PAR'[ ]V.

MEDICAL MISCELLANY.

Reports, Transactions, and Scientific Intelligence.

Introductory Address delivered at the opening of the Session of 1900-1 ia the Meath Hospital. By JA~ES CRAm~ M.D. Univ. Dub1.; Fellow and Registrar, R.C.P.I. ; Physician to the ~Ieath ttospital and County Dublin Infirmary; University Examiner in Medicine in the University of Dublin.

I a~ glad to be in a position to offer, on behalf of my colleagues and myself, a hearty welcome to the be~nners who come amongst us as students for the first time, as also to the old friends who are returning for a further, or it may be for a final, experience as medical students in hospital work.

Before asking you to listen to the several matters in which I shall more particularly claim your attention, a duty devolves upon me which I approach with sad reluctance--it is to record the losses which the hospital has sustained within the present year through the death of several of its most distinguished workers.

Mr. Glasgow Fatteson, who succeeded the late Sir George Porter, Bart., as Surgeon to the Hospital) had only five brief years of service in which to prove his worth before he succumbed, in April lasts to a chronic malady~ whose insidious invasion he fought to the last with admirable courage. At the time of his death he was one of the most brilliant of the younger surgeons in Dublin. He was clever, skilful, brave, and honest ; he taught will, for his knowledge was great; he operated well, for he knew what was necessary to be done and how best to do it ; and these, I fancy, are the attributes which a hospital surgeon should most desire to have associated with his memory.

Ill as we could afford to be deprived of a valuable worker like Mr. Patteson, the shadow of a yet greater loss Yeas soon to fall upon the hospital, for on the 18th of A u ~ s t the unwelcome tidings reached the city that Sir William Stokes had that day died of pleurisy in Pietermaritzburg. His appointment &~ Consulting Surgeon to the Forces in South Africa, his departure from Dublin

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at the commencement of the present year, and the services which he afterwards rendered by his experience and skill to our wounded soldiers at the front I need not dwell upon. Neither is it within my province here to speak of his surgical fame in the outer world, but I prefer rather to confine my remarks to the friend and teacher who has been lost to us in this hospital. Here, for twelve years, Sir William exercised his wonderful surgical skill in the relief of human suffering; here he delivered those clinical lectures which his remarkable gifts as a teacher made acceptable to the meanest intellect among his hearers. Of the care with which these dis- courses were prepared, and of the delight which accompanied the success of his teaching, I can bear ample testimony. Sir William was the type of truest gentleman--he was an enthusiastic worker, a model teacher, a great surgeol~, and a loyal colleague, whose place it will, indeed, be hard to fill.

I cannot but also refer to the death of another distinguished though past member of the hospital staff. Dr. Ar thur Wynne Foot was for twenty-one years a physician to this hospital, but owing to failing health he was compelled to resign his position in 1892. Few here, and certainly none of the students of to-day, had the great privilege of being taught by him, or of coming within his magnetic influence. No one is better able than myself to appre- ciate the misfortune which his retirement entailed on the hospital, for it fell to my lot to become his successor. I shall go no further now than to say that my old master was to me an object of reverence and deep affection, but, withal~ an ideal clinical physician whom it was possible to copy but not to equal.

The vacancies on the surgical staff created by the lamented deaths af Mr. Patteson and Sir William Stokes have been filled by the well-deserved promotion of our two former surgical assistants, Mr. William Taylor and Mr. Richard Lane Joynt.

The subject of Consumption, on which I have decided to en- deavour to interest you, is one of exceptional importance, and to myself a daily source of sorrowful contemplation. In point of fact, the duties connected with the medical work in the out- patient department, which formerly I approached with the greatest pleasure, have become so distressing that I now positively shrink from the difficulties that I am there forced to face. Numbers of patients suffering from consumption present themselves daily at the dispensary; they bring letters of recommendation from sub- scribers or not, as the case may be ; they have no means ; they are unable to work ; they should not be admitted to a general hospital,

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and so it is left to my colleagues and myself to get rid of them as best we can.

The members of the medical profession, in addition to rendering themselves competent in the treatment of the sick, have also im- posed upon them the grave responsibility of educating the public in the matter of the prevention of disease, and the purpose of my re- marks to-day is, if possible, to arouse the public conscience to the crying necessity which exists for a vigorous and sustained effort in endeavouring to lessen the prevalence of the national scourge of consumption, and to provide accommodation for the poor who have contracted the disease.

Nearly ten thousand people in Ireland die every year from pul- monary consumption, and these numbers do not include three thou- sand more who succumb to other forms of tuberculosis. Dublin itself, with a population of 350,000, is responsible for some 1,300 deaths per annum, and Belfast with practically the same population, is a good second with over 1,100 fatal cases in the year. On an average, therefore, 24 inhabitants of this city die every week from a disease which is now regarded as preventable. Several facts in connection with this astounding mortality arc worthy of notice : - -

(1.) In England the date-rate from consumption has been show- ing a steady decrease for the last twenty years, whereas in Ireland ehe reduction has been scarcely appreciable.

(2.) The death-rate in London from phthisis is less than one-half of that which obtains in Dublin.

(3.) The fatalities in our city from a combination of the principal zym(~tic or infectious diseases are leas than those caused by consumption.

(4.) The victims of consumption are chiefly the men and women between twenty-five and thirty-five years of age, who are the most active workers and bread-winners in the community.

The idea that consumption could ever be stamped out, in the same way that typhus fever has been rendered practically extinct in Ireland, may seem to many to be a chimerical one; but the advantage which we now possess in knowing the specific cause of the malady, and the evident benefits which have followed improved sanitation in regard to other forms of infectious disease, should encourage us to hopefully attack this the deadliest enemy to the health of our people.

I shall, in the first instance, d~vell with brevity on the manner in which the disease is acquired and spread, so that the methods which should be adopted to resist its occurrence and provide a possible cure may be the more readily understood.

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Consumption is due to infection by living germs from man or animals who suffer from the malady. I t is true, however, that the inheritance of weak constitutions, the employment at certain occu- pations, and the manner in which people live, are all factors in rendering some individuals more susceptible than others in acquiring the germs of the disease. Inhaling dust impregnated with the dried expectoration, or directly breathing the spray from their mouths while coughing, of those who suffer from consump- tlon must be regarded as the main source of the infection, although evidence is forthcoming in abundance to show that the milk and flesh of tuberculous cattle may be the means of introducing the germs into the body. Moisture and heat are as favourable to the growth of the germs as dry, fresh air and sunshine are inimical to it. The poor are undoubtedly the greatest sufferers from the dis- ease, and the reasons for this are not far to seek. Overcrowding, especially in a sleeping-room which fresh air never enters, insuffi- cient food and clothing, dirt and a general disregard of the most elementary laws of sanitation~ are a combination of conditions by which the germs of infection are encouraged to grow and spread with alarming rapidity.

How frequently does the saddening experience occur to many of us to witness the gradual extinction of a large family who, in theh. occupation of a tenement-room, have successively infected each other by reason of the conditions just enumerated! Probably the evil does not even rest with the destruction of the family referred to, for the clothing and bedding of the victims may find their way to the pawn-shops, and there become the property of others who acquire the infection from them. Indeed, the very room in which the family has lived and died~ unless it be thoroughly disinfected, will be a veritable death-trap to those who inhabit it later on.

I now come to speak of the methods which should be adopted to prevent the spread of the disease, and of necessity my observations must be confined to a few general hints. The teachers in the primary schools, who themselves will instruct the young, must be taught the importance of sunshine, fresh air, free ventilation, and cleanliness in the prevention of consumption. The Jubilee nurses afford one of the readiest metros of directly carrying into the homes of the poor the information as to the dangerous character of tuber- culous expectoration, the necessity for ventilation, fresh air, and whatever isolation may be possible. The employers of labour, in whose places of business numbers of workpeople are congregated together, must see to the proper heating and ventilation of the rooms, to the banishment of dust, and to the destruction of

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expectoration; while working in damp cellars is almost suicidal. Every movement for improving the homes of the poor, and every organisation to lessen the waste of money in the consumption of drink, should be encouraged.

The sanitary authorities should undertake a room-to-room and house-to-house dissemination of circulars containing practicable advice to be followed by persons infected. The excellent principle adopted by our Medical Superintendent Officer of Health to encourage notification of the disease, and the disinfection of the clothing and homes of those who suffer from or have succumbed to its ravages, should be rendered compulsory throughout the entire country. This much, at any rate, should be required without further delay~that thorough disinfection should be compulsorily carried out in every home where a death from consumption has occurred. The earliest symptoms of the disease should also be made known.

Finally, more stringent measures are required than at present exist to prevent the sale of tuberculous meat and milk, or their contamination by attendants who are themselves consumptives.

I have now at length reached the consideration of the more pressing evils whose existence demands our most earnest attention, so that a cure may be obtained before the disease has progressed, and, for the sake of simplicity, I propose to divide the consumptive poor, whose circumstances I desire to discuss, into three groups--

1. Those who, in an early stage of the disease, offer a fair expectation of cure, and are willing to subject themselves to isola- tion and treatment.

2. The consumptives who are the bread-winners of a family, and are, therefore, compelled to remain in their homes and engage in their daily work while any strength remains to them.

3. Those who, in the latest stages of the disease, are no longer fit to work, and to whom a hope of cure is practically impossible.

In regard to the first class, there is positively no accommodation provided in connection with this city to which pauper consumptives can look for treatment and a hope of cure.

I fully recognise the good work which is already being done by the Consumpuve Hospital at Newcastle, Co. Wieklow, but it is not available to pauper inmates: and it contains only thirty-two beds.

The second class is a large one. The individual probably occupies a room in a tenement house, where there is no attempt at reasonable isolation, especially by night, and so the other members of the family are almost absolutely certain to become infected.

The ease of the third class is the most pitiable of al]~ and repre-

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sents the final stages of the others. The sufferers are no longer able to work, are absolutely without means, are in the most infective stage of the disease, the general hospital is no place for their reception, and the co~lvalescent homes in connection with the city have one and all decided to close their doors against them. What , therefore, are the prospects to which they may look forward for the remainder of their lives? To remain half-starved in their miserable homes, spreading the infection to any members of the household who have still escaped i t ; in a few instances to gain admission to the Hospice for the Dying, where they will be cared for most excellently~ or finally to become unwilling inmates of the Union Hospital, where the conditions~ however excellent, are by no means the most suitable for the amelioration of the symptoms of advanced consumption.

I do not in the foregoing category include the l~oyal Hospital for Incurables, for although a most excellent organisation prevails there, still it is intended for a better class of patients than I am referring to, and a considerable amount of interest is required before admis- sion can be obtained.

The problem, then, which confronts us - -and it is one which the Public Health authorities in the city must conscientiously endeavour to solve--is~ by what methods the circumstances of each of the three classes whose position I have attempted to define can be most effectively improved.

Sanatoria, however rude, should be provided where fresh air and shelter would be available in the treatment of adults and children for whom a cure may be reasonably expected.

I t will not be out of place here to direct your attention to the way in which some of the other countries have endeavoured to cope with this world-wide scourge by the provision of sanatoria where the poor can be treated in the earlier and more hopeful stages of the disease.

France, in addition to several sanatoria for adults, has provided by priyate subscription two splendid institutions, with 350 beds, available for consumptive boys ; and over twenty ~caside sanatoria, very much like our own convalescent homes, exist, where from two to three thousand ehildren with a consumptive tendency are capable of being accommodated and restored to health.

Germany~ in 1895~ had only two sanatoria and two small houses where the poorer classes could be received for hygienic t reatment; but in the three years which followed nearly thirty of these insti- tutions were established~ and that~ too~ indirectly by the poor themselves ; for~ on account of the law which enforces compulsory

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insurance against sickness and old age on all whose annual income is less than ~150 per annum, the insurance companies were quick to realise that the readiest way to save themselves from the disburse- ment of sick pay was to expend a large share of the premiums they received in the provision of sanatoria for the treatment of consump- tion. The result is that, " At the present time, every large town and every district in Germany has its local Sanatorium Society, and often already its own sanatorium."

Russia was aroused to a sense of its duty in 1895 by a report from the medical practitioners of St. Petersburg as to the need of sanatoria for the treatment of the consumptive poor, and an appeal was made to the public for funds. This was followed by the for- mation of a Society under distinguished patronage, to which the Emperor Nicholas II. contributed a sum of nearly s for the erection and maintenance of a sanatorium in memory of the Empress Maria Alexandrovna, who was herself a victim of con- sumption, and, in addition to this, he handed over to the society a large property of his own where a famous sanatorium has since been placed.

Many more of these institutions have been also provided which are supported by individual and public generosity, by local r~es and by church collections.

In Norway the popular present to the King in commemoration of the 25th anniversary of his accession to the throne~ amounting to upwards of s was chiefly devoted by him to the establish- ment of sanatoria for the consumptive poor. In that country, too, I may say in passing, compulsory notification of the disease has become law, and many useful reforms have been enacted to prevent the spread of the disease.

Switzerland, Austria-Hungary~ America, the Colonies, and, in faet~ every eivilised country on the globe, is making provision for the proper hygienic treatment of consumptlon~ while in Ireland what has been done, although deserving of the highest praise~ is microscopic in comparison to the needs of the community.

Dnblin~ with nearly 1~300 deaths in the year from consumption (more than half of whom are among the strictly poor), can boast of the hospital in Co. Wicklow with its 32 beds, which have been provided and are maintained by public and individual generosity~ aided by the minimum charge of 5s. per week which the inmates are called upon to pay ; and Belfast~ with a mortality of 1,100 per annum, has 40 beds at its command in the hospital which was erected through the munificent contribution of s by the late Mr. Forzter Green.

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There the provision for the poor in Ireland who might hope to be cured ends.

I t is obvious, therefore, that sanatoria must be provided on a much more extensive scale than at present exists for the treatment of hopeful cases among the poor who are unable to pay for it.

I have no desire to propound visionary or impossible suggestions ; on the contrary, I am prepared to admit that we must content our- selves with small but gradual improvements. Tile hospital at Newcastle is capable of great extension ; let it be supported by every legitimate means known to the charitable public, let the rate- payers of the city and county-at-large be taxed with a small additional stun for this deserving purpose, and soon we shall find ourselves in a position to maintain not only 100 beds at Newcastle but several further hundreds in ruder shelters, where consumptives among the very poor may not be denied the curative influences of fresh air and wholesome food.

I am beset with apparently insurmountable difficulties when I approach the task of attempting to suggest any certain methods by which members of a family who inhabit a single room can be pre- vented flora acquiring the disease when one of their number who has become infected is compelled to eontinue to work. The real difficulty lies in the necessity for isolation at night. The evil would be minimised if due regard were observed in the matter of ventilation~ the frequent boiling of clothes, and the destruction of expectoration by fire; but as these precautions are almost unattainable, it is a question whether it would not be possible for the Public Health Authority either to provide a separate room in the same tenement house in which the infected person might sleep, or to set apart special houses which, under their own immediate supervision, might be utilised by victims of the disease who fear to spread the infection to their relatives.

This matter, I understand, is under the consideration of the Medical Superintendent Officer of Health and a few members of the Public Health Committee of the city, but practical suggestions on the subject from other sources would, I am certain, be gladly welcomed by them.

The pitiable condition of those who, in the latest stages of the disease~ are past work, are probably infecting others, and have no prospect before them but the Hospice for the Dying or the Union Hospital, is that which most directly appeals to myself in my daily work at hospital. Homes akin to the Hospice are an absolute neces- sity~ and the plain duty of the Public Health Committee is to draw the attention of the Corporation to the state of affairs which

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exists in the c i t y ~ v i z , that numbers of respectable half-starved consumptives~ who are a menace to public health, require a spot in which to end their days~ and for which the Uuion Hospital may be considered sufficiently adequate, but where they certainly are unwilling to die.

I cannot help thinking, in face of the facts which I have placed before you~ how far distant the realisation of the poet's dream must still b e -

"All diseases quenched by Science, no man halt, or deaf, or blind ; Stronger ever born of weaker, luetier body~ larger mind ! "

Let me, however, quote for your benefit the hopeful words of Dr. F. R. Walters~ to whose work on "Sanatoria for Consumptives" I am much indebted. He says~ in reference to Great Britain : - - '~ Our country's sanitary past has been great and fruitful~ and there is every reason to hope that with growing consciousness of the possibility of destroying this dread scourge of humanity~ by the abolition of town smoke~ the improvement of our dwellings~ the better ventilation of rooms and streets~ the admission of sunshine into our midst, the inculcation of more rational habits of life~ the destruction of sput% the erection of sanatoria~ and in many other ways~ she will gradually prepare for herself a still more great and glorious future."

This bright picture~ I am ~orry to say~ does not extend to Ireland~ for the neglect of sanitation is undoubtedly the cause of our great mortality from consumption ; nor are the prospects for the future as encouraging as they might be. The condition of the city of Kilkenny, as given to the public a few days ago, does not tend to diminish the stream of emigration from our shores~ or engender much hope for improved sanitation in the fu ture~no proper water supply~ no system of sewerage~ 300 cases of diphtheria in the past year, typhus and enteric fever always prevalent~ and the Urban Council ignoring for years the reports of their Medical Officers of Health and of the Inspectors of the Local Government Board as to the sanitary needs of the town.

I have no hesitation in saying that the action of the Govern- ment in the administration which is again about to take office is responsible for the neglected condition of sanitary reform throughout Ireland. The promoters of the Local Government Act of 1898 obstinately refused to put this country on an equal footing with England or Scotland. They refused to accede to ~he representations of the Irish College of Physicians to render it even permissive for County Councils to appoint l~Iedical Superintendent Officers of Health over a county or a group of

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counties, who, as experts and independent of private practice, would have, in conjunction with the existing Medical Officers of Health, done more in one year to establish efficient sanitation through~ut the country than can ever be effected by the present organisation.

Let us turn to a brighter subject. The fact that the two clinical medals offered by the medical staff of the hospital have been won this year by lady s tudents - -a feat not accomplished for the first time e i ther- -has induced me to give a passing glance at the position of women in the medical profession.

Of the three so-called learned professions, that of medicine was the first and for so far the only one to throw open its portals to women, and the success which has already been achieved by the lady doctors who availed themselves of the opportunities thus afforded to them is in itself sufficient proof of the wisdom which prompted the concession.

As far back as 1876 the Royal College of Physicians of Ireland was the very first medical corporation to give its consent to examine a lady for the licence to practise medicine. That the candidate who presented herself for examination was less fair to look upon than the one who had made the successful appeal, and that on this account the concession was almost revoked, is a rumour around which a vestige of truth may possibly hang ; but, however that may be, since the aforesaid date the College has granted its licence in medicine to no less than fifty-eight women, eleven of them being in conjunction with the Royal College of Surgeons. The Royal University, commencing many years later, has sent forth twenty- five sweet girl graduates in medicine and surgery, but the Univer- sity of Dublin has up to the present turned a deaf ear to the just claims put forth by women for the opportunity to obtain its ancient hall-mark of professional skill. Haply, however, in the near future~ a more progressive spirit will prevail in the Councils of the University and this injustice be finally swept away.

The chief claim put forward by the pioneers who fought for the opening up of a medical education for women was incontestable, and was briefly th is - - tha t , in case of illness, where one of their own sex was anxious to obtain the services of a lady doctor such a desire should be attainable. In addition to that, however, the estimable fact was patent that in this way an additional means of livelihood would be possible to women of education. I venture to think that the original motive in many instances in the present day has been consigned to the limbo of the past, and women are now entering the profession, to a large extent at all events, for the sake of

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individual work and the recompense which accrues to it. I t becomes, therefore, a matter of some moment for a prospective lady medico to consider what openings in the profession are available to her, and what chances of success in a medical career l ie before her, for a medical education is not only an expensive one but entails as well heavy and sometimes repulsive work.

The position which has been attained by numbers of lady prac- titioners, even in centres where the competition is keen, leaves the question of success a matter to be decided by the qualifies of the competitor. In the thirty years that have passed since the compe- tition first began it has been abundantly proved, however, that women in general are still quite content to leave the cure of their bodily ailments to the skill of man; but, at the same time, it is equally obvious that many women will readily avail themselves of the services of medical women where such services can be obtained.

In the Indian Empire, with its mission work, and later on, it may be, in China, there must be a wide scope for lady practitioners, but at home, apart from private practice and the openings which exist in the asylums for the insane, where many women are doing excellent work, few positions are as yet open to them.

The following notice appeared in the British Medical Journal several weeks ago : - -

APPOINTMENT OF A LADY LOGUM TENBNS FOR A DISPENSARY DOCTOR.

The Poor Law Guardians at Cookstown have appointed Miss Annie H. Cr&wford, M.B., looum te~ens for Dr. Bell, Pomeroy, at the r~te of three guineas per week. Both the Guardians and Dr. Cr&wford are to be congratu- lated on this progressive step.

This called forth a ~trong protest from Dr. Ar thur Wiglesworth, of Liverpool, who, by a remonstrance, expressed the opinion that " i f the option of choice remained to these poor people there would not be much cause of complaint, but to force the poor to bring their complaints before a female practitioner is a moral wrong of no mean order." Later on, Dr. Isabel Theme, of London--a pioneer of the medical education of women--contributed her views on the appointment in the following words : - - " I f it obliged men to consult a woman for medical aid I should strongly protest against it."

These, I fancy, are the old world views which most of us hold, and while I gladly take part in the medical edocation of women whose devotion to work is in the highest degree commendable, and while I watch their after success with the most unalloyed pleasure, I consider it to be ray duty to warn those who aspire to work in

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our ranks that their services will as yet be required only in a limited sphere of medical and surgical practice.

I have left myself little opportunity for offering a few words of advice to the students. I am not sure that the omission will be a matter for grief on their part~ but this much I must say-- that the keynote of your success in life will be work. I f you do not work in your student days, so as to enable you to take up a position for which your services will be fairly remunerated, I have no doubt but that in the toils of a rough practice in England you will con- sider you are reaping the harvest of neglected opportunities, even although you can reckon your yearly income by thousands.

Yet a still more serious aspect of the matter presents itself, for, by your neglect of the facilities for acquiring knowledge which are here afforded you, valuable lives may be allowed to perish which a greater experience and skill would possibly have saved ; so, there- fore, in ending by asking the students to take for their motto the words Earnestness, Industry, and Perseverance, and to give effect to that motto, I feel that I am pointing out the surest way to their future happiness and success in the noble profession to which they aspire to belong.

A L V A R E N G A P R I Z E O F T H E C O L L E G E O F P H Y S I C I A N S OF

P H I L A D E L P H I A .

TH~ College of Physicians of Philadelphia announces that the next award of the Alvarenga Prize, being the income for one year of the bequest of the late Senor Alvarenga, and amounting to about one hundred and eighty dollars, will be made on July 14, 1901, provided that an Essay deemed by the Committee of Award to be worthy of the Prize shall have been offered. Essays intended for compe- tition may be upon any subject in medicine, but cannot have been published, and must be received by Thomas R. Neilson, M.D., the Secretary of the College, on or before May 1, 1901. Each essay must be sent without signature, but must be plainly marked with a motto and be accompanied by a sealed envelope having on its outside the motto of the paper and within the name and address of the author. I t is a condition of competition that the successful essay or a copy of it shall remain in possession of the College; other essays will be returned upon application within three months aff~r the award. The Alvarenga Frize for 1900 has been awarded to Dr. David De Beck, of Cincinnati, Ohio, for his Essay entitled :

Malarial Diseases of the Eye."