THE DUBLIN JOURIkTA.L OF

M E D I C A L S C I E N C E .

D E C E M B E R 1, 1892.

PART I.

O R I G I N A L C O M M U N I C A T I O N S .

ART. XXI.--The Surgery of To-day." By EDWARD HAMILTON, M.D. ; President of the Royal College of Surgeons in ireland.

IT is one of the privileges of the office which I have the honour to hold to address a few words to you by way of introduction to the business of our session. My remarks shall be very brief. I have read over the list of papers set down for this meeting's considera- tion, and I find that they are full of surgical interest ; so that your time will be much more profitably spent in discussing them than in listening to empty generalities, or the crambe repetita of a formal address. We must be up and doing We must gird ourselves for our work ; for it is a self-evident proposition that scientific minds, whatever their pursuit may be, must from the nature of their surroundings be ever in a state of unrest. There is a constant yearning after finality in every department of knowledge--finality which, phantom-like, eludes our grasp and tempts us onward in search of the unknown.

Our special work is no exception. Surgery cannot stand still-- there are too many fresh and busy minds coming to the front; too many inventive faculties are straining every nerve to swell the impetuous overwhelming tide of progress.

�9 Being the Presidential Address delivered at the opening meeting of the Section of Surgery in the Royal Academy of Medicine in Ireland, on Friday, November 11, 1892.

VOL. XCIV. - -NO. 25~, THIRD SERIES. 2 H

466 The Surgery of To-day.

Having witnessed the changes which surgery, has undergone through a long vista of years, I can remember that at hospital on dispensary days four or five patients sat on a long form, each with a tin dish provided with four cups to measure the blood according to the surgeon's prescription, in which not only the quantity of blood was indicated, but also the mode in which it should be drawn. I have often witnessed in a strong, healthy labouring man, struck down with acute pleurisy--bent in two with stitches, shallow breathing, high fever--the instant relief given by the escape of four or five ounces of blood. Seldom was any other treatment resorted to or required.

How can we explain the wonderful difference between this and the practice of to-day ? I t must be something more than caprice or mere fashion. How is it that plans of treatment so diametrically opposite appear to be followed by the same results ? Treatment by the lancet is a matter of history. From that we have plunged into the stimulant treatment so strongly advocated by Todd, and now a reaction has set in against that also. We may ask ourselves has the type of disease undergone a remarkable change, or has the constitution of the human frame become altered by environment, by the influences of civilisation, and devitalising effect of our social system.

The surgery of to-day seems elevated on a tripod of three solid and enduring fee tRthey are, anmsthetics, antiseptics, and experi- mental research.

I t would be presumption on my part, and waste of your time to address an audience like this on the subject of anmsthetics. Com- mission after Commission have exhausted discussion on the merits of different materials and the least dangerous mode of administra- tion, so that it remains for the individual to make his own selection. My own conviction is decidedly in favour of ether for adults and chloroform for children.

But I can recall the morning I first saw ether administered. I t was by my respected teacher, the late Professor Bevan, for an amputation at Mercer's Hospital. I can easily recall the intense interest with which we watched with bated breath the different stages of anmsthesia as they were developed until unconsciousness and immunity from pain were produced.

The calm and unruffled progress of the operation to its comple- tion, the removal of the patient still sleeping to his bed, the gradual rettu'n of mental activity, the joy of the sufferer when told

By D~. EDWARD HA~IILTON. 467

that his limb had been safely removed and his wound dressed-- What a contrast to the shrieks and struggles, the hurry to get the operation over and send the poor victim to his bed while a spark of life yet remained ! What have I seen since then ?

The impetus which the use of antiseptics has given to surgery is self-evident, more especially the boldness with which the cavities of the human body are opened, the contents exposed and dealt with as circumstances demand, and all this with almost perfect immunity from inflammation or other dangers so long the bugbear of operations of this kind. And yet the ground is not so sure ; there are even now some sceptics. There is much in the theory and practice which is difficult to understand. The wavering faith in special antiseptic materials, which we were taught to regard with implicit confidence, shakes the belief in the whole system.

Fresh in my memory are the words of De Morgan, as he per- sonally urged me to wash all operation wounds with Burnett's solution, and thus, without any knowledge of the germ theory, he covered the surface with a protective film, and handed down to us a practice of inestimable value--a great help to the modern antiseptic methods.

I have seen Mr. Lister of that period apply his antiseptic putty and tin-foil in the wards of the Richmond Hospital. Since then I have seen those infant facts of science develop into the giants of to-day.

That experimental research is an important element in the advancement and certitude of surgical knowledge cannot for a moment be questioned. The substitution of actual facts for theory, the evidence of our senses for the mists of imagination--how many errors have been corrected, what a flood of light has been thrown upon the mysteries of nature, by the study of her actual working illuminated by an intelligent mind l

We need no further proof of the value of this mode of research than the recent advances which have been made in the surgery of the brain. Where all was dim conjecture and uncertainty we now require only the simple exercise of reason. Symptoms read by this light now express in the plainest manner the actual area of the brain which is affected, and the surgeon, no longer poking in the dark, can now plan the steps of his operation with mathen, atical precision, and with confidence proceed to remove the tumour, blood, or pus which is paralysing its functions.

And perhaps here we may feel that w e have not done as much

468 Tile Surgery of To-day.

as we could have wished in this important and attractive field of work ; but there are sumcient reasons why this has been so. Work of this kind demands much self-sacrifice, much expenditure of time and, to put it plainly, of money--and in Ireland we have not these fiscal endowments which make it worth a young man's while to forego more lucrative work and devote himself to abstract science. I t is an unpleasant fact that scientific chivalry does not pay in Dublin. We muse not repine, however, but we must make the best use of such means as we possess. I am proud to say that we have now amongst us a band of young and devoted workers full of ardour and enthusiasm in this direction, willing to toil for the sake of the brilliant results which are sure to follow, and I have no doubt they will elevate the prestige of the Irish school of surgery by advanced and independent rcsearch.

All honour to those who by patient thought, by careful experi- ment, and the truthful record of actual facts, have given to anatomy a higher value, and raised it above physical drudgery and the mere mechanical exercise of the memory. Anatomy as applied to the investigation of function has made much progress and is well worth a careful and patient study, as the only structure on which sound physiology can rest. I t is the fashion now to disparage the study of anatomy and to regard the time spent in its pursuit as wasted--that it does not help us in actual practice, and is soon forgotten--hence the tendency to cut it out more and more from our curricula. The development of new subjects has fostered this idea. But we must not forget the training which anatomy gives to the mind, and the fact that surgery is so easily grafted on to it. Another cause has retarded the advance of experimental research, the irritating and vexatious requirements of the Cruelty to Animals Act, with its license of place and person, and its six varieties of red tape certificates. This so-called amended Act stands on the statute book of the British Constitution an insult to an educated and refined profession, branding its members as wretches who take a vulgar delight in torture, and require to be licensed like cabmen or the sellers of beer--a millstone about the neck of those who would work by the only method of any real value--the demonstration of physiological fact by observation made on the living animal--driving them to study in other countries more liberal and enlightened in their views of what science demands

This question of experimental research has come very much to

By DR. EDWARD HAMILTON. 469

the front in the present day, and has been attacked with much rancour and overheated debate. Even in our own city, at the recent Tercentenary of Trinity College, Dublin, an attempt was made to assert the principle that no one engaged in this special kind of study was worthy of any academic distinction.

I t is ludicrous to read the violent invective which has taken the place of argument in this controversy. One dignitary of the (~hurch has denounced his fellow-Christians who practise this form of research as " inhuman devils," and their search after truth "abominable sin."

I t is evidence of a weak cause when they ridicule as "sport" the careful study and anxious investigation of men of science, and to find no parallel for their methods better than the harrowing agony depicted in the nine circles of Dante's Hell:

I have no hesitation in pronouncing my own opinion. I do not pledge you to it. I do not pledge this Academy to it. I do not pledge this College to it. But I fearlessly proclaim my individual opinion that if, by the opening of the chest of a living animal, the heart was seen to contract and dilate, the blood alternately leaving and returning to it, and by this observation Harvey was enabled to forge the final link in the chain of proof as to the circulation of the blood--1 say, if this fact was established by so-called vivisec- tion, it is worth all the dogs that ever howled on the face of the earth.

We must not be carried away by too roseate a view of surgical progress, or plume ourselves too much on our achievements. Facts which we cannot ignore must "give us pause."

What progress has surgery made in the treatment of cancer, tubercle, syphilis ? I venture to say simply none. As to cancer, we have, no doubt, done much towards developing its pathological history, its microscopic anatomy, its relation to normal tissues, and we have learned to differentiate varieties of the disease; but are we better able to diagnosticate or cure a malignant growth than the Cusacks, Colles, Porters, or Smiths who have lived before us? I think not. The disease is still hopelessly incurable, an oppro- brium of surgery, the happy hunting-ground of quacks and charlatans.

In our treatment we, no doubt, emphasise tile value of early operation--the importance of removing all infected glands, and we have gone a step further in the removal of all glands from the vicinity of cancer while they are yet perfectly healthy, that they

470 T]~e S,,rgery of To-day.

may not be left in the path of the lymphatics to receive contamina- tion through them. And yet, with all our care and boldness in the use of the knife, is it not a melancholy reflection how many of these cases return either locally or remotely. Our workhouse hospitals are full of such cases which have been paraded in our medical journals as cures. I t may be fairly questioned whether those growths which do not return were ever cancer at all.

What progress has modern surgery made in the treatment of tubercle ? My answer is that since the writings of Lugol it has made little or none. As in the case of cancer, we have done all that the microscope can do. We have exhausted the efforts of organic chemistry, we have demonstrated its microbe, we now remove strumous glands with greater promptitude and freedom, and thus we shorten the period of prolonged suppuration. With the aid of antiseptics we scrape tuberculous ulcers, but the diathesis which has produced them still remains to deposit fresh tubercle and invade remote parts of the body.

The time is not far distant when portions of diseased lung will be removed by surgical operation. Vomicse will be scraped or excised ; tubercle at its earliest formation will be destroyed. No doubt the difficulties to be encountered will be very great, but they are not insurmountable--viewed by the light of surgical progress. The unceasing movement of the thoracic cavity, the intense vascularity of the contained organs, must ever be a source of difficulty and danger ; but the hand of the surgeon, guided by the surgeon's mind, has achieved more than this. Whether those bold ventures will be followed by a cure of lung consumption the future alone can tell. We all know the wild excitement which seized the profession and the public, almost amounting to phrenzy, when the announcement was made that Koch had discovered a cure for this terrible scourge of humanity, which so frequently cuts away the fairest and most lovely of our sisters. The stampede to Berlin, as in sober earnest we recall the picture, was simply laughable. :No doubt, this was mainly brought about by the scientific attainments, the character for honest and truthful work of the exponent of the new departure ; but how sadly disappointing the result has been.

The treatment of syphilis has made little or no progress since Hunter proclaimed the dogma--" If there is such a thing as a specific at all, mercury is a specific for this venereal disease." Those who have widely studied the natural history of the disease must have come to the conclusion that it is a struggle between the con-

By DR. EDWARD HAMILTON. 471

stitution and a specific poison which occurs in paroxysms or waves, and that as a rule the constitution if carefully trained and nursed will triumph and expel the invader, and what shall I say of the use of mercury--that two-edged sword so powerful for good or evil. This I will say as the result of long uninterrupted obser- vation--that there are two abuses of this potent agency. There is the terrible overdosage which is now, thanks to the master- mind of Carmichael, a matter of history, and there is the timid and vacillating use of the remedy carried on for months and years, which is the fashion of the present day, leaving it off as it is about to produce good results.

How often have I seen it laid aside when a hard chancre began to soften and expand under its beneficial use. The surgeon throw- ing down the claymore, and running away from it.

This apparent extension of the ulcer, the first step in its im- provement, is too often regarded as the advent of the dreaded phagedmna which has haunted the mind of the inexperienced practitioner. We have learned the immense value of hygienic treatment--good air, good food, early hours, temperance in all things, the Turkish bath, with the blood-making property of cod- liver oil. These give the constitution a better chance.

I have no doubt whatever that the disease is fading away, and losing its intensity day by day--although we now and then meet with cases which resist all treatment; fresh symptoms arising time after time until the constitution becomes vanquished in the fatal struggle. Thus we find that there is "amply verge and room enough for work" to occupy our hands and our minds, and I trust the present session will prove that we have not retrograded, and that the spirit of the old Surgical Society of Ireland is still alive,active, and enduring.

I trust our debates will be carried on regardless of personal self- interest, with one common object--the advancement of surgery.

I cannot close this address without alluding to the loss which the Academy has sustained by the death of William Colles--a name cherished wherever the science of surgery is cultivated. Himself revered in his native city, and beloved by all his pro- fessional brethren, wise, sagacious, calm and modest in his demeanour. The Council of the College has lost a Nestor--I myself have lost a guide, philosopher, and friend.