CHAPTER XX

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_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.”

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