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LONDON: SATURDAY, JANUARY 9, 1897.

THE elevation of Sir JOSEPH LISTER to the Peerage is anevent to be regarded with unqualified satisfaction. Nothingis more noticeable than the universal approval which it hascalled forth from all quarters. The press of every partyand shade of political feeling has been hearty in its praiseof the creation of the new peer and so far from regrettingthe departure has pleaded for an even wider recognitionof the claims of medicine. The fact is a very signifi-cant one and will go far to encourage our statesmen to be

less timid in extending, or rather in using, the Royal pre-rogative to create peers at pleasure-a prerogative which hasnever been disputed. Though the unanimity of the pressand of all parties in this matter is very gratifying it is

satisfactory to notice that the new departure has been

taken by a Conservative Minister-or, to speak more

accurately, by the Conservative head of a Unionist Ministry.When the party taking such a step forwards is one whichis supposed to stand on ancient ways, and one most aptto see the difficulties and the objections to innovations,there is the more assurance that the advance will not

be retraced, but that with favouring circumstances it

will be succeeded by others in the same direction. HER

MAJESTY’S appreciation of the services which medicine

has rendered to humanity is well known. Her loyal andconstant confidence in those distinguished members of theprofession by whom she has been faithfully served has

been an example to the public. In the many anxious times

of her history when she, and her people in sympathy withher, have been awaiting the issues of life and death she hasever known how to support her medical advisers by hertrust and to reward them with her favour. We are quitesure, therefore, that when her responsible Ministers came tobe of opinion that medicine should be honoured by a

representative in the House of Lords they found no

difficulty in getting HER MAJESTY’S gracious consent.

That such a proposal should have been made by the

Marquis of SALISBURY will enhance the satisfaction of SirJOSEPH LISTER. His Lordship is not only at the head ofa powerful Ministry, but his knowledge of science, andthe fact that he has himself been President of the British

Association for the Advancement of Science, increase thevalue and significance of a medical peerage granted uponhis recommendation. Sir JOSEPH LISTER may well dwell

on the fact of his progression in honours and the divisionof the credit cf them between the two most conspicu-ous statesmen of the country. It was Mr. GLADSTONE

who, under HER MAJESTY’S authority, conveyed to SirJOSEPH LISTER the intimation of his baronetcy, and whodid so with every expression of personal satisfaction.And now it is the Marquis of SALISBURY who, in fullsympathy with the public opinion of Sir JOSEPH LISTER’S

merits and his world-wide fame, calls him into that

branch of the Legislature where his rare knowledge andforesight may serve to guide legislation in ways of safetyon questions deeply affecting the health and happiness ofthe empire.We have treated this action on the part of Lord SALISBURY

and his Ministry so far from a purely public point of view,conceiving the admission of members of the medical pro-fession into the House of Lords as an obvious advantage tothe public and the House. There is a deep faith in theSecond Chamber, which faith will be strengthened by theaddition of men of commanding character and wisdom,who have not been called to it by the accident of birth.

To Sir JOSEPH LISTER himself this elevation will bringstrange associations and varied thoughts. He is too deeplyabsorbed in the great problems of modern medicine, whichexcite hopes beyond the dreams of our immediate

predecessors, to be spoiled or dazzled with the con.

ventional grandeur of his new position. But he maywell be trusted to appreciate the honour to him and

to his profession which it implies, as well as the

responsibility. We do not expect him to develop anynew ardour in party politics or even to hear of his fre-

quent participation in debate. But for all that we expecthim to be a power on occasion in defence and furtherance

of the health and happiness of the people and, if need be,of the profession of which he is a most distinguishedleader and ornament. To that profession at large the eventis very pleasing. Had a plebiscite of all British medical

men been taken for the nomination of one man the

vote must -have been unanimous in favour of Sir JOSEPH

LISTER. He was one of the most careful of surgeonsand one of the most successful. Whether his patient wasa hospital patient or a private patient he had the samecare for him. But beyond his solicitude for individual

patients he was ever the scientific seeker after those

truths the bringing to light of which resulted in the

establishment of the antiseptic treatment, with its splendidresults. For thirty years at least he has unceasinglypursued this end with a result in the saving of life com-

parable only to that effected by EDWARD JENNER.In conclusion, we have only to say that our own gratifica-

tion is complete. For years we have urged this step onsuccessive Ministries as eminently indicated by the wants ofthe public and the importance of the profession. Verylately we even ventured to suggest both the step which

Lord SALISBURY has so happily taken and the individualname which he has selected. We have waited long tosee the realisation of our wishes and have been conscious

sometimes of almost impatience; but this is not the timeto complain. Lord SALISBURY has, indeed, made this

year a notable one for medicine and infused fresh encourage-ment into the hearts of those who pursue it, and he will

long enjoy the gratitude of the profession for a new

and truly statesmanlike departure.

RATHER more than ten years ago we drew the attendedof readers of THE LANCET to the importance which thrust

1 THE LANCET, July 17th, 1886, p. 143.

114

wounds of the orbit possess from the very great fatality or

which follows their infliction. The extreme thinness of the th

bones forming the roof and inner wall of the orbit makes inpenetration of the cranial cavity by a slight thrust from an or

umbrella, walking-stick, foil, pipe-stem, &o., ea?y of attain- m

ment, whilst the elasticity of the skin and orbital contents ar

causes the wound of entrance to appear of far less con- si:

sequence than it really is. We can find excuses for the a

surgeon of bygone days, who was chiefly dependent on the tc

few cases of surgical interest which could be seen when T.

walking the hospital of the period for the experience vf

which was to guide him in future life and who could ir

obtain but limited information from books. To-day the tl

conditions of professional training and practice are quite k

changed, For years the medical press has been accumu- o

lating cases of the rarer diseases and injuries until almost b

all that can be known about them has been placed before s

the profession. At intervals we have considered it advisable x

to make a 7’Mm.e of our knowledge on some subject and take tl

thought of our position with regard to it. As regards the fi

subject of which we are writing now no advance has, in our CI

opinion, been made during the time which has passed since w

we last drew the attention of our readers to it. When cl

investigating the subject a few years ago 2 we found the w

mortality from these injuries to be over 90 per cent., p:and we think this excessive mortality to be the result tl

of the policy of non-intervention which was formerly tl

the bane of abdominal surgery. If the surgeon is aware, IE

as he should be, of the dangerous character of wounds fe

inflicted by thrusts of the kind under consideration, t]

harmless though they appear, he has no excuse for not rl

treating the case in the same manner as he would treat b

a punctured fracture of any other part of the cranium with a

probable injury to the brain. Careful examination of the t’

wound must be made, the track rendered as far as possible b

aseptic, foreign bodies and bone splinters removed, and v

adequate provision made for drainage. This need not t

involve the loss of the eye unless that organ has been irre- t

parably injured by the instrument which caused the t,

damage. Nor need the scar which must result from the f,

operation cause much disfigurement ; this muit not, a

however, be allowed to weigh with the surgeon in the v

face of the great danger to life. "Waiting for symptoms "

c

cannot be too strongly condemned in the light of "

our present knowledge; this course, which is so much 2

the easier in the presence of a wound which is appa- 1

rently of trifling extent, is almost invariably a fatal one. sSometimes, however, brain substance escapes from the (

wound and there is no doubt that the brain has been 1

penetrated and severely injured. The indication is then clear, 1

but not always followed. We know of two or three cases of ithrust wound of the orbit which have been recently under J

treatment in hospitals in which it was decided to wait forsymptoms ; all proved fatal. As the late Mr. HULKE 3 wrotesome years ago of the course of events after such injuries :11 Of brain symptoms there may be none. Two or three daysmay pass over, during which the patient goes about as usual ;then brain symptoms make their appearance, sometimes

suddenly, and the patient dies in the course of a few hours

2 THE LANCET, July 4th, 1891, p. 15.3 A System of Surgery, vol. i., p. 585 (Holmes), third edition.

or days, and the true nature of the case is revealed only bythe post-mortem examination." The portion of brain usuallyinjured is not very important in the carrying on of the

ordinary cerebral functions, and the inflammatory mischief £

may be too extensive for repair when the symptoms whichare supposed to justify interference are first noted; the

surgeon may not find the abscess should there be one (as ina recently published case) ; or the fatal event may supervenetoo rapidly although the symptoms are delayed for a week.The cases of recovery to which we have access are not

very numerous. Sir FBESCOTT HEWETT,4 in his lectures on

injuries to the head, mentioned two. The first was

that of a boy aged four years who fell with a cheese

knife in his hand. The point of the knife entered the

orbit, and on its withdrawal, which required force,brain substance followed. He recovered and was well

seventeen years afterwards. The second case is taken from

MORGANI. A young man received a punctured wound inthe left orbit, became paralysed on the same side, and hadfits on the opposite side with aphasia and delirium. He then

complained of pain in the right ear, and in three weeks therewas discharge from the ear ; after the cessation of the dis-charge he recovered. LAPLACE had under his care a man

who received the end of a foil in the left orbit. Coma with

paralysis of the right side of the body and left side of £

the face rapidly ensued. The pulse rose to 140 and

the temperature to 1045°. On the fourteenth day the

left temporal region was trephined; the dura mater wasfound to be congested; a platinum wire was’ passed to

the cavernous sinus and about a drachm of blood clot

removed. The trephine opening was plugged, and a tightbandage applied. He recovered, but with some ansesthesiaaround the orbit and internal squint. It was supposedthat the foil had entered the sphenoidal fissure. HULKE’ 5

had a patient aged thirty-six years under his care,

with the vulcanite mouth-piece of a pipe embedded in

j the orbit, who recovered ; but it is not certain that. the dura mater was wounded. BEAUMONT’S 7 case is his-

torical. A man who was watching the firing of a rocketfelt a sudden blow in the left eye. A piece of wood five, and a half inches long, the transverse section of which3 was four-tenths of a square inch, was extracted with did’’

culty. A profuse gush of blood followed, but was arrestedf with the application of iced water. He suffered severe head-1 ache and vomiting for the first twenty-four hours, but was- not rendered unconscious. He lost vision in the eye on that

. side and had anmsthesia in parts supplied by the infra’e orbital nerve. Three years afterwards he was in good health,n but had an impaired memory. Mr. A. F. HAWKINs re-

’, moved a piece of broken knitting-needle nearly three inchesf in length from the orbit of a child three years of age whor had fallen on it. The child appeared somewhat dazed forr a moment, but went on with her work. On the fourth morn.

e ing there was paralysis of the left side, more marked in the: upper than in the lower extremity. The end of the needle

’s was about three-quarters of an inch from the puncture in the

4 Medical Times and Gazette, 1858, vol. i., p. 237. See also THE LANCET,1827-8, vol. ii., p. 817.

5 THE LANCET, Dec. 19th, 1891, p. 1405.6 THE LANCET, July 4th, 1891, p. 15.7 THE LANCET, June 14th, 1862, p. 626.8 THE LANCET, July 17th, 1886, p. 144.

115

skin. The paralysis continued for ten days after removal ofthe needle, then began to subside, and afterwards rapidlypassed off. She was quite well a year later. Mr. GODLE]J

and Dr. PoPE9 had a patient under their care who hadreceived a stab from the point of an umbrella in the

left orbit. Much shock and vomiting followed. Later

he had aphasia, epileptiform seizures, paralysis of the

right side of the face and tongue, and somewhat irregulartemperature. He recovered. A horse-hair drain was placedin the wound about the third day and replaced by a small

drainage-tube on the eighth day, which was shortened on thethirteenth. The wound was twice explored and the questionof trephining considered. PoLAiTJjON’s 10 case was that of a

boy aged eighteen years who had the point of an umbrellathrust through the roof of the orbit. He was found in a stateof coma; the foreign body had been removed with difficulty.An incision was made in the forehead and a portion of thefrontal bone chiselled away; the dura mater was incised

and some blood and cerebro-spinal fluid escaped; five

splinters and a portion of damaged brain-substance wereremoved and a small artery tied with catgut ; the debris

of the eyeball was enucleated and a drain passed fromthe frontal wound through into the orbit. The patientbecame conscious in a few hours and had no bad symptomsafterwards. Healing took place well and quickly. In

THE LANCET of Jan. 2nd, p. 38, will be found the accountof a case under the care of Mr. A. WINKFIELD, where thewound was carefully drained at first, and on the occurrenceof symptoms at a later date trephining was resorted to withmuch benefit. HuLM’s’1 statistics on the subject show thediminished mortality which follows surgical interference inall cases of foreign bodies in the brain when the surgeonoperates at the present day and observes modern precautions.

THE increase of longevity is one of the main objects ofall work in the field of preventive medicine, and the questionits longevity increasing 2 is only another form of the stillmore pertinent question-" Has the recent development ofpreventive medicine yielded any tangible results on the

duration of human life ? " At this season of the year in-

dustrious paragraphists in some of our lay contemporariesoften exercise their ingenuity by tabulating the ages of

persons whose deaths were announced in their obituarycolumns during the recently completed year. It may be

interesting to some of the readers of a newspaperto learn, for instance, that during 1896 its obituarycolumns contained notices of 7743 deaths, 1141, or

nearly 15 per cent., of which were of persons agedupwards of eighty years, and that 165 were deaths

of nonagenarians. It is scarcely necessary, however,to point out the absolute futility of this class of statistics,even when we are further told the proportion of the

announced deaths of octogenarians in a given newspaper ina series of years. A high proportion of deaths of agedbersors may be due to the epidemic prevalence of influenza,or be the result of exceptionally severe weather, but thisBB’rm!c1 not prevent this class of statistician from claimingit as evidence of so-called "longevity."

9 THE LANCET, June 19th, 1886, p. 1158.10 Sajous: Annual of the Universal Medical Sciences, vol. iii., A38.

11 University Medical Magazine, Philadelphia, 1892, vol. i.

If we would seek an answer to the question Is longevityincreasing "? we must consult a very different class of

statistics. The series of Life Tables published by the

Registrar-General during the last fifty years clearly provethat the mean duration of life in England is steadilyincreasing and that this increase is an increasingrate of increase. During the thirty years 1841-70

the English death-rate was practically stationary at 22 per1000 ; in other words, preventive medicine was only able inthat period to counteract the deleterious effect of the con-

stantly increasing aggregation to towns. Under the stimu-

lating sanitary influence of the Public Health Acts of 1872and 1875 the national death-rate fell in 1871-80 to 21 per1000 and further to 19 per 1000 in the decennium 1881-90.

The effect of this marked decline in the English death-rateis clearly shown by the three principal Life Tables publishedby the Registrar-General. For instance, the mean durationof the life of males, according to Dr. FARR’s Life Table,

based upon the mortality statistics of the seventeen years

1838-54, was forty years; according to Dr. OGLE’S Table,based upon the ten years 1871-80, it had increased to forty-one years ; and by Dr. TATHAM’s Table, based upon themore recent decennium 1881-90, it had further increased to

nearly forty-four years. Thus the mean duration of life

among males has increased under the influence of preventivemedicine by four years during the past fifty years. The

increase of longevity among females has been still greater.Thus the mean duration of life of females, which was not

quite forty-two years by Dr. FARR’s Table, rose to nearlyforty-five years by Dr. OGLE’s Table and to forty-sevenyears by Dr. TATHAM’S Table, showing a total increase offive years in the same period.Some are inclined to depreciate the value of this increase

of the mean duration of life in England in recent years,because it is mainly due to the reduction of mortality inchildhood. It is indeed true that after middle life the

expectation of life has not increased, and has, indeed,slightly declined. The effect of this is, however, far morethan counterbalanced by the largely increased proportionsof persons who survive childhood and reach middle life.

Thus, as has been pointed out, there has been a very con-siderable increase in the proportional number of years lived

by succeeding generations between the most useful age-

period of from twenty to sixty years. This may clearly beclaimed as one of the results of the labours of preventivemedicine. It remains to be seen whether further sanitaryprogress will make it possible to entirely counteract theeffect of the increasing intensity of competition and the

struggle for existence and survival which undoubtedly arenow depressing the expectation of life after middle age.

If, therefore, longevity signifies mean duration of life therecan be no doubt about its increase in England in recentyears. If, however, by longevity is meant the chance of

middle-aged persons reaching extreme old age, English LifeTables do not supply so satisfactory an answer to our

question.

So far back as Oct. 17th, 1885, we referred in an annota-tion beaded "A New Objection to taking Oath," to the

possible risk of infection from kissing the Book when takingthe oath in a court of Jaw. Allusion was madP. s that

116

annotation to the circumstance that a medical man, Mr. i

STRATHEM of Middlesbrough, on being summoned to

give evidence in a case of drunkenness objected to swear e

on the Testament, not for the ordinary reason, but on J

account of the risk of infection. The objection astounded ’the legal authorities, who ruled that it was not a con- c

scientious objection within the meaning of the Act. The i

witness at length swore under protest. Remarking on

these facts it was observed at the time that " it

must be allowed that there is something in the objection."In the following year we published a letter from Dr.

HARK1’ES9 of Derby complaining that when giving evidencein the Divorce Court he had been required to kiss the samebook which had just previously been handled and kissed bytwo common prostitutes. His objection to do so on the

very possible, not to say probable, grounds of infection

afforded much amusement to the late Mr. Justice BUTT and

some members of the Bar present, while other members

supported the witness in his very reasonable objection.Ultimately, at the suggestion of the learned judge,Dr. HABKNESS kissed the open Book, though, as

he urged in his letter, this did not prevent his

handling an unclean thing. Many more letters, annota-tions, and articles too numerous even to summarise

followed, and then the Oaths Act, better known, perhaps,as Bradlaugh’s Act, was passed. This Act, as is well

known, relieved all persons who, like its author, had no

religious belief from taking an oath, permitting an

affirmation instead of it. It continued to relieve

also from the necessity of taking an oath those to whose

religious belief it was contrary. It also contained a

section (the fifth) which has already become memorable

and promises to become more so. This section per-mitted any person to whom an oath is administered who

desired to do so to swear with uplifted hand in the

form and manner in which an oath is usually admini-stered in Scotland. When this section became known

to us, we used every effort to make it known to our

readers and to induce them to take advantage of it. Here

a serious difficulty occurred. Though the Act had for sometime become law its fifth section was wholly unknown to

many of those whose duty it wa to have had it at their

fingers’ ends-legal coroners, stipendiary magistrates, judgesof county courts, recorders, registrars, and magistrates’clerks. Medical witnesses on claiming their rights underthis section were treated not only illegally by being askedquestions clearly contrary to the words of the section, butwere also treated with rudeness and incivility. Indeed,such was the prevailing ignorance that Mr. ASQUITH,then Home Secretary, was moved to issue a circular to

all coroners’ and magistrates’ :clerks, calling their attentionto the section and its provisions. Even this did not preventsome magistrates from acting illegally, as duly recorded inour pages. Fortunately a change for the better is at hand.The Times in its issue of last Saturday published a letterfrom Mr. FRANCIS A. STRINGER, of the High Court of

Justice, author of "Oaths and Affirmations," and an

undoubted authority in all that relates to the oath. In

this letter he, with a courage and boldness much to

his credit, condemns the English form of oath as

liable to spread syphilis. He gives the forms in

use in France, Belgium, Austria, Spain, and Italy’and shows that kissing the Book is unknown in any

of these countries. He also shows that the Scotch

form, like the French, is much more solemn than the

English one, and that though anyone may take it, not

one witness in a thousand knows of the existence of the

section of the Act which permits it. Consequently the

uncleanly English oath remains in general use, for unless

a witness asks to be sworn in the Scotch form the

usher has no choice but to administer the usual

English one. Mr. STRINGER concludes a most able

letter by suggesting the bringing in a Bill to providea short simple form of oath similar to that of Scot-

land and so making it uniform in the United Kingdom.The limes of Monday had an excellent leading article

supporting Mr. STRINGER’S views and condemning the

English form of oath on all grounds. What will, we

trust, prove to be the beginning of a most interestingcorrespondence has commenced in the columns of our con-temporary, and will, it is to be hoped, aid in the reform forwhich we have so long contended,

Annotations."Ne quid nimis."

NEW YEAR HONOURS TO THE MEDICALPROFESSION.

THE New Year has brought to the medical profession, inthe person of Sir Joseph Lister, the honour of a peerage.This is a departure in the bestowal of titles which all willwelcome-and welcome not only because of the spirit whichhas suggested the offer of nobility to Sir Joseph Lister, butbecause of the undoubted deserts of the recipient. We makefurther reference to this grateful topic in a leading article.Dr. Richard Douglas Powell has received the honour of abaronetcy. Dr. Powell has for many years been a leaderin the profession. He is physician to the Middlesex Hospital,consulting physician to the Brompton Hospital, and authorof an excellent book on pulmonary disease. He is Senior

Physician Extraordinary to Her Majesty the Queen and hiswell-merited title was expected for him by all his friends.Mr. William Raymond Kynsey, C.M.G., receives the honourof a knighthood. The Hon. Sir William Raymond Kynsey,a, retired surgeon-captain in the army, is a member of the

Legislative Council of Ceylon and Inspector-General of

Hospitals and Asylums in the island. Deputy-Surgeon-General Charles Benjamin Mosse, C.B., receives a Com-

panionship of the Order of St. Michael and St. George.The new C.M.G. is the superintending medical officer ofJamaica.

___

THE FIGURES OF THE MEDICAL PROFESSION.

THE Medical Directory for 1897 shows the numbers of theprofession to have again increased, as they have done

steadily for the last decade. This time the number ofnames included is greater by 958 than it was last year, theincrease being the largest but one that has ever occurred inthe course of one year. The exception occurred in 1894,when the number of practitioners was greater by 1062 thanthe number in 1893. The increase is fairly distributedbetween town and country and between the respec-tive countries of the United Kingdom. The London

list has gone up from 5835 to 5992 ; the provincial list for

England from 14,702 to 15,081 ; the list for Wales from 1028to 1062 ; the list for Scotland from 3264 to 3369; and the