the vomit is black, you can seldom cure them. Morphine is very useful immediately following these ori- ficial operations as it abates the nerve-shock. Of course in many cases it is unnecessary. I have never seen any harm come from its moderate use and I have seen a great deal of good. It is only necessary to continue it through the first forty- eight hours usually. Arnica and hypericum have both been used to quiet the pain with fairly good success, but nothing "gets there" like the morphine. I would suggest, especially after the American operation where there is a great deal of contracting pain, that you give the morphine, give it in quarter grain doses ; give it to the point of relief. After the slit opera- OBIF1CIAL SURGERY. 633 tion, the hot compresses against the rectum will relieve the pain. Tak a fold of a piece of flannel and wring it out of hot water and put it against the buttocks and the anus, it re- lieves the pain, reduces swelling and stops a good deal of the oozing. The first dressing of the wound is iodof orm ; subsequently, if the patient objects to the odor, and a great many are nauseated by its use, we change to either aristol, iodol, quinine, acetanilid, boracic acid or bismuth. We prefer to dress wounds dry, especially while stitches are in situ. Then apply either iodoform gauze or sterilized dressing and bandage. Douche twice a day with solution of either boracic acid, carbolic acid or bichloride of mercury, pledget of sterilized gauze. Dr. Bessey: You give the douche right along after the operation ? Dr. Holbrook : Yes, with rectal work, and forty-eight hours after uterine work. A Doctor: Doesn't that soften the stitches? Dr. Holbrook: Not if dried thoroughly. A Doctor: Wouldn't it be better to use silk stitches? Dr. Holbrook: I prefer catgut. Silk sutures have to be removed, which is a very painful operation. The catgut will not absorb under four or five days if you take good care of it, using the dry dressing. When the uterus has been curetted and packed, the pack- ing is allowed to remain in the cavity from twenty-four to forty-eight hours, unless patient complains of great pain, and there is too much reaction. Then you should remove the pack- ing and give a douche even as early as three or four hours fol- lowing the operation. When the operation is trachelorraphy, at the time of the operation iodoform gauze should be inserted in vagina ; allow to remain about two days, then renew it, but don't pack the vagina full. Be as careful as possible when in- serting the speculum, as opening it will force the margins of your wound apart. After hysterectomy, we douche with bichloride, 1 to 4000. With celiotomies and vaginal hysterectomies nothing is al- lowed in the stomach for twenty-four hours, not even water. 634 ORIFICIAL SURGERY. After that time coffee, tea, milk or broth can be given in very small quantities. If this sets up vomiting or distress, it should be discontinued for twenty-four or forty-eight hours, then by that time you will probably find the patient in a con- dition to retain it. In the meantime feed the patient by way of the rectum, using either bovinine or Murdock's food, milk or any nourishing liquid which may be absorbed readily for nourishment. For the thirst following these major operations, a little hot water thrown into the rectum will satisfy quickly. Now as regards the first and subsequent movement of the bowels after the operation on the rectum. We allow the bowel to remain inactive for four full days; give a cathartic on the evening of the third day, following with an anema the fourth day. Dr. Bessey: What, doctor? Dr. Holbrook: For cathartic compound licorice powder, Garfield tea, cascara sagrada and salts are the mildest and most effectual. Inactivity of the bowels for three or four days is attend- ed with the best results and least pain, but I have noticed that those patients whose bowels move three, four or five times a day immediately following operation, from chronic diarrhea, usu- ally make quite as good a recovery as the others. The first movement of the bowels is sometimes associated with great pain and often a chill, so you'd better have somebody with them. If patients have a chill, give a quarter grain of mor- phine ; this will stop it quicker than anything else. You will have to use a catheter in ninety per cent, of the cases of orificial work for a few days. Where the rectal wound is slow in healing use such stimu- lants as hydrastis, compound tincture benzoin, carbolic acid, sulphate of copper, eucalyptus or quinine. We often use a rock oil called "Jo-He." It allays inflammation, relieves pain, and is excellent in healing wounds. Patient should remain in bed one week after the slit opera- tion; with the American operation one ought to lie in bed ten days or two weeks to get the best union, the best results, and OBIPICIAL SURGERY. 635 less trouble afterward. With a uterine operation where you have curetted and repaired the cervix, it is unsafe to allow the patient up in less than ten days. Dr. Morley spoke of letting them up the next day; I think he had reference to repairing the cervix by simply scraping the end of it and putting in a few stitches that's all right. But where you curette a uterus, put in packing and do an operation that will take ordinarily half an hour, give an anesthetic too, and then allow her to get up the next day, why, I think it is very unsafe and almost criminal. (Applause.) I once repaired a cervix and perineum, all without an an- esthetic. I packed the vagina, and told the woman to stay in bed a week. At the end of that time I went down to remove the silver stitches and found her sitting up. I told her I want- ed her to stay in bed till the stitches were removed. She said, "I have been up every day since you were here." I removed the packing placed there the week before ; of course it smelled simply frightfully, but the wound had healed perfectly and she didn't have a particle of trouble; however, I don't recom- mend this method. After vaginal hysterectomy, patients may get up in two weeks, providing they are in good condition, their temperature has been normal for a number of days, appetite and sleep has been good and wound healed ; and after a celiotomy the same rule applies. After ventral fixation the person should lie in bed from two to three weeks, and the stitch which fixes the uterus to the peritoneum should remain in a week to two weeks according to the conditions. If the wound is healthy and no discharge or redness about it, there is no reason why the stitch should not remain in two weeks. There is scarcely any pain with ventral fixation, or with laparotomy wounds, and very little pain with hysterectomy by the Pratt method. The pain and distress which are common, I think come from the accumulation of gases. I have noticed that there is less pain after sewing the wound as you saw it done today, than by the other methods. In doing an American operation, if you get union by first inten- tion you will find a distinct line of demarkation between the 636 ORIFICIAL SUEGERY. mucous membrane and the skin which will mark the location of the scar, and that scar will contract as patient gets up and goes around ; and at the end of two or three weeks or a month, perhaps, you will be surprised to see that the anus is not any bigger than the end of a pencil and there is a hard cicatricial scar. The scar should be clipped in four places, not in the an- terior or posterior parts of the wound, but just at the left and right, either side of the median line ! insert the speculum and dilate the rectum gently. This was our method of correcting the stricture by taking a patient ten days or two weeks after the American operation. When the scar begins to contract, if you will practice massage on this scar and the buttocks, using the Jo-He as a lubricant, you will be surprised at the ease you will give the patient, and the rapidity with which the scar will absorb. The lack of control, either of the feces or of gases, is not due to a ruptured sphincter in ninety-nine cases out of one hundred, it is simply due to the cicatricial contraction they cannot contract that scar, because it is non-elastic. You must absorb the scar before you get full control of the sphincter. Sometimes in healing you will find a pouting condition of the mucous membrane; clip that off with the scissors, there is no pain. You will sometimes operate for an enlarged prostate, per- haps doing the American operation, perhaps doing the slit operation, possibly circumcision ;pass sounds, clip the meatus and clip the frenum. The patient will be immediately relieved by the operation ; then in about ten or twelve days the old symptoms will return ; you will find the prostate as large as before if not a little larger. To reduce that congestion use massage ; put the finger in the rectum, outline the prostate and do the same work on the prostate that you do on a uterus or cicatricial scar; in five minutes time you can reduce that con- gestion so that the prostate is normal in size. Repeat the mas- sage every day or two according to the symptoms manifest. There is art in this business as well as science ; insert the finger in the rectum easily, gracefully and nicely ; massage with skill and you will do no harm, but if you are rough you will do more harm than good. ORIFICIAL SURGERY. 637 Subsequent to this work the passing of sounds is bene- ficial and should be used for the enlarged prostate about two or three weeks after the operation. Heat the sound with hot water first, insert in the urethra, let it remain about ten min- utes, then put sound in cold water and insert in uretha again and remove immediately ; to massage while sound is in situ is very beneficial. Regarding the after-treatment, so long as your patient is improving, let him alone. Perhaps they come to you with dyspepsia, headache, or similar troubles, and you operate on them; they are better from the work, recovering nicely from the operation and feel better in every way. Let them alone, don't dilate them or do anything of that kind. It is all right to attend to the local^wound, but don't begin the use of sounds or rectal dilatations or anything of that kind to tone them up and make them better until they come to a stand-still, then use sounds, dilatation, etc. A Doctor: Suppose the mucous membrane draws up and granulates after the American operation? Dr. Holbrook : In the American operation where the mu- cous membrane breaks loose, I would handle that wound the same as any other wound, curette it, use the dry dressing, or stimulate it with boracic acid, benzoin or tincture of hydras- tis. If the gut has retracted all around, broken loose entirely, and if there is a raw surface and it causes distress, you must put your patient to sleep again, pull the retracted gut down again, sever the longitudinal fibres that pull it up and stitch as before. You may use a suture, the same as you saw in the ven- tral fixation; take two buttons, put one button in the rectum and the other on the buttock, about an inch out from margin of anus, with stay suture. Then if you will dress the wound as before you will get good results. Dr. Walker: One question in regard to the after-treat- ment of the rectum. In the classes heretofore, I have noticed that the roll of cotton used was about eight inches long and as large as the wrist, introduced into the rectum, called the rectal packing, to remain from twenty-four to forty-eight hours. I notice now that the rectal packing is about the size of two 638 ORIFICIAL SURGERY. fingers. I want to ask if there are any bad results from the packing, or is it to prevent the escape of the gases? I want to ask why the change of treatment ? Dr. Holbrook : Early in the work the packing was pretty large, I remember, and was hard to insert sometimes; the size now is suitable for the majority of the cases. In the after- treatment of the sigmoid, for constipation especially, we use the Kelly sigmoidoscope or the old Brinkerhoff speculum, through which we can pass medicated cotton or wool into the sigmoid. For constipation we have used all sorts of prepara- tions on this packing by way of medication, glycerine, ham- amelis, Jo-He, etc. ; have obtained the best results in constipa- tion from the use of inspissated ox gall; saturate the pledget of cotton with it and insert it high up in sigmoid; this over- comes the constipated habit of the bowels quicker than any- thing else I know of. A Doctor: You mean temporarily? Dr. Holbrook: No; the bowels are often sluggish after the orificial work has been done, and only need a little treat- ment to complete the cure. A Doctor: You don't refer to the habit of constipation. Dr. Holbrook: Yes, when the local condition has been relieved by operations and the constipation continues, it is usually due to a sigmoid condition, which needs treating be- fore the case will clear up. Dr. Sharp: I understand Dr. Holbrook to say that the most important thing to do in severe vomiting is to establish downward peristalsis. If that is so, why does he give large doses of morphine, which paralye the bowels and lock up the secretions ? Dr. Holbrook: I don't think it does, doctor. After an operation, an orificial one for instance, where the nerves are all shaken up, the morphine will quiet them down, prevent the vomiting, keep them quiet, allow the system to swing back into tone and get back its equilibrium. I don't think a quarter of a grain of morphine will, to any great extent, check the action of the bowels; I don't think it will stop the secretions or par- alyze them to any great extent. The shock of the rectal work ORIFICIAL SURGERY. 639 will often stop the secretions by setting up contractions. The morphine overcomes this condition. Dr. Morley: We don't use morphine, after perhaps about twelve hours, in some cases not so long. We find some cases of the American operation, which is always the most painful, where perhaps one injection will answer for several hours; other cases have injections from half an hour to an hour apart for two or three times. Dr. Sharp : The reason I spoke of it, I saw Dr. Senn last summer at the St. Francis Hospital, and in the majority of op- erations he gave no morphine. I asked why not; and he said it locked up the secretions, and he found it was a bad thing to do. Dr. Holbrook: Were they rectal operations? Dr. Sharp: No, they were laparotomies. Dr. Carriker : In some cases after the American operation in nervous patients, there seems to be pain close on to the ex- ternal nerves, there is spasmodic contraction of the sphincter. I'd like to ask the doctor what he does in those cases to keep the sphincters quiet? Dr. Holbrook : The sphincters will contract spasmodically for a day or two after the operation. The only thing I have found that will stop these contractions is the morphine. I think the hot water and hot fomentations would stop it, but I don't like the hot fomentations and moisture where there are stitches, so I use morphine. Dr. Cole : In speaking about relieving the contraction of the sphincters, I can speak from experience. I know that the hot fomentations will relieve it; I am sure of it, and that is one of the reasons why I advocate the use of the silk suture that you can use as much moisture about the wound as you like and it saves the use of morphine. I know it will do it, because I have used it ever since I commenced closing the wound with silk. In some cases I use four interrupted silk sutures and close it with catgut, because the four will support it if the con- tinuous suture should break down ; but the hot water will re- lieve that spasmodic contraction. Dr. Sharp : I would like to ask the doctor why he objects to giving morphine? 640 ORIFICIAL SURGERY. Dr. Cole: On general principles; I believe the patient is better off without it, if possible to get along without it ; no ob- jection to it if it has to be used. Dr. Dunn (Titusville) : I have a suggestion to offer in this matter. When I operated for these troubles I immediately gave my patient ferri phos., which is an excellent remedy to control fever, inflammatory action and the like, and I don't know of any remedy that reaches so far in the direction to overcome shock and tendency to fever as that drug, ferri phos., from 3x to 6x. When I have had that spasm of the rectum to annoy me I have used hot fomentation with magnesia phos. dis- solved in it and it will almost entirely control that spasmodic action of the sphincters. Such has been my experience. I have not used morphine I have no objection to its use but I have been an allopathic physician for thirty years and I try to es- cape anything connected with the palliative mode of treatment of disease ; I seek a remedy and in this ferri phos. and magnesia phos. I find the remedies for this trouble. Dr. Erni : In my first cases I used ferri phos. ; it cured the spasmodic action of the rectum, but introducing the rectal plug relieves it quicker and more effectually than anything else I know of. Dr. Clark: In the line of treatment after the operation there is one thing I would like to mention in regard to the enema; flaxseed is the most serviceable, being very soothing and beneficial. Take a teacupful of the seed, tie it in a bag, boil half an hour in water and it is ready for use. Dr. Walker: I want to speak one word with regard to the hypodermic use of morphine. There is no question but the morphine in hypodermic doses is good, and my practice is this : if the patient is in pain give him a quarter of a grain of morphine with the atropine hypodermically, but if not in pain but restless, etc., give morphine an eighth to a half grain. I do not think bad results can come from it. [To prevent vomiting following anesthesia thoroughly wash out the stomach with tube before the patient recovers consciousness, or just before putting to bed. Also when nan- ORIFICIAL SURGERY. 641 sea is first manifested give a glass of water with two-thirds of teaspoonful of bicarb, soda. I have found codeine preferable to morphine. Where there is anuria, spartein, given hypodermically will be found very effective ; also the colon douche of warm normal salt solution, and hot fomentations to the back over the kid- neys. Editor.] SECTION XII. Some After-Thoughts, Warnings, and Helpful Hints, OKIF1CIAL SUEGERY. 645 CHAPTER LXXXVIII. SOME AFTER-THOUGHTS, SUGGESTIONS, WARNINGS AND HELPFUL HINTS. BY THE EDITOR. The entire field of the Orificial Thought is so well covered by the preceding chapters that there is but little left to be sup- plied by the editor. , He makes no claim of originality to the matter here pre- sented, as some of it is embraced in the body of the book in ar- ticles by other writers. Most of it has been gleaned from Dr. Pratt 's clinics, lectures and writings, verified where possible, and placed here for its utility and convenience. Remember in using Bovinine for a dressing that it will digest catgut. Do not use continuous sutures where there is a circle, as around the anus or prepuce. Be careful not to over-dilate the rectum. You may tear the posterior fibers of the sphincter muscle. In making up your diagnosis and applying therapeutic measures do not forget that the irritation of an organ begins at its mouth. From a pathological standpoint the rectum and uterus are twins; where you find chronic trouble in one the other will also need your attention. Blood stasis is the beginning of all pathology. Be very careful in dilatating the rectum of children and old people use caution, go slowly, or you may regret it. That which can flush capillaries, deepen or stop res- piration, is a measure of great potency for good or evil, as it may be used. Consumptives are sexual perverts, pointing to sympathetic nerve waste : a valuable index to the treatment required. 646 OKiPICIAL SURGERY. Always search for sympathetic nerve waste in chronic diseases. In Orificial Therapeutics the central idea is to secure un- embarrassed sympathetic nerve terminals at the pelvic outlets. Almost every case of insanity of single women will have erosion of the cervix. When your patient is irritable, cross, cranky, there is rectal trouble; when depressed, has the blues, there is catarrh of the colon. Many of your old cases of gleet that have long resisted medication can be at once cleared up by doing proper orificial work on the rectum. Irritation at one end of a tube is often reflexed to the other, as pin worms at the anus will make the lips pale and the nose itch. This might suggest appendectomy in some rectal troubles. In the male the condition of the inner surface of the lips of the meatus is an index to the condition of the prostate gland, as the tongue is to the stomach. A good operation for laceration of the cervix involves the removal of all the scar tissue. Those cases that heal without treatment are the ones that cause trouble. Rectal pockets and papillae are liable to return after re- moval and may require three or four sittings to eradicate them. In doing slit work for hemorrhoids, removing pockets or papillae, to avoid hematocele, dilate the rectumafter you have done your work, and not before, unless you are going to put in stitches. In trachelorrhaphy, when making the first incision to ex- pose the scar tissue, remember that you are holding the uterus down, or you may cut too high and cut off the uterine artery. The greatest resussitant from whiskey, morphine, chloral, chloroform from any narcotic, shcxck, or collapse from any cause, is an appeal to the last inch of the rectum, by dilatation and heat. Your fingers or Pratt 's rectal speculum will give you di- latation but not heat. The hot water plug will provide both at the same time. This is a hollow metal plug or dilator with ORIFICIAL SURGERY. 647 two short tubes at its base. Place a syringe tube on one and a waste rubber tube on the other. Insert into the rectum and let the hot water 115 degrees to 120 degrees flow from the syringe through this dilator into a slop pail. When your patient is cyanotic, lungs filled with mucous and rattling in the throat, you will be astonished and gratified at the result of this measure. It will also promptly relieve the worst cases of asthma. Every doctor should have a hot water plug. The blood stream is that which does all bodily repair, heals all diseases, removes all pathology, induces growth and sustains life. How important that we study and use every measure that can improve the circulation and flush capillaries. Irritation in the last inch of the rectum, if on the an- terior surface will affect the sexual organs; if on the posterior surface, the spine ; if on the lateral surface, the sciatic nerve and legs. Spasmodic action of the internal sphincter lowers the vitality of the whole body. To diagnose a fistula where you can find no opening, in- sert the forefinger into the rectum and with thumb and finger carefully palpate the perianal tissue. You can feel the "pipe" or tract of the fistula. Where there is an external opening and you can not find the internal apparently external blind inject peroxide of hydrogen into the external opening and through the open rectal speculum watch for the foaming into the gut. Where the rectum is impinged by the uterine fundus it would be worse than useless to remove pockets and papillae or hemorrhoids without relieving the impingement. Your rectal work without relieving the impingement would invite and ag- gravate hemorrhoids. In some cases of exaggerated retroflexion or retroversion of the uterus, pressing on the hypogastric plexus of nerves, thereby causing difficult or loud breathing, the uterus must be lifted up into position. If there is a tuberculous tendency this condition spells doom if permitted to remain. General ori- ficial work without replacing the uterus would not relieve her ; 648 ORIF1CIAL SUKGERY. it would be fanning the feeble flame of vitality while a stream of water is constantly pouring over the fuel. Where the patient has little vitality and rectal dilatation produces great effect on the respiration at its initiation but meets with no response by repetition, you may know he is on the verge of the precipice of death. Look out ! be very careful, or your patient may slip through your fingers. Gently and cautiously do a little dilating and remove what nerve impinge- ment he will bear, wait five days or more, when he will take the anesthetic kindly and hold up well under the operation. In performing colporrhaphy, for systocele, before suturing the vaginal flaps, peel these flaps of the vaginal mucous mem- brane so that they will slide over the muscular coat of the bladder for three quarters of an inch. Otherwise the stitches will be strained by a tight suture line, leaving cicatricial tis- sue as a thorn in the flesh at the base of the bladder. This little point is the door between success and failure in operating for cystocele. Orificial work may arouse a sleeping demon or a lot of little devils. This is more liable where the patient has not taken a course of preparatory treatment. It may so stir up the waste and excretory organs that they will become clogged. In an old chronic it may awaken the evil spirit of his malaria so that he periodically marches his progeny of chills and fever through the body; or the old suppressed gonorrhea may burst the confining dam and overflow the banks. It is well to warn the patient that a repetition of his old trouble may take place. The great majority of chronics have a loaded colon an impaction; consequently there is auto-infection from absorp- tion. There is poison in the kitchen. You must clear this colon, open the emunctories and start the funeral trains. Throw eight to sixteen ounces of olive oil into the colon and follow with all the soapsuds the bowel will hold. Then let him evacuate the bowel. To the soapsuds may be added one dram of ox gall or half a teaspoonful of turpentine. At first repeat this every day, then every other day, then twice a week. This, and this only, will remove the fecal matter that clings to ORIFICIAL SUEGEEY. 649 the lining of the colon. Also flush the kidneys with normal salt solution thrown into the colon three or four times a week. As an antiseptic in Orificial Surgery, both as a dressing and to disinfect the field before operating, I have found soluble iodin very satisfactory. I wish here to commend the prepara- tion known as lodum-Miller. It is effective, reliable and ready for use. It is soluble in water but free from water and alco- hol. I have no financial interest in it nor am I under any obli- gation to the proprietors. If you cannot get the patient 's permission, or her condition contravenes a surgical procedure for lifting and retaining the uterine fundus from its backward mal-position, you may pack the vagina after Pratt 's method with excellent results. Pratt 's method is as follows : Hook a tenaculum into the anterior lip of the cervix and drag the uterus down, pass the forefinger as high up on the anterior surface of the neck as possible, and force the neck upwards and backwards. The fundus following the curve of the sacrum throws the uterus forward. The tenaculum holds the cervix down while the pressure of tlie finger bends the middle of the uterus backwards toward the curve of the sacrum. You now begin the packing in the front of the uterus (not behind, as other so-called authorities direct), with the finger and ten- aculum holding the organ in place, pack first in the middle, then on either side, and repeat in this manner until the whole vagina is well filled with gauze. After forty-eight hours take out and repack. SUBCUTANEOUS OPERATION FOR VARICOCELE. Pratt 's Method. Seize the lower part of the scrotum with the thumb and finger and palm of the hand. Secure the tissues below the cord. Feel your way along until you come to a part that is hard like a knitting needle; that is the vas deferens. Let that and the spermatic artery slip by, retaining all else between your thumb and finger. Now with a needle, threaded with carbolized catgut, transfix the scrotum by passing between the 650 ORIF1CIAL SUBGEEY. vas deferens and the variococele. Next enter the needle at the same point where it came out; hug the skin and pass on the opposite side of the varicocele from the other suture, and emerge at the same point of first entrance. Drawing the thread it will now surround the veins forming the varicocele within the scrotum. The same suture is put in one inch above this first one. Before tightening these ligatures hold up the testi- cle and milk the blood out of the veins between them. Next tighten the ligatures pretty tight and hold them apart so tnat you can feel the bunch of tissues that have been isolated ; take a scalpel and subcutaneously sever the veins between the liga- tures, being careful not to wound the vas deference and not cutting the skin except at the point where the knife entered. Cut the ligatures short and pull the scrotum over them. Re- covery is rapid, but little soreness, and there will be no pus. The sexual system is the creative force. We are conceived and born through it. A new thought is creative work and is born through the sexual system just the same as a new baby. Great artists, poets, orators, inventors those who do creative work* and give the world something new, are strongly endowed sexually. Strong sexual endowment is a fertile field for new growths; it is the factory where new things are made; the foundry where new ideas are molded. The prodigal who spends this endowment in riotous living will soon find him- self wallowing in the mire and feeding with swine. It is a hot bed that may produce noxious weeds, or rich wholesome fruit. Metastasis, with its marvelous phenomena, spreads before us a great map for our careful study in the geography of Ori- ficial Philosophy. There may be metastasis from within out- wards and from without inwards; from nerve terminals to nerve centers, and from nerve centers to nerve terminals ; from skin to mucous membrane, and from mucous membrane to skin ; from the physical body to the emotional and intellectual cen- ters metastasis in every conceivable way. From a rusty nail in the foot the irritation may go to the other end of the nerve and produce lockjaw or insanity. The foot does not hurt; the patient can walk on it. If you have metastasis in mumps ORIFICIAL SUEGERY. 651 the irritation leaves the upper glands and moves down to the sexual organs. In other words, in metastasis there is a drain- ing away, a leaving the primary congestion to some other part. Following exaggerated hemorrhoids, fistula or gross pathology in the pelvis, there may be rheumatism, dyspepsia, asthma, etc., etc., but there will now be atrophy where there was congestion or inflammation. The class of cases where you can do the most good is not the one where you find gross pathology at the lower openings, such as extravagant hemorrhoids, fistula, etc., but where the patient is down with something else asthma, rheumatism, neuralgia, insanity, headache, some chronic trouble that does not respond to other measures of therapeutics. The patient is not conscious of any rectal or pelvic trouble. But here you will find a more profound condition than hypertrophy; you will find atrophy ; tissues pale, anemic ; perhaps a small meatus, short frenum, long, tight or adherent prepuce, pockets or papilla? in the rectum, an impinged clitoris, etc. This is the class of cases where this work will do wonders. Index. A Chronic Invalid 208 Acne in Young Men 591 After-treatment 627 After-treatment 629 Anatomy and Physiology of the Eeetum ." 250 Anemia, Headache and Neu- ralgia 172 A Plea for Orificial Surgery. 55 A Plea for the Insane 179 Asthma 563 A Surgical Talk on the Orifices 19 Bed Wetting 60 Birth of Orificial Surgery 17 D Dangers and Possibilities of Orificial Surgery 173 Diarrhoea 581 Dilatation 184 Dilatation of the Foreskin. . .188 Dilatation of the Urethra 189 Dilatation of the Vulva, Vag- ina and Urethra 454 Dropsy 193 Dropsy 563 E Epilepsy 586 Capillary Circulation 90 Cerebro-Spinal and Sympa- thetic Systems 92 Cerebro-Spinal System 93 Cervix Uteri 461 Cervix Uteri, Amputation of. 464 Cervix Uteri, Lacerated 464 Cervix Uteri, Strawberry Ero- sion of 462 Circumcision 392 Circumcision 401 Circumcision of Girls 482 Clitoris, Adhesions of 491 Constipation 578 Constipation 584 Constipation and Diarrhoea. .581 Female Sexual Organs 431 Fibroids, Uterine 172 Fistula, Rectal 328 Fistula, Eeetal 345 Fraenum 408 Functional Disturbance . ..555 G General Practitioner and Ori- ficial Surgery 82 General Practitioner as Orifi- cialist 211 Gynecological Reflexes 495 654 INDEX. H Hallucinations 157 Hay Fever 157 Heart Disease 160 Helpful Hints 645 Hemorrhoids 293 Hemorrhoids Acute External. 297 Hemorrhoids Active 300 Hemorrhoids Chronic 298 Hemorrhoids External 300 Hemorrhoids Excision of..... 302 Hemorrhoids Middle Variety. 299 Hemorrhoids Passive 299 Hemorrhoids Slit Operation for 306 Hemorrhoids Slit Operation under Cocaine 311 Hemorrhoids Treatment of... 296 Hemorrhoids Treatment of Middle 301 Hemorrhoids Treatment of... 312 Hiccough 595 History of Orificial Surgery. . 26 Hypnotism 611 Hystorectomy Vaginal 466 Hysterectomy Vaginal 474 Insanity 78 Insanity 81 Insanity 561 Insanity 568 Insomnia . 566 Lacerated Cervix 157 Laparotomy and Orificial Phi- losophy 229 Lowered Vitality 551 M Malaria 79 Marasmus, Dyspepsia and In- somnia 37 Massage 198 Meatus and Urethra, Male... 407 Mental Healing 529 Mental Healing 543 Methods of Operations 181 N Nature as a Surgeon 102 Nerve Distribution, manner of 101 Nervous Dyspepsia 72 Nerve Impingement in Surg- ery 216 Neurasthenia 575 Nipples of Nursing Mother.. 105 O Orifieial Methods of Cure 120 Orificial Philosophy 114 Orificial Reflexes Clinically Il- lustrated 155 Orificial Surgery 55 Orificial Surgery 61 Orificial Surgery, a Primitive Measure 173 Orificial Surgery Fact, Fad, or Fancy 39 P Papillae 274 Paralysis 35 Perineum Repair of 499 Philosophy of Orificial Surg- ery 122 Pockets and Pupillae 118 Pockets and Pupillae 250 Prepuce 4U* Proof of Experience 202 Prostate Gland 418 Prostates and Wombs 619 R Rectal Plugs and Tampons.. . .199 Rectal Surgery 281 Rectal Surgery and General Surgery 242 Reflexes 141 Reflexes an Diagnosis 160 Reflex Neuroses 153 Relation of the Two Nervous Systems 92 Rectum and Anus 237 Rectum Exterpution of 388 Rectum and Sigmoid 365 Rectum Stricture of 335 Rectum Toilet of 247 Rectum Ulcers of 335 Rectum and Uterus 105 INDEX. 655 Sexual Habits and Necessities 601 Sexual Organs Anatomy and Physiology of 387 Sigmoid 365 Sigmoid 369 Sigmoid 372 Sigmoid Diseases of 380 Sigmoid and Rectum 365 Skin Lesions and Dropsy. . . .564 Sounds .199 Stricture of the Rectum 33'5 Suggestions 196 Suggestive Therapeutics 505 Surgical Judgment 171 Surgical Operations by Nature 102 Sympathetic Nerve Charact- eristics of 106 Sympathetic System 95 Sympathetic Nerve Terminals in Women .... . .444 Technique of Orificdal Surgery 165 The American Operation 318 The American Operation 320 The 'Composite Physological Man 87 Tissue Reading 612 Tuberculosis .34 U Ulcers of the Rectum. .335 Vaginal Hysterectomy 466 Vaginal Hysterectomy 474 Varicocele 649 Vaso-motor Centres 129 Vitality, Lowered 551 Vomiting, Dyspepsia 161 Vomiting, Sympathetic 593 W Water a a Therapeutic Agent 197 Why this Method Cures Chron- ic Diseases 133 University of California SOUTHERN REGIONAL LIBRARY FACILITY 405 Hllgard Avenue, Los Angeles, CA 90024-1388 Return this material to the library from which It was borrowed. / PRINTED IN U.S.* CAT. NO 24 161 A 000502560 WO 500 D272 o 1912 Davson, Benjamin E Orificial surgery; its philosophy, application and technique MEDICAL SCIENCES LIBRARY UNIVERSITY OF CALIFORNIA, IRVINE IRVINE, CALIFORNIA 92664 UC IRVINE LIBRARIES H } \ f