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FEBRUARY 21, 1925.

THE

Lunterian Oration ENTITLED

JOHN HUNTER AS A MAN.

Delivered before the Royal College of Surgeons ofEngland on Feb. 14th, 1925,

BY SIR D’ARCY POWER, K.B.E., F.R.C.S. ENG.

HUNTER AS A PIONEER.

MR. PRESIDENT, LADIES AND GENTLEMEN,-Broughtup, as I have been at St. Bartholomew’s Hospital,in the straitest sect of the Hunterian School, Imight fairly claim some knowledge of the pioneerin surgery, the anniversary of whose birthday weare assembled to celebrate to-day. Sir WilliamSavory, my revered master, learnt from Sir WilliamLawrence, and he from John Abernethy, who him-self sat at the feet of John Hunter and was everafterwards his eulogist. But much as I had heardof John Hunter a reperusal of his works has shown mehow little I really knew about the originality of theman, of his limitations, or of the handicaps underwhich he worked. It is on these subjects that I shallspeak to you to-day, and my wish to do so is the greaterbecause the principles of surgery which he laid downhave fallen somewhat into the background, being over-shadowed by advances in chemistry, physics, andphysiology, by the advent of bacteriology, and by thework of Lister.

I want you to think first of John Hunter as a pioneerin the philosophy of surgery, not as a skilled operator.Like all pioneers, he lived and worked alone, for noneof his contemporaries could think as he thought orsee what he saw. Like Vesalius and Harvey, he hadLo educate a new generation to foster his ideas andexpound his thoughts.ZKeos.—The limitations of John Hunter are

obvious. He was hampered by a defective educat,ion.He had an almost mediaeval respect for words as words.He could not express himself clearly either in writingor by word of mouth when he dealt with the more diffi-cult problems of surgery which he knew existed thoughhe was unable to solve them for want of the ancillarysciences. He was a gross teleologist. His metaphorswere often strained and sometimes wholly false. Hewas confessedly ignorant of the work of his surgicalcolleagues and foreign contemporaries, and, as I shallshow presently, he suffered from frequent and severeattacks of illness which would have incapacitatedanyone possessed of a less dauntless spirit. But whenwe have said this we have said all there is to sayagainst him as a man.Handica.ps.-Now consider his handicaps. There

was no chemistry in his day, no physics, no acquain-tance with minute anatomy, for the microscope wasnot; yet in common use, no knowledge of animal cells,hardly even a theory of fermentation to account fordisease, because humoral pathology and the doctrineof climatic conditions still held sway.

Joseph Black discovered " fixed air " or carbondioxide in 1754 : Priestley prepared " dephlogisticatedair " in 1774. Three years later Lavoisier called it"

respirable air " or " oxygine," and taught the truenature of the interchange of gases in the lungs.Hunter by this time had done much of his work onrespiration. The want of a well-calibrated thermo-meter vitiated many of his experiments on animal heat.He was obliged, therefore, to stumble along and explorethe fields of surgical knowledge as best he could, forhe was half a century before his time. He would havegotten the true explanation of many of his facts hadhe been born in 1778 instead of in 1728. With allthese limitations and handicaps he often arrived verynearly at the truth, and his writings are full of themost astounding presages of knowledge to come,

presages which have been fulfilled for the most partby the advance of science, although some still awaittheir accomplishment.

Animal Heat.Hunter’s methods and the advances he made are

nowhere seen to better advantage than in his experi-ments and observations on animals in regard to theirproduction of heat. Just a century earlier his greatpredecessor, William Harvey, who equalled him inoriginality of thought and excelled him in logicalexposition, had dealt with the subject of animal heatin the seventy-first essay of his treatise " De Genera-tione Animalium." John Mayow had solved theproblem at Oxford in 1674, but he died young and the" Tractatus Quinque " fell stillborn from the press.He left no successor; his discoveries had to be madeafresh and applied by others more than a hundred yearslater. Albert Haller, who did so much to advancephysiology in general, was not particularly interestedin the subject of animal heat, so there had been nomaterial change of thought about it in the centurywhich separated Harvey from Hunter. It is fair,therefore, to compare the two monographs, bearing inmind that Harvey was already well-stricken in yearswhen he wrote on " calidum innatum," whilst Hunter-aged 38-was in the prime of life when he performedhis experiments, although they were not elaboratedand published until 20 years afterwards.Harvey is trammelled throughout by his knowledge

of history ; his treatise is filled with quotations fromAristotle, yet he arrives at the very practical conclusionthat the heat of the blood in animals during life isneither fire nor derived from fire as the ancientsthought. It is a principle inherent in the blood, buthe then loses himself in speculating whether or not theblood is the Soul or Life itself.Hunter starts in a very different manner. The

lapse of 100 years had given him an instrument ofprecision-the mercury thermometer invented byFahrenheit in 1720-whilst the work of Black hadafforded some insight into the composition of theatmosphere and the interchange of gases. But thescience of physics had not advanced sufficiently toenable Hunter to appreciate the relationship of heatto cold. He speaks of animals which " seem to possessa power of generating cold," whilst to him, as in thetime of Harvey, heat was still a principle. How newan instrument the thermometer was is shown by aletter to Jenner on July 6th, 1777, in which Huntersays :-

" The thermometer is very useful when understood. Youwill observe the scratch upon the glass stalk, perhaps about2 inches from the globe, which is the freezing point.Put 0 or nought which is upon the ivory scale 2 degreesbelow the scratch, the 0 becomes the thirtieth degree and thescratch being 2 degrees above it stands at the freezingpoint ; then from that count upwards ; or, if the cold isbelow 30 then put 1 or 2 at the scratch and count down ;every No. is 10 degrees. What the devil becomes of youreels in the Winter ? but try them in the Summer and seewhat you can make of them."

Jenner does not seem to have been very fortunatein his management of the thermometer. A few yearslater Hunter writes chaffingly to him : " You arevery sly although you think I cannot see it. You verymodestly ask for a thermometer. I will send you one,but take care that those damned clumsy fingers do notbreakitalso." Nevertheless, even with such inadequateinstruments Hunter set out to determine experiment-ally the cause of animal heat not only in differentvertebrata and invertebrata, but also in the vegetablekingdom. He came to the conclusion that " animalheat is owing to some decomposition going on in thebody in pretty regular progression, though it is notthe process of fermentation." He thus gave for thefirst time the correct answer to a problem which hadbaffled philosophers from the earliest days. He thenadds the very important statement : " I expect theblood has an ultimate standard heat in itself whenin health and that nothing can increase that heat butsome universal constitutional affection." Ignoranceof the functions of the nervous system prevented him

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from studying the mechanism of heat regulation inanimals, though he distinguished clearly between thehomoiothermic and the poikilothermic-the warm-and the cold-blooded-for he says " the expressionshould rather be animals of a permanent heat in allatmospheres and animals of a heat variable with everyatmosphere." A strange perversity led him to spoilhis result, for he limits the place of heat production to" some part of the body, perhaps the stomach," and

by ill fortune it did not occur to him to measure thefever in disease.

The Causes of Disease.The shifts to which John Hunter was put to explain

the general principles of disease in his ignorance ofmicro-organisms are both interesting and ingenious.He was in the position which we occupied until latelyin regard to tubercle and syphilis and where we stillstand about cancer. He knew the clinical facts butcould not interpret them, for he had no knowledge ofthe part played by micro-organisms.How near he got to the truth is shown by his defini-

tion of disease when he says : " The most simple ideaI can form of an animal being capable of disease isthat every animal is endued with a power of actionand a susceptibilily of impression, which impressionforms a disposition, which disposition may produceaction, which action becomes the immediate sign ofthe disease ; all of which w ill be according to thenature of the impression and of the part impressed."This seems at first sight to be a mere cloud of wordshiding nothing. Interpret it by latter-day knowledgeand it shows how far Hunter had advanced in surgicalpathology. What he calls the power of action we nowspeak of as the predisposition to disease or the diathesis ;the susceptibility of impression is the infective organism ;the disposition is the exciting cause, and the action isthe manifestation of the disease by signs and symptoms.Take tuberculous arthritis as an example. The tuber-culous diathesis (power of action) allowed the tuberclebacillus (the susceptibility of impression) to settle inthe joint in consequence of a sprain (the disposition),and the joint then became hot and swollen (the action).He says, indeed : " A true specific disease is one

that probably cannot arise but from one cause andwhich probably always belongs to morbid poisons."He gives as an example " Scrofula, which is one ofthose diseases that is supposed to be hereditary, but itis only a readiness to fall into the peculiar action whenproperly irritated that is hereditary, and when sucha cause does not exist we find no scrofula."

Surely nil nisi clavis deest, the key alone is wanting,and the key was not forged until Pasteur and Lister--the master locksmiths-came to maturity more than70 years after the death of John Hunter. He was evena little in advance of the earliest Listerian teaching,for he showed by experiment that " air simply has nopower to excite inflammation." He returns over andover again to the problem of the causation of diseasewhen he is considering the causes of inflammation.Thus he says : " It is the cause producing inflammationwhich is the disease and not the inflammation itself,for all inflammations that can be called diseases havespecific causes." And he is driven at last to confessthat " inflammation may arise from a vast variety ofcauses with which we are at present unacquainted,nay, which we do not even suspect."

THE HUNTERIAN SCHOOL.

If Hunter was born half a century too soon to allowof his genius giving the best results, the span of his lifecoincided with the time needed to establish a schoolof scientific surgery in this country. No great surgeonsexisted in England from the death of Richard Wisemanin 1676 until William Cheselden began to make hisreputation by teaching anatomy privately in 1711.The industry of Mr. G. C. Peachey has shown thatHunter was not the first to hold private classes, as ademand had already grown up for more advancedteaching than was provided by the formal lecturesat the United Company of Barbers and Surgeons-lectures which had once been of the greatest service

to surgery but which in process of time had becomeobsolete. Cheselden, Nourse, Chovet, Sharp, and Potthad lectured to large classes before Hunter, but theydealt only with their own experience and with surgeryin its clinical aspects. It was left to John Hunter toinvent surgical pathology. His teaching only appealedto a few, and his lectures were sometimes attended soscantily as to give point to the story of his orderingthe skeleton to be brought into his lecture-theatre thathe might address the audience with the usual prelude" Gentlemen."How then did the school spread from such small

beginnings ? His few pupils became the leaders ofthe next generation of surgeons. Sir William Blizardof the London Hospital; Henry Cline of St. Thomas’s;Astley Cooper at Guy’s ; John Abernethy at St.Bartholomew’s ; Anthony Carlisle at the Westminster;William Hey at Leeds ; Philip Synge Physic and hisnephew John Synge Dorsey in Pennsylvania receivedthe Hunterian teaching with enthusiasm. These greatsurgeons transmitted their knowledge in turn to SirBenjamin Brodie, Sir William Lawrence, Joseph HenryGreen, John Collins Warren, and Valentine Mott,who in their generation became teachers at the greatschools of medicine in England and in America. Theteaching of John Hunter was thus disseminatedamongst the rank and file of the profession, whilst thedoctrines he enunciated were so novel, so ingenious,and seemingly so heterodox as to become the subjectof acrimonious discussion. Attention was thusdrawn to them and they quickly found their way intoa text-book so widely read as Benjamin Bell’s " Systemof Surgery," and they thus became public knowledgeboth at home and abroad during the lifetime of theirauthor.

But something more is needed to account for therapid diffusion of Hunter’s teaching. It is to be foundin the spirit of devoted affection which he inspiredin his pupils and in all with whom he was brought intopersonal contact. Those, who like myself have beenpupils of Huxley, of Rolleston, and of Ray Lankester,can easily enter into their feelings of hero-worship.Adams says of him : " He was almost adored by therising generation of medical men who seemed to quotehim as the Schools, at one time, did Aristotle."

Rough, coarse, and prone to anger as he was inlater life, he had the personal magnetism inherent inevery great teacher, whether of religion, philosophy,science, or even quackery-a magnetism whichattracts kindred spirits, rarely amongst contem-poraries, generally in a younger generation. Thus itwas with John Hunter. To his pupils he was " theDear Man " with whom they were in constant com-munication either by letter or by word of mouth andto whom they looked for guidance and instruction inthe experimental methods he had taught them to usein scientific surgery.

THE HUNTERIAN TRADITION.

The Hunterian tradition passed down the nextcentury in two great streams, theory and practice,uniting sometimes but for the most part flowingseparately, because it was only now and again that asingle mind could embrace the whole. Both streamstook their source in a sound knowledge of humananatomy gained by daily dissection. The streamsparted early. Blizard, Astley Cooper, Hey, Physic,Gibson, and Dorsey became great operating surgeonsand advanced the teaching of Hunter along the linesof arterial surgery, the anatomy and treatment ofhernia, and the pathology of fractures and dislocations.John Abernethy, on the other hand, developed thephysiological side of surgery and investigated thecauses of disease and its non-operative treatment, forhe took but little pleasure in the manipulative partof his profession.

Sir Benjamin Brodie was great enough in the secondgeneration to combine the science with the art ofsurgery-the theory with the practice. He wasequally good as a morbid anatomist and as a clinicalsurgeon, whilst his general knowledge of science enabled

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him to fill with distinction the important position ofPresident of the Royal Society. Joseph Henry Green,the Hunterian orator in 1840, alone followed Hunteron the metaphysical side and delved so deeply intophilosophy that he soon lost himself in speculationand did but little to advance the practice of surgery.

Sir James Paget in the third generation developedsurgical pathology on truly Hunterian lines ; whilstSir William Savory was more interested in the teachingand dissemination of the surgical principles laid downby John Hunter, though he was a skilful operator, anddearly loved to tie an artery or extirpate a tumourso placed as to demand all his knowledge of anatomy.You, Sir, like myself and many others of the fourth

generation hold firmly to the teaching of John Hunter.We recognise with thankfulness the great work whichhe accomplished, but we realise it was the work of apioneer and that the fields he pointed out are beingexplored by methods and by instruments of which hehad no conception. The museum, Sir, has alwaysbeen your especial care, but you have not neglectedthe equally important subject of teaching both byexample and precept. You have shown, too, so

enlightened an interest in the habits and customs ofthe beasts of the field and the fowls of the air as wouldhave drawn you very near to the heart of John Hunterhad you been privileged to sit at his feet. To you alsohe would most certainly have been the " dear man."

THE MENTALITY OF JOHN HUNTER.The attitude of John Hunter to Nature and the

human body always had something of the poetic in it,and was akin to the feeling expressed by Longfellowwhen he wrote of Agassiz :

And Nature, the dear old Nurse,Took the child upon her knee

Saying, " Here is a story bookThy Father has written for thee."

Hunter looked upon Nature as a conscious person-ality. He says: "Everything in Nature involves twoconsequences, the one beneficial, the other hurtful.But if we understood thoroughly all the remote causeswe should probably see its utility in every case." Hespeaks of muscles as " being conscious of their actionsand almost endowed with reason." "Nature," hesays,

" acts purposively in the repair of dead bone,"and " the clot adheres to the side of an aneurysm froma consciousness on the part of the artery of the weak-ness of its wall." He says in like manner that" Naturelays claim to and removes what she pleases," andhe speaks of two surfaces lying in contact with eachother and " agreeing mutually not to inflame." Healso maintains that the first and immediate cause ofthe absorption of tissues is " a consciousness in theparts to be absorbed of their unfitness or impossibilityof remaining under such circumstances, the actionexcited by the irritation being incompatible with thenatural actions in existence in the parts whateverthese are : wherefore they become ready for removalor accept of it with ease."The blood, too, is for him so living a tissue that

the clot " has the power of becoming vascularised initself," and when blisters and setons have been usedas derivatives to draw off the humours he " is unableto ascertain fully how they act, that is, how far thereal disease is invited and accepts the invitation."

, A MARTYR TO SCIENCE.

I wish now to draw your attention to a new aspectof John Hunter’s life. It has always been assumedthat the statement was the truth, the whole truth,and nothing but the truth, which was made by SirEverard Home in 1794-the year after his brother-in-law’s death-that " the symptoms of Mr. Hunter’scomplaint for the last 20 years of his life may beconsidered as those of angina pectoris and form oneof the most complete histories of that disease uponrecord."

Reading the account of his illness in the light ofnlodern knowledge it seems to me that John Hunter

died of syphilitic disease of his arterial system, andthat, in addition to the angina pectoris due to thiscause, he suffered for many years from cerebralsyphilis. Both conditions were due to the action ofthe spirochetes with which he deliberately inoculatedhimself in May, 1767. He may be looked upon, there-fore, as one of the great martyrs to science. Personally,I do not think lie was justified in this martyrdom, forthe consequences of his experiment were visited uponhis children as well as upon himself, whilst all surgerysuffered by the shortening of that life which wasadvancing its bounds in every direction.On a Friday in May. ] i&bgr;7, Hunter inoculated himself

with pus from a patient suffering from gonorrhoeato determine whether the poison of gonorrhoea wasidentical with that producing syphilis. Surely thatFriday must have been May 22nd, a well-recognised"

Egyptian day," or Dies lllccled-icti, when it was mostunfortunate to embark upon any new undertaking.The prepuce and glans were scarified and it was noticedthat the incisions itched on the second day-May 24th.The prepuce was inflamed on May 26th, and onJune 2nd a small ulcer appeared and was cauterised.A slough separated on June 6th and the sore wascauterised a second time. The glans itched on

June 7th, and on the following day a second sloughdetached itself from the prepuce whilst the sore

on the glans ulcerated and was cauterised. Sloughs sseparated from the glans and prepuce on June 12th,and the ulcers healed leaving scars. The lymphaticglands in the right groin enlarged during the weekending June 13th, but they did not suppurate.The rapidity with which the two seats of inoculation

ulcerated and the appearance of a bubo suggest thatthe pus contained Ducrey’s bacillus causing two softsores. Spirochaetes were also present because thegland in the groin began to enlarge again after atime, and in July the right tonsil ulcerated. Copper-coloured spots appeared on the skin in September andthe tonsil ulcerated a second time. The administrationof mercury soon healed the ulcer but it returned athird and a fourth time. The rash on the skin appearedon three separate occasions, and mercury was then" taken in a sufficient quantity and for a proper time,"Hunter says, " to complete the cure. The time theexperiments took up, from the first insertion to thecomplete cure, was about three years." How completethe cure was will be shown ! It is certain, therefore,that Hunter also inoculated himself with the Spiro-chceta pallida and that his mercurial course was

insufficient. The gonococcus having been inoculatedupon skin surfaces did not multiply.He married Miss Anne Home on July 22nd, 1771.

There is nothing to show that she became infected, asit was then understood. John Banks Hunter was bornin June, 1772, and lived until 1838 ; Mary Anne, bornin December, 1773, only lived two months. James,born in November, 1774, died in February, 1775.Agnes, the youngest child, born in 1776, lived until1838. It may be remarked that neither of the twosurviving children left offspring and neither wasabove the average in mental attainments.

Except for an attack of pneumonia in 1759 andoccasional poisoned wounds, from which everyanatomist suffers from time to time, Hunter consideredhimself a healthy man until the spring of 1769, whenhe had some toxic disturbance which, in accordancewith the fashion of the time, was diagnosed as " a fitof the gout." It returned in the three followingsprings but not the fourth. Its place was taken inthe spring of this year (1773) by his first attack ofserious illness. The record reads : " In the spring of1773, having met with something which very forciblyaffected his mind, lie was attacked at 10 o’clock in theforenoon with a pain in the stomach about the pylorus.The sensation was limited to those parts and becameso violent that he tried change of position to procureease. He sat down, then walked, laid himself down onthe carpet., then upon chairs, but could find no relief.He took a spoonful of tincture of rhubarb with30 drops of laudanum without the smallest benefit.

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While he was walking about the room lie cast his eyeson the looking-glass and observed his countenance tobe pale and his lips white, giving the appearance of adead man. This alarmed him and led him to feel forhis pulse, but he found none in either arm. The painstill continued and he found himself at times notbreathing. Being afraid of death soon taking place ifhe did not breathe, he produced the voluntary act ofbreathing by working his lungs by the power of thewill: In this state he continued for three-quarterb ofan hour, during which time frequent attempts weremade to feel the pulse but in vain ; however, at lastthe pain lessened and the pulse returned, although atfirst but faintly,and involuntary

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breathing beganto take place.In two hourshe was perfectlyrecovered."

This attack ofepigastric anginaoccurred sixyears after theinoculation withsyphilis. It mayhave been causedby toxic changesin the smallerblood-vesselssupplying thevagal nuclei, or

it may have beenthe first indica-tion of syphiliticinflammation atthe root of theaorta. I am in-clined to thinkthat it was dueto cerebralchanges ratherthan to inflam-mation in thelarge arteries, forit would hardlyhave passed offso rapidly with-out leaving anymarked ill-effects. It isnoteworthy, too,that from thistime until hisdeath, 20 yearslater, Hunterdrank little, ifany, wine. Not,we may be sure,because he likedabstinence, butbecause, as hesays, it went tohis head.Four years later-in 1777-and again in the spring,

he was seized with a severe and dangerous illnessagain in consequence of anxiety of mind, as he had beenobliged to pay a large sum of money for a friend forwhom he had gone security and which circumstancesmade extremely inconvenient.

" At 2 o’clock in the forenoon he ate some cold chicken andham and drank a little weak punch ; immediately after thishe went eight miles in a post-chaise. While lie was 011 thejourney he had the feeling of having drunk too much butpassed the remainder of the day tolerably well ; at 12 o’clock ’at night his stomach was a little disordered, for which he Itook some caraways and went to bed. He had no sooner ’Ilain down than he felt as if suspended in the air and soon Ifafter the room appeared to go round ; the quickness of this imotion seemed to increase, and at last it was very rapid. ! IIt continued for some time, then became slower and ::;lOWC1’ ,until the whole was at rest. This was succeeded by vomitingwhich was encouraged and gave him a good night’s rest.

Next, day he was to!erab).v Bveil but fatigued. The morningafter. thinking ]J&Icirc;JIlSp]f quite recovered, he went out beforebreakfast, drank some tea. and ate some bread-and-butterwhich he was not <LCCUatome<1 to do. At 11 o’clock he felthis stomach in much the state as before ; in abouthalf an hour the sensation of the room appearing to turnrecommenced and continued for some time but not with suchviolence as in the last attack. He became sick and vomited.The sensation of himself and everything else going roundwent off, but that of being suspended in the air continuedwith giddiness. He could now hardly move his head from thehorizontal position, and about o’clock was brought homein his carriage, the motion of which was very disagreeable,giving him the sensation of going down or sinking.

" After lie went to bed the giddiness and the idea of beingsuspended in the

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air increased, andthe least motion ofthe head upon thepillow appeared tobe so great that hehardly durstattempt it; if hebut moved hishead half round itappeared to bemoving to some

distance with greatvelocity ; the ideahe had of his ownsize was that ofbeing only 2 feetlong, and when hedrew up his footor pushed it downit appeared to himto be moving a

vast way. Hissensations becameextremely acute.He could not bearthe least light, so

that although thewindow blinds weredrawn a curtainand a blanket wereobliged to be hungup against it, thefire to have a

screen before it,and the bed cur-

tains to be drawn.He kept his eyesclosed, yet if a

lighted candle ecame across theroom he could notbear it. His hearingalso was painfullyacute, but not somuch increased ashis sight. Thesmell and tastewere also acute,everything he putinto his mouthbeing much higherflavoured thancommon by whichmeans he relishedwhat he ate.

" He remained inthis state for about

ten days ; by this tune he was rather better, that is,he could move his head more freely. All his ideas ofhis present state became natural at the end of ten days,the strange deception concerning his own size was inpart corrected, and the idea of suspension in the airbecame less. But for some time after the fire appeared of adeep purple red. When lie got so well as to be able to standwithout being giddy he was unable to walk without support,for his own feelings did not give him information respectinghis centre of gravity, so that he was unable to balance hisbody and prevent himself from falling. He gradually! recovered from this state. and as soon as he was able went toBath at the end of August, stayed there until the middle ofNovember, and drank the waters which were thought to beor service to him. He returned to town much better and ina few weeks got quite well."

Here, again, the symptoms point to cerebral ratherthan to cardiac disturbance, to syphilitic inflammationof the smaller cerebral arteries, perhaps in the nature

[Copyright, Wellcome Historical Medical Museum.FIG. 1.-John Hunter at his house in Leiccster-square just after his return from

Belle Isle. The sign above the door is the golden calf, and probably theartist intended the two asses to be symbolical of the patients who weregoing to consult him.

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of a syphilitic periarteritis. There was vertigo butneither tinnitus nor deafness, so that the auditorysymptoms were due to stimulation or the vestibularnerve rather than to changes in the labyrinth. The

photophobia was of retinal origin and was due to

hyper&aelig;sthesia, such as led to exaltation in the sensesof smell and taste. The lesions were multiple, andalthough the results lasted for some time, as in thecase of the purple red fire, yet they were compensatedin the end. Hunter’s brain adapted itself fairly well to the

altered conditions for the next eight years, althoughhis arterial system was undergoing progressivedegeneration, and his friends noticed with concernthat he was ageingr a n i d 1 v . At the

beginning of April,1785-"He was attacked

with a spasmodic com-plaint which at firstsight appeared slightbut afterwards becamevery violent and ter-minated in a fit of thegout in the ball of thegreat toe. Like theprevious attacks itwas brought on byanxiety of mind. Thefirst symptom was asensation of themuscles of the nosebeing in motion, butwhether they reallywere or not he was

never able to deter-mine. This sensationreturned at intervalsfor about a fortnight,attended with un-

pleasant feelings in theleft side of the face,lower jaw, and throat,which seemed to ex-

tend into the head onthat side and downthe left arm as low asthe ball of the thumb,where it terminated allat once. These sensa-tions were not constantbut returned at irregu-lar intervals. Thevsoon became more

violent, attacking thehead, face, and bothsides of the lower jaw,giving the idea thatthe face was swelled,particularly the cheeks,and sometimes theyslightly affected the

right arm. After theyhad continued a fort-night they extendedto the sternum, pro-ducing the same disagreeable sensations there and givingthe feeling of the sternum being drawn backwards towards the spine as well as that of oppression of breathing,although the act of breathing was attended with noreal difficulty. The heart seemed to miss a stroke atthese times, and when feeling the pulse the artery was verymuch contracted, often hardly to be felt, and every now andthen the pulse was entirely stopped. He was afterwardsattacked with pain in the back about that part where theoesophagus passes through the diaphragm, the sensationbeing that of something scalding hot passing down theoesophagus. He was next seized with pain in the heartitself, and last of all with a sensation in the left side nearlyin the seat of the great end of the stomach attended withconsiderable eructations of wind. All these symptoms, thosein the stomach and nose only excepted, were in addition tothe first, for every attack began with the first symptom. Thecomplaint appeared to be in the vascular system, for thelarger arteries were sensibly contracted and sore to thetouch, as far as they could be touched, principally in theleft arm.

"

These symptoms increased in violence at every return, andthe attack, which was most violent, came on one morning

about the end of April and tasted, about two hours. It began as.the others had done, but having continued about an hour thepain became excruciating at the apex of the heart. The throatwas so sore as not to allow the attempt to swallow anything,and the left arm could not bear to be touched, the leastpressure upon it gi ving pain. The sensation at the apex of theheart was that of burning or scorching, which by its violencequite exhausted, him, and he sank into a swoon or doze whichlasted about ten minutes, after which he started up withoutthe least recollection of what had passed or of his precedingillness. He then fell asleep for half an hour and awoke witha confusion in his head which went off in a few days."

These attacks were of a more complicated naturethan the previous ones. They were due in the mainto syphilitic changes taking place in the heart and

aorta, and were thusanginal in character,out in part theymay have been dueto alterations in thecerebral circulation.He went to Tun-bridge in the Augustof this year, 1785,but finding no im-provement there hetravelled to Bath inSeptember, and inDecember he was

again in London,where he performedhis first operationfor the cure ofaneurysm by liga-turing the artery inits continuity.The attacks of

angina continued,though they did notincrease in severitythroughout the year1786, until hebecame so accus-tomed to them thatthey formed a partof his daily life. Hewas unable, in con-sequence, to takemuch exercise andpassed his time insuperintending theprinting and publi-cation of the" Observations on

the Animal (Economy " and the" Treatise on theVenereal Disease,"’which were issuedfrom his own pressin Castle-street,Leicester-square. In

[Copsright, Welleonze Historical Medieal Museum.FIG. 2.&mdash;John Hunter showing his new house in Leicester-squa,re, the

suggestion being that he is touting for patients in addressing Martinvan Butchell.

the following year, 1787, Sir Joshua Reynolds paintedthe striking portrait which has made his appearanceso familiar to all of us.He wrote to Jenner in May, 1788, saying that a

severe indisposition for three weeks had preventedhim from writing, although "when two guineas temptme I cannot resist." It is noteworthy that the firstattack of these complaints was produced by an affectionof the mind and every future at t ack of any cor s qu neearose from the same cause, and although bodilyexercise or distension of 1 he s omach brcught onslighter attacks it si ill required t he mind t o be affectedto render them severe, and as his mind was irritatedby trifles these produced the most violent effects onthe disease. His coachman being late or a servant notattending to his order: brought en the spasms, while areal misfortune prcduced no effect,.About the beginning of December, 1789, he was

attacked with a al loss of memory when he was

spending the evening with a friend.

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" He did not know in wliat part of the town he was, noreven the name of the street when told it, nor ivhcro his ownhouse was. lie had no conception of any place existingbeyond the room he was in and yet was perfectly consciousof his loss of memory. IT was sensible of impressions of allkinds from the senses and therefore looked out of the window,although rather dark, to see i he could recognise the situationof the house.

" This loss of memory gradually went off and in less thanhalf an hour lie was recovered. About a fortnight afterwards,as he was visiting his patients in the forenoon, he noticed.occasionally a little giddiness in his head and by 3 o’clockit was attended by an inclination to vomit. The giddinessbecame severe, but went off again about 7 or 8 o’clock;about 9 our 10 o’clock it returned with more severity and whengoing to bed about 11 o’clock he had entirely lost hiscentre of gravity, although he could move his limbs as

the will directed. Light became offensive and everythinghad a kind of yellow cast ; sounds became more acute thanusual; objects had lost their true direction ; a perpendicular,for instance, seemed to him to lean to the left, making asnear as he could conjecture an angle with the horizon of50 or 60 degrees. Objects were also smaller than the naturalrecollection of them ; his idea of his own size was that ofbeing only 4 feet high ; objects also appeared to be at anunusual distance as if seen through a concave glass. Motionof his head was extremely disagreeable; he therefore moved

1777, more than 12 years before, and perhaps not fara-way from. tlw areas originally involved, althoughthere is no doubt, that the disease in the large arterieshad made considerable progress. I am not a neurolo-gist, but so far as a surgeon can guess the lesions mayhave been situated in the immediate neighbourhood ofthe basal ganglia or even still nearer the cerebralcortex..1 1 do not think they were in the cortex itself,nor do the spinal cord or the peripheral nerves seemto have been affected. The subjective sensation in thenose and the pain in the great toe might help tolocalise them more accurately.The illusions as to size and shape may, perhaps, be

accounted for by changes occurring in those " silentareas

" of the brain which it, is so difficult to exploreexperimentally. It is certain that a generation whichknew nothing of the individual functions of the brain,and which attributed every form of toxic absorptionGO " gout." explained the pain in John Hunter’s toeis being caused by that disease, just as in later yearswe have been contented to say that he suffered fromangina pectoris without looking farther for the cause.The permanency of the defect in vision and thempairment of memory also point to widely spiead

changes in the brain___________________

which were almostcertainly vascular

for, as will be seenpresently, no grosslesion was foundafter death. Thesleeplessness and dthe increasing irrita-bility must be attri-buted rather tochanges takingplace in his largerarteries than tolesions in the brain.He never went to

bed at this timewithout having anattack which wasbrought on by theact of undressing.They came on inthe middle of thenight, and the leastexertion and con-

versation afterdinner was attendedby them. He feltobliged, therefore,to confine himselfwithin a certainsphere of actionand to avoid diningin large companies.Even operations insurgery, if attendedwith any nicety,now produced thesame effects.

In the autumn of1790 and in thespring and autumnof 1791 he had moresevere attacks than

[Copyright, Wellcome Historical -1-ledie(il Museum.

FIG. 3.-Hunter’s buffalo carriage in which he used to drive down Piccadilly from Earl’s Courtto Leicester-square. The drawing suggests that he would get fuller advertisement if herode on a dromedary aecompanied by a black servant.

it with great caution, although coughing and snnezing didnot affect it. The disposition to sleep was a good deal gone ,an hour or two in the 24 being as much as could be obtained.These symptoms were much the same for a week and beganto diminish gradually, so that in a fortnight he was able tosit up and in three weeks went for an ainng in his carriage.He felt a pain in the joint of his great toe which inflamed’gently but soon left it.

" His recovery from this indisposition was less perfectthan from any of the others. He never entirely lost theoblique vision, his memory was in some respects evidentlyimpaired, and the spasms became more constant."

These attacks were probably due to cerebral changes ssimilar to those which caused the first symptoms in

during the earlier periods of the year, but of not morethan a few hours’ duration. In the beginning ofOctober, 1792, one was so violent that Everard Home,who was present, thought he would have died in it.

" The end came on Oct. 16th, 1793, when in his usualstate of health, he went to St. George’s Hospital, and

"

meeting with some things which irritated his mind and not Ibeing perfectly master of the circumstances he withheld hissentrments, in which state of restraint he went into the’ next. room and turning round to Dr. Etobinson, one of the! physicians of the hospital, he gave a deep groan and idropped down dpad.! The post-mortem examination showed a small heartin a thickened pericardium. The coronary arteries

Ft

375

were bony tubes which were with difficulty divided by the knife, when their transverse sections did not Icollapse but remained open. The mitral valves were

partially and irregularly calcified and the aorticvalves had lost their natural pliancy. The aorta,a little beyond the semilunar valves, had its cavitylarger than usual, puttingon the appearance of anincipient aneurysm. Theinner coat of the vesselhad entirely lost t its snatural polish and wasstudded with opaquewhite spots raised higherthan the general surface.The cranium and duramater were in a naturalstate but the pia materwas congested. The in-ternal structure of thebrain was carefullyexamined, and the dif-ferent parts both of thecerebrum and of the cere-bellum were found in themost natural and healthystate. The internalcarotid arteries were

ossified and the vertebralarteries lying along themedulla oblongata hadalso become bony, whilstthe basilar artery hadopaque white spots verygenerally along its coats.

THE CAUSE OF HUNTER’SDEATH.

A review of these factsabout the illness anddeath of John Huntershow that he died withwidespread disease of hisarterial system-thelargest as well as the

smallest arteries beinginvolved. He may haveinherited some family weakness of the vascular system,for his brother William, had died ten years before atexactly the same age of 65 after suffering the vaguesymptoms associated with arterial degeneration.The post-mortem examination of John Hunter’s brainshowed no gross lesions-such as a gumma&mdash;whichwere not likely to be overlooked by the trainedanatomists who carried it out. The cerebral symptomsfrom which he began to suffer two years after he hadinoculated himself with syphilis, and which continuedintermittingly until the time of his death 20 yearslater, were, therefore, due to lesions of a microscopiccharacter. They were caused by cerebral syphilis ofthe interstitial variety, that is to say, they were dueto the action of toxins produced by the Spirochcetapallida in the lymphatic sheaths of the smallerblood-vessels. These changes in the outer coat of thearterioles interfered with their vasa va,sorum and sowith the nutrition of the middle coat, thus leading tothrombosis or even complete obliteration of the littlevessels as a consequence of the endarteritis. Such a sequence of events recurred several times and weremore frequent and severe as he grew older and thearteriosclerosis became more pronounced. We canonly be thankful that the stress of the disease fell uponthe deeper parts of the brain, and that his intellectualfaculties were so little impaired that he could givesound judgment in consultation, invent, new methodsof operating, and retain those powers of collectingwhich enabled him to form his magnificent museum.

It never seems to have occurred to Hunter toassociate any part of his ill-health with the inoculationexperiment of 1767 ; indeed, he says expressly: "Itwould appear that some parts of the body are muche ss susceptible of the lues venerea tlran others ; and,

not only so, but many parts as far as we know ate notsusceptible of it at all. For we have not yet had everypart of the body affected ; we have not seen the btainaffected." How great, therefore, would have been hisjoy if his cerebral cortex could have looked down upoathe great basal ganglia of his brain and recognised that

[Copyright, Wellcome Historical Medical Museum.

FiG. 4.-Hunter’s body being removed from St. George’s Hospital in Mrs. Hunter’s sedanchair with his chariot following behind. Note the two magpies, one on and one over thecarriage, "one for sorrow, two for joy."

parts of them were suffering from the effects of thevenom which he had himself introduced into hissystem so many years before. We look upon him as amartyr to science ; he would rather have consideredthat the fresh knowledge was worth the penalty hepaid to gain it. It is marvellous to us that he couldaccomplish so much, crippled as he was mentally andphysically.

HUNTER BEING DEAD YET SPEAKETH.

Whilst praising John Hunter and his pupils for whathas been done in the past, it is the duty of the oratorto point to the influence of his teaching on the presentgeneration of surgeons and to call attention to any out-standing work which may have been executed sincethe last oration was delivered in his honour. His spiritstill lives and exerts its influence upon those of theyounger generation of surgeons who are endowed witha portion of his originality of thought and actionstimulating them to attack and advance along oldlines which many had long since abandoned as useless.

THE HEART SUBDUED TO THE HAND OF THESURGEON.

Sir Lauder Brunton, in the year 1902, suggested thepossibility of treating mitral stenosis by surgicalmethods. He had already performed some preliminaryexperiments in the dead-house and upon animals, butill-health and the generally expressed feeling which isalways against any new operation involving greatrisk to life prevented him from carrying his designinto execution upon the human subject. Nothingfurther was done in this country, although it had longbeen known to physiologists that the healthy m.am,-malian heart could be handled with impunity, whilst

376

surgeons had repeatedly sutured cardiac wounds. Atan rate, nothing was done, and it was left to Prof.Eliiott C. Cutler, of the Western Reserve University atCleveland, with the help of Dr. S. A. Levine and Dr.Claude S. Beck, to subdue the diseased human heart tothe hand of the surgeon. Lately, whilst visiting theUnited States, I had the good fortune to make theacquaintance of Prof. Cutler and to see him operateon a dog. As the original idea was put forward by SirLauder Brunton, the lineal successor of Harvey at St.Bartholomew’s Hospital, we must regret that it didnot bear fruit there. But no one who knows Prof.Cutler, young, generous, enthusiastic, painstaking, andscientific, will grudge him the laurels he has won byhis brilliant and successful operation, and all wishhim godspeed in what we hope will be a long andprosperous career.

NECROLOGY.

The terms of the trust, Sir, demand of me themelancholy duty that I should draw your attentionfor a few moments to the losses which British surgeryhas sustained since the last oration was delivered.Death has been busy in our ranks during the last twoyears. Very noticeable is the gap left by the departureof Sir William Macewen whilst still in the full exerciseof his mental and physical powers. A surgeon of suchoriginality that he is worthy to be placed amongstthe greatest of his own century. A pioneer in thesurgery of the brain, in the surgery of the lung, and inthe study of the infective inflammations of bone.His name seems likely to be handed down to futuregenerations by that operation for the cure of knock-knee which should become less and less frequent asrickets becomes more rare under the influence of abetter hygiene during childhood.The name of Sir Frederick Treves will live long in the history of England. To us he appeared as a good

anatomist, a fine abdominal surgeon, a fluent writer ofinteresting books, and a travelled gentleman. By hisprompt action in an unparalleled crisis he showedhimself master of the greatest attribute of a surgeon-the ability to take upon himself infinite responsibilitymindful of the Hippocratic maxim that time is urgent,experience deceitful, and judgment difficult.

Mr. W. H. A. Jacobson, " the gentle cynic," and theauthor of the first sat,isfactory text-book on operativesurgery in the English language, abandoned his pro-fession at the height of his reputation, taking withhim the sympathy of all his colleagues and friends.What shall be said of Mr. S. G. Shattock-the humble-

minded disciple of John Hunter, whose name hevenerated and whose methods he copied, strivingfaithfully and zealously to advance and improve theknowledge of morbid anatomy in which, like hisMaster, he excelled beyond his fellows ? Very few arepermitted to gain the confidence, the esteem, and theaffection of a whole profession. Shattock did so Ibecause he was truly the helper and adviser of allwho sought him.

Three of our colleagues on the Council of this Collegehave left us since you, Sir, delivered the last orationin 1923-Sir William Thorburn, Sir Charles Ryall,and Mr. W. Harrison Cripps.

Sir William Thorburn after an arduous and usefullife at Manchester, where he did much to advance thesurgery of the spine, saddened by domestic affliction,the direct outcome of the war, had just settled inLondon and was looking forward to a period of leisurewhen death seized him.

Sir Charles Ryall we miss because he was as genialas he was trustworthy in all matters committed to his charge, and to him the Cancer Hospital owes much.

Mr. Harrison Cripps possessed talents which-whencombined as they were in him-are rare amongst us,first-rate business capacity, great powers of adminis-tration, and high surgical skill. He spoke but rarelyat our meetings, yet his opinions always carriedweight and his views usually prevailed.Nor must I omit to mention those who worthily

maintained the position of surgery in the provincesand whose loss we deplore : Mr. G. P. Newbold,

Mr. R. A. Bickerstelli, of virtuous father virtuous son;and Mr. George Heaton, the first two of Liverpool, thelast of Birmingham. All pupils of my own.

CONCLUSION.

My task, Sir, is ended, and in bringing it to a con-clusion I would ask you to remember that if Hunterwith the knowledge and means at his command seemsto us to-day to walk haltingly or even often to havegone astray, shall not we seem to have done the sameto those who read our story a hundred years hence ?It is one of the lessons of history that each age stepson the shoulders of the ages that have gone beforeand that the value of each generation is in great parta debt to its forerunners.

The oration finished with the exhibition of a series of lanternslides, four of which are here reproduced, made from water-coloursketches for Jesse Foot who wrote a scurrilous life of JohnHunter. They show Hunter as he appeared to his contemporaries,and not as he was idealised by Sir Joshua Reynolds in his well.known portrait. Sir D’Arcy Power stated that he was indebtedto his friend, Mr. C. J. S. Thompson, for permission to show thedrawings which are contained in a volume in the possession ofthe Wellcome Historical Museum.

THE DIAGNOSIS OF

UNILATERAL PHRENIC NERVEPARALYSIS.

AN IMPORTANT POINT IN MEDIASTINAL

LOCALISATION.

BY SIR CHARLTON BRISCOE, BART., M.D.,F.R.C.P. LOND.,

PHYSICIAN TO KING’S COLLEGE HOSPITAL.

THE diaphragm belongs by origin to the muscles ofthe neck, but in the process of the evolution of thebody it has shifted its position to a lower plane whilestill retaining its original nerve-supply. The shifthas thus entailed the development of a phrenic nervetrunk on each side, which in proportion to its lengthis liable to become involved in lesions of neighbouringorgans.From the frequency with which these neighbours are

affected by disease we might expect unilateral phrenicparalysis to be a not uncommon event., a view whichseems confirmed by the fact that 15 of the 30 caseson which this paper is based have been observed in thelast 12 months. Yet, in general, the clinical diagnosisis one not often made, and the literature on thesubject is scanty and unsatisfying, facts which suggestthe existence of inherent difficulties such as have ledto the condition being overlooked. Indeed, thesedifficulties are very real. One is obvious and everpresent. We have not to deal with a simple muscleexerting a straightforward easily ascertained actionupon fixed points, but with a double sheet of complexfibres hidden deep in the body, the actions of whichare far from simple, and only to be recognised byeffects which are not only for the most part indirectlyproduced, but are always complicated by the inter-fering action of other muscles. Other difficulties willappear in the course of this paper.

Literature.

The text-books in general state that when the wholediaphragm is paralysed there ensues overaction of theintercostals and of the accessory muscles of respiration,together with inspiratory recession of the epigastrium.When one half only is affected there may be limitedpropulsion of the epigastrium on the affected side.Oppenheiml states that Litten’s sign may be absentand the respiratory sounds faint, and concludes thatunilateral paralysis is difficult to detect. Nesbit 2

diagnosed a case as paralysis of the left phrenicnerve. At first there were over expansion andincreased resonance of the left side of the chest.Later, dullness appeared over the root of the left lungin front. The case was one, however, of gradual

i