Another important subject was the question of treatment of Tubercular fistula. For a number of years Dr. Tuttle said he was most discouraged in his results and had almost abandoned any attempt to cure this class of infections, but of late he had obtained most excellent results by introducing his soft flexible probe and following this tract with a grooved director; opening this throughout its entire extent, and then completely cauterizing at dull red heat with the actual cautery. This is then packed with iodoform gauze, and since using the cautery, his results have been decidedly better. Under the direction of his assistant, Dr. J. M. Lynch, a class of three was formed, with regular work and instructions in the dispensary of St. Bartholomew's Clinic, where we were given cases to diagnose and treat. This course consisted in introduction of proctoscope and sigmoidscope diagnosis of ulcerations specific and benign, and local treatment through this instrument. To the inexperienced the results and probabilities gained through the use of this pneumatic instrument of Tuttle's, which is a modification of the Laws proctoscope, are surprising. By the electric illumination with which it is equipped one is able to introduce the instrument with absolute safety to the patient for a distance of 10 to 14 inches, exploring the entire circumference from the anus up through the sigmoid.
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 Amœbic 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.