Look You, My Friends ",~ CURTICE ROSSER, A.B., M.D., D.Sc. Dallas, Texas

No ONE in this attdience, conceivably, knew during his lifetime the noble individual whom we c o m m e m o r a t e at this time. We h o n o r Joseph Mathews not only because he was the originator of our specialty in the world but because he was one of the great citizens of his era, whose life continues to offer inspiration to every aspirant to a medical career. From a substantial but not opulent family, his whole career was activated by a wholesome and continuing ambition to better himself in order to better serve humanity. His graduate education culminated in a year of study under Mr. ~Viiliam Allingham at St. Mark's Hospital in London, still the Mecca of every neophite of our Specialty, and thus began a long period of mutual friendship and appreciation between American proctologists and British surgeons which has heartened our specialty over the years. T h e coming reunion of our British and American groups in London is an effective example of our debt to Mathews and Allingham for inspiring this now traditional fraternal coalition which has endured for more than 80 years. Even those who never knew Mathews can visualize him from his writings and the descriptions of his contemporaries. We are told that he was eloquent in voice, magnetic in personality, admirable in his character, catholic in his interests, aggressive where principle was concerned and a valued and vital teacher. His writings, which I reviewed in an earlier discussion,l* ~ T h e Biennial Mathews Oration, presented at the annual meeting of the American Proctologic Society, Atlantic City, New Jersey, June 15 to 17, 1959.

were frank, explicit and helpful; because of native intelligence, industry and medical honesty, his contributions to the literature are excellent source material for those interested in tracing the beginnings of a specialty. Long after his retirement, he continued to manifest the affectionate concern for his co-workers and their field which, I proudly hold, still characterizes those of us who become inextricably enmeshed in the fortunes of our comparatively small professional group. Illustratively, the generous letter to the American Proctologic Society written eight years before his death contained a phrase which i have adopted as the title of this address: "Forty years have elapsed since I e m b a r k e d in Proctology as a specialist. At that time no one anywhere had done so . . . . T h e field was covered and in the hands of the charlatan. (But) look yo~L, my friends, what you, by persistent effort, have wrought." T h e high point in J o s e p h Mathews' career and in the history of the tembryonic specialty of proctology came just 60 years ago, when Mathews called together in Columbus the small group of proctologists then available in the U n i t e d States and organized the American Proctologic Society. He had just served as President of the American Medical Association, then meeting in the same city, having already been the presiding officer of m a n y other medical organizations, inchtding the Louis~ille Surgical and Clinical Societies, the Kentucky State Medical Association and the Mississippi Valley Medical Association. He recalled later his gratification that he could lend some measure of his prestige to the new organization. A n d so, three 380

LOOK YOU, MY FRIENDS score years ago, this little b a n d of dedicated men officially launched our specialty on the troubled sea of American Medicine. In a recent symposium on specialism published in the Journal o[ the American Medical Association, I found the following observation. " I t is of interest how m u c h of specialization is dependent on instruments and instrumentation. Historically, m a n y specialties were literally made possible only when the effective tool came to hand. T h e classic example is the ophthahnoscope. Another is the roentgen tube. It is not too much to postulate that the toot made the specialist no less than the specialist the tool "5 T h e essential triad in large bowel diagnosis today includes the tubular sigmoidoscope, the inverting examining table and the roentgen barium enema. Apparently, our own specialty, unlike others, antedated its tools, as Mathews and his contemporaries labored without any of these devices. T h e examining speculae available to them were short, cumbersome and painful, consisting of a varied n u m b e r of expanding blades. An ancient but stili occasionally used example is the bivalve "Pratt" speculum whose anlage was uncovered at Pompeii. Many, like Mathews, preferred to use the finger or even the hand instead of the devices then available. Candlelight, sunlight and finaIIy electric Iig.ht reflected from a head mirror were used to illmninate the brief segment visualized and it is curious to note that long after a gynecologist presented medicine with the concept of a tubular examining instrument, habit caused m a n y proctologists to cling to these outdated methods of visualization. We all know the story so ingeniously recounted by Granville Hanes s of his accidental discovery of the advantages of the inverted position for inspecting the terminal bowel, a fortunate example of scientific serendipity. Simple air inflation of the colon to aid palpation of the abdomen was used by physicians long before the discovery of

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the roentgen ray and the earliest x-ray examinations of the colon were made after the introduction of air or gas only. However, Groedel6 in 1907 suggested the ingested opaque meal as an effective method of visualizing the intestinal tract, and soon after, Haenisch7 urged the superiority of the contrast enema over the contrast meat for examination of the colon. You will find in the Transactions of this Society for the year 1912 an interesting discussion of this then novel radiologic technic 9 in which the radiologist advocated the ingestion by the patient of a satt of bismuth in buttermilk, followed in 24 hours by an enema of a bismuth-mucilage-acacia-water mixture to reveal atony or spasm of the colon, anomalies, adhesions and an entity regarded as quite i m p o r t a n t , the kink in addition to ulcers and tumors. In the discussion which followed, J. P. T u t t l e of New York warned against p e r m i t t i n g fallible pictures to take the place of careful abdominal research o r exploratory operations, F. C. Yeomans urged clinicians to study the plates and make their own diagnosis, aided by their exclusive clinical information, and Louis H i r s c h m a n of Detroit stated that he personally administered the bisnmth and later injected the bismuth enema himself-helieving in teamwork with the roentgenologist. Real progress was made in i923 when Fischer 4 of Germany described his method of accomplishing the double contrast examination of the colon, which was improved and firmly established in this country by H a r r y }Veber~5 of Rochester, Minnesota. By this technic, relatively small intraluminal polypoid tumors may be detected. More recently, %Vyatt .7 suggested, as an alternate or supplementary expedient, the addition of tannic acid to the b a r i u m suspension, revealing intraluminal tumors, after contraction of the bowel, as sausageshaped swellings. T h e three score years which have elapsed since the American Proctologic Society came into existence have seen continual

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changes, some noteworthy, some of m i n o r importance, in the m a n a g e m e n t of surgical conditions of the colon and rectum. Anal pruritus, hemmxhoids, fistulas and other benign anal derangements receive the same general type of treatment as they did 60 years ago--subject to those refinements of technic which have characterized other phases of surgery. On the other hand, new information, new skills and new adjuncts to surgical safety have revolutionized the surgeon's comprehension and the surgical treatment of certain m a j o r lesions of the lower bowel-diseases such as ulcerative colitis, diverticulitis and cancer. Although ulceration of the colon had been described by pathologic anatomists, the entity now termed chronic ulcerative colitis had not been screened from the numerous other ulcerative processes of the large bowel during the nineteenth century. T h e specific term ulcerative colitis was first used by Allchinl in an address before the Royal Society of Medicine in 1885 but his contribution did not identify the disease as we know it. Mathews wrote of dysenteries and discussed ulceration due to syphilis and other causes, but shared the general lack of information concerning this condition. However, early in the twentieth century, surgeons began to interest themselves in the treatment of ulcerative colonic disease. Wier I6 suggested appendicostomy in 1902 and 30 years later Lockhart-Mummery I~ still championed this device to make possible through and through irrigation of the diseased colon with solutions containing salt or bismuth. In this cotmtry, however, ileostomy was beginning to be urged for selected cases, often those in final stages of illness. Confirmation of the specific etiology of this disease was retarded for years by the conflicting claims of psychiatrists, dietary authorities and those who regarded it as a sequela of bacillary dysentery. T h e work of Bargen3 in 1924 was epochal in pointing the way toward final delineation of chronic ulcerative colitis as a specific inflammatory

disease--even though the resulting era of vaccines and sera f u r t h e r postponed the time when the surgeon could be of real aid. However, d u r i n g the past 15 years, surgeons of experience have adopted a m u c h more courageous attitude toward the treatment of ulcerative colitis, a t t e m p t i n g to cure the disease by e x t i r p a t i o n of the colon instead of providing a means of irrigation or diversion of the fecal stream. T h i s change in surgical thinking has been influenced by the unquestioned fact that even in the best hands there continue to be frequent deaths a m o n g patients who are continued too long u n d e r medical management, and because m a n y other individuals with the disease seem doomed to a life of recurring invalidism. It also stems from the recognition that an individual who harbors an ulcerated colon for longer than a decade is exposed to the constant threat of the development of carcinoma of the colon, now known to occur in one third of" such persons. Diverticulosis and its complications have been studied intensively by physicians only during the last half century, although we know from autopsy reports that these lesions existed long before. However, since the surgeon only began to recognize diverticulitis in the early part of this century, and since the roentgenologist first described the lesion only 45 years ago, the clinical manifestations previous to the twentieth century had probably been overlooked or been classified under some other clinical heading. At any rate, the syndrome had not invaded the diagnostic horizon of the founders of this society and no reference to it is found in their writings. It is quite natural that in the brief period diverticular disease has been recognized and definitely observed, our concepts concerning it have been changed and amplified from decade to decade as the m a t e r i a l for study has increased. No d o u b t some of our present conclusions as internists or surgeons will be subject to a m e n d m e n t in the future. T h e earliest surgical procedures were

LOOK YOU, MY FRIENDS based on the belief that cancer originated in the inflammatory lesions complicating the disease, a belief fostered by gross resemblance and the occasional coincident association of benign inflammation and carcinoma. This apparently led to a precipitancy of surgical action unjustified by the technics and safeguards of the day. In the 1930's this concept began to be disproved and staged operations came into vogue. More and more we now realize that a sharp division between diverticulosis, diverticulitis and diverticulitis with complications as separate clinical entities is unwise; the three should be considered manifestations of the same process and the treatment of diverticular disease, an all-inclusive term, based on the same principles. W i t h the advent of antibiotics, extended preoperative preparation and improved technics, one-stage resections are again found useful; particularly is this justified in early or interim situations. It is now generally agreed that a patient who has recurring episodes of diverticulitis with bleeding, pain, fever, urinary symptoms suggesting impending colovesicaI fistula or narrowing of the lumen of the bowel. should be given the opportunity for elective surgery during a quiescent period. Resection of the involved bowel can then 5e done with comparative safety in one stage, thereby avoiding the m u h i p l e operations which may become necessary if the condition is permitted to run its course and, also, avoiding the high mortality rate which occurs from hemol-rhage, perforation, pelvic necrosis or prolonged obstruction. Mathews sunnnarized his experience with the surgical treatment of rectal cancer in a p a p e r published the year the American Proctologic Society was organized52 Unfavorable resuhs had reversed his originally optimistic opinion. He noted that untreated patients with cancer live three to four years and questioned whether surgery improved this life expectancy; apparently in the patients who came to him the lymphatics and neighboring structures were already in-

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volved. He described the removal of the rectum as "one of the bloodiest operations that I have ever a t t e m p t e d " and doubted that any good accrued to the patient even though the rectum was removed successfully. His experience with the fairly new Kraske operation, in which a large segment of bone and a small segment of bowel were removed, led him to prophesy correctly that the time would come when surgeons would abandon the method. Since he also hesitated to advise total removal of the rectum in the occasional instance of incipient disease, where only a nodule was present, it is apparent that this fornr of cancer had a hopeless prognosis in this country 60 years ago. H o w quickly the picture changed is best illustrated by events connected with the first joint session of our Society and our British confreres, which celebrated the twenty-fifth anniversary of the American Proctologic Society. T h e high point of the program of the Sub-Section of Proctology of the Royal Society of Medicine meeting in L o n d o n in July 1924 in conjunction with the American Proctologic Society was the "Discussion on the T r e a t m e n t of Carcin o m a of the Rectum"2 which was opened by Mr. Ernest Miles, advocating his abdominoperineal resection and by Mr. LockhartMummery, who c h a m p i o n e d a perineal extirpation following a previously constructed high epigastric colostomy. T h e two procedures, which have served to pattern rectal cancer surgery since, were each well defended. In this debate Mr. Miles described three zones of spread of the disease which, he argned, could not be adequately removed by a perineal procedure. L o c k h a r t - M u m m e r y believed that the perineal operation had a lower mortality, especially in old or stout individuals and reported that 159 perineal resections of this type had already been performed. T h e reported mortality of each procedure was near ten per cent. " T h e Uses of the Past" was the title given to a series of essays written by H e r b e r t Mutler ta in 1952. These were an inquiry

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i n t o t h e w a y h i s t o r y works, c o n c l u d i n g t h a t mankind cannot count on miracles but m u s t a c c e p t d e s t r u c t i o n or s a l v a t i o n , relying on our humanistic tradition for wisdom or, if necessary, c o n s o l a t i o n . T h e p a s t d o e s h a v e its uses a n d it is n e v e r w h o l l y lost. I t r e m a i n s w i t h us a n d w i t h o u t this persiste n c e of the past, life w o u l d lose all continuityJ 0 S o m e o n e has said t h a t t o d a y is always g o o d b e c a u s e it l i n k s y e s t e r d a y a n d t o m o r row. F r o m t o d a y we s u r v e y t h e p a n o r a m a of t h e p a s t w i t h its g r a d u a l j o u r n e y i n t o n o w a n d b e c a u s e this v i s t a b r i n g s w i t h it the c h a l l e n g e of the f u t u r e - - w e in m e d i c i n e are w i s e l y d e t e r r e d f r o m a s m u g c o m p l a cency b o r n of t h e v i c t o r i e s of t h e p r e s e n t . V~Thile we c a n n o t p r e d i c t t o m o r r o w , the p a s t suggests t h a t it m a y s h a m e t o d a y . N o o n e w i l l c h a l l e n g e the g a i n s w h i c h h a v e a c c r u e d to h u m a n i t y f r o m a d v a n c e s i n t h e field of m e d i c i n e a r i s i n g as t h e y h a v e f r o m the use of exact, o r g a n i z e d a n d classified k n o w l e d g e . B u t cycles of p r e v i o u s h i s t o r y r e v e a l that, just as d e c a d e n c e f o l l o w s in t h e w a k e of i n c r e a s i n g d e m a n d s for security, c i v i l i z a t i o n s , as t h e y r e a c h t h e i r peak, invariably replace broad cultural t r e n d s by e m p h a s i s u p o n e x p e d i e n c y or u p o n c o n f o r m i t y to t h e u n y i e l d i n g f r a m e of s c h o l a s t i c i s m . I n m e d i c i n e t h e r e is m u c h to be said for the c u l t u r a l phases of out" p r o f e s s i o n w h i c h set it a p a r t t h r e e score years ago f r o m o t h e r v o c a t i o n s less d e d i c a t e d to p e r s o n a l service. M e n s u c h as M a t h e w s a n d such as o u r f a t h e r s pract i c e d t h e art of m e d i c i n e , s t r i v i n g for u n d e r s t a n d i n g w i s d o m as w e l l as scientific progress. As p h y s i c i a n s , w e m u s t h o p e t h a t o l d ideas w i l l n o t be sacrificed for p r a c t i c a l gains; as teachers, we m u s t e n c o u r a g e n o t o n l y i n t e l l e c t u a l p r o ~ c i e n c y b u t the m o r e intangible spiritual values which provide a f i r m a n d i n d i s p e n s a b l e a n c h o r for t h e i n d i v i d u a l in society a n d w h i c h d i s t i n g u i s h the g r e a t p h y s i c i a n .

References

1. Allchin, W. H.: Ulcerative colitis: An address introductory to the subject. Proc. Roy. Soc. Med. 2: 199, 1885. 2. Andrews, C. F.: Discussion on the Treatment of Carcinoma of the Rectum. (Abstr.) Internat. Abstr. Surg. 40: 207, 1925. 3. Bargen, J. A.: Experimental studies on the etiology of chronic ulcerative colitis: Preliminary report. J.A.M.A. 83: 332, 1924. 4. Fischer, A. ~V.: Crber eine neue R6ntgenologische Uatersuchungsmethode des Dickdarms: Kombination yon Kontrasteinlauf nnd Luftatlfbl~hung. Klin. ~,Vchnschr. 2: 1595, 1923. 5. Galdston, Iago: The natural history oF specialism in medicine. J.A.M.A. 170: 294, 1959. 6. Groedel, F. M.: Roentgen ray examination of the digestive tract. Arch. Roent. Ray. 12: 122, 1907. 7. Haenisch, G. Y.: Die R6ntgenuntersuchutlg bei Verengungen des Dickdarms: R6ntgenologische Frtihdiagnose des Dickdarmkarzinoms. M/_inchen, med. Wchnschr. 58 (pt. 2): 2375, 191i. 8. Hanes, Granville S.: The value o[ the proctoscope and suggestions concerning its use. Tr. Am. Proet. Soc., 1927, p. 6t. 9. Holding, A. F.: The roentgenologic method of examinLng cases oF constipation and obstipation--a method of visualization of abdominal lesions of the intestinal tract. Tr. Am. Proct. Soc., 1912, p. 56. 10. Lee, Umphrey: The uses oF the past. Tr. Philosoph. Soc. Texas, 1957. I1. Lockhart-Mummery, J. p.: Diseases of the Rectum and Colon and Their Surgical Treatment. Ed. 2, Baltimore, William Wood and Company, 1934, p. 468. 12. Mathews, J. M.: The proper operation for cancer of the rectum. Medicine. 5: 284, 1899. 13. Muller, Herbert J.: The Uses of the Past. Profiles of Former Societies. London, Oxford University Press, 1952. 14. Rosser, Curtice: The first proctologist. Tr. Am. Proct. Soc_, 1946, p. 429. 15. Weber, H. M.: A method for the roentgenologic demonstration o~ potypo[d lesions ar~.d polyposis of the colon. Proc. Staff Meet., Mayo Clin. 5: 326, 1930. 16. Wier, R. F.: A new use for the useless appendix, in the surgical treatment of obstinate colitis. NEed. Rec. 62: 201, 1902. 17. Wyatt, G. M.: Survey examination oF the colon with barium and tannic acid. Am. J. Roentgenol. 66: 820, 1951.