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Introductory Address ON MILITARY SURGERY.
DECEMBER 12, 1857.
Introductory Address ON
MILITARY
SURGERY.
DELIVERED AT THE
ROYAL COLLEGE OF
SURGEONS, IRELAND, Monday, November 23rd, 1857.
BY JOLLIFFE
TUFNELL, F.R.C.S.I., M.R.I.A., REGIUS PROFESSOR.
(Concluded from page 569.) THE reform in our military arrangements resulting from this has extended also to education in the army. Competitive examinations have been already introduced for the artillery and medical services, thereby opening up to the youth and in telligence of the country appointments which it is of such paramount importance to have ably filled. A commission, too, has sat and reported upon the subject of military education ai large, and a system has been sketched out which will shortly be promulgated, and as far as can be learned, the general conclusion seems to be, that a liberal rather than an exclusively military education is best suited to the requirements of the case. The officer, it is said, must be a soldier; but he must be something more. "He should, in addition, possess that enlargement of mind and knowledge that will enable him to act usefully under the various circumstances in which he may be placed in our wide colonial empire; sometimes in the capacity of governor, sometimes as diplomatist, and oftentimes as judge," and without a liberal, sound education how can any individual possibly anticipate that he will be qualified to fill such situations ? And, gentlemen, allow me to ask if the necessity is at all less as regards yourselves ? Believe me you require much more than a mere professional education. In the table appended above my head you will read the qualifications that are absolutely demanded from every candidate presenting himself for admission into the medical department of the army; but ample as it appears, it does not contain all, or nearly all, that is nepessary for you to pass ably through the path of life, for there are collateral scientific branches not included in it; there are living languages almost equally essential to you. You may say, what sciences other than those set down can by possibility be of use to you as army surgeons, and why should you need language more than those practising in civil life ? In a few words I will tell you. You will have to serve out of your native country; they will not. You of course cannot be expected to be familiar with the tongues of all those nations far away with whom in the course of service you will be brought into communication, but you ought to know, so as to speak fluently, one or other of these three languages—French, German, or Italian, and of these I should say, from my own experience on the Danube, Italian is not the least useful. It is a language whose study, in this country at least, has hitherto been almost exclusively confined to the female sex, and, therefore, in all human probability, not one word will ever have been acquired by any one of you. It would, therefore, be Utopian to suppose that you could now find time to learn a fresh language; but I do advise you strongly to keep up and improve whatever knowledge you do possess, either of French or German. Still you may say desirability does not prove necessity. No, it does not, but if in the course of service you are either taken prisoner, or necessitated to deliver yourself up to the enemy, when, from want of carriage, the badly-wounded cannot be borne along with a retreating army, then you will find how absolutely necessary does it become for you to have the power of communicating with the enemy ; and how very, very desirable it is that this should be done directly by you yourselves instead of through the medium No. 1789. war
a paid interpreter, one totally indifferent to the wants and sufferings of your men. Well,’then, perhaps you will say that you yield the point so far as languages are concerned, but what are the sciences, and which are they ? In the first place, geology; for it is necessary that you should be properly qualified to judge of the fitness of locality for encamping ground. You should have a knowledge of soil and substratum, and be competent to tell the nature of
of
the surface,whether loam or clay; the substratum, whether is retentive calcareous or rocky, whether, in fact, the of water or not, and thereby its influence in causing marsh miasm, or the reverse-information which is as necessary for the medical officer in charge of a force, as is a knowledge of the proximity of the enemy to the General in command. Meteorology, too, is another science full of interest and importance to those who are to have the direction and guidance of large bodies of men living in an unnatural condition, in temporary dwellings of wood or canvas, or altogether in the open air. The influence of climate upon health, the effects of summer heat and winter cold, (when in excess,) of fogs and wet, of night and morning temperature, should be carefully studied, for their importance can hardly be over-rated. A general acquaintance, too, should be gained, and familiarity established with all those instruments which are employed in the conducting of meteorological observations. I might go on still, but I think I have said enough to show the necessity of more than mere professional education. Still in relation even to it there is one branch not yet included in the curriculum, but which is of essential import to younamely, the performance of operations upon the dead body by yourselves. It will not suffice to you in practice merely to have seen operations performed by others, you must have done them for yourselves, to acquire that power of execution which is requisite for service in the field. Such a course of instruction is no novelty in this college, but has ever been at the disposal of the student desirous of fully qualifying himself. It is now, as it has been for the past forty years, at your command, and prav let me urge you to avail yourselves of the opportunity afforded. The oversight, hitherto, I say, has not been on the part of the council, or of the professors of this college, but on the part of the students, who have been slow to avail themselves of the advantages offered. In advocating the study of professional subjects, I cannot lose the opportunity of bringing before you the opinion of Sir Astley Cooper upon this head, for his name has but to be mentioned to command respect. He says, " Nothing in our profession is to be known by guess. From the first dawn of medical science down to the present day, not a single correct idea has ever emanated from conjecture. It is right, therefore, that those who are studying thpir profession should be aware that there is no short road to knowledge : that observations on the diseased living, examinations of the dead, and experiments upon living animals, are the only sources of true surgical knowledge, and the inductions from these are the only source of legitimate
ground
"
theory.
then urge upon you, gentlemen, in the session now to acquire, as far as possible, a practical acquaintance with your profession to cultivate all the branches laid down in the curriculum. In the hospital wards to attend equally to medical as to surgical cases, for in your subsequent career you will be called upon to administer indiscriminate relief. You must recollect, that in a public service you cannot limit the sphere of your practice as men do in private life. You will not be able to select this or that special subject for study, regardless of almost any other. Such may do for metropolitan, but it is not compatible with cosmopolitan practice. The eye, the ear, the heart, lungs, stomach, liver, kidneys, rectum, and urethra, and, though last not least, the mind, are in.private life, each made the subject of a specialty in practice, and men recognised as authorities upon the disease of one organ are not consulted for affections of another. But by you they cannot be so separated ; all and each, as component parts of the same body, must collectively be studied and considered. In the hospital wards you will observe the intimate connexion that exists between one organ and another in sympathy, as between surgery and medicine in practice. You will see both to be practically indivisible, medical cases often requiring the fullest surgical knowledge, and surgical cases the best medical treatment, the body being one, and the laws of life and health that are disturbed in the two classes of cases the same. And here, whilst speaking of the hospitals, I must beg to say a few words to you of the School of Medicine and Surgery in Dublin. As an Englishman born, bred, and educated, and familiar with the opportunities of acquiring knowledge here Let
me
commencing,
In it you will find, either in model, drawing, or the actual elsewhere, I have no hesitation in saying that you need regret having studied your profession in Dublin. I know object itself, almost everything accessory to the preservation of well, from having been myself a student in London, the vast life and health. My respected colleague, Dr. Jacob, when fields for observation that exist in that metropolis, the magni- opening the College this session, rightly told you that this
and
never
and the multitude of patients which each I know equally well that, so far from this vastness being of any advantage to the student, it is the reverse, for his attention is perpetually passing from one fresh case of admission to another. For acquiring a steady, sound, wellgrounded medical and surgical education, I do believe that the separate and detached hospital system as carried out in Dublin is to be preferred ; whilst the capabilities for prosecuting auatomy, that only basis of all surgical knowledge, are here infinitely greater than either in Edinburgh or London. Upon the capabilities of the teachers in the three metropolises, it would be invidious to remark; but as for trouble taken in teaching, both in the hospitals and schools, Dublin cannot be surpassed. I am led to make these observations in consequence of having been lately asked by a student, who is qualifying himself for the East India Company’s competitive examination, whether I would not advise him to go over and spend some portion of his time in London? To him my reply was, No, remain at home and study; for I need hardly tell you that without study he will gain nothing in competition, no matter where he goes; and I believe I am justified in saying, that by the teachers in Dublin will the separate branches of education entrusted to each be as fully and faithfully taught to him as anywhere else in the world. As regards the special duties of my own chair, I can only say that they shall be performed to the utmost of my power. The subjects which will be brought under consideration during the winter session are here set forth, and comprise, I believe, everything that can conduce to the preservation of life and health in the soldier. They areThe examination of the recruit, and the points on which the efficiency of a soldier depends. The clothing of troops in reference to climate, and extremes of heat and cold. The victualling of soldiers. The influence of diet upon health. The modes of cooking in a camp, and on the field. The means of obtaining and preserving a supply of water. The mal-effects of habitual intoxication. The construction of fixed and temporary residences for effective men and sick; of canvas, wood, and earth. Ventilation and drainage. The medical inspection and arrangement of transports. The embarkation of troops. Medical duties on board ship; and means of preserving health during long voyages. Medical duties and arrangements on disembarking and landing before an enemy. Medical duties and arrangements on taking the field during and after a general action; and establishment of field hos-
tude of the
hospitals,
contains; but
pitals.
Points to be attended to in the selection of
encamping
grounds.
Medical duties with an advancing army; with a besieging force. Trench duties and arrangements prior to an assault. Medical duties and arrangements in a besieged town or fort. Medical duties and arrangements with an army in retreat. The removal of sick and wounded, by hand conveyances, by horses, camels, and elephants; by two-wheeled and four-wheeled
carriages. The fitting of transports for wounded, and of hospital ships for convoys or to remain stationary. The organization of reserve hospitals in the rear of an army. The injuries of warfare-gunshot wounds, sabre and bayonet or lance wounds; burns from powder explosions. Conditions consequent upon these injuries-shock, tetanus, mortification, hectic. Primary and secondary amputations, and excision of joints.
Zymotic frost-bite,
or
camp scurvy.
diseases—diarrhœa, dysentery,
cholera,
Ophthalmia as affecting troops. Hospital diseases-gangrene, typhus. Tropical diseases-intermittent, remittent, and yellow fevers; hepatitis, acute dysentery, coup de soleil, beri-beri, dracunculus. Fictitious diseases and
malingering.
Military punishments.
’
Invaliding.
In order to illustrate these subjects, and to make you familiar with objects which you could not otherwise possibly gain any knowledge of, Her Majesty’s Government has provided, at .a very considerable expense, a special museum for this purpose.
594
would be for your free use and inspection. Gentlemen, it is my wish that you should copy everything that is in it, and examine and make yourselves masters of it in detail, for this is its intention, and for this purpose was it originated. You will find it a museum strikingly antagonistic to all others you may have seen in connexion with surgery and medicine, for whilst their direct object is the acquirement of matters of pathological interest, the special intention of this museum is to hinder as far as possible the production of diseased conditions, and to oppose pathological changes. During the past twelve months, there have been very many additions made to it, and some of these of so peculiar character that I cannot but refer to them to-day. To that collection have been forwarded by four of the leading sovereigns of Europe-viz., the Emperors of France and Russia, the King of Sardinia and the Sultan-the infantry equipment of each country, generously and willingly contributed, in order that from each might be selected anything that might appear to be likely to conduce to the comfort and efficiency of the British soldier. Rightly regarded, these donations must be considered as expressive of a good feeling and liberality that cannot be too museum
highly appreciated.
The Hon. the East India Company, too, have as readily afforded their assistance, the Government of India having had prepared for this museum a very beautiful collection of specimens, illustrative of Indian diseases. And here I would beg to intimate, that it is to the Principal and Professors of the Grant Medical College of Bombay-particularly to Drs. Morehead and Ballingall-that this College is principally indebted, since it is through their exertions that it has become possessed of these very valuable preparations. All, gentlemen, that has been done during the past years has been effected with one great object-viz., that of preserving the soldier’s life. From the Queen downwards such has been the case. Her Majesty’s sympathy for her sick and wounded during the Crimean war must be known to all, and since peace has been declared she has manifested her desire for increased attention and care being bestowed upon the health of her soldiers, and to this end has directed a Royal Commission to be appointed. Now, addressing, as I do to-day, a mixed assembly of civil and military, I would wish to advert more particularly to the subjects selected for the consideration of this Commission, for it has been almost universally regarded, and erroneously regarded, as an inquiry affecting only the interests of the medical officers of the army, whereas it has a far wider and more extended bearing, for it is neither more nor less than the drafting of a great medical scheme for the future welfare of our troops. To place this in the clearest light, I will now lay before you an abstract of the directions which have been issued under the sign-manual for the guidance of the Commission. They are these :" Considering the great importance of maintaining and im. proving the health of all ranks of our army, at home and abroad, and of providing for their medical care and treatment in cases of wound and disease, in the most approved manner, we do direct an inquiry into the organization, government, and direction of the medical of our army. Firstly,-We command you to inquire into the mode by which candidates are selected for the medical department of the army, their promotion and service, their pay and retire-
department
ment.
Secondly,-Into the best means of keeping up, acquiring, adding to their professional knowledge. Thirdly,-Into the best means of preventing disease in our
and
army; accommodation in barracks and camp, at home and abroad; clothing and rationing of our troops, having regard to the various climates to which they are exposed. Fourthly,-Into the condition of our military hospitals. Fifthly,-Into the management of the civil hospitals of the country, and to consider whether any portion of such arrangements can be advantageously introduced into the medical department of our army. Sixthly,-Into the expediency of making provision in our military hospitals for the officers of our army, when suffering from injury or disease. And, lastly, we command you to report what changes you may consider it expedient to make in organization, management, and expenditure, with the view to the utmost efficiency of this branch of the military service."
I have here read her Majesty’s words, and from them ] would frame a reply to two questions that are put to me nearly every day. The first is, as to whether the pay, position, ami retirement of the army surgeon are to be materially increased’ and the second, as to whether, in the present state of uncer. tainty on this head, students ought to join the public service To both of these questions I reply distinctly, Yes. or not ?
Upon what authority
do I do so ?
Simply upon this-namely,
that the Crown has here implied its intention to effect suet alterations as are shown to be necessary, and the educational bodies of the United Kingdom have expressed their opinions that the present pay, position, and retirement of the army surgeon are insufficient. The Universities of Edinburgh and Dublin, the Royal Colleges of Physicians of London, Edin
burgh, and Dublin, the Royal Colleges of Surgeons of London, Edinburgh, and Dublin, the Faculty of Physicians and Sur geons of Glasgow, and the Colleges of Aberdeen, have one and all officiilly reported their corporate opinions on this head.
let me offer to you one word of It is this : In the course of your future service you will be brought into contact with a large number of individuals. You will at one time be under, and at another time in authority. Discretion and judgment are required in both these situations. You certainly may servein both in a manner that will carry you through, in the former without censure, and in the latter without odium; but this is not enough. Your endeavours should be from the very commencement, from the day on which you obtain your commission, so to discharge your duties as to command the esteem of all, but more especially of those of your professional brethren over whom you may be placed. You willfind by experience the advantages even which accrue to the public service from courteousness in professional intercourse, in the readiness with which duty is at all carried out, more especially so when any undue exertion is required. Better examples of the characters that I would hold up for your imitation cannot be adduced than by the mentioning of those who last in succession have retired from the medical charge of the garrison of Dublin, Peile, Pitcairne, and Maclean. The two former, still amongst us, connecting links between the great ones of the present and the past, venerated and beloved; the latter only just departed out of office, but taking with him into private life, from the service from which he is retiring, the warm regard and good wishes of all who have been brought into communication with
And now, in
conclusion,
friendly advice.
times
have done so through the Minister-for-War—a noble’ whose anxiety for the elevation of the profession has been avowedly declared; and their representations are certain tc receive assistance from the present royal head of the army, whose interest in all that concerns the welfare of the soldier is well known. This, then, is the authority on which I ground my first reply. In answer to the second question, as to whether you should enter the service now, and before this amelioration has been him. specifically announced ? I say equally, Yes. Why ? Because your services at the present time are urgently demanded, and REMARKS it is unknown to our profession ever to hold back when the ON THE country needs its aid. And now, gentlemen, let me offer to you a few remarks in INFLAMMATION AND BLOODLETTING reference to the advantages which are to be derived from the CONTROVERSY. the services. introduction of the public Firstly, competitive system insures the power of entrance to all who possess suffiBY W. O. MARKHAM, M.D., F.R.C.P., cient merit; and interest, that stumblingblock of former ages, PHYSICIAN TO ST. MARY’S HOSPITAL. stands no longer in the path of intellect and exertion. Se(Continued from page 573.) condly, although the absolute amount of the army surgeon’s pay, even after it shall have been increased, will be but small in comparison with the income which may be realised by priTHE more any one reflects on the subject of Bleeding and its vate practice, still it is attended with these great advantages : the more, I think, he will be convinced that the prineffects, viz., that of being a certain provision during the prime of life, and a sure retirement in old age. You, too, who are now about ciples which have been at various times laid down for our to enter will enjoy advantages which your predecessors never guidance in the matter are of an unsatisfactory nature. What did. To you the honours and rewards of war will be freely we evidently need is, that the proper uses of the practice ’open; and-the soldier’s highest aim-the Victoria Cross may should, if possible, be so explained as to bring them into some - one day hang upon your breast. Already two assistant-surgeons better accordance with the pathology of the present day. The wear, and more than two have merited, this proud distinction. And for what (where conferred) was it given? I will tell you. principles referred to are the principles of the ancients, and ,t)n the 8th of September, memorable for the attack upon the therefore cannot but be ill-suited to modern pathology. One Redan, when all in the immediate neighbourhood retreated cannot deny, it is true, that in the present condition of mediexcepting one officer (Lieutenant Hope), Dr. Egerton Hale, of cine, the conclusions arrived at respecting the general therathe7th Fusiliers, remained, endeavouring to rally back the peutical effects of remedies, must be drawn from their results men; and, failing this) he himself stayed to protect and attend He next, after the as observed in individual cases, rather than from any & priori a wounded brother officer, Captain Jones. regiment had retired into the trenches, cleared the advanced theoretical considerations of their action ; and in so far, physisap of the wounded, and carried in, under a heavy fire, several cians of former days might be considered as able judges of the wounded men from the open ground. matter as ourselves : but, nevertheless, theory, in the matter Assistant-surgeon William Henry Sylvester, of the 23rd Fusi- of bleeding, aided by modern light, may be allowed to suggest liers, received this distinction for going out, on the 8th of Sep- a few things as regards its practical effect. We cannot bleed, tember, 1855, under a heavy fire, in the front of the 5th parallel, to Lieutenant and Adjutant Dynely, of that corps, who was indeed, without in some way exercising our judgment as to the lying mortally wounded, and for dressing his wounds in that mocius operandi of the loss of blood. And if, indeed, it be posdangerous and exposed situation; and for his courage, on other sible to argue usefully of the way of acting of any curative occasions, "in going to the front under heavy fire to assist the means, wemay surely anticipate that we should especially be able nowadays to do so in the case of bleeding-the operation wounded. I bring these cases forward for your imitation and example; of the remedy being so direct, and its immediate eifects so A candid consideration of the subject and I do not think there can possibly be any occasion more fit- clearly appreciable. ting, or season more suitable, for the recording of professional will, I am persuaded, show us that theoretical considerations merit, than such an one as that on which we are assembled to- of the action of bloodletting are quite in accord with the reday-when the walls of this college are honoured by the pre- sults of our practical knowledge of it at the present moment. sence of the highest military authority in this land. Admitting that a typical case of pneumonia, as described by And yet there are those who object. I can only say that I Cullen, was in his days, and in all days before him, and still is pity the miserable feeling that exists in some men’s breasts, at the present day, a case in which bleeding is a right remedy, that jealousy of the deeds of others which cannot be overgot. if practised at a right moment, and that the necessity of the Thus it was that when, last year, I brought forward those operation may be judged of from the severity of the symptoms medical officers of the army who had obtained special decora- - from the state of the pulse, of the breathing, from the fever, tions during the Crimean war, some anonymous writer was &c.-admitting this, still it does not follow that the same symp" could have been a sufficient guide to practice in ordinary, of names as to such mention their pleased designate claptrap." Gentlemen, my reply to this individual is, that it will be to ! every-day cases. We know, indeed, that such well-marked me indeed most gratifying, and I believe to the country also, if symptoms are not our usual guides, and for the reason, that the record here to-day of Dr. Egerton Hale and Mr. Sylvester they beloug only to the rare and exceptional case. And if we should induce you in the hour of danger to imitate their daring enter a little into this matter, 1 believe we shall hardly fail to ( arrive at the conclusion, that he who trusts alone to these signs= example.
They
man
toms
595
Introductory Address ON
MILITARY
SURGERY.
DELIVERED AT THE
ROYAL COLLEGE OF
SURGEONS, IRELAND, Monday, November 23rd, 1857.
BY JOLLIFFE
TUFNELL, F.R.C.S.I., M.R.I.A., REGIUS PROFESSOR.
(Concluded from page 569.) THE reform in our military arrangements resulting from this has extended also to education in the army. Competitive examinations have been already introduced for the artillery and medical services, thereby opening up to the youth and in telligence of the country appointments which it is of such paramount importance to have ably filled. A commission, too, has sat and reported upon the subject of military education ai large, and a system has been sketched out which will shortly be promulgated, and as far as can be learned, the general conclusion seems to be, that a liberal rather than an exclusively military education is best suited to the requirements of the case. The officer, it is said, must be a soldier; but he must be something more. "He should, in addition, possess that enlargement of mind and knowledge that will enable him to act usefully under the various circumstances in which he may be placed in our wide colonial empire; sometimes in the capacity of governor, sometimes as diplomatist, and oftentimes as judge," and without a liberal, sound education how can any individual possibly anticipate that he will be qualified to fill such situations ? And, gentlemen, allow me to ask if the necessity is at all less as regards yourselves ? Believe me you require much more than a mere professional education. In the table appended above my head you will read the qualifications that are absolutely demanded from every candidate presenting himself for admission into the medical department of the army; but ample as it appears, it does not contain all, or nearly all, that is nepessary for you to pass ably through the path of life, for there are collateral scientific branches not included in it; there are living languages almost equally essential to you. You may say, what sciences other than those set down can by possibility be of use to you as army surgeons, and why should you need language more than those practising in civil life ? In a few words I will tell you. You will have to serve out of your native country; they will not. You of course cannot be expected to be familiar with the tongues of all those nations far away with whom in the course of service you will be brought into communication, but you ought to know, so as to speak fluently, one or other of these three languages—French, German, or Italian, and of these I should say, from my own experience on the Danube, Italian is not the least useful. It is a language whose study, in this country at least, has hitherto been almost exclusively confined to the female sex, and, therefore, in all human probability, not one word will ever have been acquired by any one of you. It would, therefore, be Utopian to suppose that you could now find time to learn a fresh language; but I do advise you strongly to keep up and improve whatever knowledge you do possess, either of French or German. Still you may say desirability does not prove necessity. No, it does not, but if in the course of service you are either taken prisoner, or necessitated to deliver yourself up to the enemy, when, from want of carriage, the badly-wounded cannot be borne along with a retreating army, then you will find how absolutely necessary does it become for you to have the power of communicating with the enemy ; and how very, very desirable it is that this should be done directly by you yourselves instead of through the medium No. 1789. war
a paid interpreter, one totally indifferent to the wants and sufferings of your men. Well,’then, perhaps you will say that you yield the point so far as languages are concerned, but what are the sciences, and which are they ? In the first place, geology; for it is necessary that you should be properly qualified to judge of the fitness of locality for encamping ground. You should have a knowledge of soil and substratum, and be competent to tell the nature of
of
the surface,whether loam or clay; the substratum, whether is retentive calcareous or rocky, whether, in fact, the of water or not, and thereby its influence in causing marsh miasm, or the reverse-information which is as necessary for the medical officer in charge of a force, as is a knowledge of the proximity of the enemy to the General in command. Meteorology, too, is another science full of interest and importance to those who are to have the direction and guidance of large bodies of men living in an unnatural condition, in temporary dwellings of wood or canvas, or altogether in the open air. The influence of climate upon health, the effects of summer heat and winter cold, (when in excess,) of fogs and wet, of night and morning temperature, should be carefully studied, for their importance can hardly be over-rated. A general acquaintance, too, should be gained, and familiarity established with all those instruments which are employed in the conducting of meteorological observations. I might go on still, but I think I have said enough to show the necessity of more than mere professional education. Still in relation even to it there is one branch not yet included in the curriculum, but which is of essential import to younamely, the performance of operations upon the dead body by yourselves. It will not suffice to you in practice merely to have seen operations performed by others, you must have done them for yourselves, to acquire that power of execution which is requisite for service in the field. Such a course of instruction is no novelty in this college, but has ever been at the disposal of the student desirous of fully qualifying himself. It is now, as it has been for the past forty years, at your command, and prav let me urge you to avail yourselves of the opportunity afforded. The oversight, hitherto, I say, has not been on the part of the council, or of the professors of this college, but on the part of the students, who have been slow to avail themselves of the advantages offered. In advocating the study of professional subjects, I cannot lose the opportunity of bringing before you the opinion of Sir Astley Cooper upon this head, for his name has but to be mentioned to command respect. He says, " Nothing in our profession is to be known by guess. From the first dawn of medical science down to the present day, not a single correct idea has ever emanated from conjecture. It is right, therefore, that those who are studying thpir profession should be aware that there is no short road to knowledge : that observations on the diseased living, examinations of the dead, and experiments upon living animals, are the only sources of true surgical knowledge, and the inductions from these are the only source of legitimate
ground
"
theory.
then urge upon you, gentlemen, in the session now to acquire, as far as possible, a practical acquaintance with your profession to cultivate all the branches laid down in the curriculum. In the hospital wards to attend equally to medical as to surgical cases, for in your subsequent career you will be called upon to administer indiscriminate relief. You must recollect, that in a public service you cannot limit the sphere of your practice as men do in private life. You will not be able to select this or that special subject for study, regardless of almost any other. Such may do for metropolitan, but it is not compatible with cosmopolitan practice. The eye, the ear, the heart, lungs, stomach, liver, kidneys, rectum, and urethra, and, though last not least, the mind, are in.private life, each made the subject of a specialty in practice, and men recognised as authorities upon the disease of one organ are not consulted for affections of another. But by you they cannot be so separated ; all and each, as component parts of the same body, must collectively be studied and considered. In the hospital wards you will observe the intimate connexion that exists between one organ and another in sympathy, as between surgery and medicine in practice. You will see both to be practically indivisible, medical cases often requiring the fullest surgical knowledge, and surgical cases the best medical treatment, the body being one, and the laws of life and health that are disturbed in the two classes of cases the same. And here, whilst speaking of the hospitals, I must beg to say a few words to you of the School of Medicine and Surgery in Dublin. As an Englishman born, bred, and educated, and familiar with the opportunities of acquiring knowledge here Let
me
commencing,
In it you will find, either in model, drawing, or the actual elsewhere, I have no hesitation in saying that you need regret having studied your profession in Dublin. I know object itself, almost everything accessory to the preservation of well, from having been myself a student in London, the vast life and health. My respected colleague, Dr. Jacob, when fields for observation that exist in that metropolis, the magni- opening the College this session, rightly told you that this
and
never
and the multitude of patients which each I know equally well that, so far from this vastness being of any advantage to the student, it is the reverse, for his attention is perpetually passing from one fresh case of admission to another. For acquiring a steady, sound, wellgrounded medical and surgical education, I do believe that the separate and detached hospital system as carried out in Dublin is to be preferred ; whilst the capabilities for prosecuting auatomy, that only basis of all surgical knowledge, are here infinitely greater than either in Edinburgh or London. Upon the capabilities of the teachers in the three metropolises, it would be invidious to remark; but as for trouble taken in teaching, both in the hospitals and schools, Dublin cannot be surpassed. I am led to make these observations in consequence of having been lately asked by a student, who is qualifying himself for the East India Company’s competitive examination, whether I would not advise him to go over and spend some portion of his time in London? To him my reply was, No, remain at home and study; for I need hardly tell you that without study he will gain nothing in competition, no matter where he goes; and I believe I am justified in saying, that by the teachers in Dublin will the separate branches of education entrusted to each be as fully and faithfully taught to him as anywhere else in the world. As regards the special duties of my own chair, I can only say that they shall be performed to the utmost of my power. The subjects which will be brought under consideration during the winter session are here set forth, and comprise, I believe, everything that can conduce to the preservation of life and health in the soldier. They areThe examination of the recruit, and the points on which the efficiency of a soldier depends. The clothing of troops in reference to climate, and extremes of heat and cold. The victualling of soldiers. The influence of diet upon health. The modes of cooking in a camp, and on the field. The means of obtaining and preserving a supply of water. The mal-effects of habitual intoxication. The construction of fixed and temporary residences for effective men and sick; of canvas, wood, and earth. Ventilation and drainage. The medical inspection and arrangement of transports. The embarkation of troops. Medical duties on board ship; and means of preserving health during long voyages. Medical duties and arrangements on disembarking and landing before an enemy. Medical duties and arrangements on taking the field during and after a general action; and establishment of field hos-
tude of the
hospitals,
contains; but
pitals.
Points to be attended to in the selection of
encamping
grounds.
Medical duties with an advancing army; with a besieging force. Trench duties and arrangements prior to an assault. Medical duties and arrangements in a besieged town or fort. Medical duties and arrangements with an army in retreat. The removal of sick and wounded, by hand conveyances, by horses, camels, and elephants; by two-wheeled and four-wheeled
carriages. The fitting of transports for wounded, and of hospital ships for convoys or to remain stationary. The organization of reserve hospitals in the rear of an army. The injuries of warfare-gunshot wounds, sabre and bayonet or lance wounds; burns from powder explosions. Conditions consequent upon these injuries-shock, tetanus, mortification, hectic. Primary and secondary amputations, and excision of joints.
Zymotic frost-bite,
or
camp scurvy.
diseases—diarrhœa, dysentery,
cholera,
Ophthalmia as affecting troops. Hospital diseases-gangrene, typhus. Tropical diseases-intermittent, remittent, and yellow fevers; hepatitis, acute dysentery, coup de soleil, beri-beri, dracunculus. Fictitious diseases and
malingering.
Military punishments.
’
Invaliding.
In order to illustrate these subjects, and to make you familiar with objects which you could not otherwise possibly gain any knowledge of, Her Majesty’s Government has provided, at .a very considerable expense, a special museum for this purpose.
594
would be for your free use and inspection. Gentlemen, it is my wish that you should copy everything that is in it, and examine and make yourselves masters of it in detail, for this is its intention, and for this purpose was it originated. You will find it a museum strikingly antagonistic to all others you may have seen in connexion with surgery and medicine, for whilst their direct object is the acquirement of matters of pathological interest, the special intention of this museum is to hinder as far as possible the production of diseased conditions, and to oppose pathological changes. During the past twelve months, there have been very many additions made to it, and some of these of so peculiar character that I cannot but refer to them to-day. To that collection have been forwarded by four of the leading sovereigns of Europe-viz., the Emperors of France and Russia, the King of Sardinia and the Sultan-the infantry equipment of each country, generously and willingly contributed, in order that from each might be selected anything that might appear to be likely to conduce to the comfort and efficiency of the British soldier. Rightly regarded, these donations must be considered as expressive of a good feeling and liberality that cannot be too museum
highly appreciated.
The Hon. the East India Company, too, have as readily afforded their assistance, the Government of India having had prepared for this museum a very beautiful collection of specimens, illustrative of Indian diseases. And here I would beg to intimate, that it is to the Principal and Professors of the Grant Medical College of Bombay-particularly to Drs. Morehead and Ballingall-that this College is principally indebted, since it is through their exertions that it has become possessed of these very valuable preparations. All, gentlemen, that has been done during the past years has been effected with one great object-viz., that of preserving the soldier’s life. From the Queen downwards such has been the case. Her Majesty’s sympathy for her sick and wounded during the Crimean war must be known to all, and since peace has been declared she has manifested her desire for increased attention and care being bestowed upon the health of her soldiers, and to this end has directed a Royal Commission to be appointed. Now, addressing, as I do to-day, a mixed assembly of civil and military, I would wish to advert more particularly to the subjects selected for the consideration of this Commission, for it has been almost universally regarded, and erroneously regarded, as an inquiry affecting only the interests of the medical officers of the army, whereas it has a far wider and more extended bearing, for it is neither more nor less than the drafting of a great medical scheme for the future welfare of our troops. To place this in the clearest light, I will now lay before you an abstract of the directions which have been issued under the sign-manual for the guidance of the Commission. They are these :" Considering the great importance of maintaining and im. proving the health of all ranks of our army, at home and abroad, and of providing for their medical care and treatment in cases of wound and disease, in the most approved manner, we do direct an inquiry into the organization, government, and direction of the medical of our army. Firstly,-We command you to inquire into the mode by which candidates are selected for the medical department of the army, their promotion and service, their pay and retire-
department
ment.
Secondly,-Into the best means of keeping up, acquiring, adding to their professional knowledge. Thirdly,-Into the best means of preventing disease in our
and
army; accommodation in barracks and camp, at home and abroad; clothing and rationing of our troops, having regard to the various climates to which they are exposed. Fourthly,-Into the condition of our military hospitals. Fifthly,-Into the management of the civil hospitals of the country, and to consider whether any portion of such arrangements can be advantageously introduced into the medical department of our army. Sixthly,-Into the expediency of making provision in our military hospitals for the officers of our army, when suffering from injury or disease. And, lastly, we command you to report what changes you may consider it expedient to make in organization, management, and expenditure, with the view to the utmost efficiency of this branch of the military service."
I have here read her Majesty’s words, and from them ] would frame a reply to two questions that are put to me nearly every day. The first is, as to whether the pay, position, ami retirement of the army surgeon are to be materially increased’ and the second, as to whether, in the present state of uncer. tainty on this head, students ought to join the public service To both of these questions I reply distinctly, Yes. or not ?
Upon what authority
do I do so ?
Simply upon this-namely,
that the Crown has here implied its intention to effect suet alterations as are shown to be necessary, and the educational bodies of the United Kingdom have expressed their opinions that the present pay, position, and retirement of the army surgeon are insufficient. The Universities of Edinburgh and Dublin, the Royal Colleges of Physicians of London, Edin
burgh, and Dublin, the Royal Colleges of Surgeons of London, Edinburgh, and Dublin, the Faculty of Physicians and Sur geons of Glasgow, and the Colleges of Aberdeen, have one and all officiilly reported their corporate opinions on this head.
let me offer to you one word of It is this : In the course of your future service you will be brought into contact with a large number of individuals. You will at one time be under, and at another time in authority. Discretion and judgment are required in both these situations. You certainly may servein both in a manner that will carry you through, in the former without censure, and in the latter without odium; but this is not enough. Your endeavours should be from the very commencement, from the day on which you obtain your commission, so to discharge your duties as to command the esteem of all, but more especially of those of your professional brethren over whom you may be placed. You willfind by experience the advantages even which accrue to the public service from courteousness in professional intercourse, in the readiness with which duty is at all carried out, more especially so when any undue exertion is required. Better examples of the characters that I would hold up for your imitation cannot be adduced than by the mentioning of those who last in succession have retired from the medical charge of the garrison of Dublin, Peile, Pitcairne, and Maclean. The two former, still amongst us, connecting links between the great ones of the present and the past, venerated and beloved; the latter only just departed out of office, but taking with him into private life, from the service from which he is retiring, the warm regard and good wishes of all who have been brought into communication with
And now, in
conclusion,
friendly advice.
times
have done so through the Minister-for-War—a noble’ whose anxiety for the elevation of the profession has been avowedly declared; and their representations are certain tc receive assistance from the present royal head of the army, whose interest in all that concerns the welfare of the soldier is well known. This, then, is the authority on which I ground my first reply. In answer to the second question, as to whether you should enter the service now, and before this amelioration has been him. specifically announced ? I say equally, Yes. Why ? Because your services at the present time are urgently demanded, and REMARKS it is unknown to our profession ever to hold back when the ON THE country needs its aid. And now, gentlemen, let me offer to you a few remarks in INFLAMMATION AND BLOODLETTING reference to the advantages which are to be derived from the CONTROVERSY. the services. introduction of the public Firstly, competitive system insures the power of entrance to all who possess suffiBY W. O. MARKHAM, M.D., F.R.C.P., cient merit; and interest, that stumblingblock of former ages, PHYSICIAN TO ST. MARY’S HOSPITAL. stands no longer in the path of intellect and exertion. Se(Continued from page 573.) condly, although the absolute amount of the army surgeon’s pay, even after it shall have been increased, will be but small in comparison with the income which may be realised by priTHE more any one reflects on the subject of Bleeding and its vate practice, still it is attended with these great advantages : the more, I think, he will be convinced that the prineffects, viz., that of being a certain provision during the prime of life, and a sure retirement in old age. You, too, who are now about ciples which have been at various times laid down for our to enter will enjoy advantages which your predecessors never guidance in the matter are of an unsatisfactory nature. What did. To you the honours and rewards of war will be freely we evidently need is, that the proper uses of the practice ’open; and-the soldier’s highest aim-the Victoria Cross may should, if possible, be so explained as to bring them into some - one day hang upon your breast. Already two assistant-surgeons better accordance with the pathology of the present day. The wear, and more than two have merited, this proud distinction. And for what (where conferred) was it given? I will tell you. principles referred to are the principles of the ancients, and ,t)n the 8th of September, memorable for the attack upon the therefore cannot but be ill-suited to modern pathology. One Redan, when all in the immediate neighbourhood retreated cannot deny, it is true, that in the present condition of mediexcepting one officer (Lieutenant Hope), Dr. Egerton Hale, of cine, the conclusions arrived at respecting the general therathe7th Fusiliers, remained, endeavouring to rally back the peutical effects of remedies, must be drawn from their results men; and, failing this) he himself stayed to protect and attend He next, after the as observed in individual cases, rather than from any & priori a wounded brother officer, Captain Jones. regiment had retired into the trenches, cleared the advanced theoretical considerations of their action ; and in so far, physisap of the wounded, and carried in, under a heavy fire, several cians of former days might be considered as able judges of the wounded men from the open ground. matter as ourselves : but, nevertheless, theory, in the matter Assistant-surgeon William Henry Sylvester, of the 23rd Fusi- of bleeding, aided by modern light, may be allowed to suggest liers, received this distinction for going out, on the 8th of Sep- a few things as regards its practical effect. We cannot bleed, tember, 1855, under a heavy fire, in the front of the 5th parallel, to Lieutenant and Adjutant Dynely, of that corps, who was indeed, without in some way exercising our judgment as to the lying mortally wounded, and for dressing his wounds in that mocius operandi of the loss of blood. And if, indeed, it be posdangerous and exposed situation; and for his courage, on other sible to argue usefully of the way of acting of any curative occasions, "in going to the front under heavy fire to assist the means, wemay surely anticipate that we should especially be able nowadays to do so in the case of bleeding-the operation wounded. I bring these cases forward for your imitation and example; of the remedy being so direct, and its immediate eifects so A candid consideration of the subject and I do not think there can possibly be any occasion more fit- clearly appreciable. ting, or season more suitable, for the recording of professional will, I am persuaded, show us that theoretical considerations merit, than such an one as that on which we are assembled to- of the action of bloodletting are quite in accord with the reday-when the walls of this college are honoured by the pre- sults of our practical knowledge of it at the present moment. sence of the highest military authority in this land. Admitting that a typical case of pneumonia, as described by And yet there are those who object. I can only say that I Cullen, was in his days, and in all days before him, and still is pity the miserable feeling that exists in some men’s breasts, at the present day, a case in which bleeding is a right remedy, that jealousy of the deeds of others which cannot be overgot. if practised at a right moment, and that the necessity of the Thus it was that when, last year, I brought forward those operation may be judged of from the severity of the symptoms medical officers of the army who had obtained special decora- - from the state of the pulse, of the breathing, from the fever, tions during the Crimean war, some anonymous writer was &c.-admitting this, still it does not follow that the same symp" could have been a sufficient guide to practice in ordinary, of names as to such mention their pleased designate claptrap." Gentlemen, my reply to this individual is, that it will be to ! every-day cases. We know, indeed, that such well-marked me indeed most gratifying, and I believe to the country also, if symptoms are not our usual guides, and for the reason, that the record here to-day of Dr. Egerton Hale and Mr. Sylvester they beloug only to the rare and exceptional case. And if we should induce you in the hour of danger to imitate their daring enter a little into this matter, 1 believe we shall hardly fail to ( arrive at the conclusion, that he who trusts alone to these signs= example.
They
man
toms
595