_SIR JAMES PAGET AND SURGICAL PATHOLOGY._
The foremost surgical philosopher and orator of his day, Sir
JAMES PAGET was called to occupy the presidential chair of the
International Medical Congress which met in London in August 1881.
This was the culmination of a long career of scientific usefulness
and successful practice. Sir James is a younger brother of Dr. G. E.
Paget, Regius Professor of Medicine in the University of Cambridge,
and was born at Yarmouth in Norfolk in 1814. After a course of
professional study at St. Bartholomew’s Hospital, London, Mr. Paget
qualified as a member of the London College of Surgeons in 1836. His
energy and acuteness were soon made manifest to the authorities, and
he was selected to catalogue and describe the Pathological Museums of
St. Bartholomew and also of the College of Surgeons, in conjunction
with Mr. Stanley. These important works contributed not a little to
establish Mr. Paget’s scientific reputation.
In July 1842 Mr. Paget, while Demonstrator of Morbid Anatomy at
St. Bartholomew’s, published in the _British and Foreign Medical
Review_ an exhaustive report on the chief results obtained by the
use of the microscope in the study of human anatomy and physiology;
it was afterwards issued separately. Being derived from the original
authorities, and full references being given, it was of great value
at a critical period in the growth of the knowledge of minute
anatomy. For some years Mr. Paget drew up valuable reports on the
progress of human anatomy and physiology.
Forty years ago Mr. Paget was already Warden of St. Bartholomew’s
College and Lecturer on Physiology in the Hospital. At the opening
of the session of 1846 he addressed the students in an eloquent and
practical way on “The Motives to Industry in the Study of Medicine.”
His appeals to the highest motives were most forceful, and very
indicative of the spirit which was to animate himself throughout
life. “Do not imagine,” he said, “that your responsibilities will
be limited to the events of life or death. As you visit the wards
of this hospital, mark some of the hardly less portentous questions
which, before a few years are past, you may be permitted to
determine. In one, you will find it a doubt whether the remainder of
the patient’s life is to be spent in misery, or in ease and comfort;
in another, whether he and those who depend upon his labours are
to live in hopeless destitution, or in comparative abundance. One
who used to help his fellow-men finds ground to fear that he may
be a heavy burthen on their charity. Another counts the days of
sickness, not more by pain and weariness, than by the sufferings and
confusion of those who are left at home without a guide, and, it may
be, starving. Oh, gentlemen! I can imagine no boldness greater than
his would be, who would neglect the study of his profession, and yet
venture on the charge of interests like these; and I can imagine no
ambition more honourable, no envy so praiseworthy, as that which
strives to emulate the acquirements of those who are daily occupied
in giving safe guidance through the perilous passages of disease, and
who, in all these various difficulties and dangers, can act with the
energy and calmness that are the just property of knowledge.”
About the same time Mr. Paget published an interesting pamphlet
containing all the records of Harvey preserved in the Journals of
St. Bartholomew’s, with notes elucidating them. Meanwhile, having
been appointed Professor of Anatomy and Surgery to the College of
Surgeons, an office which he held from 1847 till 1852, the lectures
which he delivered being reported in the medical journals, as well
as listened to with delight by large audiences, were recognised as
among the most masterly modern contributions to surgical science.
His prolonged study of the pathological collections belonging to the
College and to St. Bartholomew’s in preparing the catalogues, enabled
him to illustrate his lectures in a most interesting and valuable
manner. The lectures were collected and published in 1853, and have
ever since occupied a similar lofty position to the lectures on
medicine by Sir Thomas Watson. They illustrate the general pathology
of the principal surgical diseases, in conformity with modern
advances in physiology. In several recent editions a distinguished
pupil of Sir James Paget, Professor Turner of Edinburgh, has revised
the lectures from the pathological point of view, while the author
has continued to revise them in their clinical aspect.
The leading topics under which these famous lectures are comprised
are: Nutrition, Hypertrophy, Atrophy, Repair, Inflammation,
Mortification, Specific Diseases, and Tumours. The concluding passage
of the second lecture, on “The Conditions Necessary to Healthy
Nutrition,” is a fine exposition of a view of the relation between
the mind and a changing brain. “In all these things, as in the
phenomena of symmetrical disease, we have proofs of the surpassing
precision of the formative process, a precision so exact that, as
we may say, a mark once made upon a particle of blood or tissue is
not for years effaced from its successors. And this seems to be a
truth of widest application; and I can hardly doubt that herein is
the solution of what has been made a hindrance to the reception of
the whole truth concerning the connection of an immaterial mind with
the brain. When the brain is said to be essential, as the organ or
instrument of the mind in its relations with the external world,
not only to the perception of sensations, but to the subsequent
intellectual acts, and especially to the memory, of things which have
been the objects of sense—it is asked, how can the brain be the organ
of memory when you suppose its substance to be ever changing? or how
is it that your assumed nutritive change of all the particles of the
brain is not as destructive of all memory and knowledge of sensuous
things as the sudden destruction by some great injury is? The answer
is—because of the exactness of assimilation accomplished in the
formative process; the effect once produced by an impression upon
the brain, whether in perception or in intellectual act, is fixed
and there retained; because the part, be it what it may, which has
been thereby changed, is exactly represented in the part which, in
the course of nutrition, succeeds to it. Thus, in the recollection of
sensuous things, the mind refers to a brain in which are retained the
effects, or rather the likenesses of changes that past impressions
and intellectual acts had made. As, in some way passing far our
knowledge, the mind perceived and took cognisance of the change made
by the first impression of an object, acting through the sense organs
on the brain; so afterwards, it perceives and recognises the likeness
of that change in the parts inserted in the process of nutrition.
“Yet here also the tendency to revert to the former condition, or
to change with advancing years, may interfere. The impress may be
gradually lost or superseded, and the mind, in its own immortal
nature unchanged, and immutable by anything of earth, no longer finds
in the brain the traces of the past.”
In 1854 Mr. Paget gave one of the series of lectures on Education
at the Royal Institution, in which Whewell, Faraday, and others
took part. His lecture on the Importance of the Study of Physiology
as a branch of education for all classes, was marked by elevation
of thought and practicality of aim. One interesting point that he
dwelt on was that a wider scheme of education would be more likely
to discover men fitted for particular work. “It has seemed like
a chance,” he said, “that has led nearly every one of our best
physiologists to his appropriate work; like a chance, the loss
of which might have consigned him to a life of failures, in some
occupation for which he had neither capacity nor love.” The value
of physiological instruction is now generally admitted, but the
practical application is almost as generally neglected.
Sir James Paget has published but too few of his thoughts to the
public and the profession; but all that have been given to the world
have been of sterling worth. His Clinical Lectures and Essays,
collected in 1875, include some of the most interesting reading
imaginable. He deals among other subjects with the various risks of
operations, the calamities of surgery, stammering with other organs
than those of speech, cases that bone-setters cure, dissection
poisons, and constitutional diseases. Some of the most instructive
of the series are those which describe forms of nervous mimicry of
serious diseases. An extract from “The Calamities of Surgery” gives
clear expression to Sir James Paget’s views on preparation for
operating:—
“Look very carefully to your apparatus. I have no doubt that you
will look very carefully to the edges of your knives and your saws
and all things that are mighty to handle; but look to the plaster,
look to the ligatures and the sutures, and all the things which are
commonly called minor. When I have seen Sir William Fergusson and
Sir Spencer Wells operate, I have never known which to admire most;
the complete knowledge of the things to be done, the skill of hand,
or the exceeding care with which all the apparatus is adjusted and
prepared beforehand. The most perfect plaster, the most perfect silk,
not one trivial thing left short of the most complete perfection
it is capable of. I have no doubt that the final success of their
operations has been due just as much to these smaller things as to
those greater things of which they are masters.”
The lecture on Dissection Poisons was especially called forth by an
illness from which he suffered for three months in 1871, caught from
attending the _post mortem_ examination of a patient who had died
of pyæmia. Yet he had no wound or crack of the skin of any kind. In
closing the lecture Sir James remarked: “Sir William Lawrence used
to say that he had not known any one recover on whose case more than
seven had been consulted. Our art has improved. I had the happiness
of being attended by ten: Sir Thomas Watson, Sir George Burrows, Sir
William Jenner, Sir William Gull, Dr. Andrew, Dr. Gee, Mr. Cæsar
Hawkins, Mr. Savory, Mr. Thomas Smith, Mr. Karkeek. In this multitude
of counsellors was safety. The gratitude I owe to them is more than I
can tell—more than all the evidences of my esteem can ever prove.”
In an address on Theology and Science, delivered to students at the
Clergy School at Leeds, in December 1880, Sir James Paget remarks
that “in theology, and in the Christian faith which it expounds,
there are not only clear evidences which, in their accumulated force,
cannot, I think, be reasonably resisted by those who will fairly
collect and try them; but there are convictions of religious faith,
not always based on knowledge, or on other evidence than the faith
which is ‘the evidence of things unseen,’ which may justly be held
as unalterable, because they are consistent with revelation, and
have been sustained by the testimony of clouds of witnesses, and,
I believe, have in many minds the testimony of God’s indwelling
Spirit.” He expresses the belief that the truths and highest
probabilities of science and religion may justly be held together,
though on different grounds, and that they are not within reach of
direct mutual attack. He advises clerical students, if they touch
upon such questions, to undertake some real study in science, by
observation, by experiment, by collecting, as well as by reading.
“And let your reading be in the works of the best masters, that
you may learn their true spirit, their strength, their methods of
observing and thinking, their accuracy in describing.”
Sir James Paget appears as a champion of moderation in the
_Contemporary_ controversy on the Alcohol Question. He says that the
presumption in favour of moderation is strengthened by comparing
those of our race who do not and those who do habitually use
alcoholic drinks. “As to working power, whether bodily or mental,
there can be no question that the advantage is on the side of those
who use alcoholic drinks. And it is advantage of this kind which is
most to be desired. Longevity is not the only or the best test of
the value of the things on which we live. It may be only a long old
age, or a long course of years of idleness or dulness, useless alike
to the individual and the race. That which is most to be desired is
a national power and will for good working and good thinking, and a
long duration of the period of life fittest for these; and facts show
that these are more nearly attained by the people that drink alcohol
than by those who do not.”
Sir James Paget holds or has held appointments too numerous to
mention. After a long and honourable career as Assistant-Surgeon and
Surgeon to St. Bartholomew’s, he became Consulting Surgeon. As a
member of the Council of the College of Surgeons and for some years
President, and also as a member of the Senate, and for some years
Vice-Chancellor of London University, he has exercised powerful
influence on the improvement of medical education and on medical
politics generally. He is Surgeon to the Prince of Wales and Serjeant
Surgeon-Extraordinary to the Queen. A baronetcy was conferred upon
him in August 1871, and he has received honorary distinctions in
abundance from both British and foreign universities.
In 1882 in his Bradshawe lecture, “On some Rare and New Diseases,”
Sir James Paget remarked on the increase in the number of real
students, which he has had a large share in creating. “I have been
often made happy by the contrast which I have seen while working at
the new edition of the catalogue of the pathological specimens in the
College of Surgeons’ museum. While I was writing the last edition,
between thirty and forty years ago, scarcely a student ever entered
the museum. Hour after hour I sat alone; I seemed to be working for
no one but myself, or for nothing but the general propriety that a
museum ought to have a catalogue, though no one might ever care to
study with it. Now, and for some years past, a day rarely passes
without many pupils and others being at work in every part of the
museum.”
In the same lecture Sir James clearly showed the value of studying
cases not agreeing with the ordinary types. “We should study
all exceptions to rules; never thinking of them as unmeaning or
accidental. Especially, we should never use, in its popular but wrong
translation, the expression, ‘exceptio probat regulam;’ as if an
exception to a rule could be evidence that the rule is right. If we
use it, let this be in its real meaning; translating it, as surgeons
should, that an exception probes the rule, tests it, searches it—as
the Bible says we should ‘prove all things’—to its very boundary.”
Finally we may quote some sentences from Sir James Paget’s lecture
on “Elemental Pathology,” delivered before the British Medical
Association in 1880, as expressing his philosophy of life. “I hold
it to be very desirable that every one of us should, all his life
long, study some science in a scientific manner. There seems to be no
equally good method for maintaining the temper and the habits, which
by making us always good students, will make us as good practitioners
as we can be. There is no method so good for maintaining a constant
habit of inquiry, with accuracy and perseverance in research, the
power of weighing evidence, of calmly judging, and of accurately
speaking; none better for cultivating the love of truth, the
contempt for fallacies, whether others’ or our own, the gentleness
and courtesy which are appropriate to the consciousness of the
imperfection of our knowledge.”