■ '■ J, . ■ ' 1 , ',■' ' I ; 1' PROPERTY OF ^-dJ) R JACKi^l^ CA8E ANo.25t PRESIDENTIAL ADDRESS AT THK MKKTINC; OF TIIK Maritime Medical Association, HELD IX St. John, N. B., July 22nd and 23rd, 1891. 15 V WILLIAM BAYARD, M. D., Etc. » 5 / At P^vid H^ssell Oci ^ok tji ■qci PRESIDENTIAL ADDRESS Of D1{. WILLIAM BAYAKD, At the ^rEETiX({ OF THE ^LARFriME Mkdical AssocrATiox, Held ix St. Jonx, X. B., Jily 22xd axd 23rd, 189L ors of this Association. For, l)clicvo iiic, iiicotiiius of this kind tend to cnltivato tlic lu'ait as well as the head, and to jtromote a'ood will and «!;ennine hrotherhood anionu' tlieir constituent members. They also tend to promote the study of medicine. Onr mutual intercourse, criticisms, and discussions, form "at once a school and an ordeal," teachini:' us to heconje more riii'id ()l)servers of the medical i)henom- ena occurrinsi* in our }»ractice, more careful in our classifi- cation of these phenc^mena, and more }»erfect in our deduc- tions from them. J am far in the evening; of mv life, havinii- been an humble worker in onr noble [trofession for upwards of fifty years, (biring which time wonderful progress has l)een made in every department of liunian knowledge, and we can proudly assert that medicine in all its l)ranches has bountifully shared in that progress. The mechanical inven- tions of the day have conferred vast benefits upon mankind; luxuries are within the reach of the poor that were formerly unobtainable by monarclis. But these benefits and luxuries are sniall when compared with the diminution of human suffering produced by the discovery and application of " anjesthetics," and the saving of life conseipient upon the more rational methods which have prevailed, and are daily extending themselves over the whole ran w of modern medi- cine and surgery. Revolving in my mind to fint^ subject upon which to address you that will command your interest, I think I can- not do better than give a brief epitome of the advances and improvements that have taken place in the theory and prac- tice of medicine and surgery since 1837, when I received from my " alma mater " at Edinburgh, legal authority to kill or cure as best I could. With my degree in my hand, I was vain enougli to think that I was ready for any emer- gency ; but I was not long at work before I found I had much to learn, and that my real study was only then commencing. Had I rested content with w^hat I then knew, I should not Jf(/)'>'fillll' 3f(«l'cflf A ■'-'Socio f inn liave ol)tainc'o aceoniplished in the ordinary period of ii life. But he who wishes to keeji ahreast of the ever-advaneing knowledi^'e of the day, must not he idle. In 1887 the doetrines of Ih'oussais htul spent their force. The disturhiui;' influence i»roduced hy irahnenian and Brown, (hud and S[)urn-heim, liad eonie and u'one, and men turned from the dogmas of authority to close ohservation and the study of f'ictft. (\)nse(|uently a revolution has followed in the theory and treatment of many diseases. At that period the Lcuicef was in the hands of every practitioner, in daily, and T miii'ht almost say. hourlv use. To treat a case of in- tlammatorv disease without the ahstraction of hlood, would have insured censure. J hit it was not long hefore observa- tion, guided hy the vascular theory of Cohnheim, and the cellular theory of Yirchow, taught the medical world that rest, cold or hot a[)plications at certain stages of the disease, together witli aconite, opium, etc., and supporting diet should take the i)lace of the loss of the vital fluid, and with such results that hleeding is now one of the rare surgical operations, though some contend that its disuse has been carried too tar. ^filk has largely tidcen the place of stim- ulants in the treatment of fevers, and all diseases attended with febrile debilitv. Materia medica, with the aid of chemistrv and botanv, has greatly advanced. Many new remedies have been added to the Pharmacopiea, and some have properly been expunged from it. Experimental research has taught us the therapeu- tic value of many, others unjustly vaunted, have been drop- ped, not hearing the test of clinical investigation. In these days of progress there is a rage for new things, and among the rest, for iiew medicines, but we should pause before PresyhnliaJ . 1 (/t/riss. \ ! \ we accept tlie HtatciiR'nts ot cliemists regarding tlieir action, until their toxic effects have been established bv bedside ex- perience. And this experience should be carefully weii^hed. It is not sufficient to (piote a number of recoveries after the exhibition of a reined v; we also want a control list of the failures. Bacon's advice should be followed, — to " observe patiently, experiment cautiously, and i^eneralise slowly." The practitioner of the present (hxy has the means of ex- liibiting some of the most useful and powerful medicines in a concentrated form, not in the shape of large powders, nauseous tinctures, infusions, and decoctions, but in the form of alkaloids, extracts, elixirs, capsules, etc. AVe have a valu- able list of hypnotics and analgesics, some fulfilling all that is claimed for them, others not. But none of them possess the combined properties of ]>roducing sleep and relieving pain e([ual to opium and its alkaloids. But the unguarded use of them too often causes an unconquerable appetite for. or dependence upon the drug. It is true Alexander A\"ood. in 1858, gave us, by means of his Hypodermic syringe, power in a measure of controlling this baneful appetite ; still they, with all other In'pnotics, siiould be prescribed with caution. Modern research has, I may say, established the use of digitalis and strophanthus as heart tonics, the nitrite of amyl and nitro-glycerine in angina pectoris, the salicyl compounds in acute rheumatism, autipyrin and antifebrine as febrifuges. And since 1848 electricity has been much used as a thera- peutic agent. Chemical analysis has arrived at such per- fection that poisons can be detected in various parts of the body years after death from them. Pathological chemistry is daily adding to our knowledge. Through it and with the aid of the microscope, Pasteur, Tyndall and others have established the fact that living organisms are constantly float- ing in the atmosphere, and when planted in a genial soil multiply and produce fermentation and decomposition, a dis- covery which has so revolutionized our ideas of the causes of many diseases as to justify the belief that in the near Mar it 'no c Meilicol Associafhrt. 7 luture we may be al)le to combat diseaHes now classed as incurable. Inabl)age in 1H47, and perfected by Von Helmh^ltz in 1851, stands pre-eminent as having i,nven us a knowledge of the secrets of the eve. It has taught the oculist that he is not now obliged to class a num- ber of deep-seated discuses of that organ under the head of "Amaurosis," a condition where the patient saw nothing, and the doctor also nothing. Tlie microscope has vastly aided experimental research. Through it Virchow worked out the celhdar pathologv. The germ theorv of disease owes its existence to it and clien)istry. The })loo(l and almost all of the tissues, secretions and structures of the i)(»dv are being dailv studied through it, with advantage. Indeed, that instrument has become as necessarv to the liraetitioner of the present day as was the lancet in my early 'ovcrn its exhihition ? There are various anjcsthetics in use, chloroform, ether, methylene hichloride, A. ('. K. mixture, ethyl hromide, and nitrous oxide. The first four may he selected for prolonged operations, the last two for hrief ones. Before maUiuii; a selection F may say a word ahout the comiuirative mortality from chloroform and ether, the two atiiesthetics in common use. A recent report to the j^overnment in Paris gives the mortality from chloroform as 1 in 1,280, and that from ether as 1 in 13,581. Dnrinij: the last three vears 41 deaths have heen reported in England from chloroform, and 3 from ether. Surgeon-major Lawrie informs us that he has given ('hlorof(5rm 40,000 times in India without a death from it. The climate must influence the mortality, or he is a very fortunate man. It has been contended with much force that chloroform should be given to children, to aged people, to alcoholics, to excessively obese persons, and in o[>erations where the actual cautery is employed. In all other oper- ations I think it decidedly safer to make use of ether. Knowing tliat deaths may take place during the exhibition of any ansesthetic, the ana'sthetist cannot be too careful, }ils finrjer shoxld he ercr on the pnlse and his eye on the Inrafhinfj. Neglect of this precaution has doubtless caused many deaths. The moment he detects heart failure he should remove the ansesthetic, — should the breathing fail do the same, draw out the tongue and resort to artificial respiration. Every- 10 Pirsidcittial A fh/irss. thing uboiit the patient should be loose, he should lie in a horizontal position, and i)reteral>ly on his back, and his stomach should contain little or no food. On no accounf shoifhl h' he alhrccd to in/xflc the (/rn(/ irliilc striff/f/Hng. If forced upon him when taking a deep inspiration, he may receive into the lungs a poisonous dose. I wish to emphasize this precept. Tliough this precept has been recently combatted by ])r. Xirk, of Glasgow, who declares that the anu'sthetist should use the druic freely, and contrary to the general belief, he accepts pallor as an indication for more chloroform. And the operating surgeon should never administer the ansesthetic ; he cannot watch its effects and do his work. Wlien JIii)pocrates recommended that wounds should be dressed witli water having been previously boiled, he fore- shadowed the antiseptic treatment. But it must be acknow- ledged that the " ge^-m theory " of disease gave rise to the brilliant experiments and teachings of Sir Joseph Lister, which have so revolutionized the treatment of wounds. For however much his theory and the details of his system may be disputed, it must be acknowledged that the mortality from wounds has been vastly lessened as a result of his teaching. Believing that [)utrefaction in wounds is caused l)y the germs that are constantly floating in the atmo5j)here, he devised a system to exclude the access of air from them, to drain them, and to disinfect everything that can come in contact with them. AVhile his antiseptic theory dominates surgical practice the world over, and the great necessity for thorough cleanliness, sterilization of hands, instruments, tield of operation and dressings, is universally recognized, there exists a wide difference of opinion as to the means of sterilization. The a}>proyed antiseptic of to-day may be superseded to-morrow. Sir Joseph has recently given us a new one, in the double cyanide of mercury and zinc incor- porated with starch. Every surgeon of experience must luive seen wounds heal by what is called the " first intention," prior to the 3L(r(futic Mcilii-nl A-^soriatiott. 11 introduction of the antiseptic treatment of them. I can call to mind instances after amputation of the thiirh, excision of the hreast, and the operation for strangulated hernia, in which not a drop of pus was seen. Xor is it contended that niicrohes have not heen found in wounds under antiseptic dressing, but this is largely the exception to the rule. The germ theory of disease inaugurated by Pasteur, Tyndul and Carnot, and made practically applicable to the therapeutic treatment of disease by Pasteur, Lister, Koch, and others, Justifies the belief, that in the near future brilliant results will be achieved. It has been contended, and 1 think justly, that many diseases are caused by certain bacilli. AVhile the microbe of rabies has not been discovered, Pasteur, working u|>on that line, "by the inoculation of attenuated virus of the rabies," has, it is claimed, reduced the mortality of that dread disease from 15 per cent, to 1.3(] per cent. Koch, the discoverer of the tubercle-l)acillus of consump- tion, and the comma-bacillus of cholera, working upon the line of Pasteur, has recently startled the world with his " rciiieily for tuhcrcHlons (fiscascs," which consists of " c *, as to sorelv tax one's credulitv. But from authentic sources we have the sttitement that be- tween 3 and 6 hours after its introduction under the skin, the following symptoms appear, — pain in the limbs, nausea, exhaustion, inclination to cough, followed by ague, vomit- ing, rapid and difficult breathing, increased frecpienc}- of ]»ulse, and rise of temperature, — these symptoms last about 12 hours, followed l)y more or less lassitude for a few days. It is asserted that this reaction is sometimes so great in tuberculous individuals as to cause death. But when intro- duced under the skin of one having no tuberculous bacilli, little or no reaction follows. Hence if this statement should 12 Presidcntitd A(lrove correct, wo iniiy hope tliat it will aid in i'oniiing oui- (liaijiiosis in the earlv stafhiic Jlc/licfil Assoc'iiillou. 13 craiiium and remove tumours, matter anid extravasated blood. He also taps the mastoid cells for the removal of matter. The same mav be said reu'ardino* diseases and in- juries of the spinal column. The successful o[»erations of Macewen, Ilorsley, Godlee, etc., are examples encouraging us to follow in their line. Ophthalmology has largely ad- vanced. ^Vith the aid of cocaine and im}»roved instruments the various operations upon the eye are more easily and more successfullv performed. Cominij: to the throat we have intubation of the (osophagus and intubation of the larynx. as a substitute for tracheotomv and (i'soi)ha<2:ot()mv. The larvnx has been successfullv removed. Many cases of tuber- culosis of the larynx have been cured by the ap[>lication of lactivi acid and curetting. Xew and improved trachcotomcs have much assisted the surgeon in the operation of tracheo- tomy. The advance in thoracic snr2:erv has l)een remarkable. The aspirator has enabled us to remove fluids from the pleural cavity and even to invade the " citadel of life " by penetrating the pericardium with its needle. Portions of necrossed ribs, sternum and luno; have been successfullv re- moved, the surgeon irrigating the cavity of the pleura with antiseptic solutions. When we turn to the surgery of the abdomen, it is there that the greatest success has followed the knife of the mod- ern surgeon. It is true that McDowall, in 1809, opened the road to ovariotomy, having operated up to 1830, 13 times with a mortality of 7. But he had few followers until Sir Spencer Wells, in 1858, commenced his series of cases, having' up to 1884 performed the operation 1,000 times, with 231 deaths. It is now practiced in every civilized country in the world, yielding about 75 per cent, of recoveries, instead of a* mortality of 50 per cent, as formerly. The surgeon no longer dreads the effect of his knife upon that delicate mem- brane, the peritoneum. Indeed he attacks every viscus in the abdomen with it. He opens the gall-bladder for the 14 Premkv tkd Adtlrcs.^. removal of calculi, and even extirpates that organ. Portions of the liver have been successfully removed. lie does not hesitate to open the stomach for digital divulsion of the cardiac, or pyloric orifices, for the removal of foreign bodies, to cut open the pylorus for cicatricial stenosis of that pass- age ; or with the aid of Senn's decalcified approximation bone plates, he creates an artificial connecting canal betv een the jejunum and the stomach. lie has successfully removed 22 inches of the colon. He does not hesitate to resort to the knife for the removal of matter within the cavitv of the j)eritoneum. The kidne}' ar.d the spleen have been success- fully removed. The radical cure for hernia is one of the modern operations. (lunshot wounds, penetrating the viscera of the abdomen, yielded a mortality of 85 per cent., until it was reduced by earh' laparotomy to 25 per cent. Lithotritv was a novelty in mv earlv day, ])ut Sir H. Thompson, by removing the calculus at one sitting, with the aid of Bigelow's aspirator, has established it as the operation for all stones of less weia:lit than two ounces. He has also revived the " supra-pubic " operation for large calculi and for the removal of vesical tumours. L^terine surij-ery has kept pace with the rest. The surgeon does not hesitate, should the existing disease demand it, to remove the womb with its appendages. The ovaries, I fear, too often come under his knife, lie has the advantage of improved sup- ports for the various displacements of the uterus. The oper- ation for " vesico-vaginal fistula " should be named as a modern imi)rovement, and the galvano-caustic battery has been brought to his aid. While portions of the nerves had been removed for the relief of neuralgia, nerve-stretching, nerve-grafting and suturing their ends wdien they have been divided, had not been done in my early day. Also skin- grafting and tendon suturing. Formerly the tourniquet was the instrument used for arresting hemorrhage during amputations. As a con- sequence the blood contained in the removed limb was lost. Jlaritiiiw Medical ^is.soc' ftinn. 15 Ksniiircli's l)loo(ll(.'s3 method is now Lcoiiorariy adopted, though it is contondod that it causes sk)ug]iing of the fiaps and secondary hemorrhage, hy unnaturally augmenting the blood in the body. Simpson's acupressure needle has not accomplished that which was claimed for it. Hot water has taken the place of cold as a hicmostatic. The drainage tul)e is another improvement. Sayre's ])laster jackets and the various mec'hanical appliances devised by him and others for the sui)port of the diseased spinal column are well wortliy of mention. Orthopcedic surgery has made great strides. The excision of Joints, especially tliat of the hip — so popu- larized by Sayre — as a substitute for that formidable and fatal operation, the removal of the entire limb, with its mortality of (10 per cent., while that of the removal of the joint and leaving a tolerably useful liml), is about 20 per cent,, and the subcutaneous divisions of tendons is worthy of mention. And now, gentlemen, it may be asked, what has this proi^ress in medicine and surgery done towards lesseninu- the general mortality ? for it will not be disputed, that upon the saying of life and human suffering, depends the yalue of our work. The mortality in England has steadily de- creased since 1841 ; it now stands between 21 and 22 per 1,000. In some towns, as for example, in Hastings in Eng- land, it has recently been quoted as low as 11 per 1,000. The death rate in the army in England is only two-fifths of what it was before the Crimean war; in India one-third, and in the West Indies one-tenth. The span of individual life for women in 1854 ^vas 41*9; for males 39*9. Xow it is for women 45-8, and for men 41"9. This is largely due to the various sanitary laws that have been enacted since that period, and to the better observance of those hiw's. While the enforcement of them at first caused more or less friction, communities are being educated to the fact that it is more costly to provide for sickness than to prevent it. But when we give credit to the observance of sanitary laws, we must 16 Pri'sif/cHfiff/ . \t/'/l'('S.9. bear in mind that tliosc law8 onumated tVoni tin* workers in the medical professnio!). And when we investii;"ate fnrther, we find tliat the laws wonld be a dead letter npon the statute book, were it not for the gratnitons support given by that body, therefore we are Justified in arriving at the eonelnsion that to them l)elong nearlv all the credit. Let me remind you of " ovarian (h'opsy," a disease which runs its fatal course in a verv hugv miijoritv of cases, with- out operation, in from '1 to 5 years. IFero we have an ex- am[>le of the triumph of modern operative surgery, now 75 per cent, are saved, and it has been com})uted that in Great Britain and the United Stifles alone, ovariotomy lias, within the last 30 years, directly contributed more that 30,000 years of active life to women, all of which would have been lost, had the operation never l)een performed. Every successful operation upon the l)rain may be credited as having saved a life. Very many lives have been saved by modern thoracic and abdominal surgery, also by the excision of the hip joint instead of that fatal and formidable operation for the re- moval of the entire limb. The antiseptic treatment of wounds, with the observance of hygienic laws, have reduced the mortality from amputations, 20 per cent. The same may be said of all serious wounds. That devastating scourge, typhus fever, conse(|uent upon over-crowding, impure aif and contagion, with its mortality of 40 per cent, has been very nearly banished, since Sir "Wm. .Tenner in 1840, pointed out the difference l)etween it and typhoid fever, and the mode of guarding against it. The present death-rate from fever in England amounts to about 385 per 1,000 of all deaths, formerly it was 539. The deatli-rate of women in London from child-birth and its con- sequences, is one-third of what it was 50 years ago. Without going into further detail, I think enough has been shown to justify the claim, that to the medical pro- fession belong the credit for annihilating pain when under the surgeon's knife, for largely reducing the luortality from JlI'ii'ifntH' 31i't/i<'// A'^socKifiiiiK 17 fiuri>'ic'al oiKTations, aiul tor lessoiiiiiu' tlu' u'cnonil mortality : results, which in their effects upon the well-heini;' of man- kind, have never heen eijualled hy any body of men. Men who, contrary to their pecuniary interests, are ever found initiating' and supporting modern reforms which aim at the prevention of disease, pointing out tiie coiisequences of in- temi)erance, im})roper hygienic surroundings, and other transgressions of nature's laws, in fact, devoting their lives to the benefit of their fellow-men, and noblv irivinii' anv dis- coverv thev mav make to the world, askinu" no reward save ''Heaven's well-done"; and I would not have it otherwise. It is well that the charm of the profession lies in the variety of its work, in the sympathy for the sick and in the scientific interests in its pursuits, not in tlie shadowy prosjtects of honours. I Jut it mav be asked wliv the doers of all this ii:ood have received and continue to receive such scant recoijrnition from the State, and f mav add, from those who are daily reaping the benefit of their A\ork, and who accept tlie gift as a right, ignoring or forgetting the donor? Indeed, were he to retain anv discoverv he mio:ht make, for his in- dividual benefit, he would l)e "soundlv denounced." This neglect lias been exemplified in our own little province. It is not long since I, with other medical men, signed a re(iuest that a worthy [)liysiciaii in the Xorth, should take the place of a senator who had recentlv died in that district. Our re- quest was "tabled,"" notwithstanding there is not a member of the profession in the senate, from this province. It is true that the doctor had not been made eliijible for office bv rejection at the polls. Let us contrast their position with that of a general com- manding British soldiers, and directing them against a semi- savage horde, — himself keeping without the range of shot or shell — killing hundreds to avenge some wounded pride, or to satisfy some craving demand ; he receives the thanks of Parliament, is presented with a large donation in money, and created a lord or an earl. While a " Jeiiner," who, it 18 Pr(><(d('Hfiifl A'/ifnss. is estimtited, Iuih saved more lives than have been destroyed by the sword and gim-powder since the time of Ararll)orou<;:li, — received no mark of distinction. It is trne the paltry sum of i;10,000 was voted for him, and 40 years at\er his death a monument was placed in Trafalgar ^Mpiare to his memory, but with shame be it said, it has since been rele- gated to an obscure corner at the far end of the Serpentine^ to be admired by nurse-maids engaged in keeping erratic chifdren from falling into its stagnant water, — a disgrace to the nation c'aiming the honour of his work. Again, com- pare the work of the general with that of Simpson, Lister, Wells, and others, whose highest distinction has been a baronetcy, and then oidy when they had private means suf- ficient to sup'^ort the title. The clergy-man has the bishop's mitre, the lawj er the bench, as a goal looming in the distance. The medical man has no such goal to stimulate his ambition, yet he perseveres in his good work, and I maintain that he is equally deserving. It may be asked, what is the remedy for this state of things ? I think we have the remedy in our own hands, — by combination, by a determination to stand shoulder to shoulder, by strictly observing that golden rule, " to do to our conferes as we wish our conferes to do to us, by sinking all diti'erences of opinion for one grand object, the elevation of the standard of our profession, so that when we speak, our united voices may carry weight in the community. The members of the profession in the ami}' and in the navy have shown us a good example, by such action they have obtained large concessions from the government. Differences of opinion will exist, but in 00 cases out of 100, an explanation of five minutes between men wishing to act honorably, will heal the breach and silence that odious remark " Doctors differ." In conclusion, gentlemen, let me say to you tliat I have by no means exhausted my subject; it covers such a wide field that the time allotted me will only permit a sketch, but 3Iar'itutii' 3Ii