No. 4184

NOVEMBER 7, 1903.

An AddressON

MEDICINE AND SCIENCE IN THE MODERNUNIVERSITY.

Delivered at the Opening of the New Medical School of theUniversity of Toronto on Oct. 1st, 1903,

BY C. S. SHERRINGTON, M.A., M.D. CAMB.,F.R.S.,

HOLT PROFESSOR OF PHYSIOLOGY IN THE UNIVERSITY OF LIVERPOOL.

PRESIDENT LOUDON, DR. REEVE, LADIES AND GENTLE-

MEN,-Believe me, it is a difficult thing for a stranger,even at your invitation, to address you on an occasionlike the present. So many significant events crowd in

upon him and time for reflection is needed to weld into

a connected whole the impression he would wish to offerto you. Not that the growth and doings of this Univer-sity have not been followed and watched with interest byus in the old country; on the contrary, your activity hasbeen felt not only as a matter of mutual congratulationbut as a spur to arouse us to effort in our own similar pursuitof educational aims. But the stranger coming among younecessarily feels the shortcomings of his acquaintance withthe details of these academic enterprises you have taken inhand. One advantage, however, is his. His view, gainedfrom a distance, necessarily has freedom and truth of per-spective that may give it a value in your eyes. Some thingslose by perspective. Some things large when close tohand dwindle when viewed from afar. Not so Canada. The

perspective given by the width of the Atlantic is but an

appropriate setting across which to view her greatness andher far-reaching activity. And this event, this academiccelebration, this diesfestus in your University to-day, retainsfrom afar off all the significance of a great event. It losesno tittle of its dignity and import when viewed across theocean from the crowded turrets of the older Cambridge or thehoary spires of Oxford. It shines, I assure you, like a beaconto the new university whose buildings are as yet unfinishedon the hill above the port of Liverpool.Coming from a region where history is long and the land

little, to this where written history is short and the expanseof land incomparably great, one realises how relative is size.And in regard to the event of to-day the largeness of thiscountry rises in my thought, not as a matter of mileage, butthat with you, more than with us in the old country, the sizeof to-morrow is vaster than the size of to-day. Each step ofprogress here, more than with us, has to be measured by itsample consequences in a more rapidly widening horizon ofthe morrow. These new laboratories have a field alreadydemanding them and a still larger lies before them in animmediate and historic future.

PURSUIT OF SCIENCE A CIVIC DUTY.

Biology is the study of life in regard especially to growthand to organisation. Every medical man is a biologist,and as a biologist it may be but natural if I regardto-day’s event from a biological standpoint and the com-munity as an organism and the university as a livingorgan essential to the healthy life of the community.Science-especially medical science-is growing in import-ance to the community. We must have organisation inscience as in industry. This University to-day makes pro-vision of first-rate importance for the organisation of medicaland allied sciences in the region which centres here.Capacity to rear and to support men constitutes the extentof a country, and population is the biological measure of thesocial organism. The ceaseless energy of the race has begunto plant a great population in this land. Growth, great andrapid, is inevitably before it. The growth of nations, as ofindividuals, requires the vigilance of guiding hands. Growthfor it to take its course rightly towards perfection requiresthat provision for the security and expansion of the liberalarts and sciences forerun rather than halt behind the actualrequirement of the hour. Not only for their direct utilitarianservice. They form a whetstone for man’s most universal tool-his intellect. Also a discipline for character in the pursuit

No. 4184.

of truth for its own sake. Scientific truth, when found, hasoften proved unpalatable to man-as when it dethroned himfrom his fancied seat at the centre of the whole perceptibleuniverse, a universe he had imagined simply subservient tohis needs ; or again, as when it taught him that instead ofbeing a creature altogether apart from brute creationthere are flesh and blood bonds between himself andthem. Regardless of its cost to his cherished fanciesman strives for scientific truth. And, as the old Greeksaid, this purpose puts him further from the brutes andnearer to the gods. In nurturing science I would urgethat a community cultivates more than mere utility. Andeven with regard to mere utility, as the fields of knowledgefall ripe under the ceaseless husbandry of the world’s

thought, those who would join in the great reaping andnot only glean where others reaped before them mustcultivate for themselves. To do this requires more than thedevotion of individuals. It requires the intelligent coöpera-tion of whole groups of individuals. Organised scientificinquiry becomes in advanced countries a conscious aim ofthe community as a community.

THE VARIOUS WORKERS.That society may draw due benefit from wells of natural

knowledge three kinds of workers have to stand side by side.First, the investigator who, pursuing truth, extends dis-covery with little or no reference to practical ends. Heconstitutes the fountain-head of the knowledge that is fordistribution. Other hands may reap the harvest but hisset and rear the seed. After the investigator comes theteacher. To him it belongs to diffuse the knowledge won.This honourable and difficult task receives its best rewardin seeing the small spiritual beginnings of a pupil wideninto the spiritual beginnings of a master. Thirdly, there isthe applier of natural knowledge. His part consists in

making scientific knowledge directly serve practical needs.It is this work which to the popular idea often representsthe whole of science, or all of it that is commonly termed’’ useful " The practical results of this work are often

astounding to those ignorant of the steps by which they havebeen reached. The greatest of these steps, however, is

usually the first one, made in the laboratory of the investi-gator. These three co-workers are co-equal in the priest-hood. Science and the applications of science are one

growtb, united together even as the fruit and the tree. The

proper hearthstone round which the community shouldgroup these labourers, labouring for a common end, is theuniversity. There the sacred flame of learning is fed frommany sides by many hands.

THE BIOLOGIST AS CITIZEN.It is sometimes said that pursuit of science renders a man

deaf to the appeals of practical life-that it tends to with-draw him from the everyday interests of the people. That Ido not believe of any science, certainly not of biology andthe medical sciences. Why, from their very outset thesesubjects draw the mind towards study of an organisationthe most complex and the most perfect it can examine.The ancient simile that our old school classic, Livy,drew between the human body and the body politic, theState, has not lost but won significance as the centuries haverun. The achievement of the microscope has been the dis-covery that living things, whether plant or animal-allliving things of more than minutest size-are commonwealthsof individually livirg units. These cells, as they are called,are living stones that build the house of life. In that houseeach stone is a self-centred individually-living microcosmindividually born, breathing for itself, feeding itself, con-suming its own substance in its living, and capable of, anddestined for, an individual death. Each cell lives by ex-changing material with the world surrounding it. In otherwords, its bulk depends on its surface Hence surface in-

creasing as the square, and volume as the cube, cell size iscircumscribed by tiny limits-microscopic limits. Had the

dependence been greater than it is and the averagesize of the cell less and too small for resolutionand discovery by the microscopes of 70 years agoit is hard to imagine where biology would stand to-day.For two generations every biologist has been accustomedto think in terms of the cell theory. Every shred of the

body he knows as an intricate interlacement, embodyingcooperation and mutual support of associate thousands ofindividually existent cells. Division of la,bour has gone onand with it differentiation of structure: while this group ofcells combines with its own inner life some special function

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subservient to the needs of the great commonwealth as awhole, another group is specialised for another duty againsubservient to the general needs. Each organism, with all itssolidarity, each one of ourselves here, is built up of livingmyriads. Each such organism consisted at the outsetbut of a single cell and from that in his life’s growth havearisen the countless myriads composing him to-day. Theblood relational? is close between all the cells of each oneindividual body. The cells of our nerves, of our muscles, ofour lime-hardened bones are all blood relations through onecommon ancestor. Yet so far has specialisation of theseunit lives gone on, so far does function reflect itself inmicroscopic form, that there is greater likeness between mynerve cells and the nerve cells of a fish than between my nervecells and my own muscle cells, despite the blood relation-ship between these latter. And in the commonwealth ofcells that constitute each one of us goes forward day long,night long, as in the body politic, the birth of new units toreplace the ones outworn, the subordination of many indi-vidual purposes to one, the sacrifice and destruction of theindividual life for the benefit of the many.

Trained in study of such an organism surely the biologistand the medical man will be the last to underrate the

importance of organisation to the community for the commonweal. Therefore I am rejoiced, but I am not surprised,that it is your Faculty of Medicine which to-day in its

public-spiritedness erects and instals these fine laboratories,this potent addition to the organisation of your communityfor its activities in medicine and biological science. I wouldalso, as a friend among you, offer you my congratulations onthe consolidation of your two schools of medicine. Unionmeans not only greater strength but the more effectiveapplication of that strength.

Two ASPECTS TO MEDICINE.

I need not extol medicine to this assembly. Many ofher votaries are here ; I venture to count myself as one. B it

to-day the relation toward her of education is a matter onwhich our minds are naturally set. Am I wrong if in regardto this it rises Mdiectly to me that from the educationalstandpoint medicine, like Janus of old, in a good sense,bears a double face? 7 On the one hand, she is an empiric.She has learned to cure by what the comparative psychologistcalls the ’’method of trial and error "-conquests over ick-ness acquired purely as the result of experience without helpeither from a priori or from inductive reasoning. And greatand glorious is the r6le of her achievement on these linesOf her humanitarian triumphs probably still-certainly untila generation ago-the greater share is assignable to this

part. The use of quinine in malaria, the curative effects ofthe iodides and various metals, the discovery of chloroformand ether as anesthetics—these and the names of a long lineof famous physicians from the Renaissance down to some asjustly famous as the past and with us now to-day suffice tocertify the inestimable gifts that medicine as empiric hasgiven to sundering mankind. This face of medicine may wellwear a garland.

In her other aspect medicine is not an empiric but ascientist. Who will refute me if I assert that medicineis as well an art as a science ? 7 S0mewhere it is said thatwoman is the last thing man will ever civilise. So thescientific aspect, the male face of two-visaged medicinethinks of that female face, the empiric, wilh whom his lotis linked. He feels sometimes that his othf-r half is the last

thing science will ever render wholly rational. By dint ofpatient toil he improves her praftice, showing her a

reason now and then. No so ner that than she is off (-n a

fresh flight into the inexplicable and he must cudgel hisbrairs anew to find her a fresh logical position.That feminine, ever-youthful trait in medicine has to the

student an UI d3 ing charm. But on the whole the countenanceof medicine has of recent Je1fS for the student becomemasculinely severe. The masculine head of medicinehas in eed become the larger. Hydrocephalic even in

appearance, yet is it filled not with water but withreasoned facts. All this development proceeds in the mainfrom certain data acquired in the century lust parsed. Thchemi.t, in discovering that all the million-sided chemicaldiversity of the perceptible universe is composed fr<lma few-some 70&mdash;substances, therefore called elemental,discovered also that living matter instead of containingelements different from and subtler than those of thedead world, consists of just a few of the commontst o’

those same ones. Further, the doctrine of the indestructi-

bility of matter was demonstrated in a new form-namely,

as the indestructibility of energy, and the convertibilityof any one form of energy into other forms. Thus dead andliving matter have become united as subject material forstudy. It became really possible to consider the living bodyas a chemical and physical machine, a machine to which thelaws of chemistry and physics can be applied. But thisscientific progress in medicine, fruitful of benefit to the

community, lays on the community a burden of obligation.HISTORICAL SKETCH.

The empirical part of medicine is’at once the most easyand the most difficult thing to teach. The preparation forlearning it requires but little training in other subjects. Itsfacts lean on nothing but themselves.With the scientific part of medicine it is different. That

is based upon initiatory studies. Medicine, historicallytraced, we find first drawing help from the simplest and

nearest at hand of these adjuvant studies. First she bent

to the study of the gross form of the parts and organs of thebody. The gross form of these is significant chiefly wherethey are machinery for application of mechanical powers.The greater part of the corporeal machinery is, however, notdestined for such work, but has its purpose in processes,chemical, thermal, and electrical, to which-marvellousappendage-mentality is adjunct. Medicine in the courseof the seventeenth and eighteenth centuries sucked dry forthe most part what the study of the gross form of the body’sparts could yield her. She then turned to the study of micro-!-copic form-examined what Bichat first named the tisslles,the fanric of the body. In so doing she came upon a greatgeneralisation, the cell doctrine, discovering an essential andvisible similarity of microscopic structure in all that has life,differentiating it from all whi(h has not life.But even before the advent of the cell theory medicine had

begun to ask of chemistry what it could give her. With thediscovery of oxygen and of the nature of combustion thelinks between biology and chemistry began to be tightlydrawn. The young Oxford physician, Mayow, had per-formed the fundamental experiments on respiration and haddiscovered oxygen more than a century before Priestley andLavoisier. But the time was not ripe until the stupendouswork of Lavoisier had founded modem chemistry. The celltheory was from the first not only morphological but

physiological. It meant, for the application of chemistry tobiology, that the chemistry of the body or of one of its organswas a chemistry resultant from a thousand tiny livingfurnaces, individual seats of oxidation, deoxidation. poly-merisation, hydrolysis, and what not. Not only that, butthe living laboratory of the cell itself manufactures even themedium in which the cells themselves exist : the saps and

juices of the body. And we are beginning to know, thanks topathology, that every species of animal produces an internalmedium specific to itself. Further, your distinguishedphysiologist here, Profest-or Macnllxim, who has done so muchto reveal the distribution of the chemical elements within thecell, tells us that the internal medium which the cells of eventhe highest animal forms produce, as appropriate for them-selves, still approximates in its t-alts to the water of theancient geologic sea-- in which their ancestry aro-e and stillreveals in fact the composition of that ancient ocean. Inthat respect these living ce)]s, with all their flux of change,have been more durable and constant even than acf an itself.The contrast bring-! home to us a deep nihtinrtion betweendead matter and living-the latter a moving equilibrium,gaining stability from the very motion of itself. f.

’I he bonds between medicine and chemistTy with Schwannand Pasteur were drawn still tighter by their dcnveriesconcerning those subtle influences named " ferments."Pathology, the study of the-e processes of the body indisease, even more than physiology as yet has drawn helpfr.om this part of modern chemistry. If the processes ofhealth are in fact the resultant of the due c<’operation often million little foci of healthy chem’cal action in the body,the processes of disease are similarly divisible and have to betraced to the unhealthiness of certain of the-e minute centresof activity. How extreme is the importance of chemistry tomodern medicine no single statement can perhaps em. husise,-o well as this-that is, I believe, acknowledged rn all hands-that in virtue of his chemistry a chemist. Louis Pasteur,during the latter half of last century was ahle to domore to alleviate the diseases of mankind and animalsthan any single physician of his time. To the physicistalso medicine has made appeal From him she has

got understanding of the body’s heat, the basis of the

knowledge of fever; she has learned the intricacies of

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the mechanism of the eye and refined methods of examining ’that organ and of remedying many of its defects ; the laws 1

that govern the circulation of the blood, and the subtlest 1means of detecting the forces liberated in the working of 1the nervous s3stem. In some cases, as sciences grow, their I

discoveries seem to sunder them the further one from Ianother. In my belief that merely shows they are at theoutset of their careers. To-day we find physics andchemistry converging and conjoining within a field of

physical chemistry. It early became convenient to have aspecific name for living material wherever found. The name

given was ’’ protoplasm." " It might have been better to call

it " x " or " y " so far was it in many respects an unknown

quantity. Instead of looking forward to this material as achemical entity we incline now to regard it rather as a fieldfor chemical action satisfying certain particular conditions.Probably discoveries regarding these conditions will fall tothe physical ctemist, perhaps in a future very near at tund.Probably such dis-coveries will be among the most valuablethat medicine has yet received from any source.

MEDICAL EDUCATION.I have said enough to remind us how interlocked with

science medicine has become. She is applying sciences toher own problems and they form a vast capital fund fromwhich she can draw wealth. To give instruction in this partof medicine, to turn out men trained in it, is now one ofthe duties of a medical school. The earnest student hasa right to expect such training from his alma mater.But for it the requirements are importantly different fromthose that suffice as an introduction to empiric medicine.In the first place, as Pasteur said, we cannot have the fruitwithout the tree. For scientific medicine the student mustperforce be thoroughly trained in his sciences before he canreally grasp instruction or truly profit from his medicalteaching. One of the aims of his instruction in empiricalmedicine is to teach him to observe for himself. So in hisinstruction in scientific medicine one of its aims is to enablehim to apply science for himself. How small a fraction ofall the realities of medical practice can be met in the fewyears of preparation of the student in the clinic as he passesthrough it in his school career. His teacher knows that welland uses the cases there as types whereby the principles ofmedicine can be fixed as a beginning. The rest must be

accomplished by the man himself as his life’s work. Themore necessary that the man go forth from his schoolequipped, not only with the present applications of scienceto disease, but so possessed of root principles of the sciencesadjunct to medicine that he may grasp and intelligentlyuse the further developments of scientific medicine after heis weaned from his instructors and the school. That is a

way to obtain enlightened progress in professional practice.What truer safeguard can a man have, alone it may be, andisolated from the centres of knowledge-what truer safe-

guard can he have against all the pseudo scientific quackeriesof the day than some real knowledge of the principles of thesciences along whose lines the discoveries of medicine mustdevelop ?

BURDEN ON TEACHERS.

Therefore it is that the burden of obligation falls heavynowadays upon the teaching resources of every faculty ofmedicine worthy of the name. There is, in the first place, theburden of increased intellectual labour. For both the learnerand teacher is this true. To seize the proffered assistanceof these great and complex sciences is not always easy.These studies are more difficult than those that were neededonce and they take longer to acquire. The mere instru-mentarium of modern chemistry and physics as applied tomedicine, and of physiology and pathology and bacteriologyand of hygiene of itself suffices to bring conviction of theincreased difficulty and longer training due for these studiesnow preparatory to medicine. Further, these initiatorystudies have become vastly more costly than was all thatformerly was required. Experts have to be found who candevote themselves heart and soul and undividedly to theirparticular subject. Laboratories have to be erected andequipped and on a scale that makes them a distinct featureof the modern world. Those that we see now here are

models of their kind ; wise foresight has planned them ;public-spirited enterprise has constructed them accordantwith that plan. Nor does the achievement end with theirerection. The laboratories and their equipment are but thefactory and the plant ; both fail in their purpose if they haltfor sustenance. And beyond that the likeness does not go.

The factory, once started, if it be wanted, can expect to pay,to support itself. Not so the laboratory. The laboratory isboth a school of instruction and a school of thought. Well,no higher instruction can be expected unaided to pay theexpen-es it involves ; it can only do so at the expense ofthose who come to learn, and that is to ut its teachingbeyond the reach of all but the wealthier few. And theinstruction is costly. for it has to be practical.

’ Another source of expense is that the laboratory has notonly to distribute knowledge but to manufacture it. Theduties of a university do not begin and end with the dis-ciplinary and didactic. Besides schools of instruction theymust be schools of thought. T be this latter the lat oratorymust pursue research. Even for the welfare of the class-

teaching this is essential. Instructive lectmes may be givenby men of ability the whole of whose knowledge is second-hand, but it is doubtful whether the real lite ot science canbe fully felt and communicated by one who has not himselflearnt by direct inquiry from nature. Nothing mere augmentsthe teacher’s power of impressive and incisive teaching of asubject than to have faced problems in it h mself as anoriginal inquirer. And after rudiments have been once fairlyacquired there is for good students no training equal to thatgiven by following even a small research under an experiencedleader.

SCHOOL OF THOUGHT.

So, truly, does the laboratory become a school of thought.Your laboratories are arranged with admirable provision forresearch. The student should enter on his study of a naturalscience through the portal of its fundamental experiments.The attitude his mind thus takes is the true one-the onlytrue one-for further insight into the subject. Too oftenhumanistic studies at school have tended to kill the naturalphilosopher within the child-to destroy that innate curiosityfor facts, the healthy heritage of childhood. He leaves schoola little bookman. Even as to the phenomena of nature hehas been insensibly led to ask for statements upon authorityrather than to turn his own senses and observation to the

phenomena themselves. To learn a science or to acquire anart resting upon sciences the first thing to do is to look atthe fundamental facts for ourselves. Our great teachers ofmedicine teach upon this plan. They teach where theylearned, not in the library, but at the bedside of the sick.In laboratories such as those raised here for pa’hology andphysiology students can learn these sciences as medicineis learned in the hospital ward, by direct inquiry into nature.The teachers you give them are men who have won widelyrecognised distinction as themselves direct inquirers intonature. Worthy students will appreciate this double boontheir alma mater gives them-the means of learning at firsthand those secrets of nature which lie at the root of theircraft’s skill, and to learn them under guidance by men whoexcel in unravelling such secrets.

ENGLISH ACTION.

Only by enabling men to continue their learning after theirteaching is over can we secure the greatest advantage anyeducational system can afford. Your laboratories here will

encourage post-graduate work. We look with keen interestto the researches that will flow from them. No subjects offerfiner fields for research than do the progressive studies,physiology, pathology, and hygiene, to which your newUniversity buildings are consecrated. And of the functionsof a laboratory, research is not the least costly. We in theold country find that. Our central Government has donelittle to support research. Our nation, proud of its successin things practical, has been prone to despise the abstractand the theoretical. We do so foolishly ; we do so at ourperil. Behind all practical application there is a region ofintellectual action to which, though our practical men havecontributed little, they owe the whole of their supplies.Theory, if a goose. is the goose of the fairy tale that laysthe golden eggs. No more such eggs if once you let her die.To speak of theoretical knowledge slightingly is for the lipsof the fool. The value of abstract research to a country isbecoming more widely acknowledged among us than it was.Sir John Brunner said the other day at Liverpool that therewas no better investment for a business man than the

encouragement of scientific research and that every pennyof the wealth he possesses has come from the application ofscience to commerce and to manufacture. And we find thatmunificent citizens have, and do, come forward among usand meet by their individual gifts the pressing needs in thisrespect of our community at large.

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NEW ERA DAWNING.But we welcome a new era dawning on us. Liverpool,

Birmingham, Sheffield, and other great centres begin to

regard the local university as an institution entitled to

support from the public means-for instance, by subsidy frompublic rates. Such subsidies can be used also for studieswhich do not come within allotment from the smaller subsidyfrom the central Government-medicine,. for instance.Proud of the young universities-to which yours of Torontois a time-honoured veteran-communities and local govern-ments are encouraging research within our universities.They do not expect such research to be able to pay its ownway, but they recognise that indirectly it does pay the

community that gives it a home. They feel it a duty whichthey owe themselves. Is not the university a part of theirown life, and is not research a part of the university’s lifeblood ? They feel it a right due to their own higher selves.It stimulates progress. Supported by the large-handedsympathy of the community and the local government, itmeans quicker advance, both material and mental, it meansinvention, and it means medical discovery. And qui facitper ali16m facitper se is a moto worthy of a State.

USES OF LABORATORIES.

What, then, are finally the uses of these laboratories nowopened by your University ? They will assist in training menfor various honourable callings, especially for that mostancient one of medicine. They will assist, no doubt, also torender life by practical applications of science superficiallystill more different from what it was only a short generationago. They will assist to bring home and to distribute to

your community treasures of knowledge from all the quartersof the globe. They will themselves assist-and it is a thoughtdear to a high-spirited people-to add to the sum total of thetreasures of knowledge of the whole human race. "Noblesseoblige " appeals to chivalrous nations as well as to chivalrousindividuals.But their highest office seems to me, perhaps, not even

these high ones but a more difficult still. Genius can-

not by any community, however wealthy and powerful,be made to order. In biblical language it is the giftof God. All a community can do toward obtaining it, beour riches and willingness a thousandfold what theyare, is to ensure the rare and glorious plant a meed offreedom, light, and warmth for blossoming upon our soil.Who can doubt that in this population here genius exists-not sown, it is true, broadcast, for nowhere is it thus-yetexistent, scattered up and down ? This it is for the com-munity to foster, to discover. By help of these finely builtand complete laboratories this much in one direction can bedone. The problem to which a wise country turns is thediscovery less of things than of men. By these laboratories,adequately supported, your community can create oppor-tunity for the exercise of powers which come from sourceswithin itself but are utterly beyond its power to produce atwill. Their loftiest function is creation of this opportunity.For that aim the studies in them must be followed with nosingle narrow technical purpose but must be wide of scopeand full of access to every rank of student. So shall theselaboratories prove a corner-stone for the upbuilding of a

temple of knowledge and a touchstone for the best ore ofintellect within the bounds of this great land.

CHARING CROSS HOSPITAL. - On Thursday,Dec. 10th, a dance will take place at the Whitehall Rooms ofthe Hotel M&eacute;tropole, under the patronage of Princess Louise,the Duchess of Argyll, President of the Hospital, theDuchess of Devonshire, the Duchess of Sutherland, theDuchess of Marlborough, and the Duchess of Portland, withthe object of raising a fund for the renewal of the floors ofthe old wards of Charing Cross Hospital. The music will be

supplied by the string band of the Royal Engineers.MOUNT VERNON HOSPITAL FOR CONSUMPTION.-

On Oct. 27th Lord Zetland, President of the hospital,formally opened the newly erected east wing. This

hospital, which is situated on Hampstead Heath, con-

tains 145 beds. The present extension has been erected ata cost of .E16 000 and the cost of the whole building amountsto .E43,500, or .6300 a bed. Of the 45 beds provided in thenew wing the committee does not feel justified in openingmore than 25 at present as it still needs a sum of 10,000to defray the cost of the extension, furnishing, and othercharges.

The Bradshaw LectureENTITLED

SOME OBSERVATIONS ON TUBERCULOSIS OFTHE NERVOUS SYSTEM.

Delivered at the Royal College of Physicians of Londonon Nov. 5th, 1903,

BY E. F. TREVELYAN, M.D., B.Sc.,F.R C.P. LOND,

HONORARY ASSISTANT PHYSICIAN TO THE LEEDS GENERAL

INFIRMARY; PHYSICIAN TO THE LEEDS SANATORIUMFOR CONSUMPTIVES; PROFESSOR OF PATHOLOGY,

YORKSHIRE COLLEGE, LEEDS.

MR. PRESIDENT AND GENTLEMEN,-My first duty is t0

acknowledge the honour done to me in asking me to givethis lecture and to express the hope that I may prove worthyof it. I propose to address my remarks (1) to the formswhich the tuberculous infection may assume in the nervous

system ; (2) to the mode of infection of the brain and

meninges ; (3) to some points in diagnosis connectedwith spinal puncture ; and (4) to the possibility of recovery.I have to express my obligations to my colleagues on

the staff of the Leeds General Infirmary for permission touse the records of 114 fatal cases which have occurredduring the past 20 years in that institution. I must alsothank Dr. Ursula Chaplin for much able help in laboratorywork. To Professor S. Delepine and Professor G. SimsWoodhead, Mr. G. Dean of the Jenner Institute, and Dr.Steegmann of the Royal Commission on Tuberculosis I amindebted for some virulent cultures of the tubercle bacillusand to the last-named also for valuable references.

FORMS WHICH THE TUBERCULOUS INFECTION MAYASSUME IN THE NERVOUS SYSTEM.

The various forms of tuberculosis of the nervous systemconsist of tuberculosis of the dura mater, tuberculous

meningitis in its more general and limited forms, tuberculousmasses in the brain and cord, and a possible miliary tuber-culosis of the brain itself. An old question mentioned byRilliet and Barthez many years ago has been much dis-cussed lately as to whether it is possible to have a tuber-culous meningitis without the presence of tubercles, or atany rate with only a minimal tubercle formation. Such anaffection has been compared to certain benign tuberculousaffections of joints and serous membranes and the name oftuberculous meningopathy has been suggested to distinguishit from the ordinary fatal form of tuberculous meningitis.Poncet,2 Patel, Sepet,4 and Galliard are the chief ex-

ponents of this view and the subject has been well sum-marised by Bouclier6 in a recent Lyons thesis. Amongthe 114 fatal cases at the Leeds General Infirmary thereare 14 in which thickening or exudation is noted at thebase of the brain without visible tubercles. Cerebralsymptoms were present before death in 12 of thesecases and abundant tuberculous lesions elsewhere in thebody in all. I think it is fair to conclude that tubercleformation was at its minimum or even absent, at any rate insome of these cases, and that the changes noted were amanifestation of the tuberculous infection and were respon-sible for the symptoms. It has been suggested that thepoisons of the tubercle bacillus may cause this more

exudative or serous form of meningitis. Armand Delillehas separated a poison which produced in his experimentsproductive tissue changes. On the other hand, the poisonsof the tubercle bacilli injected intrameningeally may causerapid death, as in Martin and Vandreuver’s experiments.7Sicard states that the tubercle bacillus and its toxin canproduce exudation and granulations. In three instancesof intrameningeal injection of measured quantities of

1 Rilliet and Barthez: Maladies des Enfants, 1854.2 Poncet: Bulletin de l’Acad&eacute;mie de M&eacute;decine, 1902.

3 Patel: Gazette Hebdomadaire, December, 1902.4 Sepet: M&eacute;decine Moderne. 1902.

5 Galliard: Soci&eacute;t&eacute; M&eacute;dicale des H&ocirc;pitaux, 1902.6 Bouclier: Th&egrave;se de Lyon, 1902.

7 Martin and Vandreuver: Soci&eacute;t&eacute; de Biologie, 1898.8 Sicard: Ibid., 1898.