338 J~lodern Progress in Surge~ T.

disease in early cases, or checking its course in the further advanced stages. This form ~)f treatment may seem at variance with the successful results of FrSnkel's treat- ment by regulated exercises, but I believe everyone who, has used the latter method has recognised the danger of excess, and its chief advocates warn against a too vigorous course, or continuing it till the patient is tired. Finally, the results which have attended this method of treatment are a strong argument in favour of the theory.

Edinger further pointed out that the connection be- tween, and the frequent association of, tabes with general paralysis of the insane can easily be understood if his theory be accepted, and the relation of both to syphilis. When the higher cortical centres, which represent the physical sphere, are subjected to a relative excess of physical activity, the latter disease results. The fact that numerous authors (M6bius, Raymond, Mort, and others) regard both symptom-complexes as manifestations of one and the same disease, is interesting in this connection.

ART. XIV. - -Modern Progress in Surgerp. ~ By WILLIAM TAYLOR, F.R.C.S.I. ; Surgeon to the Meath Hospital and f~ounty Dublin Infirmary; Surgeon to Cork-street Hos- pital; Demonstrator of Anatomy, Royal College of Sur- geons in Ireland.

IN accordance with the time-honoured custom in this institution a member of the medical staff is entrusted with the duty of inaugurating the session. Through the kindness of my colleagues it has fallen to my lot to be that member to-day, consequently my first duty is to thank them for the honour thus conferred upon me.

At first I was disposed to look upon the honour of being selected as the inaugural lecturer of the 149th session of this hospital as an unenviable one, but on consideration I am inclined to think that, to place one so young in sucl~ a responsible position--a position filled in former days by so many great men, whose names in Irish medicine and

a An Address delivered at the opening of the 149th Session of the Meath Hospital, on Monday, October 14, 1901.

By MR. WILLIAM TAYLOR. 339

surgery are household words amongst you, men not only renowned in their profession, but distinguished in the art ef oratory--is an honour deserving of my respectful thanks. As there must then be an absence of that literary finish and polish so characteristic of some of the addresses I have listened to in this place, I must only claim the indulgence of my audience for nly first attempt. Mean- while, permit me, on behalf of my colleagues as well "~u on my own behalf, to extend to you a hearty welcome. ~()n former occasions, I understand, inaugural lectures were devoted to the students--advice, some good and some indifferent, being given as to their course of study. But on recent occasions lecturers have been inclined to give up this method of introducing our teaching session, and have devoted their discourses to subjects of more interest to those who, though not members of our profes- sion, fake an interest in our hospital and work, and honour us with their presence on occasions like these. The lecturer, in fact, believed that advice unasked, and thus proffered to students about to resume their duties, or to those who take their stand for the first time on the threshold of a profession through whose portals many enter, but few with a full realisation of the responsibility they incur, was so much time wasted. If, then, I were to direct your attention for a few moments to some of the giant strides made in surgical therapeutics, I might later on be excused for giving you some little advice which might be profitably followed during your student days. At any rate I will run the risk of incurring your reproach both for what may be termed presumption and perhaps for wearying you with the repetition of an oft-tohl tale. Let us just for a mmnent glance at the position of the surgery of the brain.

Some few years ago this was a part of the body for- bidden to the surgeon's knife, owing chiefly to defectiw~ knowledge of its functions, and I may say to almost total ignorance of cerebral loealisation. Thanks to the inde- fatigable industry and perseverance of Ferrier, MacEwen, tlorsley, and many others, this ignorance has been re- placed by a fairly accurate knowledge of function and

340 Modern Progress in Surgery.

localisation, with the result that the surgeon now no longer hesitates to open the cranium and explore its con- tents.

Sdrgical affections, such as tumours and abscess, are now early recognised, accurately localised, and promptly treated with almost the same precision and accuracy as ~umours or abscesses in any other part of the body, and that, too, with a large measure of success.

Nor are tumours or abscesses the only conditions for which the cranial cavity is explored, for it is fair ly com- mon to see the operation of trephining performed for injury caus;ng fracture and hmmorrhage, leading to compression of the brain a condition almost certainly fatal if left untreated.

Epilepsy, that dreaded condition, especially when due t~ injury, may also be radically dealt with by operation.

To such an extent have the risks of operation diminished that exploration of the cranial cavity in doubt- ful cases, rather than leave tke patient to certain death, is not only suggested, but actually practised with excel- lent results by surgeons both at home and abroad.

Many brilliant results have been achieved by operative interference in cases of gunshot wounds of the skull o a the battle-fields in South Africa.

You may have heard some years ago that craniectomy was the procedure recommended and practised for micro- cephalic idiocy, but rightly this operation had only short existence. In these cases the whole central nervous system is developmentally defective, and no operation of taking out slices of the bones of the skull could possiSly remedy that defect.

There seems to me to be but one condition left in con- nection with the brain, which may in the distant future, when its pathology is known, become amenable to sur- gical interference. I allude to insanity.

Here I may mention tkat although the results of injuries to the spinal canal and its contents are not benefited to the same extent by operative interference, still surgery can point with pardonable pride to brilliant achievements in some cases of fracture-dislocation, and

By ME. WILLIh)i TAYLOR. 341

tumours causing pressure on the spinal cord--aye, and even in some cases of Port's caries.

Let us now pass to the thoracic cavity. I t is not so many years since the radical treatment'

of empyema became thoroughly established, and to KSnig must be given a good deal of the credit for having so persistently urged the necessity of resection of a portion of a rib as an essential part of every radica~ operation for empyema.

If pus is present in the pleural cavity to any exten~, unless operation is undertaken it can be recovered from only by spontaneously bursting externally or into a bronchial tube, and then expectorated--a by no means savoury way of draining a pus sac. In very old-standing cases the procedure required is the formidable one of resection of the entire bony wall of the chest.

The proposal has been made, and actually carried ou~ in a few cases, to resect the affected apex of the lung in some cases of that disease, which is at present engaging the attention of not only the whole medical scientific world, but the public at large--viz., phthisis. Such a surgical procedure seems to me unwarrantable from the results. Cavities in the lung in phthisis and bronchi- ectasis have been opened and drained with some measure of success in the latter condition.

Abscess of the lung and gangrene of a localised nature have been successfully dealt with by surgery.

The pericardium is frequently opened now for the drainage of purulent effusions, which in former days were left untreated to terminate in all cases fatally.

The present position of surgery in these cases, so far as I can gather from the literature of.the subject, is t h i s : - Out of 51 cases operated upon for purulent pericardial effusion 20 recovered--that is 39"2 per cent. of cures.

Nor does surgery stop with the sac in which the heart lies, for on no less than six occasions the heart i tself has been sutured for wounds in man, two of which terminated successfully. Rehn sutured a wound six-tenths of an inch in the right ventricle with three silk sutures, while Parozani sutured a wound eight-tenths of an inch at the

342 ~]lodern Progress in Surgery

apex with four sutures. These werd the two recoveries. Giordani, another surgeon, sutured a wound eight-tenths of an inch in the left. auricle with four sutures, and found the wound in the process of cicatrization at the autopsy, death having resulted on the 19th day from empyema.

Surely these results of surgical interference in connec- tion with the heart and the serous sac in which it lie~ must be looked upon as brilliant.

I t is, however, to the abdomen we must turn for tho greatest advances of all in surgery within recent years. No region of the abdomen, no viscus therein, can b~ claimed as exempt from operative interference.

The stomach has been not only opened for the removal of foreign bodies, to supply nutrition in cases of cesopha- gem sienosis, or to remedy the various other conditions of a surgical nature that are amenable to interference through direct incision of the stomach, but also partially resected, and that with considerable success, too, for the relief of gastric cancer, l~ay, more, for that same fel! disease, when more extensive, the entire stomach has been successfully removed.

The first case of complete gastrectomy was successfully accomplished in September, 1897, by Carl Schlatter, of Ziirich. Connor, of Cincinnati, effected the complete removal as long ago as 1883, but the operation was promptly hushed up on account of the death of the patient, and it is only since Schlatter's success that other s.imilar operations Ix.ave been performed. As yet the number of cases in which the operation of complete gas- trectomy was performed is too small (only 12) from which to draw any deduction. Gastric ulcer, with all its com- plications and sequelee, has within recent years become an important source of surgical interference.

Operation has now been proposed, and has on many occasions been successfully performed, for copious and repeated h~emorrhages from the ulcer.

Operative procedures are now of frequent, one might almost say of daily, occurrence for others of its complica- tions and sequelze, such as the loosening of adhesions (gas- trolysis), or for the relief of pyloric stenosis (pyloroplasty,

By MR. WILLIAI~I TAYLOR. •43

,,r gastro-jejunostomy), for hour-glass contraction (gastro- plasty or gastro-gastrostomy), while gastro-enterostomy is frequently performed for the cure of chronic ulcers that resist other lines of treatment. Perforation, too, has been treated, and with great success--the only essential to success in this latter condition being early diagnosis and rapidity of operation, provided, of course, the surgeon be one experienced in abdominal surgery. Formerly almost all cases of perforation ended fatally, while now, by timely operation, 70 per cent. at least shoulld be saved. In fact, Keen gives a mortality of only 16"6 per cent. when operation is performed within 12 hours, while for opera- tions performed between 12 and 24 hours subsequent to perforation the mortality is more than doubled.

Perforation of the intestine in typhoid fever, formerly looked upon as absolutely hopeless, now shows from 25 per cent. to 33 per cent. of recoveries after timely operative interference. Indeed, in Professor Osler's clinic during the past three years out of 11 cases operated upon five were saved--a percentage of recoveries of 45"4. This re- sult is attributed to the early stage at which the operation was (lone. The only contra-indication to operative inter- ference in these cases is extreme collapse.

Resection of the intestine for injury, tumour, disease or gangrene is of almost daily occurrence.

A few years ago the infant mortality from acute intus- susception was something appalling. ~*ow, in my opinion, there is nothing more successful than the treatment of this condition by laparotomy, provided, of course, the ease be seen early and operated upon by a skilled surgeon before the infant is exhausted from pain and vomiting or poisoned by septic absorption from the intestines, and before adhesions have formed.

Operations for appendicitis have become, I might almost say, a fashionable craze. Still I am of the opinion that the earlier we operate for this very common condi- tion the less the risk and the fewer patients will die from general septic peritonitis. There ~s one condition in cou- nection with the alimentary tract that still shows an appalling mortality. I allude to acute intestinal obstrl~c-

344 Moderu Progress in Smyery.

tion. This seems to me to be due to the pernicious habit of meddlesome medication and delay until the patient is poisoned by the absorption of septic matter from his intestines, and thus rendered incapable of withstanding any operation.

The sooner physicians and surgeons recognise tha~ purgation and delay mean death, and that the only hope of recovery lies in early operation, the sooner this mor- tality will diminish.

The kidney has frequently been successfully removed, and many of you have often seen this organ the subject of operations for the removal of calculi, &c. ; but at the present time conservatism comes into sway and portions only are excised in certain conditions, for which a few years ago the whole organ would have been sacrificed.

Recently Mr. Reginald Harrison has been advocating the exposure through the loin and incision of the kidney for the relief of increased renal tension and vascularity. In other words, he advocates operation, and shows from his own practical experience very good results therefrom in certain cases of Bright's disease arising from scarlatina and cold.

The gall bladder has likewise been the subject of great surgical achievements in recent years- - the pioneer in this respect being Mr. Mayo Robson, of Leeds.

Operations on the liver for hydatids and abscess were of common occurrence, but during the past decade it has been attacked and large portions removed for simple tumours, for cancer extending from the gall bladder, as well as in a few cases of primary malignant growth when of a localised nature and early recognised.

In rupture from injury prompt operative action has diminished the rate of mortality from 85 per cent. to 55 per cent. In gunshot wounds the mortality has been re- duced from 45 per cent. to 30 per cent., and in stab wounds from 36 per cent. to 25 per cent.

In this connection I should mention that surgery is now invoked by the physician in cases of ascites due to cirrhosis of the liver rapidly recurring in spite of treatment, the object being that of promoting adhesions

By MR. WILLIAM TAYLOR. 345

between the omentum and abdominal wall and between the upper surface of the liver and abdominal wall, and thus forming a new collateral circulation.

The spleen, too, has been anchored in its proper place in case of great mobility, while its conservative surgery in case of injury is now pretty well established, and many cases of complete removal with success have been re- corded.

Nor has the surgery of the limbs been neglected while these advances were being made in connection with the body cavities.

Conservatism has largely replaced amputation. Antiseptic and aseptic surgery have frequently

succeeded in dealing successfully with complications that hitherto were considered ample to justify a mutilating operation such as an amputation is.

All other things being equal, the surgeon who has the lowest amputation statistics is the one who is most useful and successful.

He who can save a limb is deserving of more cred.fi than the man who can remove it by a brilliant operation, performed with lightning rapidity.

Time prevents me entering more fully into the achieve- ments of surgery of the present day, but what I have men- tioned will suffice, I hope, to rouse your enthusiasm in con- nection with the work of the profession into which you have elected to enter.

The study of medicine has been divided into two divi- s ions - the first relating to practical usefulness, the second the scientific part.

The former is that which you will chiefly learn amt study within these walls, while it is upon this part of your profession most of you will have to depend for the where- withal upon which to subsist.

The second furnishes you with the desire for investigat- ing new phenomena, and establishing on a scientific basis such phenomena as are not already so founded.

Surely in either of these you will have sufficient motive to work.

Do not imagine from what I have said of the great ad-

346 Moder~, Progress in Surger#.

vances of surgery during the past few years that finality has been reached.

Let me mention to you one subject in which the public are intensely interested, and one which we see more of now than formerly--this increase may be only apparent owing to more accurate diagnosis--a subject the cause of which, in spite of all the observation and investigation which have been expended upon it, is still obscure, and consequently the treatment of which, until the cause is definitely settled, cannot be placed on a more scientific basis than with our present knowledge it already rests upon. The malady to which I allude is cancer--a word that conveys tremendous significance to the public--a word that generally heralds to the unhappy sufferer his death knell, an extensive and often a dangerous operation alone giving him or her a small hope of recovery without recurrence, and that only when the operation is per- formed at the earliest stage of the disease, iNo sphere of life is exempt from the ravages of this malady. I t is no respecter of persons, from a ruler to his humblest subject. For him who places the causative factor beyond dispute, and establishes a cure, which it is quite possible may be accomplished by other means than the use of the knife, I may safely predict a place amongst the greatest dis- coverers and benefactors of mankind the world has ever known. Scientific fame, social distinctions, and wealth will all be heaped upon him.

To acquire a practical knowledge of your profession a fair knowledge of anatomy and physiology with their ancillary subjects will be necessary. Then, and then only, will you be in a position to study injuries and diseases and their immediate and remote results as ex- emplified in this aml kindred institutions.

From the moment you enter the wards or dispensary train your eyes, ears, and fingers---three of your five gateways of knowledge. You must then learn to draw de- duetions from the information thus acquired, founding these deductions on your anatomical and physiological knowledge, and thus make your diagnosis. This ability to make a correct diagnosis is the essential difference be-

By MR WILLIAM TAYLOa. 347

tween an accomplished physician o1' surgeon and a quack, consequently, unless you can learn to make correct, diagnoses, your treatment must be mainly quackery.

After this follows the prognosis, to make which with anything approaching accuracy can be done only by knowing the different courses the disease may take, by experience acquired by previous accurate observation o f similar cases, and by a careful study of the constitution of your patient.

In an introductory address, delivered here in 1887 by the late Dr. Ar thur Wynne Foot, he took as his text on that occasion the three words--" Industry, Energy, and Perseverance." Any one of these he advised his hearers to take and make it mentally his watchword and it would prove an amulet or talisman against idleness, waste of time, slothfulness, and all the snares and toils which beset students, and perhaps more especially a student of medi- cine.

Lord Lytton has well said: " A man will always be eminent according to the vigilance with which he ob- serves and the acuteness with which he inquires.'~ " To,

this," he says, " must be added perseverance." " I am no believer in genius without labour, but I do believe," he says, " that labour judiciously and continuously applied becomes genius in itself."

Dr. Arnold has said the difference between one boy and another was not so much in talent as in energy. " Perseverance is energy."

Perseverance then you will find, if you look around and inquire, is the characteristic of all those great men whc~ have attained eminence, whether as statesmen, mili tary or naval, professional or mercantile. Ask Lord Roberts to what he attributes his success as our greatest mil i tary general, and he will tell you it is to a " tireless attention to minutise, the undismayed pursuit and study of an ide~ and all its developments." Ask Lord Lis te r~one of the greatest benefactors of the race that ever l ived--to what he attributes his success in the discovery of antiseptics-- a discovery that has so revolutionised surgery, and saved countless lives all over the world --and he will tell you it

348 ~]+[oderu Progress in Surgerg.

is to perseverance. What was said by Lord Lytton well nigh half a century ago is no less true to-day.

Dr. Foot, in the address already alluded to, said : - - " There is no funeral so sad to follow as the funeral of our own youth, which we have been pampering on seli~sh or ignoble aims to the neglect of good and wholesome food."

Study then, I implore of you, while yet you have time and opportunity, for every hour and every day you spenc~ in idleness will rise up and confront you with a demand for payment from you of ceaseless yet unavailing regrets.

T r y and fill your minds with information which will enable you, when necessity and emergencies demand it, to deal effectively and scientifically with the problem before you--a problem which in many cases brooks of nO delay, for it is that of life or death. What , then, will ba the penalty of your mistakes or ignorance? For those who trusted their beloved ones to you it will be broken hearts and. empty homes. For you a ruined career.

"'Tis now the summer of your youth." Youth, it is well said, is the period by far the best fitted.

to the improvement of the mind. Then everything is clothed with a freshness and curiosity which time will ~oon efface.

=~-t this time, too, it is well known memories have a tenacity to an extent surprising to those but a few years older. Then you have but few cares, save those of a~ examination at the end of your session's work, to rise up and trouble you. Few sleepless nights are spent in anxious though~ for the morrow, for the result of desperate case, or in planning out a serious, and it may be a dangerous, operation for the cure of some deadly malady.

At present you view from a pedestal of comfort the deep- ening lines of anxious thought on the faces of those em~ barked upon the tempestuous sea of practice. In a few short years you, too, will be plunged into that whirlpool, it may be to look back with regret to the days that, alas, will then be gone far beyond recalling.

I warn you the fault will be yours if you emerge from

By MR. WILLIAM TAYLOR. 349

this place feeling tha t there are things which you might , nay, which you would have done differently, if you only had another opportunity.

" For of all sad words of tongue and pen, The saddest are these, ' I t might have been.''

Do not imagine tha t when you have passed the exami- nations necessary to have your name placed on the regis- ter all your s tudy is over. Fa r from it. Your whole l i f e - - and it ought to be a source of great gratification to you to know i t - -wi l l be one long studentship. The old Grecian aphorism " ~ $~ i c a [ p o ~ @ ~ , " " opportunity is fleeting," is worth remembering. Opportunity, i t is said, domes to everyone, but few are prepared to seize it ere it passes. Some of you, I m a y be permitted to hope, possess abilities, as yet ly ing dormant but equal to any emergencies or discoveries which may ul t imate ly make life pleasanter, soothe pain, or cut short sickness and disease, if only aroused and infused with energy.

You may now asl~ me what is to be the ul t imate end a~d reward you are to obtain for all your trouble ? Never has there been such a dearth of young medical men. Whi le the Census shows a steady increase in the popula- tion, the Medical Register shows a steady decrease in the numbers seeking to have their names placed thereon. Never have there been such fine openings for those jus t qualified or about to qualify as at present exis t--openings which will br ing in a qu2cker return for the outlay than in any other profession; but for you there are u l t imate ly no great prizes to which I can point as a st imulus to your energy such as lie await ing abil i ty and perseverance for those practising at the Bar. For you there is no " Bench," with its handsome income and nice pension to soothe the recipient 's old age and " make his path to the ~ m b less gloomy." The medical man must die in harness.

True it is, some dmass fortunes, but these are few in- deed. The reward of man is not always proportionate to his merit. Many a scientific man makes but a mere p i t t ance- - scarcely sufficient to keep body and soul together- -whi le many a quack amasses a fortune.

:350 Modern Progress in S~,rgery.

An easy conscience is often t ru ly the scientific man's sole reward.

" In the lexicon of youth, which Fate reserves For a bright manhood, there is no such word As fail."

"YOU may fail to acquire wealth, bu t you cannot fail to acquire proficiency in your profession if you persevere.

Many of you, and often those of you who seek af ter and acquire the greatest degree of proficiency in your pro- fession, will meet with disappointments. Do not be dis- couraged. Pa t ience is necessary in this as in every

o t h e r walk in life. I t is said the suicide of ambit ion is

the refusal to wait. But r e m e m b e r -

"When Fortune means to men most good She looks upon them with a threatening eye."

Le t me ment ion the fields tha t are open to y o u : - The Ind ian Medical Service. The Royal A r m y Medical Service. The Naval Medical Service. Poor Law Medical Appointments . Assistancies in Engand. Fore ign Government Services. Pr iva te pract ice at home or abroad, and, hardest of all,

pr ivate teaching. A Royal Commission has sat, and made impor tant

alterations and improvements in the Royal A rm y Medical Service, so that the authori t ies should no longer find any difficulty in obtaining the requisi te number of well-trained medical men.

Similar changes, I am in a position to say, are likely soon to be made in the sister service. As regards Po~r Law Medical Appointments , these are to my mind the worst paid appointments and their officers the hardest worked in the world, while the manner of election is s imply in- iqu i tous- - the qualifications mainly considered are those of religion, politics, and the school in which the candidates received their education ra ther than proficiency in the i r profession, while I am informed that even br ibery is not unknown.

g v ~R . WILLIAM TAYLOR. 351

Beneath the rough coat. and blunt exter ior of tile coun t ry pract i t ioner , said Sir Wa l t e r Scott, you will o~ten find professional skill, entlmsh~sm, intell igence,

humani ty , courage, and science. True it is, aml no ()lie. will deny that the poor in the count ry require skill and knowledge as much as those in our large cities, but until' the method of election of poor law me<lical officers is simply that of competi t ive examinat ion, and unti l the salaries are raised from the mere pi t tance they are il~ most cases (many men pay thei r coachmen as much a:l these officers get), we can scarcely expect first-class men to become candidates for such appointments. I t may be said thei r salaries are supplemented by the private pra('- rice of the districts in whitql they work; true, but what private practice, may I ask, is a man likely to get in the Isles of Ar ran or in Achi l l?

In asking you to make use of energy and perseveran<'c in the study of your profession we ~annot (lo so wi thout leading you to expect something from us in retm'n. The student is no bad critic. ;[{is opinions may be often hast i ly formed an<l perhaps forcibly expressed, but they a~re general ly correct, l i e will not be slow t,) rccognis(, the abilities of his teacher, who mnst not be a man ()~ .one book, or of antiquate<l ideas. "" @t i ~+oJ+ pp.oficit </c- f ic i t ." He who does not advance goes backward. Y, nl:' teacher must ever keep reading and learning. En thu- siasm begets enthusiasm, and st) a teacher influences fro. good or the reverse each member of his class.

I t now only remains for me to conclude by thankinp,~ you for your indulgence and by ('ommen<ling to you th(: last words of the il lustrious Yelpeau, who, when Death was already seizing him in his icy grasp, fal tered t(~ :~ fai thful fr iend beside him Traca i l lom; to~@~llrs."