PART IV.

M E D I C A L MISCELLANY.

Reports, Transactions, and Scientific Intelligence.

T R A P S F O R T H E U N W A R Y .

An Address introductory to the Clinical Session of 1891-9 ~ delivered in the Theatre of the Meath Hospital and County Dublin Infirmary on Monday, October 5th, 1891. By RXWDON MACSa~ARA, F.R.C.S.I . ; one of the Surgeons to the Hospital.

A~o~G the traditions of the Meath Hospital there remains one of which I am this day the victim, and i t is that our clinical work should be annually inaugurated by an Introductory Address delivered in rotation by one or other of the staff, and in virtue of this rotatory system the dis- charge of this duty has fallen to my lot upon the present occasion. In professional minds much difference of opinion exists as to the value of such Addresses-- in some schools they are entirely ignored, in others the time-honoured custom is still respected ; but I must confess that to me it seems, I might almost say, a cold-blooded measure to plunge at once in medias res without one word of grateful welcome to students who, pre- serving their allegiance to their Alma Mater, return here to continue their s tudies--one word of encouragement and i t may be of warning to the student commencing with us his career--one word of God-speed to such of you as axe about to qualify yourselves to enter upon life's struggle, and who probably are destined hereafter to be our successors, and upon whose shoulders will devolve the task of upholding the reputation won for the "O ld Meath" by our predecessors. To such of our class as have qualified themselves during the year that has elapsed since my distin- guished and much-loved colleague, Mr. Smyly, so brill iantly discharged the task that I , proximus sed proximus longo intervallo, am now essaying, personally, and on behalf of my colleagues~ I tender our warmest con- gratulations, and I desire most earnestly to assure them of the deep interest each one and all of us take in their future success.

From our first entrance on professional life to its termination, our paths are beset by what I term traps for the unwaxy~ and to some of these I would wish to draw attention upon the present occasion. The first of these traps is found in the fact that in but too many instances

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the choice of a profession is not left to the par ty primarily interested in it, but is decided for him, irrespective of the young man's vocation, by some outsider, whether parent, guardian, or other responsible party. To the majority of our students there must be something singularly attrac- tive in the study of medicine, else would they not struggle on through what is admittedly per t~dia et labores to attain the object of their ambi- tion. But there remains a minority to whom each succeeding day's duty makes their task more repulsive, and if there be such a one amongst you, to him would I give the advice given by Queen Elizabeth to Sir Wal ter Raleigh on a memorable occasion, " I f your mind fail thee, climb not at all." Seek for the talents with which Providence has blessed you some other outlet more congenial to your tastes. In my own experience I am aware of several instances where the course I am now recommending has been pursued--one instance occurs in the person of one of our leading Dublin solicitors, another in the person of a distinguished cavalry officer, another in the person of a colonel in the artillery, and yet another in the person of a leading London bar r i s te r - -a l l of these commenced their career as students in this Hospital, but finding that they had no vocation for medicine, they gave up its study and betook themselves to more congenial occupations, wherein they respectively gained subsequent distinction.

The most remarkable example, however, constitutes what I look upon as an historic episode in the Meath Hospital h i s to ry- -an episode which has not been recorded in its annals, either as furnished us by our Standing Committee, or by Dr. Ormsby in his most interesting History of the l~eath Hospital. Ear ly in the year 1871 the prelate whose recent death the Christian world is still deploring, the Archbishop of York, at that time Bishop of Peterborough, stopping on a visit in this city with his old friend Dr. Newell, C.B., and suffering from an anthrax on the back of his wrist-joint, sought the services of one of our surgical staff, and on the termination of the treatment asked the surgeon in question what was his fee ; the surgeon replied that he was afraid that his lordship would con- sider his demand exorbitant, but that the only fee that he would accept was a charity sermon in aid of the funds of the Meath Hospital. Af te r a moment's reflection the bishop consented to preach the sermon, but pressed the surgeon himself to accept a cheque for his services, to which the reply made w a s - - " No, my lord, the sermon, the whole sermon, and nothing but the sermon," and so the matter was arranged. Month.~ elapsed, the bishop had long returned to his diocese, and the occurrence had entirely slipped the surgeon's memory, when one morning he received a letter from the bishop stating that he was prepared to come over at his own expense, and to preach the sermon on any of the four Sundays named. The sermon was preached in St. Ann's Church, on Sunday, the 13th of November, 1871, and there accrued to the funds of the hospital the sum

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of s 6s 3d. But what points the moral of my tale remains to be told. The bishop informed us that his first start in life was as a medical student for six months in the wards of the Meath Hospital, but~ finding mere congenial work in the service of his Great Master~ he made up his mind to abandon medicine in favour of divinity. A m I not justified in saying that such an historic episode as this is worthy of being recorded in our Annals ?

The second trap that awaits the student at the commencement of his professional career has~ I regret to state, been laid for him by an august body of which, as the representative of the Royal College of Surgeons in Ireland, I am a m e m b e r - - I mean the General Medical Council. In their wisdom they have made Greek an optional instead of a compulsory subject at the Arts Examination~ which must be passed previous to registration as a medical student. This procedure has been justified by some on the score that Greek is a dead language, but to medical practitioners it is a more living language than any modern one, so many are the terms sup- plied by i t to our nomenclature ; in fact~ one cannot now-a-days read any of our journals without meeting terms of which we have never heard before~ and of the meaning of which we would remain in ignorance had we not even some slight acquaintance with the' Greek language. So much so is this the case that the thought has flashed across my mind that authors who indulge in such a display of classic erudition might well, in mercy to their less learned readers, append glossaries to their papers.

To understand the next trap into which even the industrious student may fall, I must be permitted to explain the important distinction which, in my mind~ exists between clinical lecturing and clinical education. In the first of these, too often but one of the student's senses is appealed t o - - that of hearing ; he is told this~ that, and the other~ but no effort is made to induce him personally to bring into play his remaining senses. In clinical education he is not told what he is to hear, see, feel, or smell, but he is asked what he does hear, see, feel, or smell~ and if wrong he is set right, and after a few such lessons he at last learns correctly to use these senses. The proper use of your senses is not so simple a matter as you may imagine ; to do so efficiently requires, in the etymological sense of the word--educat ion, and at that all conscientious clinical teachers should aim. The vis inerti~e, however, is so deeply planted in human nature that with many students the clinical orator is frequently more popular than the painstaking clinical educator, but in after-life, however, they are sure to find out how mistaken they have been in their estimate.

In alluding to one of the senses, that of smell, I will not be surprised did you smile r but frequently from it alone will the experienced physi- cian gain a hint of paramount importance, one remarkable example of which statement I shall mention. When resident surgical pupil in this hospital I was carrying round his prescribing book with the late Pro-

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lessor Porter, and in one of the wards upstairs we came to the bedside of a patient, where that great surgeon paused, then, turning to me, said, "Stop this man's mercury," and, pulling down the bedclothes, exhibited to my astonished gaze a well-marked example of mercurial erythema~ for which he prescribed appropriate treatment. I cannot put in words the feelings that thronged my mind at what seemed to me an exhibition of superhuman surgical acumen, but when subsequently he honoured me with a visit in my room, an honour of frequent occurrence, I timidly asked him how, without seeing it. he had diagnosed the existence of the erythema, he replied, " I smelt it," and from subsequent experience I can assure you that it is an odour once experienced that will never be forgotten. Believe me~ gentlemen, that the Horatian max im- -

"Segnius irritant animos demissa per aureIn~ Quam qusa sunt oculis submissa fidelibus"

is applicable to other senses than that of vision alone. Another trap that awaits the unwary student originates in the fact of

his completely ignoring the class of diet ordered for the patient under treatment. Many are the students who complete their hospital atten- dance without even once casting a glance at the dietary sheet which hangs in each of our wards, and yet when he goes out into practice and is called upon to treat a sick person, one of the questions invariably asked is, What nourishment is the patient to get ? This , and another frequently-asked question, How did the patient contract the disease ? constitute two out of several subjects comprised in that most important branch of our profession--Hygiene--under the names, dietetics and ~etiology. So much to the front has this subject of hygiene come, that the legislature has sanctioned the registration of diplomas in it~ conferred on terms satisfactory to the General Medical Council, and valuable and important letters emanating from the pens of Drs. Boyd and Roche have lately appeared in the public press, urging upon the consideration of the several medical authorities the propriety of introducing into their curri- cula courses of lectures upon sanitary science; but, in my opinion, the movement will not stop there, and many years will not have elapsed ere, in addition to the qualifications in Medicine, Surgery~ and Midwifery, now indispensable for admission to the Medical Register~ a short Act of Parliament will be passed, requiring a license in Hygiene at the hands of candidates seeking such registration.

A. remarkable illustration of the importance of the careful study of that branch of hygiene which treats of dietetics is to be found in the well- known request of our great Graves, that the epitaph inscribed on his tomb should consist of but three words- -" he fed fever ; " and, connected with this, I once was witness of an amusing scene in the clinique of the celebrated French physician, Trousseau, who was an ardent admirer of Graves, and who had translated into French his lectures on the practice

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of medicine. Suddenly interrupting his conversation with me, in a voice of thunder he addressed a erouching~ trembling fgure at the door of the w a r d - - " Voil~ le coquin! voilh le vilain! Malheureux venez iei done." He then explained to me that~ wishing to use these three memorable words as a motto for the work~ he rendered them " I1 nourrissait les fi~vres~" but to his dismay they appeared " I 1 pourrissait les fi~vres" (made them putrid). The trembling creature was the printer.

I f there breathes a man with soul so dead to humanitarian instincts as to be indifferent to the diminution of a nation's death roll~ appeal to his pocket~ point out to him that unsanitary conditions mean sickness, possibly death~ with poverty~ discontent~ and increased rates~ whilst the opposite conditions are attended with opposite results, and you will quickly win him over to the cause of hygiene. A t the same time I scarcely think it fair that the existing population should be called on to bear all the ex- penditure that may be necessary ; posterity which will benefit by the outlay~ should assist in defraying the costs. I t has been convincingly proved that by improved sanitation the death roll in our Indian army~ which some years ago stood at the rate of sixty-nine per thousand~ has been now reduced to less than twenty per thousand~ but not only this, that i t has resulted in an annual saving of ext~enditure to the amount of five hundred thousand pounds; and pretty much the same story can be told of our home army.

Another trap lying in our path is found in our disregard of the advice given us by P o p e -

"Be not the first by whom the new is tried, Nor yet the last the old to lay aside."

Never perhaps in the history of medicine has there been a period of greater unrest in our profession than we have experienced in the past quarter of a century. New medicines have been forced upon our notice~ and~ but too frequently~ to the supplanting of older and more valuable medicines of the same class. Surgeons' minds have been exercised in devising operations for the relief of diseases previously considered outside the pale of their art. Physicians have been earnest in their efforts at the elucidation of hitherto obscure~ in some instances unreeognised, symptoms. But perhaps in no department have we more strained after new departures than in our search for reliable antiseptics. I t is perhaps but natural that the pioneers in these respective branches should ignore Ta]lyrand's advice, "pus trop de z~le~" and vehemently force upon our ~cceptance their respective views. Here it is that I would wish to press upon their consideration the advice given in this very theatre to the assembled class by my venerated master~ the late Sir Phil ip Crampton : - - " Gentlemen~ when you mount your hobby horse~ be sure that you do not ride it to death ;" and to urge upon your consider- ation Pope's advice and the propriety of exercising a due amount of reflection and ~)f caution in accepting as gold that which only glitters.

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Bearing upon this subject of antiseptics, some years past I was con- sidered a fossil, because I would not bow down and worship the carbolic acid spray, which en passant I may remark was as frequently as not directed upon the operator's back instead of on the patient's wound; however, time has passed, and we do not hear its advocates now-a-days as trumpet-tongued as to its efficacy as was formerly the case. Gentle- men, let no antiseptic, no matter how loudly vaunted, no matter how high be the authority advocating it, blind your eyes to the paramount importance of nature's own two antiseptics--fresh air and pure water. I n a time not so long past every effort was made to exclude from the sick room the night air, and it remained for Florence Nightingale to point out to our common sense that the only air we could breathe at night was night air, and that the fresher it was the better it was for the invalid. Whilst it remained for our great Macartney to insist upon the value of water-dressing as a substitute for the farrago of unguents pre- viously in use under the name of "digestives," curiously enough, fre- quently is this great advance in surgery erroneously attributed to that great surgeon, Liston. Well might Macartney~ if made aware of this fact, exclaim from his grave, with V i r g i l -

" Hos ego versieulos feci, tulit alter honores." In addition to his other valuable contributions to surgery, my colleague,

Mr. Smyly, has devised a plan for utilising this most efficient antiseptic in our operative procedures in this theatre, a plan by which the wound can be thoroughly cleansed by irrigation with water at any required tem- perature, a plan well worthy of adoption in similar institutions. This carbolic acid spray fad has, however~ not been altogether devoid of value, for, believing in its virtue, surgeons have been emboldened to undertake, under its influence~ operations, notably abdominal sections, for the relief of diseases previously considered unsuited for operative interference, and the brilliant results seemed to justify its claims to importance. How- ever, equally brilliant results have been attained in a long series of abdominal sections by my friend, Mr. Lawson Tait, of Birmingham~ who dispenses altogether with its employment. Believe me~ gentlemen, that nature's antiseptics are those upon which you should place your greatest dependence.

The next trap into which we all are likely to fall, and the most dan- geroas of all, inasmuch as the bait employed has about it an appearance of science, is Medical Statistics. For many reasons to which I shall pre- sently allude~ in my opinion it may be laid down as an axiom that the statistics of the coincidences affecting our lives are but too often mis- leading, whereas the statistics based upon finalities in life are reliable and guiding. Statistics to be of any value must be based on figures, and these figures must be exhaustive and accurate. Anti-vaccinators trium- phantly base their opposition to Jenner's immortal discovery on statistics,

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pointing to the numbers who, after vaccination, develop some form of disease. That this is the fact I admit, but I deny their contention that the virus was introduced into the baby's system through or along with the vaccine matter employed. Upon one of these alleged examples, and, probably, the most likely, I venture to speak with some authority, inas- much as I see many such cases, and never yet have I failed in ascertain- ing that what apparently was due to the vaccination was really due to the fact that the sins of the parents had been visited on the offspring. Often has it happened to my knowledge that infants have been born of undoubtedly specifically diseased parents, and have exhibited no taint of inherited disease up to the period of dentition, when the result has proved that after all it was but a case of latet anguls in herba. As in the case of dentition, so I hold that it is in vaccination, the resulting fever has acted as a ferment developing the lurking disease, and fortunately at an age when I find it easier to cure than did it develop itself at a more advanced period of life. In my opinion an outcry against dentition might be sustained on as reasonable grounds as is the outcry against vaccination, for I have at this moment three little babies suffering from varying forms of cutaneous affections, the outcome of dentition, where there is not even a suspicion of specific disease. To my mind it is incomprehensible how any person blessed with memory and endowed with powers of observation, arrived at my age, could be an anti- vaccinator. Why, when I was a boy, the number of middle-aged people one met disfigured with smallpox was simply appalling; now I challenge my youthful hearers to go beyond the fingers of one hand to enumerate such of their acquaintances as are so disfigured. Anti-vaccinators, not being able to deny this fact, try to account for it by our improved sani- tation. But the question may be fairly asked, Has sanitation kept pace with non-disfigurement by smallpox ? - - a question that, considering the condition of the slums in our large cities, and, indeed, in many of our rural districts, must unfortunately be answered in the negative. To reason with anti-vaccinators would, however, be simple waste of time, f o r -

" Faddists convinced against their will, Are of the same opinion still."

]n the 71st Yolume of the Medical Press, page 422, will be found a paper emanating from my pen, entitled " A few words about Cancer," in which I made an effort to solve what even to this moment with me is a moot question--whether a patient afflicted with cancer of the breast would not live longer if not subjected to operative interference, than if so treated. This question was forced on my consideration by the fact that I had at the same time under my care two titled ladies, suffering from cancer of the breast; one, Lady B., laboured under the disease over twenty years~ steaddy declining any operative interference ; the second,

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Lady W., on the occasion of a visit to Dublin, was commended to my care by that most eminent surgeon, the late Mr. John Marshall, President of the General Medical Couucil, whose patient she had been, and who had removed the breast some time before, and that at an early period of the disease. Lady W. returned to London, the cancer burst out afresh, not only in its original site, but in other parts of the body, and she died before Lady B., who never bad been operated upon. Many such cases have presented themselves to my notice, but one of the most remarkable was mentioned to me a short time ago, by my colleague, Mr. Hepburn, occurring in the person of one of his patients suffering from cancer in both breasts, a diagnosis in which he was confirmed by Mr. Will iam Colles ; this was ten years ago, no operation was performed, and for some years not having seen or heard from her, he concluded she was dead, but to his surprise met her the other day, to all outward appearances in good health. My friend, Mr. Thomson, has also mentioned to me many re- markable instances occurring within his own experience. Wi th the object of t rying to solve this question by statistics I wrote the paper I have referred to, but for reasons there assigned I found it a hopeless task. ]n the Review of Reviews for January of this year there is an article, entitled " Can Cancer b~ Cured ? " in which an account is given of Count Mattei and his plan of treatment, and in which, as bearing upon the question of operative or non-operative interference, occurs the remark that the Count rather objects to undertaking the treatment of cases that have been pre- viously operated upon, preferring to get those who never have undergone the ordeal of the knife. Mr. Stead is very indignant with all parties concerned that a Commission has not been issued to investigate the Mattei plan of treatment, but the outcome of such Commissions frequently proves of but little or no value, a notable example of which is found in the instance of Miss Joanna Stephens' receipt for stone and gravel, for the disclosure of which Parl iament awarded a grant of s ; previous to which award a Committee of Surgeons had reported favourably on its efficacy in the treatment of four persons afflicted with stone in the bladder, in the bladder of each of whom, however, after death the stone was found.

Ajustum bellum is being carried on between the advocates, on the one hand, of ether, on the other~ of chloroform, as to which is the safer anaesthetic--some etherites, as I shall call them, going so far as to assert that the administration of chloroform should be considered a criminal act. The etherites, however, cannot deny that fatal results have followed the administration of ether, but they claim for it that fewer deaths follow its administration than occur when chloroform is the anes the- tic selected. In other words, they appeal to statistics. As I have already stated, statistics must be based on figures. But where can we arrive, with any pretence to accuracy, at the number of cases in which ether and in which chloroform was used~ so as to institute a reliable compa-

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risen as to the greater safety of one over the other ? 'Tis true that ~n his most interesting and most instructive work, '~ Anaesthetics ; Ancient and Modern," Mr. George Foy places on reoord a prodigious number of cases in which chloroform was employed. But even he would not claim that he has exhausted the record ; and, so far as I know, the task with respect to ether has not been even approached to anything like the same extent. But, even supposing that we had the figures accurately supplied to us with the results, the absence of certain necessary factors would render the comparison nugatory. Pr imary amongst these factors is the party administering the anaesthetic, who, when an untoward result occurs in his practice, frequently lays the blame on the patient 's idio- syncrasy, ignoring his own carelessness. Let us take a ease. A patient has had ether administered with a satisfactory result by a careful admin- istrator. On some subsequent occasion i t is attempted to bring him again under its influence, but he dies, at once idiosyncrasy is pleaded. Now, were it the cause of death, he would have died on the occasion of its first administration, for, in my experience, idiosyncrasy never sleeps.

The induction of anmsthesia by ether is based upon principles entirely differing from those which should guide us in the administration of chloroform ; and these principles are admirhbly carried out in Dr. Ormsby's inhaler. Wi th this instrument the patient certainly runs less risk, if the administrator be experienced, than he would run were chloro- form the anesthet ic selected ; and ignorance of these principles can alone excuse those who deny its merits. This, however, is not the time nor is this the place for me to enter upon the comparative merits of these two anesthetics ; my object is to point out how very unreliable must be sta- tistics which ignore all the factors tending to produce fatal results during the administration either of chloroform or of ether. These should be accurately recorded; and in the case of chloroform, for reasons clearly laid down in the seventh edition of my work on "Medic ines : Their Uses and Mode of Administration," one item, rarely attended t o 1 the temperature of the surrounding atmosphere--should be carefully noted.

Strange though the statement may appear to you, gentlemen, there is a fashion in medicine as strong as, if not stronger~ than that which rules in dress. Brandy and salt~ the grape cure, mesmerism, et hoe genus omne, have had their day, and possibly will have i t again. When I was a student venesection was extensively practised, and comfortable incomes were earned by cuppers of such repute as Betts, Minos, and Mapleson; and no surgeon was admitted into the mili tary service without the pro- duction of a certificate of proficiency in this art from some recognised authority. So universaUy general was the operation of venesection that i t was no unusual thing for me to bleed of a morning some eight or ten patients, and from some vague presentiment I kept a record of such cases, to which our great Stokes referred in his celebrated address at Oxford,

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" O n the change of type in disease "--names, age, arm, quanti ty of blood abstracted, are all set down ; but one entry is most remarkable, one qua~ t of blood abstracted, and the letters " d - n - f " appear before his name. The man was a patient of the late Professor Porter, father of the distinguished Baronet bearing that name. He suffered under thoracic aneurism, and I was directed to bleed him pleno rwo, ad deliquium, but when I had taken forty measured ounces of blood from his arm, I got frightened, bound up the wound, and put him to bed. The letters " d - n - f " signified that he did not faint. Shortly after the period to which I am referring, bleeding went out of fashion, and to have recourse to it was considered little short of being a criminal act. Bnt now the pendulum seems to be swinging again in favour of venesection, and in properly selected cases it may save a valuable llfe. One night, some years ago, I had just retired to bed, when a loud knocking was heard at my door, and the dearly-loved son, whose loss I shall never cease to deplore, rushed into my~ room exclaiming, "Fa the r , there is a gentleman dying in your study, come down at once !" I hurried down and found, sure enough, a gentleman at the point of death. I quickly bared his arm, and, to my son's horror, proceeded to bleed him. A t first the blood came like tar, but by degrees its normal flow and colour returned ; and, after some twenty ounces had been abstracted, the gentleman excla imed," Thank God, I am as well as ever I was in all my life !" and left my study apparently as well as any man could wish to be. I leave it to my medical colleagues to explain to you, as they are well able to do, the rationale of this sudden seizure, for i t came on suddenly, and why it was that the treatment was so successful.

believe that, now-a-days, surgeons might be found, who have skilfully and successfully performed all the major and minor operations in surgery who never yet have bled a patient, so complete has been the interregnum.

Gentlemen, my task, not a self-imposed one, I can assure you, and by no means of the nature of the gratum opus agrlcolis, is now concluded ; and it only remains for me to assure you that each one and all of us will gladly assist you, to the extent of our abilities, in your clinical studies, you bearing in mind Lord Bacon's aphorism, " H e that questioneth much learneth much ;" and to express the anxious hope that, as in the olden days, his proudest boast was, "e t ego civls Romanus sum," so will i t be your proudest boast, your happiest memory, as i t is mine, that you will be able to exclaim, " I also was a Meath Hospital student." Adopt as your guiding maxim through life the advice given by his grandfather to ~eoptolemus on his proceeding to the Siege of T r o y - -

u'n'e~poxoo ei~pe~a~ --Iliad vi. 208.