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The following dlagrama illuatrata the method: Lea cartea, pianchaa. tableaux, etc.. peuvent Atre filmAa A dea taux da rAduction diffAranta. Loraque la document eat trop grand pour Atre reproduit an un aaui clichA, il eat filmA A partir de Tangle aupArieur gauche, de gauche A droite, et de haut an baa, an prenant le nombre d'imagea nAcaaaaira. Lea diagrammaa auivanta illuatrent la mAthoda. ; 1 2 3 1 i ■ .,4 5 6 ^:-^■' V i^^7T.'^^^^fy . - .vw'^^ - s 'rr YESTERDAY AND TODAY. BY FKANCIS J. SHEPHERD, M.D., Professor of Anatomy, McGill IJniversity ; Surgeon to the Montreal General Hospital. Reprinted from the Montreal Medical Journal, April, 1899. 9^ YESTERDAY AND TO-DAY. AN ADDUKSS TO TUM I'NDKIfiiHADrATKV MKDK.'AI- SOtJKTY, JUNE, 1898. BY Francis .1. Shepukhu, M.D., Professor of Anatoniy, McGill University ; Senior Surgeon to the Montreal General Hospital. I have thought for some time about various subjects on which to ad- dress you this evening ; some dry and heavy, others light and airy ; and I concluded, after due consideration, that you had enough of sermons preached to you during your course, and enough advice to last you for some years alter graduation. Tlie more frivolous forms of address, 1 considered, were ill suited to the dignity and traditions of these college halls ; so, to make my address instructive as well as entertaining, I, decided to give you a short account of what the Medical Student saw twenty-five or more years ago, and to compare his opportunities and ad- vantages with those so riciily accorded to you. Medical Students of the last decade of the Nineteenth Century. I am not so sure, however, that you have so great an advantage over the men who were educated here twenty-five to thirty years ago. In the first place, they had not so much to learn and had more time for clinical work in the hospitals, for, outside of the dissecting-room, the hospitals were the only laboratories they pos- sessed; even practical chemistry, at that time, was not taught. Again, although you have many methods and instruments to aid in diagnosis, such as clinical thermometers and temperature records, cystoscopes, (h)nble barrelled stethoscopes, instruments and methods tor estimating the proportion of white and red cor|)Uscl<'s in the l)!ood, l)ivalve specula, urinometers, laryngoscopes, the typhoid reaction of blood, centrifugal machines, sphygmographs, fluoroscopcs, X ray apj)aratus, and many other iu)velties which it would be wasting time t(» mention ; still, it seems to me, that the older men trusted less to mechanical means of as- I sistance, (instrumonls), anrl moro to tlioir own MHtuml powers of obser- vation ; in surgery r'spccially. din^iiosis wjih u nin<'li more jieciiratc ac- coniplisluiiont iliat at preaunt. Now, I lie fasliion, cHpucially in abook on the pulse. lie says, "Firet learn the natural pulse, then appreciate swiftness and slowness, hardness and softness of the coats of the arteries ; then notice the inter- vals, observe equality and inequality." He then discusses the ditferent'c of tha pulses of men and women, old and young, with the effects of slec]). of baths, of wine, of mental emotions, and of pain. <'onchuling with a description of the pulse in various diseases. .At this time and till long after the pulse was not counted: it i; only within a hundnnl years that the second hand of a watch was used to count the pulse. Tn the IRth century the pulse was estimated by n wate?- chtck. Galileo tested the swing of the great lam]! in the f'atbedral at Pisa, (from which he got his idea of the pendulum) with his own pulse, which led to the isochro- nism of the penduhuu heing discovered. This led to the production of an instrument called the "pulsilogy". now long forgotten. Tt consisted of a scale of inches and a cord with a movable weight mark(»d with a transverse line. The number of V)cats of the pulse corresponding to a given length was calculated by direct experiment depending on the iso- chronism of the pendulum. Thus a pulse would he spoken of. not V)y the number of heats, but of so many inon ; a ligature was never placed upon a vein, this would have been lo(»ked upon as n i.(5er. The cause of pyjemia was not known atul it was confounded with rh umatism. We spoke of "laudable" pus and expected to see it in every wound. Healing by first intention was looked upon as a miracle. W'v knew nothing then of germs or sepsis or antisep- sis, but operated with dirty instrunu-nts and septic hands on septic parts and won-, as a rule, loats which had for years been baptized with tiie blood of the surgeon's victims.. Some operations performed with celerity were very successful, such as, removal of tumours in the neck, and of stt)ne from the bladder. Our operations, in those days, consisted chiefly in the amputation of limbs and the ligature of arteries. Very little other operative work was done. Excision of joints was just coming in when 1 commenced to study, the late Professor Fenwick being the j)ioneer of that work on this continent. (•aiu:;ers of the breast and other parts were not operated on until they were so evident tlu.t any one could tell what they were, and operative procedures, undertaken then, were -wf t m ii rr'T ^-'-Tnirfnmr^' ll H invariably of no nso bocaijso tor) lat(\ Wlint a chanpo now in our pro- ocoduro. PorhapK ill surjjt'ry the mosl niarvclloiis modern discovery after ana»fl- tliosia, wliicli lias rondorcd tin- extraordinary nuMlcrn oporati(»n8 possiide, b the knowlnl^'o (hat sepsis is due to tlic distiiu't and dofiiiilo action of certain well-known miero-organisnis, and when this actirm is suspended or these germs are killed or prevented from ent«'ring the wound, healing takes place without any ditHcuIty. In medicine, the provwl relationship of miero-organisnis to some of the most viruh'nl forms of infectious or contagious disease, has been well established and many methods have been devised I'or destroying these witiioul in any way injuring the person in whose body they are multiplying. Another remarkable discovery, which is so recent that most of \in\ iem(Mul)er its inception, is the ren- dering of the individual immune l)y the injection of some antitoxin. Not so many years ago our only hope in diphtheria was tracheotomy when the worst came to the worst, and this was only palliative. In most severe epidemics of diphtheria, 40 to r)() per cent. died. Now, under antitoxin the records at the Civic llospitail last year gave a death rate of only 8 per cent., and it would have been less had the cases been brought ear- lier, it is hoped the scojie of these antitoxins before many years will be much extended: it is used successfully now in tetanus and rabies. Another remarkable recent discovery which seems almost a fairy tale, is the knowledge of the intiuence of internal secretions of certain duct- less glands, as the thyroid and thymus, suju-arenHl capsules and pituitary gland, upon metaliulic processes. Any ouv who luis seen an idiotic Cretin or a patient with Myxcedema restored to intelligence and health will have .some idea of the scope of this method of treatment. The know- ledge that a subject that has bled to death still has in his body enough blood to have su|)|)orted life if it only could have circulated, has been known to us less than twenty years. What prevented the circulation of the blood was diminished blood pressure. Now, in consequence of this discovery, we do not inject blood, but fluid sufficient to raise the blood- pressure to its former height. Saline sidution, a teaspoonful of salt in a pint of hot water, is the simple .solution u.sed, and the solution need not l)e injected even into the veins, but if it is injected in the subscapular or sul.inammary celluhir tissue, it does equally well. Wooldridge has shown that when a jiatient recovered after transfusion of blood it meant that the transfusion had failed, the blood having escaped into the cellular tisisue outside the circulation, whilst when transfusiim was mechanically successful, it was fatal. Injection of saline has saved many lives even when injected into the rectum or left to be ab.sorbed in the peritoneum. This knowledge of the efficacy of saline solution has come to us from the experiments of the physiologists. 5 Maity oIImt novelties and wonders are daily being made known, such UH Heriini therapy, etc VVIint the future will l)ring forth one cannot say, hut if the next iwenty-five years are as rich in discoveries and the prac- tical a|^»|)lieuli()ns thereol', you will have much to interest you in your future careers. At the heginniii),' of this century, medical men thought they had reached the end of their advancement, and, in fact, Boyer, af- ter the Kreiich war, said "Surfi'(in-(i»'nt'ial i>f tlu' KorioH. He di'StrihcH the ^Hitiont, a gill, roniing into the ()|K'ratin); ntoin with great fortitudi' and even clu't'rrulni'ss. but, on the I'nslant the knile was applied to the skin she be- came s«» nnp>vernal»U' that four strong' assistants could, with the utmost ditliiulty retain her upon the table. '* The removal of the "extremity of the femur was a work of j^reat tlillleulty and danger as '* when the knife was passing between the bone and popliteal artery no "euln-aty could intiuci' the poor girl, whom terror seemed t«) have de- " prived of her reason, to renuiin one monu-nl at rest. She struggletl so "violently with both lind)s that it was with a degree of labour and anx- '" iety 1 had never before experieiu-ed that I at length succeeded in i)as- " sing the edg»' of the knife round the condyles posttiriorly thus detatch- " ing the divided end of the femur." It is interesting to know that the patient recovered and had a useful leg. " I could walk long distances '• without discomfort," she said," and a year aftt'r she was able to stand or walk the length of u day." An interesting account is given of a medical friend of Sir James Y. Simpson who was so unfortunate as t IH " lu'iiltli." * Of ('(HMMc all tliiH occurred hoforc my time, but it. in only fifty ycaiH apt that such oxju'riences \vt;rc coiiunon. Thu coiiditiuii of our hoHpitals has much improviul since my student dayn. The small, iiairow, dark, aiirhaps on the side of luxury. The beautiful rows of spotless beds, the shining dustless floor, the fresh air, the order and freedom from sadness, in fact, the universal cheerfulness (especially in surgical wards ) of the pitients, and last but not least, the nurses of whom I have already spoken. The operating rooms nowadays are palatial marble halls where formerly they were shambles, furnished with pulleys for reducing dislocations, reeking with odours and adorned with the blood-stained and blood-soaked table. In a celebrated hospital I saw in Dublin the operating room was built over a cess-pool. When I was in Vienna in 1874 and 1875, antiseptic surgery, which I had seen under Lister in Edinburgh, had not yet penetrated so far and the mor- * The Seml-Cenlunulal of Aniesthesia, Boston, 1SK7. tl i; f lality was appalling. 1 never saw a case of strangulated hernia recover iit'ter operation. The great Billroth presided over the chief surgical clinic and hia mortality was quite as great as his neighbours. In England there had always been more or less attention to cleanliness, and the re- sults of English surgery were fairly good, so that they were on this ac- count much slower to take uj) antiseptic surgery, feeling quite satisfied with their results. In (Jermany and Austria, the change from septic to antiseptic surgery worked a miracle, from being laggers in the surgical Held, the (Jermans became leaders and many ol" the triumphs of modern surgery are due to the good work )f the Germans. They were not satis- lied with the nu)dest little steam boiler of Lister, but went to extremes, iuid had a ten horse-])ower boiler in a special room adjoining the oper- ating room, and from it poured out volumes of antiseptic spray till the operators, patient, and assistants were wet to the skin and the atmos- pliere was worse than a London fog. Soon men found out that quite as good results were obtained by irrigation so the cry was "fort mit dem apraij", and the boilers became obsolete. Now there was a Niagara of antiseptic solutions, the operator and his assistants waded about the operating room in long rubber boots. Visitors who had no boots got on chairs and watched the deluge of antiseptic lotions which played contin- ually on the patient and on the floor. Soon it was found that this was doing too much and Aseptic Surgery came in, deluging with antiseptics was abandoned, and dry dressings were adopted, with aseptic and steril- ized materials and the patients did quite as well. The tendency to-day is to simplify methods and to abolish the elaborate antiseptic ritual which succeeded to the days of dirty surgery. What the next new fad will be, I cannot say. but owing to our increasing knowledge of bacteria and tluMr influence on the tissues our methods are becoming much mod- itied. As was said of Mrs Maj)p, a celebrated quack, who flourished in the last century : — " III pliysick as well as in fasliion we find." " The newest has always the run with nuiiikiiul " Byron has said. " Thus saith the preacher. Naught In-neat h tlie sun Is new, yet still from ehanK** to chanKe, we run. What varied wondi-rs tempt ns as they pass, Tne cow-pox, Inulors, ^^ulvanisni, ^as, In turn appear, to make the vulvar stare, Till the swollen Imhiile hursts, and all is air." So far I have spoken only ol" the hospitals, our college teaching, ex- cept in the Practice of Medicine and Surgery was most elementary. Our anatomy was a farce, i nevir. as a student, dissected the pharynx, the thorax, or the abdomen. We u.sed to toss up as to who should take out the intestines and the abdominal organs. The anatomy of hernia and lithotomy together with the arteries o.f the extremities comprised all the surgical anatomy. The anatomy of the convolutions of the brain was iU 9 \ unknown, and as for the course of the fibres in the brain and the spinal cord, they were a mystery. Physiology was not much better. The college possessed one inicrosco|)o and I remember well waiting my turn for over an 'lour to see the circulation of the blood in the frog's foot, Sometimes, towards the end of the session, we had a day when we took turns to look at about a dozen imported microscopic slides of the various tissues. In my student days and for some time afterwards, the cause and or- igin of phthisis created much dispute and acrimonious discussion. The discovery of the tu])crcle bacillus by Koch, followed by experiments with tuberculin soon chfaied the atmosphen- and settled the question of the origin of the disease and its contagiousness. Koch's discovery was fol- lowed by many others, and new fields of investigation were opened and much ligiii tlintwn upon the cause of disea.se. Of course this phase went to extrenu's and everybody was discovering bacilli. One was dis- covered in old age, another in fracture of the leg and so on, but the knowledgi' of the bncillary origin of disease aft'ords us some hope that in time to come remedies may be found which will abolish certain troubles which at present atllict the human animal and others. Materia Medica was of the nu)st ancient character, though dragon's teeth, powdered skull and mummy were not in the list of drugs. Still we heard a good deal about musk and eastoreum, antimony and ipecac, cassia and squills, tragacantii and gum acacia, coccus and Spanish fly. Now we have firms of manufacturing druggists who not only put up beautiful preparations of various drugs in a portable and palatable form, but they kindly tell us what to use them for, an how to use them. We shall soon have our drugs given in the streets perhaps from "penny-in-the-slot" machines. We had some very good bedside teaching from men like the late Dr. Howard wiio was a born clinical teacher. We spent considerable time in the hospitals picking up what crusts we could from the attending phy- sicians, anil nuiking out the rest for ourselves. The clinical examin- ations, like the clinic, were conducted in the hospital, I admit, but cer- tainly not at the bedside. Now, all this is changed, and any one who wishes })ractical instruction in any subject is able to get it in well i!iluiL>i)ed laboratories. Your opportunities are great. Gentlemen, and see that you take jjroper advantage of them. Much is in the womb of the future, great discoveries i)y which disease will be arrested, much dimin- ished, or aholished altogether, are in the air. We are in a progressive age, and one which is teeming with interest. God grant that our brains will keep pace with what it is necessary to learn, so that we may not be k'ft behind in the rapid march of science. I trust that this great Uni- \ei'sity will retain its place in the van which it has gained by hard work and pel-severance, aiul that it will never lag behind. In the hands of the younger generation, your hands, Gentlemen, is the lamp of scientific / 10 r .» progress. See that you keep it brightly burning and never let it run out of oil of research and careful observation. Now as to medical education, I am a strong advocate of a five years course, but believe the fifth year should be devoted to practical work only, not to lectures. Owing to the faulty preliminary education of most students, much time is wasted at first in learning how to learn, and then owing to the fact that their powers of observation have never been cul- tivated, they have to learn how to observe for themselves and not through the medium of others. I find that many students do not know the meaning of svords, and they have only a parrot knowledge of their subjects, a truly deplorable state of affairs. Learn less but leara that well. The fault of modern education is that it attempts too much. Numberless subjects are dipped into, not mastered, and all the new metliods and subjects are much elaborated whilst the old are compara- tively neglected. It is my opinion, that althougii every one should have a laboratory training, it is possible to have too much even of this ; that the true laboratory of the medical student in his final years is the hospi- tal, and hospital should be attended without the fear of a coming exam- ination before one's eyes, and without the tediousness of always attending lectures. The performing of large and important operations in the public theatre is not profitable to the student, nor should didactic lectures be given in the operating theatre, with the patient in bed for a text, be con- sidered clinical lectures. It is most diflficult to teach, clinically, large classes, hence, these should be divided up, and a number of men appoint- ed to give tutorial instruction at the bedside. In surgery, the students in rotation could be made actual helpers, should sew up wounds, tie liga- lures, etc., -under the direction of the chief or his assistants. The out-door service sho jld be made use of. I hear now it is much neglected because of want of time. This should not be, for it is a most important service, and the kriowledge gained there is of inestimable benefit to the young practitioner and furnishes the cla.ss of cases he is likely to see the most of. Besides, in the out-door clinics the instruction is truly clinical and practical. I tliink you are over examined and fear you consider examin- ations are the end of all things. Alas ! When you have got through them, the first step only has been taken, and there are many more pre- cipitous heights yet to climb. One will begin to make progress when he ; valises how very little he knows of any subject. To seek knowledge for its own sake and not merely to pass examinations or for what it will bring in dollars and cents, is one of the thing* to be expected at the coming milleniimi, but endeavour to do this as nearly as you can. " ll'ippy Is llu-! mhu that tliuieth wisdom and the inan that KcUeth underMtand- iiiK. fur tht; merchandise of it is better ihtiii the inercliaiidiMe uf silver and the gain thereof than pure Kold."