Read Ebook: The Hospital Bulletin Vol. V No. 2 April 15 1909 by Various

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THE HOSPITAL BULLETIN

Published Monthly in the Interest of the Medical Department of the University of Maryland

PRICE .00 PER YEAR

Contributions invited from the Alumni of the University. Business Address, Baltimore, Md.

Entered at the Baltimore Post-office as Second Class Matter.

VOL. V BALTIMORE, Md., APRIL 15, 1909 No. 2

THE ETHICS OF THE GENERAL PRACTITIONER.

BY GUY STEELE, M. D. Of Cambridge, Md.

A celebrated divine once said that the most difficult part of a sermon was the selection of a proper text. I must thank the President of this society for saving me this trouble. When, however, Webster's is consulted for a proper definition of the word "Ethics," and it is found to mean "The science of human duty," it would seem that he has chosen a text almost too comprehensive for the limits of a short paper, even when restricted to the "ethics of the medical profession." It may not be out of place to thank him for the honor he has conferred upon me by deeming one whose student days are scarce twelve years behind him worthy of presenting this subject to you, for a paper on this topic is almost of itself a sermon, and we naturally look up to those, whose many years of experience and works have brought them prominence, for instruction in morals and duty. Still, I take it, whether young or old, all of us like to preach on fitting occasions, and not the least part of the inspiration to effort is the character of the audience. My invitation was to read a paper before the Clinical Society, and incidentally I was told that some of the students had expressed a desire to be present. Little, however, did I anticipate such a flattering attendance from them when examination time so nearly approached, and it is evidence of a most commendable spirit when they can bring themselves to take even an hour of their most valuable time from study to devote to a consideration of the moral duties and responsibilities which shall be theirs when they shall have passed through the April ordeal. Much that I have to say tonight will be directed especially to them, and if they or their elders in the profession may in the years to come look back upon this night with the recollection that I have more forcibly brought to mind some of the old and half-forgotten maxims and axioms that make for a better and purer professional life, I will have been more than repaid for the time I have expended in the preparation of this paper.

In discussing the ethics of the general practitioner towards his patient, I would have you remember that your first and most important duty is to give to those who trust you the very best that is in you.

To you young men, full of enthusiasm for your new profession, and imbued with Utopian ideas of the mission which you have undertaken for the good of mankind, it would seem almost foolish for me to mention this as the first advice I would offer you. But I think I can see a smile of understanding flit across the faces of those who have for some years fought the battle of life, and who have had the wire edge of early ambitions and determinations blunted by contact with unappreciative patients and unworthy professional competition and the daily incidents of a busy life. They know that it is very easy to feel too tired, or be too busy, or have some other engrossing affair in mind which prevents that entire devotion to duty which all admit is essential to success in medicine. Half of success in life or in any undertaking is due to a successful start; therefore, let me ask you to firmly determine on one or two fixed principles, and to stick to those principles through thick and thin. Be fully assured that no halfway devotion to your profession will ever bring you prominence or success. The time-worn phrase that "Medicine is a jealous mistress" loses none of its truth by frequent repetition. Recently I saw in a prominent medical journal the advice given that doctors should take a prominent part in politics and bring themselves forward in other ways, and that thereby in some way unknown to me the glory of the profession would be enhanced, and much benefit result to the community. Far be it from me to discourage a proper civic spirit and a proper interest in public affairs, or to advise an avoidance of any duty which good citizenship imposes upon every honest, patriotic man, whatever his business or profession. But I take it that no more baneful, no more dangerous advice can be given to our young professional man than this. You cannot be successful in both politics and medicine, and while we can point to one member of our profession in the United States Senate, and to some notable exceptions in our own State, where men of our profession have, for a time, abandoned medicine and returned to it to win success, you can rest assured that the medical politician possesses little beyond a musty diploma to remind the world that he was once of our cult. So don't be a halfway politician and halfway doctor. Success in either field will take all of your best effort and all of your time.

What I have said of politics will apply, though not quite so forcibly, to any other engrossing business or pleasure. Time forbids me to elaborate this idea, and in concluding it let me say that you cannot be a successful politician, merchant, sport or what not and carry medicine as a side line.

It may seem useless to remind you that, in order to give the best that is in you, you must keep abreast with what is new and best in professional literature and scientific progress. You all have determined to be students, and even those who pride themselves on having passed through the University without having opened a book have a half-formed desire to really know something beyond spotting a possible examination question, and when once examinations are over, and they have reluctantly withdrawn themselves from the delights of the city by gaslight for the pine woods and mountain trail, they will burn the midnight oil and browse diligently through their musty tomes. May I tell you that nothing is harder than to find time for study. Many of us, even though city men, with the best and latest literature at our elbows, are ashamed to think how thoroughly we abhor the sight of a medical book or magazine, and how easily we can persuade ourselves that we are too tired and stale, and so engrossed during the day with scenes of sickness and suffering that we must have our brief hours of release from duty for recreation. We do need our hours of relaxation and rest and our too infrequent holidays, and they are absolutely essential to good health and good work. Don't, however, confuse the words rest and relaxation with sloth and idleness, and don't think your professional work completed when your round of daily visits is done. Indeed, if you would know medicine you must woo your mistress in the small hours of the night, and in many of the leisure moments that the day may bring you.

Much has been spoken of the man who practices by common sense, and whose school has been that of observation and hard experience. A most worthy brother he is at times, and many are his friends and wonderful his success. But if the science of medicine is to advance, more is required for progress than mere common sense, and observation untrained and experience undirected and unguided by the observation and experience of others will rarely discover a new bacillus or elaborate a side chain theory. So, to be truly ethical in the duty you owe to give the best that is in you, you should be reading men. Take one or more of the medical journals. Buy for reference the latest and best text-books. Make the opportunity to read the daily papers and something of current literature. A well-rounded man can afford to do nothing less. Besides the information you obtain, it pays in the respect of the community to have the reputation of being posted in your profession. Often the country man simply hasn't time at home to read. A busy life, with its miles upon miles of dusty roads to travel, precludes all chance for the easy chair. Then cultivate the habit of reading while driving. Many are the useful and happy hours I have spent in my carriage with my journals and magazines. I am frank to say that, but for this habit, I never could have found time for one-half of the reading I have done. Last year I was somewhat amused when a most worthy, well-educated and well-posted man summed up his opinion of another by saying that he was one of those who read magazines in his carriage. If I mistake not, this indictment was brought against the late Dr. Miltenberger, who as a young and busy man was forced to form this habit, and I could but think that, could I die with half the honor and respect and love that were his, I could plead guilty to even this mark of devotion to my profession and desire to advance in it.

Would you be ethical in giving the best that is in you to your patients, you must give ungrudgingly of your time. This may again seem a useless piece of advice, and yet almost all of us are familiar with the man whose motto is "Veni, Vidi, Vici"--"I came, I saw, I conquered." This intuitive diagnostician is by no means a myth. The man who comes in a rush and goes in a rush, and who, with pencil in one hand and prescription pad in the other, feels the pulse while the thermometer is under the tongue; who sees at a glance, without necessity of personal or family history or of physical examination, just what is the matter, and who, giving four or five prescriptions, rushes out, trusting that something in his shotgun therapy may hit the enemy. Perhaps the next day he prescribes four or five more remedies or combination of remedies, and should the patient begin to improve, prides himself that he has made and confirmed a diagnosis by his experimental therapy. Is it necessary for me to say that no ethical man with any regard for the rights of his patients and his obligation to his profession can really practice medicine in this manner? The plea that you are too busy to give the proper time to your cases is no justification for your neglect. Anything less than a careful inquiry into family and personal history, followed by a painstaking and thorough physical examination, is unjust to your patient and unjust to yourself. No ethical man can give the best that is in him by doing less than this. If you haven't the time to do your work thoroughly, make a clean breast of the matter and take fewer cases. But you will say that a man, even in large practice, cannot afford to give any of it up. He needs every dollar that honestly comes his way, and to say that he hasn't time for his work is only another way of throwing practice into the hands of a rival. This is, indeed, a proposition hard to solve, as most of us do need every dollar that honestly comes our way; but if our work is only half done, if we have neglected some important point in diagnosis, and thereby omitted some equally important measure in treatment, have our dollars been honestly earned? Let us start out with and carry in mind this axiom of a truly ethical life, that success in medicine cannot be measured by commercial success; that, while no sensible man can neglect the business side of his vocation, or refuse to demand and collect just compensation for his service, such compensation cannot be measured in dollars and cents alone; that a good conscience and whole-souled devotion to duty, giving ungrudgingly of the very best that is in you to those that have confided in you, will be your very best asset when the final account is made up.

May I impress the fact upon you that an ethical man, with a just appreciation of his duty to his patients, can never be a vendor of patent or unofficial medicines. Indeed, I would be lacking in my duty if, with the opportunity this paper offers me, I did not, from the standpoint of experience, impress upon you with all of the force at my command the necessity of being wary of the detail man and the alluring advertising literature with which your mail will be flooded. You will scarcely have opened your office, and be waiting with what patience you can command that rush of the halt, the lame and the blind to which you feel that your talents entitle you, before the suave detail man, having heard of the new field, puts in his appearance. What you lack in therapeutic experience he can supply you by drawing liberally on the experience of others who have worked little less than miracles in an adjoining town by the use of his pills and potions, his elixirs and tinctures. You will find him smooth and oily, placid and plausible. He knows his story well, and even by his much speaking can almost persuade you that what you knew, or thought you knew, or what you had recently been taught, were all out of date; that by some stroke of genius the chemist of his house had discovered some way by which compatibles would combine with incompatibles into the formation of a new and staple mixture, possessing all of the virtues and none of the defects of its original constituents, rendering chloral as soothing as the strings of a lute and as harmless as the cooing of a dove, extracting from cod-liver oil every disagreeable feature and leaving nothing but its supposed virtues behind. He will show you the short road to fortune and success. Treat him kindly; the ethical man should not be rude, and brusqueness is not a sign of Roman honesty or virtue. Be assured he feels his position keenly, and is dreading the catechism which will sooner or later display his ignorance of everything but the story that has been drilled into him like a parrot.

There has been no greater shame in our profession than the influence these men and their houses have exercised, and incidentally the indorsements and recommendations that thoughtless men have furnished them. The blame is all ours, and we cannot shun it. We pride ourselves on our scientific attainments; that we take nothing for granted; and, now that the age of empiricism has passed, we accept nothing that does not bear the stamp of scientific approval. And yet, before the campaign of the American Medical Association and the revelations of Collier's and the Ladies' Home Journal, we accepted our treatment from the hands of the manufacturing houses, and dosed our patients with nostrums about which we knew nothing except the statements of those whose sole purpose it was to sell. There are few of us who have been many years in practice to whom a blush of shame does not come at the recollection of our gullibility and our guilty innocence. Can any man deem it ethical to give even to a good dog something about which he was totally ignorant? And yet this is just what we were doing. A short time ago a particularly shrewd detail man was discussing this very point with me, and claiming that, as the formula was now required by law to be printed in each bottle and package, this most formidable objection could not now hold good. Handing me a bottle of his patent cure-all, he glibly called my attention to the six or seven ingredients, with the amount of each contained in the fluid ounce. Among other potent quantities I can recall 1-48 gr. of morphia and 1-240 gr. of strychnia. The dose was a teaspoonful three times a day. Any man can imagine the more than homeopathic effect of 1-48 gr. of morphia divided into eight doses. These well-known and well-tried drugs were not, however, the life of the nostrum, and presently we came to the twenty minims to the fluid ounce of the fluid extract of the drug from which the remedy derived its name. Something I had never heard of. Something unlisted in the U. S. P. Something discovered and owned and controlled by this house alone. As my ignorance became more apparent his eloquence increased, and I have no doubt that a few years ago, before my moral conscience had become aroused to the therapeutic sin of prescribing something whose botanical family, whose chemical formula, and even whose physiological effects were totally unknown to me, I would gladly have accepted a sample and would have tried it on some poor soul too poor to pay for a prescription. It is nothing short of a shame to think of what we have done in this line. The sin has been one of carelessness and laziness rather than of ignorance. Here we had ready to hand some remedy, beautiful to the eye, palatable to the tongue; then why take the time and trouble to bother about constructing a formula of our own when someone else of equal experience had constructed one for us? I am ready to thank God that most of these nostrums are as harmless as they are beautiful, and, while I may not have done good, I rarely did harm by their use. I am not discussing the opium and cocaine laden classes. I wish to emphasize incalculable harm that must result to the physician himself who allows someone to do his thinking for him. I am also referring to the attitude of the ethical man to his patient, and beg to ask if we are doing even part of our duty when we are doing no harm. Allow me to conclude this topic by asking you to spend an hour some day in casually glancing over the pages of the U. S. P., or a list of the remedies that have in one year received the sanction of the Council on Pharmacy of American Medical Association. If you don't find enough drugs and combinations to meet every case and every conceivable situation, you had better desert practice and exploit some wonderful cure-all as a detail man.

If we, as physicians, had nothing but our duty to our patients to consider, and incidentally our own profit and glory, the practice of medicine would soon degenerate into a mere trade. I may even say that, had we nothing but the promptings of our consciences to keep us in the straight and narrow path, if we had nothing but the knowledge of work well done, and if the desire and determination to give the best that is in us were our only incentives to an ethical life, the profession would be so beset by the temptations of commercialism, and the notoriety and prominence which commercial success brings, that the halls of Esculapius would soon need a scouring and purging greater than Hercules gave the Augean stables. Despite the high incentive to all that is best and purest in life which our noblest of callings should beget in us, physicians are only human, and human weakness, like disease, is no respecter of persons or of callings. It may have been that the medical fathers, with a knowledge of the temptations to which they were subjected, and a desire to save others from the pitfalls which beset their paths, were imbued with a determination to place their profession on a higher plane than others; or it may have been the natural evolution which inevitably resulted from and followed the promptings of man to help his fellow-man, to devote himself to the relief of pain and sickness, to sacrifice his comfort and ease and almost every pleasure in order that others might have ease of body and peace of mind and soul, which from the earliest days have placed medicine as a profession apart, and have imposed upon those who have entered its ranks certain standards of conduct and insisted on certain ethical relations which have lifted it above mere questions of gain and the vain acquisition of renown. We have been taught that Hippocrates himself was great not only as a physician, but greater still as an ethical teacher who has left with us certain maxims and proverbs which, though handed down through the ages, have lost none of their truth and none of their spotless morality. Even in the Middle Ages, when learning, not to say science, had sunk into such an abyss of ignorance that the ability to write one's name lifted one into the ranks of the educated, when human ills were relieved more often with the sword than with the scalpel, the leech was a man apart. His education, his scientific investigations, and even his supposed communion and partnership with the evil one, placed his on a pedestal above other professional callings. Then, as now, though men might scoff at our profession of superior knowledge and skill, when "pallida mors" stalked abroad or knocked at the hovels of the poor or palaces of the rich, all arose to call us blessed. It has been often said that, could a medical man live up to the ethical standards of his profession, his chances without creed or priest would not be small at the last great day. But with all of our high ideals we are only mortal, and we know and have sorrowed at the fact that many of our ethical standards are not lived up to, and that the Hippocratic law is frequently more honored in the breach than in the observance.

But for the man who deliberately goes to work to undermine another; who takes advantage of some temporary absence of the regular physician to ingratiate himself; who, appreciating the fact that people worried nearly to death by the illness of a loved one, will forget every obligation and desert every old friend in the hope that the new one may offer some encouragement or extend some hope, is ready for these emergencies. He carries satchels full of hope for all cases and occasions. He prescribes it liberally, diluted, however, to the point of despair because he was called in an hour too late, or because the case had already been damaged beyond his power of repair. This gentleman advances not only by his own deceit, but uses the power of church, of politics, of family influence and social opportunity, to lift himself along. Verily he has his reward, but it is not in peace of mind, not in the honor and respect of his community, but the contempt of every honest man, be he of the profession or laity. Not the least of the perplexing questions which beset the man who is trying to lead an ethical life is his duty in his relation as consultant. Indeed, there is scarcely a situation in professional life that at times presents more embarrassing possibilities, or calls for the exercise of more tact. It is a pleasure to be able to bear witness to the ability of the man who has called you to his aid, to assure the family that everything has been done that care in diagnosis and skill in treatment could demand. But what of the cases where gross carelessness or blind ignorance have hastened what might easily have been delayed or averted? There is only one way here, only one duty. Treat the man as his carelessness or his ignorance deserves. Again, you are called in consultation with a thoroughly good man who has given ungrudgingly of the best that is in him. Perhaps your superior skill in certain lines, perhaps your superior opportunity to observe a certain line of cases, have taught you something that he has not had the chance to learn. As before it was your duty to expose the careless ignorance of one, now it is your place to so give your opinion and explain your position that no possible reflection can be cast upon the other. Don't approach a consultation with the manner of a priest of Delphi. Don't pose as the fountain of all wisdom and of all experience. Indeed, in this work you will be surprised how often you will learn from him you are called upon to assist. He has seen the case for days, where you can spend but minutes with it. It is his part to bear the blame, yours to share his fame should success crown your combined efforts.

Frequently you will be called upon when a resort to surgery is demanded--not so much to perform the operation as to give your opinion as to the advisability of a certain line of procedure. Having determined what is to be done, don't assume the place of prominence. You have little by way of reputation to gain by performing an operation that you were known to be competent to perform or you would never have been called. Let him do the work with your assistance and advice. In this way you will have gained a fast friend for future consultations, and you will have enshrined him in the esteem and confidence of his people. Therefore, help him and uplift and bear witness to his worth, and don't humiliate him by your airs and assumed superiority.

As a last word, don't consult with an unworthy man, for be assured that your reputation is worth more to you than any consultation fee, however badly you may think you need it.

The question of fees is one that must be considered. We hate to think of the combination of medicine and money, and our patients abhor it even more. The days once were when only the sons of the rich sought the liberal professions. It was thought unworthy in the days of the dim ages for a pupil of Esculapius to charge for his services. Any remuneration that came to him was an offering of gratitude--indeed an honorarium which might be tendered or withheld at the will of the patient. A truly noble conception this, that the good we offered was beyond a mere question of price. Equally comforting was the belief that the ill which resulted despite our best efforts was no reflection on our skill, but an evidence of the wrath of the Gods. Would that we were as near Olympus now as then, and that the Gods walked with men to reward the worthy and punish the unjust. Would also that the manners and costumes and climate of Ancient Greece were still with us, so that man need take little heed of raiment beyond a robe and sandals; that he required no expensive outlay for instruments, no intricate electric outfit, and no automobile. What a life ours would be if now as then our grateful patients sought us, and we passed our many hours of leisure in eloquent discussion or in lazy lounging amid the leafy groves or shaded porticos of the temples! But the times have changed, and we have changed with them, and abhor as we will the combination of medicine and money, we are forced to take thought of the morrow and to spend many, many anxious moments in this thought and in trying to evolve ways and means by which a balance can be maintained between the honoraria of patients, both grateful and ungrateful, and the claims of persistent creditors. Perhaps it is best thus, as the average man needs some incentive to good work beyond the acquisition of honor and glory. An axiom in the question of fees is this, that in order to be respected we must respect ourselves, and no one can respect himself unless he holds his calling above a trade and bases his charges upon this feeling of respect for himself and his profession. This axiom should be held in mind in arranging any fee table, and should be insisted upon in our settlements with those who think a doctor's bill should be discounted from one-quarter to one-half. I have often wondered how this right to a discount in a doctor's bill ever got such a firm hold in the public mind. Perhaps the city man cannot appreciate this fact like his country brother. The poor, honest old farmer, part of the bone and sinew of the land, expects the highest cash price for everything that he sells. If anybody has ever heard of one who when ten barrels of corn at .50 per barrel comes to , offering to take for his bill, he should corral and cage this rara avis. But hundreds of us from the rural districts have been deemed mean and close-fisted and extortionate because we gently insist that worth of professional services rendered are worth and not .

I have only a few words to say on the subject of professional confidences. So sacred is the relation between the physician and patient regarded that the courts will not compel a physician, while on the witness stand and under oath, to tell the truth, and not only the truth, but the whole truth, to reveal what is imparted to him in confidence by his patient.

If in this exalted function of doing justice between man and man the courts will not compel the recital of some important piece of evidence, how carefully should we regard our professional relation, and see to it that neither in strict confidence or in idle gossip do we betray the secrets that suffering man has confided in us.

It may be somewhat out of place in a paper dealing with "The Ethics of the General Practitioner" to speak of the tendency, or perhaps better, the half-formed determination of the majority of every class to be specialists. I must confine myself to the predilection of the average medical student for surgery. It was so in my day, and I suppose it is so now, that almost 75 per cent. of the graduating classes are thoroughly satisfied that the end and aim of medicine is surgery; that practice and the less spectacular branches are parts of the profession essential to it as a whole, and fitted for those who intend to lead the plodding life, but too slow and too prosaic for the man bursting with the knowledge of his own brilliancy and his own special fitness. There is no question but that this tendency has done much to lower the average fitness of many classes. Men become listless and careless, neglecting everything but their hobby, and while the surgical amphitheatre is crowded, the medical clinics will be shunned, even deserted were it not that the sections are such that the absentees can be spotted and warned. There is no question also but that indifference to everything but surgery is responsible for many of the failures before the State Examining Boards. We must have surgeons, and they must begin their training in medical schools, and it is not my purpose to discourage earnest work and honest effort to this end. I wish, however, to say that every ethical specialist needs a thorough grounding in the general branches of medicine, and he should not in his student days neglect the other essentials to a well-rounded man. Most heartily do I wish to condemn the careless, happy-go-lucky manner in which so many men totally unprepared and totally unsuited by temperament for this branch "rush in where angels fear to tread." I wish especially to draw your attention to the fact that there is a vast difference between the operator and the surgeon. Almost any young man with a disregard of the sight of blood, with nerves unaffected by human suffering and a heart untouched by a knowledge of his power to do harm, can in six months' practice on the cadaver learn to cut, to sew and to ligate with neatness and despatch. Indeed, there may be many before me of the student body whose young and nimble fingers could teach dexterity to the best surgeons of the city. Very many with no pretense to this dexterity, and no equipment but a superabundance of assurance, graduate as surgeons and assume and aspire to a position of prominence that it has taken the true surgeon years of the hardest, closest, most untiring study, observation and work to reach. We are told as an excuse for this remarkable evolution from the student to the surgeon that the young man of today is taught so much more than the old men were; that the very manner of teaching, the equipment of the schools and the superior requirements for matriculation cannot but turn out better posted and more competent men. There is much truth in this. There is much truth also in the fact that while more is taught, more, infinitely more, is demanded of the student, and the knowledge that would have secured him a diploma fifty years ago will now scarcely carry him through his freshman year.

We also hear that "I want to be a surgeon, because surgery accomplished positive results." This is very true also, and it is evident that if you amputate a leg your patient will be minus a member. Don't lose sight of another fact, however, that if without being competent to meet any unforeseen emergency that may arise, you lightly open the abdominal cavity, you will have a positive result in the shape of your own little private graveyard. The newly graduated surgeon is not as dangerous as the man who left medical school years ago, before the students received one-third of the surgical training that they do now. Many of these men have not taken a post-graduate course, have never been associated with a hospital, nor have they had even an opportunity for moderate surgical observation; and yet they are attempting to do the work that only a skilled specialist should undertake. I am not speaking of emergency surgery for which any man should try to prepare himself, and be brave enough to undertake when human life is at stake. I am referring to operations of election when the services of a competent man can be secured. The point is just this, gentlemen, that medicine as a science is the result of evolution and not the creation of some brilliant brain; that what has been done in it has been accomplished not so much by inspiration as by close plodding work, exhaustive experiment and continual observation; that surgery as one of its branches cannot be mastered in the four years of student life, but that to be surgeons you must be workers and observers. It will not do to settle the matter by saying that a man must make a start. This truth is too self-evident to be smart, nor is it entirely convincing. An answer equally true will be that you will not allow the embryo surgeon to start on you, and before you put yourself or your wife or your mother in his hands you will demand that he possess some other qualification for his specialty besides his conceit, his gall and his need of the fee. There may be some exceptions where the man is born and not made, but I beg to assure you that the surgeon rarely springs full-fledged and fully fitted from the brain of Minerva.

Our profession is nothing if not altruistic. It demands daily and hourly more of self-sacrifice, more of self-devotion, than any secular calling. Indeed, the comparison is often drawn between the nobility and necessity of the duties which we perform and those of him who by divine inspiration and laying on of hands has been called to succor the diseased soul. It is not my place nor is it my purpose to enter into a discussion of this point, and I mention it only to show that we are marked men in every community; that we are placed on a higher plane and that more is expected of us than of our brethren of the other liberal professions. This, indeed, is right, for no man, the priest possibly excepted, enters into such intimate relations with his people. He is ever present with them to share their sorrows and their joys, and in his position of family friend and family confessor it is his place to bind and salve wounds more deadly than those made by the hand of man. It is a popular impression that this close relationship between the physician and his people is one evolved by the brain of the novelist or one possessed by that most beloved, but now extinct, old family physician. Let us get this impression from our minds and let us realize that our duties, our responsibilities and our relationship to those we serve are just the same, are just as close, and are just as engrossing as they were when that dear old patriarch of the profession made his rounds, scolding some, chiding others and advising all to better, purer and nobler lives. Changed as our relationship to the community may be in some respects by the translation of many of the brightest and best of our cult into the ranks of the specialist, it is still and always will be the general practitioner who is looked up to as "the physician," and by his work in professional and private life our profession will be judged.

In the beginning of my paper I stated I could do little more than rehearse to you some of the old axioms and maxims that have been handed down to us for generations. I am aware that I have taught you nothing new tonight, and that I have not tapped that fountain of inspiration from which genius gushes in poetic or oratorical streams. I trust I may have convinced you that it is not amiss for us at times to hold close communion with our souls, and to take stock of our moral and professional assets. The further I have advanced the more fully I have realized how impossible it is to evolve new ideas or elaborate new creeds to supersede those by which the fathers lived and died and earned honor for themselves and our profession.

So we face today, gentlemen, just about the same propositions that have always been ours to meet, and what was ethical one hundred years ago is ethical now.

The science of human duty simply demands that you be honest to yourselves, honest to those you serve; that you may look every man squarely in the face and not as if you feared he had heard something you had said behind his back. May I quote to you the words of the Earl of St. Vincent to the immortal Nelson: "It is given to us all to deserve success; mortals cannot command it."

THE STUDY OF RECTAL SURGERY IN NEW YORK CITY.

Having decided to take a course in Rectal Surgery, I arrived in New York and matriculated at the New York Polyclinic Hospital on October 1st for a course of instructions under Prof. James P. Tuttle, and desire to herewith describe briefly my reception:

Professor Tuttle is a finished surgeon of the old school of gentlemen, a master of his art, and, under all conditions and circumstances, adheres strictly to the ethics of the profession. I was not only most cordially received by him socially, but was most fortunate in being honored by requesting me to assist him, or be present, on operations upon his private patients at an uptown hospital. This unexpected and friendly honor gave me an opportunity to observe closely the work of this great surgeon in detail, and I had the pleasure of witnessing every case under his care during my three months' visit. As to his colossal work on cancer of the rectum and sigmoid, his results are too well known for me to dwell upon at this time, and he has an enviable record which makes him the authority of this distressing malady which is so prevalent in the cases referred to the Rectal surgeon, and have so long been unrecognized by the general profession. I had the pleasure of witnessing him extirpate the rectum by his bone-flap and perineal route, and in some of these cases was honored by being his assistant. As to the method and technique in each of the above mentioned, I will endeavor to give later. Another very important point gained by association with this surgeon was, that my own theory as to the merits of the Whitehead operation were simply an endorsement of his teachings, namely, that this particular operation, while classical, was only justifiable in selected cases of hemorrhoids, while the Clamp and Cautery or the Ligature method had no restrictions as to variety or location of the pile mass.

My next course of instructions was under the direction of Prof. Samuel Gant at the New York Post-Graduate Medical School. Dr. Gant likewise was most cordial in his reception, and on several occasions honored me by entertainments, including letters of membership to his club, and at his home with his family. Dr. Gant, also a master of his art, has made a reputation of renown, and is a most successful operator. While of an entirely different character from that of Dr. Tuttle he is equally attractive. Dr. Gant argues that the majority of cases of cancer when seen by the specialist are too far advanced to offer any hope by radical operation, and generally limits his attempts at relief to a colostomy. As to the merits of this procedure, I am not sufficiently versed to offer criticism further than to say that the results of Dr. Tuttle are certainly encouraging to the surgeon who will undertake this ordeal of extirpation in hopes of eradicating the disease, while Dr. Gant's operation of colostomy, of course, is only palliative, he making no claims of a cure, except when the growth is seen very early and is freely movable; then he will extirpate.

As to the operation for hemorrhoids, Dr. Gant uses ligature and sterile water anesthesia in nearly every case, and the patient is thereby cured without the administration of a general anesthetic. The difference in the time of recovery is a question to be always considered, in my own judgment, and is as follows: Dr. Tuttle uses the clamp and cautery almost universally, and the patient is discharged within the period of one week, while the ligature method requires local treatments to the ulcerations produced by the sluffing of the linen threads, and takes from 10 days to three weeks.

Constipation and Obstipation are treated surgically by both of these gentlemen by the operation of Sigmoidopexy or Colopexy, which consists in anchoring the gut to the abdominal parietes after having first stripped back the peritoneum over the area covered by their sutures.

Chronic diarrheas and Amoebic Dysentery are likewise treated by Appendicostomy and Caecostomy. The difference in this operation being that the former consists in delivering the appendix upon the abdomen and fixing the same with catgut sutures until the peritoneal cavity is walled off by adhesions, and then amputating later, so that the stump may be dilated to permit of regular colonic irrigations.

Dr. Gant performs a similar operation, to which he has applied the name of Caecostomy, and having devised an ingenious director consisting of one metal rod within a tube of slightly larger calibre, he is able to pass the obturator through the ileo-caecal valve, and then, by withdrawing the rod or obturator, is able to pass a rubber catheter into the small intestine. The metal tube is then withdrawn and a shorter catheter is placed parallel with the long one, which necessarily is in the caput, and after placing clips upon each tube to prevent leakage, he is able to flush out both large and small bowel at desired intervals.

As to the irrigations through these newly-made openings, it is a matter of choice with different operators, those in greatest favor, I think, being Ice Water, Aq. Ext Krameria and Quinine Solution.

A very interesting case brought before us by Dr. Tuttle was one of Specific Stricture of the Rectum, and the treatment anticipated is as follows: He performed a Maydl-Reclus Colostomy in the transverse colon, in order first to treat the ulcerations and infected area locally, and, secondly, so that he would have sufficient gut above the stricture to do a Perineal extirpation later and bring down new healthy intestine from the upper Sigmoid for a new permanent anus; then later he would close the artificial anus in the transverse colon, and his patient should have a perfect result. The period required for these three operations would cover a period of not less than nine months; and if after this there is not perfect Sphincteric action, Dr. Tuttle does a plastic operation to repair his sphincter.

Before continuing with a brief description of the technique of Extirpation as above referred to, I wish to herewith express my sincere gratitude and appreciation of the many honors and courtesies extended to me by these gentlemen, and am quite sure that the same was not all personal, but honor to the University of Maryland's Faculty of Physic, who have aided so materially this younger specialty by such men as Hemmeter, Pennington and Earle, who are constantly quoted by all intestinal and rectal surgeons.

EXTIRPATION OF RECTUM.

The operation of removing the rectum is now almost two centuries old. Faget performed it in 1739, but Listfrane first successfully extirpated the rectum for cancer in 1826. The results of the operation in nine cases were embodied in a thesis by one of his students , and in 1833 the great surgeon himself gave to the world a complete account of his operation and method, thus establishing the procedure as a surgical measure. The results in these cases were not calculated to create any great enthusiasm, for the mortality was high owing to the lack of aseptic technique. The methods described in older books give us five varieties of operation for extirpation--the perineal, the sacral, the vaginal, the abdominal and the combined. In this paper I shall only endeavor to describe briefly the two methods used by Dr. Tuttle. Before describing these methods in detail it may be well to consider the preparation of the patient, which is practically the same in each. In order to obtain the best results, it is necessary to increase the patient's strength as far as possible by forced feeding for a time, to empty the intestinal tract of all hard and putrifying faecal masses, to establish as far as we may intestinal antisepsis and to check, in a measure, the purulent secretion from the growth. It requires from 7 to 10 days, or longer, to properly prepare a patient for this operation. The diet best calculated to obtain a proper condition of the intestinal tract is generally conceded to be a nitrogenous one. The absolute milk diet is not so satisfactory as a mixed diet composed of meat, strong broth, milk and a small quantity of bread and refined cereals. The patient should be fed at frequent intervals, and as much as he can digest. Along with this forced feeding one should administer daily a saline laxative which will produce two or three thin movements, and to disinfect the intestinal canal one should give through the stomach three or four times a day sulpho-carbolate of zinc, grs. iiss., in form of an enteric pill. On the day previous to the operation the perinaeum, sacral region and pubis should be shaved, dressed with a soap poultice for two hours, then washed and dressed with bichloride dressing, which should be retained until patient is anesthetized. Notwithstanding all of these preparations, it is impossible to obtain absolute asepsis of the affected area, and so many fatalities occur from infection that it is deemed wise by many surgeons to make an artificial inguinal anus as a preliminary procedure in all extirpations of the rectum.

PERINEAL METHOD.

Under this method may be included certain operations for small epitheliomas low down in the rectum done through the anus. The patient having been properly prepared, the sphincter is thoroughly dilated; a circular incision through the entire wall of the gut is made, and the segment is caught with traction forceps and dragged by an assistant while the operator frees, by scissors and blunt dissection, to a point at least one-half inch above the cancer. The free end of the gut is then tied with strong tape, as the temptation is very great to put your finger in the bowel as a guide, and thereby invite infection. A deep dorsal incision is then made, going down to the right of the coccyx through the post-rectal tissue. The hand is then placed in the sacral fossa and the structures lifted out into the pelvis, after which this space is thoroughly packed with gauze to control the bleeding and hold the structures out of the fossa. The edges of the wound, including each half of the sphincter which has been cut posteriorly, are held by flat retractors, while the operator proceeds to dissect the anterior portion of the rectum loose from its attachments. A sound should be held in the urethra in men and an assistant's finger in the vagina in women to prevent wounding these organs. After the gut has been dissected out well above the tumor, it is caught by clamps and cut off below these. Bleeding is controlled by ligatures and equal parts of hot water and alcohol. This newly-exposed gut is then sterilized by pure carbolic acid and alcohol, or may be seared with cautery. Sometimes the peritoneum can be stripped off from the rectum and its cavity need not be opened; it is better, however, to open the cavity at once when the growth extends above this point. The peritoneum is incised, cut loose from its attachments close to the rectum, back to the mesorectum, which should be cut close to the sacrum, in order to avoid the inferior mesenteric artery. When the gut has been loosened sufficiently above the tumor, it may be still fastened by two lateral peritoneal reflections, which are the lateral rectal ligaments, and should be cut at once. The gut is then brought down and sutured to the anus, and the operator should proceed to close the peritoneum and restore the planes of the pelvic floor down to the levator ani by fine catgut sutures. After this has been accomplished, the anus, which is now well outside the operative field, should be reopened, the gauze removed, and the gut flushed with a solution of bichloride or peroxide of hydrogen. Quenu advises that in amputating each layer should be cut separately, in order to avoid hemorrhage, but there appears to be no advantage in this; in fact, we are more likely to meet with deficient blood supply, causing subsequent sloughing of the gut, than with hemorrhage. The posterior and anterior portions of the perineal wound are packed with gauze and left open to assure drainage, and the parts are covered with aseptic pads, held in position by a well-fitting "T" bandage. A large drainage tube is passed well up into the rectum, its lower end extending outside of the dressings, in order to convey the discharges and gases beyond the operative wound.

TUTTLE'S BONE FLAP OPERATION.

"The Kraske Operation" is applied to various methods in which access to the rectum is obtained by removing the coccyx or cutting off certain portions of the lower end of the sacrum. They are all modifications of Kraske's original method, with which we are all familiar. Dr. Tuttle has modified this plan, as it furnishes a rapid and adequate approach to the rectum; it facilitates the control of hemorrhage and restores the bony floor of pelvis and attachment of the anal muscles, and involves injury of the sacral nerves and lateral sacral arteries on one side only. The technique which he employs is as follows:

The patient is previously prepared as heretofore described, and an artificial anus established or not, as the conditions indicate; before the final scrubbing the sphincter should be dilated and the rectum irrigated with bichloride 1-2000 or hydrogen peroxide. It should then be packed with absorbent gauze, so that the finger cannot be introduced. The patient is then placed in the prone position on the left side, with the hips elevated on a hard pillow or sandbag; an oblique incision is made from the level of the third foramen on right side of sacrum down to the tip of the coccyx, and extending half-way between this point and the posterior margin of the anus.

All oozing is checked by hot compresses, and the concavity of the sacrum is packed with a large mass of sterilized gauze, the end of which protrudes from the lower angle of the wound. This serves to check the oozing, and also furnishes a support to the bone-flap after it has been restored to position. Finally the flap is fastened in its original position by silk-worm gut sutures, which pass deeply through the skin and periosternum on each side of the transverse incision. Suturing the bone itself is not necessary. The lateral portion of the wound is closed by similar sutures down to the level of the sacro-coccygeal articulation; below this it is left open for drainage .

REPORT OF A CASE OF GANGRENOUS APPENDICITIS, FROM THE SERVICE OF PROF. R. WINSLOW.

In selecting a case I have not taken one that is a surgical curiosity, or at all an unusual one, but I have taken this because it is just in these cases that a doubt sometimes exists as to the treatment when diagnosed, and often the condition of the appendix and surrounding peritoneum is in doubt, even if a diagnosis of trouble originating in the appendix is made.

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