From The Nineteenth Century, THE PROGRESS OF MEDICINE DURING THE QUEEN'S REIGN. Not many months ago the Duke of Cambridge, speaking at St. George's Hospital on the occasion of the opening of a new operating theatre, said: I do not believe that amid all the im provements, the advantages, and the addi tions that have occurred during the prolonged reign of her Majesty, anything has made so much progress as medical and surgical science. Whether we look at what has been or is going on in this country, or whether we turn to foreign lands, it strikes me that there has been an advance made which has been of such enormous advantage to the human race that that alone would mark this period to which I am alluding. His Royal Highness, with the practical sense of a man of affairs, in a few plain words expressed the exact state of the matter. It will be my purpose in the following pages to show how fully justified he was in making the statement which has been quoted. It is no idle boast, but the simple unvarnished truth, that medicine - in which term I include the whole art of healing, and the scientific laws on which its practice is based-has made greater progress during the last sixty years than it had done in the previous sixty centuries. The medical knowledge of the Egyptians, though considerable compared with that of other ancient peoples, was, as may be gathered from the fragments of their nosology and therapeutic formularies that have come down to us, but little above the traditional lore in such matters with which old women have in all ages been credited. The practical mind of Greece began by trying with Hippocrates to see things as they really were, but later fell away into the making of systems and the spinning of cobwebs of theory instead of observing facts. The Romans had for medicine and its professors a robust contempt, akin to that which Squire Western had for French cooks and their kickshaws. In the later days of the Republic, indeed, the Græculus esuriens brought his physic as well as his philosophy to the great market of Rome, and under the Empire medicine men flourished exceedingly. Medicine itself, however, was at its best a mere empiric art, and in this condition it remained practically till Harvey's discovery of the circulation of the blood in 1628 laid the corner-stone of modern physiology, and thus prepared a foundation for a scientific medicine. From the seventeenth till the early part of the nineteenth century, though many improvements were made in the details of the art of healing, there was no great advance either in the conception of disease or in the principles of treatment. The discovery of vaccination itself, though one of the greatest practical importance, was merely the observation of a fact, not the enunciation of a law. When the queen came to the throne in 1837, it is hardly too much to say that the average medical practitioner knew little more about the diseases of the heart, lungs, stomach, liver, and kidneys than was known to Hippocrates. Auscultation had indeed been introduced some years before, but long after the commencement of her Majesty's reign elderly gentlemen might be seen, when a stethoscope was offered to them at a consultation, to apply the wrong end to their ear. Fevers were classified with a sweet simplicity into "continued" and "intermittent," and as late as in the 'Fifties an eminent professor of surgery complained that his colleague, the professor of medicine, had invented a number of new-fangled varieties. Of nervous diseases nothing was known. The larynx was a terra incognita; of the ear it was said by the leading medical journal of the day, many years later than 1837, that the only thing that could be done in the way of treatment was to syringe out the external passage with water. The diagnosis and treatment of diseases of the skin had advanced little beyond John Hunter's famous division of such affections into those which sulphur could cure. those which mercury could cure, and those which the devil himself couldn't cure. Pathology was a mere note-book of post-mortem appearances-a list of observations as dead as the bodies on which they were made. The New World of bacteriology had not yet found its Columbus. In the domain of surgery progress had been far greater, and as regards operative skill and clinical insight Astley Cooper, Robert Liston. Dupuytren, and Larrey were certainly not inferior to the men of the present day. Anæsthesia was, however, unknown, and the operating theatre was a place of unspeakable horrors. Wounds were dressed with wet rags, and suppuration was encouraged, as it was believed to be an essential part of the process of healing. broadly speaking, it may be said that the advance of the art of healing during the last sixty years has been along two main lines-the expansion of the territory of Surgery, and the development of Pathology, which concerns itself with the causes, processes and effects of disease. It will probably help the reader to a clearer understanding of the present position of medicine if each of these two lines of evolution is considered in some detail. The progress of surgery in the present age is due to two discoveries of an importance unequalled in the previous history of the healing art-anesthesia, or the artificial abolition of pain, and antisepsis, or the prevention of infective processes in wounds. The former discovery was not made until her Majesty had been nearly ten years on the throne; the latter nearly twenty years later. Let us take a brief glance backwards at what surgery was before the introduction of these two far-reaching improvements. Of the horrors of operations before the discovery of anæsthesia there are men stil living who can speak. Not long ago Dr. B. E. Cotting, ex-president of the Massachusetts Medical Society, contributed some personal reminiscences of pre-anesthetic surgery to the Boston Medical and Surgical Journal. Speaking of the first case in which he was called upon to use the knife, in the very year of the queen's accession, he says: Our patient (a woman) writhed beyond the restraining power of strong and experienced men, and groaned to the horror of the terrified household, and afterwards to the day of her death could not think of the operation without convulsive shudders. Often did she hold up her hands, exclaiming, "Oh, that knife! that awful knife! that horrible knife!" Dr. Cotting sums up his recollections of such scenes as follows: No mortal man can ever describe the agony of the whole thing from beginning to end, culminating in the operation itself with its terrifying expressions of infernal suffering. A distinguished physician, who himseit came under the surgeon's knife in the days before anæsthesia, has left on record a vivid account of his experience. Speaking of the operation, he says: Of the agony occasioned I will say nothgreat I underwent ing. Suffering so cannot be expressed in words, and thus fortunately cannot be recalled. The particular pangs are now forgotten; but the black whirlwind of emotion, the horror of great darkness, and the sense of desertion by God and man, bordering close upon de spair, which swept through my mind and overwhelmed my heart, I can never forget, however gladly I would do so. . . Before the days of anesthesia a patient preparing for an operation was like a condemned criminal preparing for execution. He counted the days till the appointed day came. He counted the hours of that day till the appointed hour came. He listened for the echo on the street of the surgeon's carriage. He watched for his pull at the door-bell; for his foot on the stairs; for his step in the room; for the production of his dreaded instruments; for his few grave words and his last preparations before beginning. And then he surrendered his liberty, and. revolting at the necessity, submitted to be held or bound, and helplessly gave himself up to the cruel knife. The excitement. disquiet, and exhaustion thus occasioned could not but greatly aggravate the evil effects of the operation, which fell upon a physical frame predisposed to magnify. not to repel, its severity. The pain caused by operations prevented their being undertaken except as a last resource, and many patients preferred death to the surgeon's knife. Sir Charles Bell used to pass sleepless nights before performing a critical operation; and men like Cheselden, John Hunter, and Abernethy had an almost equal dislike of operations. It is related of one distinguished surgeon that when a patient, whose leg he was about to cut off, suddenly bounced off the operating-table and limped away, he said to the bystanders, "Thank God, he's gone!" Men otherwise well fitted to advance surgery were prevented from devoting themselves to it by their inability to inflict or witness pain. Sir James Young Simpson in his student days was so distressed by the sufferings of a poor Highland woman, on whom Robert Liston was performing excision of the breast in the Edinburgh Royal Infirmary, that he left the operating theatre with his mind made up to seek employment in a lawyer's office. Fortunately for mankind he did not carry out his intention, but set himself to grapple with the problem how sensibility to pain in surgical operations could be abolished. The solution of the problem came from America. On the 30th of September, 1846, W. T. G. Morton, a dentist of Boston, U.S.A., who had previously experimented on animals and on himself, made a man unconscious by breathing sulphuric ether, and extracted a tooth without the patient feeling any pain. On the 16th of October of the same year Morton administered ether, in the Massachusetts General Hospital, to a man from whose neck a growth was excised without a groan or a struggle on his part. The doctors who came to scoff remained to praise, and the operator, Dr. John C. Warren, who had at first been sceptical, said, when all was over, in a tone of conviction, "Gentlemen, this is no humbug!" A distinguished physician who witnessed the scene said on leaving the hospital, "I have seen something to-day that will go round the world." It did so with a rapidity remarkable for those days, when as yet the telegraph was not, and the crossing ‘of the Atlantic was not a trip but a voyage. On the 22nd of December, 1846, Robert Liston, in University College Hospital, London, performed amputation through the thigh on a man who was under the influence of ether, and who knew nothing of what had been done till he was shown the stump of his limb after the operation. The "Yankee dodge," as Liston had contemptuously called ether anææsthesia before he tried it, was welcomed with enthusiasm by surgeons throughout Europe. In January, 1847, Simpson of Edinburgh used ether for the relief of the pains of labor. Not being entirely satisfied with it, however, he sought for some other substance having the property of annulling sensation, and in November, 1847, he was able to announce that he had found "a new anæsthetic agent as a substitute for sulphuric ether" in chloroform, a substance then unknown outside the laboratory, and within it looked upon as only a chemical curiosity. Chloroform for a long time held the field in Europe as the agent for medicining sufferers to that sweet sleep in which knife, gouge, and cautery do not hurt and the pangs of motherhood are unfelt. With characteristic courage the queen submitted to what was then a somewhat hazardous experiment, allowing herself to be made insensible with chloroform at the birth of the Duke of Albany, and at that of Princess Henry of Battenberg. The late Dr. John Snow, who administered the anæsthetic on both these occasions, described her Majesty as a model patient, and her example had a powerful effect in dispelling the fears and prejudices as to the use of such agents which then existed in the minds of many. These feelings were by no means confined to the non-scientific public. There was strong opposition from some surgeons who held that pain was a wholesome stimulus; on this ground the use of chloroform was actually forbidden by the principal medical officer of our army in the Crimea. In childbed, too, pain was declared by one learned obstetrical professor to be "a desirable, salutary, and conservative manifestation of life force;" another denounced the artificial deadening of sensation as "an unnecessary interference with the providentially arranged process of labor;" a third condemned the employment of an anæsthetic "merely to avert the ordinary amount of pain which the Almighty has seen fit-and most wisely, we cannot doubt-to allot to natural labor." The clergy naturally bettered the instructions of these enlightened professors of the art of healing. I need only quote one philanthropic divine, who anathematized chloroform as "a decoy of Satan apparently offering itself to bless women," but "which will harden society, and rob God of the deep earnest cries which arise in time of trouble for help!" Simpson answered those fools according to their folly. quoted Scripture to prove that the Almighty himself performed the first operation under anæsthesia, when he cast Adam into a deep sleep before removing his rib. He fought the battle of sense with such convincing logic and such an overwhelming mass of evidence-chemical, physiological, clinical, and statistical-that he finally shamed his opponents into silence. common He It does not fall within the scope of this article to consider the advantages and drawbacks of the various agents that have at one time or another within the last half-century been employed as anæsthetics, general or local: or to discuss the dangers attending their use. It need only be said that the ideal anæsthetic-that is to say, one that shall render the patient absolutely insensible of pain while leaving him fully conscious-still remains to be discovered. This is the dream of those-and they are steadily increasing in number-who devote themselves to a special study of the subject; and it would be rash to prophesy that it will not be realized. Even with its admitted inconveniences and possible risks, however, anesthesia has not only been in itself an immense step forward, but has been the most powerful factor in the rapid development of surgery during the last fifty years. Without it the marvellous victories of the knife, on which modern surgeons legitimately pride themselves, would have been impossible. Nor is it surgery alone that has been revolutionized by this splendid discovery; mediand cine, therapeutics, pathology, physiology-which are the foundations on which the treatment of disease rests have all been immensely advanced by it; as without anesthesia the experiments on animals, to which we owe much of the knowledge that has been acquired, could not possibly have been carried out. The other chief factor in the modern development of surgery has been the application of the germ theory of putrefaction to the treatment of wounds. It had long been a matter of common observation that very severe injuries were dealt with successfully by the vis medicatrix naturæ when the skin was unbroken, whereas open wounds even of a trivial character often festered and not seldom gave rise to bloodpoisoning. Thus while a simple fracture of a bone was practically certain to heal without trouble, a compound fraeture, in which there was a breach of the skin covering the wounded bone, was looked upon as so sure to be followed by evil consequences that immediate amputation of the limb was the rule of surgery in such cases. The discoveries of Pasteur and his followers furnished a key to these facts. It was shown that the process of putrefaction is a fermentation dependent on the presence of vegetable organisms belonging to the lowest class of fungi. These bacteria, as they may for the sake of convenience be termed collectively, are often present in greater or less abundance in the air; and in places where are many persons with wounds the discharges from which are in a state of decomposition, the atmosphere swarms with these invisible agents of mischief. They find their way into the body through any breach of surface or natural opening, and they are carried into wounds, abscesses, or other cavities by the hands of those who minister to the patient, and by instruments, dressings, clothing, and by water, unless means are used to destroy them. The vital importance of doing tais, and the way in which it could be done, were indicated by Joseph Lister, a man who is justly venerated by the whole medical world, and whom his sovereign has delighted to honor in a manner hitherto without precedent in this country. His work forms, without excepting even the discovery of anæsthesia, the most conspicuous landmark in surgical progress; indeed, it is no exaggeration to say that the history of surgery now falls by a natural divlsion into two distinct eras: Before Lister and After Lister. Modern surgery dates from the introduction of the antiseptic treatment of wounds. Thirty years ago the idea was just beginning to settle itself into clearness in the mind in which it was conceived; twenty years ago it was still regarded by many "practical men" as a figment of the scientific imagination; but as the evidence became irresistible, unbelievers one after another found salvation. Now the doctrine finds virtually universal acceptance. Some years ago a doctor in Germany was prosecuted and punished for some breach of the antiseptic ordinance in an operation; and though we have not yet reached that perfection of medical discipline in this country, the deliberate and persistent neglect of surgical cleanliness by a member of the staff of a public hospital would be certain to give rise to strong protests on the part of his colleagues. The cardinal point in Lister's teaching was that wounds will in the absence of any disturbing influence, constitutional or accidental, remain sweet and heal kindly, if contamination from without be prevented. The theory is that such contamination is caused by micro-organisms; in practice, it matters nothing whether it is held to be due to germs or to dirt. It is certainly caused by something foreign, something in the nature of what Lord Palmerston called "matter in the wrong place;" and this something it is the aim of modern surgery to keep out, whereas to the men of only a generation ago it was an unconsidered trifle. The elaborate ritual of purification by sprays of carbolic acid and the manifold dressings, as complicated as My Uncle Toby's fortifications, by which at first it was sought to exclude the enemy from the living citadel, have been discarded as cumbrous and unnecessary; but whatever change may be made in the details of Listerism, the Listerian principle of safeguarding wounds from every possible source of contamination will stand forever as the foundation stone of scientific surgery. son. The results of the application of the principle are seen in every department or surgical practice. The risks of surgery have been lessened to such an extent that the statistics of most of the greater operations before the antiseptic treatment came into general use are now valueless for purposes of compariA few figures will serve to show the difference. Till a comparatively recent period the proportion of cases in which death followed amputation of a limb in the large city hospitals of Great Britain was at least one in three; in a series of 2,089 cases collected by Simpson it was as high as 1 in 2.4. In the Paris hospitals about the middle of the century the death rate after amputation was nearly one in two; in 1861 it was three in five, and a few years later it was estimated at fifty-eight per cent. In Germany and Austria things were not much better; the published statistics of one most skilful surgeon show a proportion of deaths following amputation of forty-three to forty-six per cent. Nowadays such figures in the practice of any hospital surgeon would probably lead to an inquiry by the proper authorities. A very large number of these fatalities was caused by septic diseases-that is to say, different forms of blood-poisoning due to contamination of the wound, leading to constitutional infection. The terrible frequency of such diseases a |