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The pointers that are very important to consider in the treatment of many chronic as well as acute diseases, and especially those that seem to resist the indicated remedy, that I wish to call attention to are those known in orificial

surgery. The term orificial surgery is usually restricted to minor and major surgery of the rectum and anus, such as dilitation of the sphincter ani muscle removal of hemorrhoids, etc., and the breaking up of prejucial adhesions and circumcision in both sexes and the repair of lacerated perineum and lacerated os uteri and the various similar operations on these parts. At the present time, as well as for several years past, there has been a great tendency for young graduates as well as many old ones to specialize in surgery and the various branches of surgery. The eye, throat, appendix and, in fact, most all other branches of surgery has received more attention by both general practitioner and the specialist than orificial surgery. According to my judgment, there is no branch of surgery that is more often needed or that is capable of doing more good that is now neglected than that known as orificial surgery.

It is not my intention for this paper

as

to be a treatise on orificial surgery, that would require a good sized volume. It is my object to emphasize only a few pointers belonging to orificial surgery, namely, the necessity of rectal dilitation in cases of contracted sphincter ani muscle and the breaking up of perputial adhesions or circumcision of both sexes. There is no text book in print that is entirely devoted to orificial surgery. There was one by Dr. E. H. Pratt of Chicago, a homeopathic physician, which is now out of print. We are in great need of a text book on orificial surgery written for the benefit of the general practitioner, as this is the class of physicians that need such information and is the class that could use it to the best advantage, and by it do the most good, which I will attempt to explain further on. Dr. E. H. Pratt said:

“Disturbance of the sympathetic nerves do not make themselves known in the language of pain greatly disturb the various functions of the body interfering seriously with its nutrition, but very readily escaping the notice of the careless observer."

It should be remembered that the sympathetic nervous system has control of the vital functions and pressure on the nerve endings in the sphincter ani mus

cle in the glans penis or glans clitoris causes various reflex disturbances which cannot be relieved only by relieving this pressure. These orificial pointers are not generally as well known as they should be, and many conditions are caused by such pressure that the average physician has completely overlooked. and his treatment has failed to relieve because he has failed to locate and remove the cause. There are many cases of convulsions (so-called epilepsy) in children that can be relieved and permanently cured by breaking up adhesions of the glans penis or glans clitoris or by circumcision of either sex. It is a well-known fact that bromides will give temporary relief in such cases, as well as in most all cases of true epilepsy, when the patient is under their influence fully enough, but they rarely ever cure, as they do not remove the cause in any or many cases. In the treatment of all diseases the thing to do is to find the cause and then remove it when this can be done. Our knowledge of pathology and the various therapeutic methods does not always make this possible. Recent researches in mechanical therapy have proved the great importance of understanding the nervous system.

Dr. C. E. Lanning said: "No matter from what standpoint we start, the nervous system is the all-important structure in curing or preventing disease."

The specialists in spinal therapy, vibratory therapy, thermo therapy, photo therapy, electro therapy and various other physiological methods of treatment have, in a great measure, neglected the importance of rectal dilitation and the breaking up of preputicial adhesions. The sympathetic nervous system can be aroused by dilitation of the sphincter ani muscle, and thereby all the vital functions that are impaired improved. It is a valuable. therapeutic measure in chloroform narcosis, suspended animation from falls,

drowning, fainting, smothering spells and various other things too numerous to mention. Dilitation of the sphincter ani muscle is a mechanical therapeutical measure, valuable not only in chronic diseases, but in acute diseases, and as an emergency remedy. It stands in mechanical or physiological therapy as a therapeutic measure similar in comparison as epinephrin as a therapeutic agent in drug therapy and has one advantage; that is, a physician can give the treatment at any time with his fingers in cases of emergency when no instrument or drug may not be at hand. I consider it very important to know the condition of the sphincter ani muscle and to relieve a contracted sphincter by dilitation.

Dr. S. H. Linn said: "I do not regard the examination of a case of insomnia, neuralgia, nervous prostration, general debility or functional derangement of any one or all organs of the body as thorough or complete without a careful exploration of the lower two or three inches of the rectum."

If all physicians would adopt Dr. Linn's plan with the addition of examinations for preputial adhesions and other orificial defects, they would more often locate the cause of the diseased condition.

Dr. Hoyt says: "How I wish I possessed sufficient command of language to paint in graphic colors all that is true regarding the beneficence of the apparently simple device of stretching the sphincter ani muscle. When this muscle loses its ordination, what a field of wickedness does it create. are a multitude of discords of reflex actions directly attributable to it and relieved by the simple procedure of stretching the sphincter."

There

I was called to see a boy 6 years old that had been a "bed wetter" all his life. I found he had the longest prepuce 1 ever saw. It extended almost an inch

beyond the end of the penis, which was an ordinary size. Another boy 3 years old that had been sick off and on all his life and subject to convulsions when he had much fever I found the prepuce just covering the glans, but contracted, and adhesions so complete that the meatus was about all that could be exposed. I treated a persistent diarrhoea in a boy about 3 years old and his brother about 5 years old for general debility who had been sickly all his life. The indicated remedies would give only temporary relief. I found both had a very long prepuce with prepucial adhesions. Another case, a married lady about 30 that had been having light convulsions for about four years, came for treatment. I was satisfied she had preputial adhesions and upon examination I found the clitoris completely hooded. I am thoroughly satisfied that preputial adhesions was one of the causes, if not the only cause, of all the trouble in these cases and that breaking up the adhesions and removing redendant tissue would be a part of the treatment, if not all that was needed. On examination of children of both sexes, I usually find preputial adhesions when they are undeveloped and do not grow as fast as they should or small to their age or lack of confidence have to be right with the mother all the time for protection or sick and puny off and on or a tendency to convulsions where feverish and various other things too numerous to mention.

Recently there has been a great deal said about the importance of a medical examination of the eyes, ears, nose and throat of school children, which is, in a measure, important, but I am unable to see why only eyes, ears, nose and throat should be selected and why they are of any more importance than any examination or for any other class of diseases except contagious diseases.

I fully believe that if the orificial

specialists were placed on such examining school boards he would find as many physical defects that was causing as much trouble and needing attention as the ophthalmologist or any other specialist would find. But regardless of all the benefit that could be derived from orificial philosophy, this is an age of false modesty when this delicate subject could only be considered with the family physician or private specialist, and then i is not always accepted in the true light or appreciated by many seemingly intelligent people.

Again the school physician should not supplant the private family physician. I am not a socialist at present, but I can readily see that by evolution and after each legislation we are rapidly drifting that way, and if it keeps on the public. physician with a job or an appointment will do all the practice for those of school age, 6 to 21. The county physicians will have charge of all contagious diseases which, according to bacteriology and the Oklahoma State Board of Health, includes pillagra, hook worm, infantile paralysis, typhoid fever, tuberculosis, puerporal sepsis, hydrophobia, measles, diphtheria, smallpox, scarlet fever and pneumonia (we are required to report the above named twelve diseases in Oklahoma), and will soon have most all others, as the list is being rapidly increased from time to time, and there will be nothing left for the physicians not in office to do.

The general practitioner should know the various derangements caused by preputial adhesions in children, for the specialist is rarely consulted in such cases, and in various communities no specialist is convenient and many are not able to pay the general practitioner's fee, much less a specialist's fee. It does not require a specialist to diagnose or

relieve such conditions, and again, if not relieved may run on until such an organic change takes place that the case. could not then be relieved by any treatment, or at least could not be relieved as quickly as when in its incipiency, not to consider what the patient would have to endure, that should have been relieved long ago.

Dr. E. A. Ballmer says: "To look for phymosis, hunger or earache in crying, fretful, nervous boy babies."

I wonder if he finds preputial adhesions in boys any more often than in girls. The value of male circumcision has been appreciated by a certain class of physicians for years, but few have learned the value of female circumcision.

In an article, "Preputial Adhesions in Girls," by Dr. R. T. Morris, Professor of Surgery, New York Post Graduate Medical School, August, 1903, MEDICAL BRIEF, he says: "Preputial adhesions. in girls are rather more frequent than in boys." If this is true, then circumcision is more often indicated in girls than in boys, and why is it that such has not been generally known? I fully believe Dr. Morris is correct, and I think if any physician would examine 100 boys as he should come to them and 100 girls as he should come to them that he would find Dr. Morris was correct. Personally I have no statistics on this, but from children that I have examined for preputial adhesions I find it far more often in girls.

Dr. Morris further states: "That all physicians should make it a matter of practice to examine the clitoris in all girls less than one year of age."

Again he says: "I do not know what proportion of causes of nocturnal enuresis in girls is due to preputial adhesions, but practically all of the cases of

this sort that I have seen were due to that one cause."

This should be sufficient reason for any physician to look after preputial adhesions in enuresis of girls.

Dr. Ballmer says: "An adherent prepuce in a small child will sometimes produce a hydrocele."

I would not doubt this statement and have often seen mention of preputial adhesions causing hip joint diseases, which I also believe is true.

Again Dr. Ballmer says: "If early attention be given to the retraction of the foreskin, circumcision seldom becomes necessary."

I cannot fully agree with Dr. Ballmer in this statement. I do not advocate circumcision in all cases by no means, and do not believe it should be performed only when needed. I know that there are many cases that do not have firm adhesions. A tight contracted prepuce or a very long prepuce can be relieved without circumcision by gradual breaking up of the adhesions and gradual dilitation of the prepuce. But when there are firm adhesions, a tight contracted prepuce or a very long prepuce, according to my opinion, circumcision is needed and very beneficial. An excessively long prepuce, as are among some entire families, is an abnormal condtion, and such an excess of redendant tissue is useless and, I believe, very harmful in many ways, even if no adhesions or contractions are present. I believe at least all of it that is not necessary to cover the glans should be removed, even if circumcision is not desired.

If the general practitioner will bear in mind a few of the principles of orificial surgery, it will open up the way for relief in may cases that he would not otherwise be able to control.