HEMORRHOIDS IN RAILWAY MEN.* BY GEORGE ROSS, M. D., OF RICHMOND, VA. Ex-President International Association of Railway Surgeons. Consulting Surgeon Southern Railway, District Surgeon Chesapeake & Ohio Railway, Etc. The necessary irregularity incident to the lives of trainmen subjects them to risks other than railway accidents, which, while rarely imperiling life, do, very surely, imperil physical comfort. Their enforced disregard of nature's admonition and the mechanical consequences of persistent unright posture, furnish the occasion for the occurrence of one of man's most common ailments. The simplicity of its treatment, and the certain relief promised in the vast majority of cases, must be my apology for consuming the time of the Association for a few moments, while I consider the subject of "Internal Hemorrhoids. An admirable paper, clean-cut and practical, appeared in the Journal of the American Medical Association, for December, 1901. The author's discussion of the etiology of the disease was conclusive, and so condensed as to be easily grasped. His treatment, the most recent from a surgical standpoint, and so simple that a novice in the management of this ever-present rectal disturbance may adopt it without trepidation. His results are all that a skilful surgeon could hope for, or a suffering patient ask for. But, while commending his paper as worthy of study, I take occasion to comment on his failure to make mention of one certainly, if not the most effective method yet devised for the cure of all internal hemorrhoids, whether attended by bleeding or not. That the treatment is permanent in results as to the tumors treated, there can be no question, because the action of the remedy is destructive; but, that a recurrence of hemorrhoids following any treatment is a possibility, is also without question, and for the simple reason that, constitutional conditions primarily producing them continuing, or, the subject of them failing to give needed attention to nature's functions, recurrence, not of the removed, but of other angiomas, is the penalty to be paid. I speak as one having authority in that I am the beneficiary of this treatment, and for more than twenty-five years have had absolute "surcease of sorrow." I have employed it in my office, in hospital, and in homes on sufferers in all conditions of life during all those twentyfive years, and have yet to record the first case of failure to cure, while a small book would hardly suffice to contain the benedictions that have been heaped on my head by the unshackled slaves to the disease. The treatment, in some form, is doubtless familiar to many of my hearers, but some, of course, it has escaped because it is hardly more than half surgical. In simple words, I describe the method of management: Given a case of internal hemorrhoids, with or without bleeding, usually protruding at stool, and lifted into the rectum after stool, by manual effort or muscular action, I direct the administration of a heaping teaspoonful of compound senna powder the night before treatment, to be followed by a glass of bitter water or a tablespoonful of Epsom salts before breakfast the next morning. Supplement their action by a high and full *Read at fifteenth annual meeting, St. Louis, Mo., April 30 to May 2. 1902. saline enema before the operation, an antiseptic cleansing of the recto-genital region, and the patient is ready. Place him in the dorsal or left lateral posture, and examine the field. If not already protruding, a slight bearing down effort usually forces the tumors into view. If found eroded, with a granular or velvety surface, mop freely with strong nitric acid, and then inject into the center of each tumor the whole or half the contents of a hypodermic syringe filled with this solution, beginning with the tumor highest up: When each tumor has been thus treated, coat the mass with carbolized vaseline, and gently push them well up into the bowel. To prevent excessive and painful sphincteric action, make thorough and forcible dilation of the sphincter muscles, after which apply an antiseptic pad and “T” bandage, and put the patient to bed. Pain may or may not be intense enough to demand an opiate. If it does, 25 drops of elixir opii will usually suffice for relief. Quiet, a light diet and unmoved bowels is enjoyed for two days. Then return to the compound senna powder at night, and salts or bitter water in the morning to secure regular stools (at which time straining must be carefully guarded against). After evacuation of the bowels and a bath, the following ointment should be sent well into the rectum by means of an applicator, night and morning: The time needed for the sloughing process varies, of course, but it is very unusual that more than one treatment is demanded. In a recently treated case, in which the projecting mass of tumors and prolapsed rectum measured seven and a half inches in circumference, I subjected the patient to three treatments, all applied in my office, and without anesthesia, and in neither instance was the patient confined to his house more than two days. Except in magnitude of output duplicate cases might be multiplied, but it is needless. Very simple, surely, very certain and well worth remembering by the youngest of us! Multitudes of people shrink with horror from the surgeon's knife, even though anesthesia be assured, and rush into the hands of either irregular practitioners or positive "quacks." Specially is this true of the class of cases under consideration. Why permit it when we can confidently promise a certain, and, in the vast majority of cases, a practically painless cure? DISCUSSION. Dr. P. Daugherty of Junction City, Kan: I am very much pleased with the doctor's paper, and to me the treatment is rather new, so far as 95 per cent carbolic acid is concerned. Twenty-five years ago some doctor in Illinois was treating hemorrhoids with hypodermic injections of 10 per cent carbolic acid solution. I believe it was some traveling quack who first started the practice there, but it was not very long before regulars got hold of it, and in many instances it seemed to be a good remedy. I tried it at that time myself, with a few successes, and some failures, but more failures than successes. I have tried almost everything except the treatment outlined by Dr. Ross, but I have never tried it as he applies it. A few years ago I spent a few weeks with my friend, Dr. Ochsner of the Augustana Hospital, Chicago, and I saw him operate with clamp and cautery. I watched his cases, and his success was so good that when I came home I adopted the same method. I have operated on a great many cases of hemorrhoids with the clamp and Paquelin cautery since that time. One of my patients had been a sufferer from hemorrhoids for twenty-five years. The longest I have had any one patient in bed has been three days after using the clamp and cautery. The operation is done under general anesthesia, of course; the rectum is dilated thoroughly, you use the antiseptic precautions that the doctor spoke of, and, with the exception of two or three cases, I think, I have never had to use, the catheter more than two or three times after the operation. After the operation I usually give a hypodermic injection of morphine to relieve pain. I remember very well of operating on a farmer who had what is called "bleeding piles," and it was not uncommon for him to find his shoes full of blood. After operating on him with clamp and cautery, he was only in bed about two days. He got up on the third day and attended to his stock. This was four years ago, and he is perfectly well at the present time. About three months. ago I operated on a man, 68 years of age, who had suffered from hemorrhoids for forty years. He had spent hundreds of dollars for different treatments, but had never experienced permanent relief. The day following the operation he got up, came down and ate his dinner. I used the catheter on him twice. Four days afterwards. he went back to his farm, he has not had any trouble since. Of course, the method of Dr. Ross may be just as good as the one I have mentioned. I do not dispute but what it is. But with his injection treatment I think he will sometimes have to make more than one operation. With clamp and cautery you will only have to make one operation. There is very little danger attending the clamp and cautery operation. If I should come across a case in which I am afraid to use the latter I shall undoubtedly adopt the doctor's method. Dr. Ross (closing): I endorse all Dr. Daugherty has said regarding the use of clamp and cautery in the treatment of hemorrhoids, but the class of cases I am supposed to deal with in this paper are not those that are usually treated by clamp and cautery. In our section of the country the method he has mentioned is designed or intended for external hemorroids, but for the distinctive internal hemorrhoid that method is not employed. As the method I have mentioned has served me well for the last twenty-five years, I propose to stand by it, and since I can cure a man without frightening him to death by the administration of chloroform and the use of instruments, I think probably I shall continue to resort to this method. I am not willing to cast aside an old love because of the possibility of getting on with a new one. EXPERIENCES IN INSTRUCTION IN FIRST AID BY A. F. JONAS, M. D., OMAHA, NEB. More than a year ago classes for instruction in "First Aid to the Injured" were organized at the several division points of the Union Pacific Railroad. One year's experience along any line of work may not be sufficient to warrant the formulation of definite conclusions, certainly such work cannot be deemed authoritative in all that pertains to this or any other problem. All knowledge is the result of accumulated observation and experience. It is the massing together of small experiences, each almost insignificant in iteslf, that constructs any scheme, that perfects all methods. It requires time not only to gather the observations and experiences, but more time to fully realize the significance of each one. Imperfections are not always corrected by the first remedy applied, a succession of correctives are often necessary before the right one is found, and this requires time. Old and well-tried plans which may be suitable to one country and a certain people, must be revised to suit other conditions, countries and peoples. A certain political or social scheme may be suited to a monarchical form of government, but may utterly fail in a democracy. A free and enlightened people may eagerly embrace every opportunity for advancement and enlightenmen. On the other hand, a people oppressed by force are by habit indifferent. Coming a little closer to our own invironment, we soon perceive that in reference to intellectual cultivation bevond the immediate needs of the man, the vast majority of men have no aspirations. He is satisfied to give the least equivalent in labor for the greatest possible recompense. To know anything beyond what is required of him in his particular line, he has no ambitions. In reference to the capability and desire for information, the vast army of men may be divided into four large groups. (a) Those eager to acquire knowledge for knowledge's sake. (b) Those who acquire knowledge solely, no more and no less, for pecuniary reward. (c) Those who acquire knowledge when it costs no effort. (d) Those who are indifferent, who will make no effort no matter what the reward. All these clases, as among other men, are found among railroad employes. Our experience has shown that a large proportion of those engaged in train service will acquire new information only when the rules of the company make it compulsory, or if it can be demonstrated that the new knowledge will be of positive interest to the individual. To appeal to them by insisting that to know something of "First Aid" will add to their common stock make them broader and more accomplished, is, to a large of knowledge, that it enhances their education, that it will proportion of them, a futile effort. It must be made plain *Read before the International Association of Railway Surgeons at St. Louis, Mo., April 30 to May 2, 1902. that it pays; that it means dollars and cents; that it means a saving of time; that it means an earlier return to their posts by hastening the convalescence from disease, if they learn and know something about the prevention of infection. A great many of the train and enginemen become suspicious with every new innovation. So it has been with instruction in First Aid to the Injured. Some wondered what this "new fangled idea" really meant, and believed it might be a new imposition, possibly a snare, by which they were to be enticed away from their regular work to look after injured comrades without recompense. Many would or could give no reason for this distrust, but, on general principles it must be a bad thing because it emanated from the railroad management. Many railroad men believe the officials to be their open enemies, or, in the language of one who spoke in the hearing of the author, "railroading is a very one-sided proposition, all the advantages are on the side of the company and nothing for the employe." Naturally there was much distrust, even open hostility, but more indifference. On the other hand there were those who were full of enthusiasm, some eager to learn for the educational advantages, some for the self-help and the assistance it enabled them to give to others. Some because it was paying investment. A few because they believed it gave them a better standing with the management. And so with these various inducements and incentives the organization in First Aid work has been slowly but successfully progressing on the lines of the Union Pacific Railroad. The greatest difficulty encountered was to select evenings when the most men were "off duty" to enable them to attend. The tremendous traffic of the last two years has made it necessary to press into service all the available men, and they have been worked to their fullest capacity. The arrival and departure of freight trains has made it impossible for freight crews to attend with regularity, so that in a course of five lectures the majority of the pupils could attend only two or three and sometimes only one. It became necessary to modify the rule that "no pupil can enter an examination for a certificate unless he has attended four out of five evenings in a given course." It was found that it was pleasing to the men when this rule was so modified that "missed" lessons could be made up in a subsequent course. It was found that the instructor had quite as much to learn as the pupils. The instruction thus far has been given by the assistant surgeons at division terminals. The instructor unconsciously made use of terms as familiar to him as household words, but too technical for the pupils. The average instructor needs almost as much drilling as the one to be instructed. The chief surgeon, under whose direction this work is carried on, frequently reviewed the entire subject, privately, with the instructor, insisting on the use of plain English terms wherever possible. When a scientific expression was unavoidable, its full meaning was to be demonstrated. The pupil was never to be left in doubt as to the meaning of a single term or method employed. Another difficulty with the instructor was that he endeavored to teach too much. The result of this was that the pupil became confused because an attempt was made to burden his mind with more than he could assimilate. It was insisted that as few matters as is consistent with First Aid methods be inculclated. The aim was to teach no more than could be comprehended and retained. To do this, each teacher was obliged to gauge his class, which he did by the nature of the interrogatories of the pupils. Classes differ not only in different localities, but also at different times in the same place, so that the instructor must vary his methods from time to time. Pupils were encouraged to ask questions. Many times thees questions brought out the most practical points. The veterans of the service had come in contact with many trying conditions that had evidently ieft a lasting impression. Their earnestness and desire to have uncertainties cleared up was most pleasing. The practical demonstrations never failed to interest. Nearly every pupil was anxious to be "shown how," but he earnestly desired to be permitted to apply a dressing or adjust an appliance. Too much time must not be devoted to theoretical matters. Too much theory often worries the medical student and becomes positively annoying to the layman. A practical demonstration was always made and then a brief and concise explanation for every step was given. It was gratifying to find how quickly the nature of infection was understood, which was shown by the care and accuracy with which the little Union Pacific First Aid Dressing was applied. It was gratifying to find that nearly every pupil appreciated the necessity of keeping the fingers out of a wound. The important points for pressure to control hemorrhage were quickly and easily comprehended. The difference between a simple and a compound fracture and how a simple fracture could be prevented' from becoming compound, did not seem difficult problems. Shock, in its general features, was easily learned. The lifting, carrying and transporting the injured with the least possible suffering were matters of greatest interest. The quiz method rather than the lecture brought out the best practical results. Morton's manual, while not strictly up to date, was found to be useful. Lessons were assigned and the pupils as a rule obtained a clear idea of what was taught. The instructor was provided with Doty's manual, a much more extensive and comprehensive work and one thoroughly up to date. So it was possible to amplify on the contents of Morton's manual. Charts and models assisted very materially in making clear the various steps in the management of given conditions. The pupils applied bandages and dressings to each other. All dressing materials, prepared and improvised, were fully explained. As to the practical results of this training we have noted several striking instances. Tobacco "cuds," soiled handkerchiefs and other infected materials commonly used by railroad men as primary dressings have been notable by their absence. The primary dressings provided on all Union Pacific trains have been intelligently used in many instances. used in many instances. A remarkable change has been noted in the care with which the injured are lifted, carried and transported. Assistant surgeons have been instructed to always bestow praise when First Aid men have made use of proper methods. Little comments have been a great stimulus to the men. They take great pride in their work. Instructors should caution pupils not to overdo their efforts at relief. For example, in case of hemorrhage an overzealous First Aid man may forget to try pressure with an antiseptic pad in case of moderate bleeding, but he at once applies an improvised tourniquet with unncessary firmness, as has happened in our work in more than one intsance. Heat may be applied to the extent of causing a burn in case of shock. Temporary splints may be applied too tight. It is of as great importance to teach what not to do, as what to do. We have found that with increasing experience on the part of the teaching force, these errors are gradually overcome. Classes have been formed at Council Bluffs, Omaha, North Platte, Cheyenne, Rawlins, Evanston, Ogden, Denver and Kansas City. Nearly 200 pupils have received certificates. This does not represent the total number who have availed themselves of the instruction. The majority of the pupils were not eligible for examination on account of not having attended the requisite number of lessons. Many who were entitled to an examination did not present themselves on account of their fear that they might not pass. The examinations at first were conducted entirely in writing, a certain number of questions being given. Many absented themselves on this account. They preferred an oral examination, as it was put by one of the men, “a railroad man can talk very much better than he can write." So the pupil is now given his choice as to the method of examination. The plan pursued in the organization of the classes was about as follows: The division superintendent was communicated with as to the most convenient date for organization. The date having been fixed, it was advertised by bulletin. In all instances the superintendent took a personal interest in the classes, urged the men to attend and saw to it that a suitable hall was provided. The chief surgeon took it upon himself to deliver the first lecture. He first detailed the objects of First Aid, its benefits and who were most benefited. He gave a short history of the origin and development of First Aid work. He then gave the anatomical lecture, illustrating by means of a skeleton, charts and models. Immediately after the completion of the lecture a class was organized. A chairman and secretary were elected from among those present. The officials immediately assumed the functions pertaining to their respective offices. The secretary was provided with a book for registration and a record of the meetings. Every railroad man present was invited to become a pupil by giving his name and occupation to the secretary. Each pupil was then presented with Norton's manual, a triangular bandage and a First Aid dressing. The assistant surgeon then became the instructor and conducted the regular course of five lectures and the examination. The names of the successful candidates were forwarded to the chief surgeon's office, where a certificate signed by the general manager and the chief surgeon was issued. It was found that interest was stimulated if an occa sional lecture were given by a non-resident surgeon on some special subject relating to First Aid. At one or two points, meetings have been held where First Aid men were encouraged to detail their experiences of actual work. It was remarkable how keenly some of the men had observed and how well they had kept in mind the principles taught them. The work of popularizing a knowledge of First Aid will be slow, not alone because of the indifference of those who most need this information, but chiefly because medical men are unwilling to give up the necessary time for instruction. We, as medical men, have been entirely too reserved in matters of public instruction. We berate the public for running after false gods. We denounce the stupidity and ignorance of otherwise intelligent people in things pertaining to medical matters, while we refuse to enlighten them. The old code had much to commend. it, but some of its features were worse than stupid. Surgeons have feared the censure of their colleagues if they appeared on the public rostrum. The crusade of the "antis" would never have succeeded in their efforts at obnoxious legislation in England, affecting vaccination and vivisection, had the profession taken a sensible stand and educated the people. We need have no fears that we will so educate the people that we will endanger our bread and butter. When a man knows the real dangers that surround him, he will the more quickly consult a competent physician. If he knows the dangers of infection, he will waste no time with a faith curist, a Christian Scientist, a high attenuationist, or that crowning glory of all quackery, osteopathy. If you instruct the man that bacteria and not devils or mortal error cause inflammation, suppuration and septicemia, he will employ the up-to-date surgeon, he will not even trust himself with "mother's infallible salve." By popularizing a knowledge of First Aid to the Injured, you will simplify wound repair by preventing the use of many harmful domestic applications. You will find that the surgeon will be sent for post-haste, for the patient knows that the fate of the wound depends on its first dressing. You will make your own work easier. You will occupy a higher place in the estimation of the people. DISCUSSION. Dr. C. R. Dickson of Toronto, Canada: I was very much pleased to hear the paper of Dr. Jonas, also the one which he read last year on the same subject, and it goes to show that this is a practical subject. I hope other railroads will follow the example of the railroad (the Union Pacific) with which Dr. Jonas is connected. The point of encouraging the railroad employes to ask questions is one of the strong features of this work. There is practically no trouble in instructing these men in regard to the principles of First Aid if they can be encouraged to ask questions. aged to ask questions. Weshould avoid technical terms, and if we encourage questioning we will find we will get at the truth. We cannot lay down hard and fast rules for all classes of employes, but we can simplify matters very materially by the interrogation method. In instructing these men, the first part of the lecture is largely theoretical, and all the steps of First Aid are explained as the lecturer goes on. At the close of the lecture the class is divided into two sections, and each man questions his fellow-student to the right or left. The instructor takes one man and goes through the maneuvers with him, particularly if it is a case of bandaging or anything of that nature, and each of the men takes his turn in making these maneuvers. In this way all of the men get the benefit of practical instruction in First Aid as they go along. As I expect to have something to say on the other papers on First Aid that are to be presented later on, I do not care to say anything more at present. Dr. Jonas (closing): I have been asked the question frequently as to how we organize these classes and as to our methods of instruction. I know there are a number of physicians who have had experience along this line, but for the benefit of those contemplating this work and introducing it, I thought it would be profitable to bring out these points in a discussion of this subject. Many points were not contained in the paper this year because they were given in the one I read last year; therefore, I simply hinted at the various points, but I believe those detailed in my paper and those brought out by Dr. Dickson are valuable ones with reference to giving instruction in First Aid. When we began this work of instructing employes in First Aid, we found it was quite a different thing from that of teaching medical students. In one instance we have had to teach laymen with a limited amount of education, and they did not grasp things as readily as medical students would; yet by adopting the quiz method rather than the lecture method, it encourages these men to think for themselves. THE TWENTIETH CENTURY SURGEON.* BY CHARLES A. L. REED, A. M., M. D., CINCINNATI, OHIO. Ex-President American Medical Association; Ex-President American Association of Obstetricians and Gynecologists; Fellow British Gynecological Society, Etc. Mr. President, Ladies and Gentlemen: When the invitation was presented to me to address you, I paused to consider whether or not I had a message to deliver to this particular audience; whether or not I had a thought that was entitled to expression in your presence, and as I asked myself this question and looked over the field for some reply, it became apparent to me, as indeed it had been for years, that you represent in your organization not only a splendid esprit de corps, but that you reflect in your personality and daily activities the progressive spirit of our profession. You are, indeed, surgeons doing the work of humanity on the great highways of commerce, and on the still greater highways of science. Reflecting, as you do, this progressive spirit in your organization, it has seemed to me well to present some thoughts which have developed in my mind relative not so much to the technical aspect of your avocation, as to the general subject of the surgeon of to-day and the surgeon of the future. I shall invite your attention for a short time to "The Surgeon of the Twentieth Century," and it is to this theme, more personal than scientific, that I shall address myself. It occurs to me at the outset, that the sagacious explorer contemplating for the first time a tour of dis *Stenographic report of address before the fifteenth annual meeting, I. A. R. S., St. Louis, April 30 to May 2, 1902. covery in an unknown land, pauses at the threshold of his journey to take some kind of step, to avail himself, as far as possible, of the present knowledge of the land he is about to invade. And so we might with equal propriety pause upon the threshold of the twentieth century to determine as far as may be the status quo of our profession of surgery, to look as far as we may into the future with reference to meeting those increasing responsibilities which we all know shall be imposed upon us with the process of the sun. I wish to admonish you at once that I shall indulge in no prophetic veil, for I am neither a prophet, nor the son of a prophet, but I realize the futility of endeavoring to depict the progressive expansion of our art, which, as it rests upon our arms to-day, is the most fully developed phase of modern science. The surgeon, standing at the threshold of the nineteenth century, could by no manner of prescience foretell the achievements that have become commonplace in your hands to-day; nor can I, standing upon the threshold of the twentieth century, foretell what greater development lies within the stretch of the next one hundred years. But we know from the past that certain definite developments must occur in the future, definite knowledge of the particular fact that with the continuance of human life there is progressive expansion of human intelligence, and with the progressive expansion of human intelligence there comes likewise the progressive accumulation of human responsibility. What, therefore, of the present? What is the status of the surgical art in this our great republic? It, perhaps, would best become us to be modest in proclaiming our virtues, because they proclaim themselves so loudly that words are not required. It has fallen to my lot in the last few years to visit practically every important educational center of Europe. I have made it a part of my journey to go into the surgical clinics to watch the daily work of the surgeons whom I encountered there, and, for the most part, permit me to assure you that I have found such visitations furnished to the average American surgeon a splendid example of what not to do and how not to do it. I have witnessed surgery in foreign clinics, and I have seen those clinics crowded with American students, which, if done by you, and reviewed in a court of justice, would deprive you of your right of membership in this association. (Applause.) And yet with that prestige which comes from age, and with that tendency of our western civilization to bow always to the rising sun, we find our students are going from our splendidly equipped hospitals, are going from our great institutions of learning, having gathered inspiration for their life work. Permit me to say to you, and I say it in all seriousness and all honesty, as I have stood in the clinics of Europe, I have thought to myself that the students who imbibed those teachings, when they returned to acquire a clientele in our own country had to unlearn much of that which they had learned abroad. So much for self-congratulation that comes from comparisons, and it is said that comparisons are always odious. If, then, this be true, let us consider the other side of the question, and take up the status of surgical subjects in the curricula of our medical institutions. Let me invite your atten |