few years ago may be judged from the fact that among six hundred and thirtyone cases of amputation collected from the returns of some London hospitals between 1866 and 1872, there were two hundred and thirty-nine deaths; and of those deaths no fewer than eighty-six were caused by pyæmia, a number of others being due to septicemia, cellulitis, and erysipelas. Conservative surgery in hospitals was out of the question. Sir Charles Bell has left a vivid description of attempts in that direction in military practice in the pre-antiseptic era:

In twelve hours [after the infliction of a gunshot wound of a limb] the inflammation, pain, and tension of the whole limb, the infiamed countenance, the bril liant eye, the sleepless and restless condition, declare the impression the injury is making on the limb and on the constitutional powers. In six days the limb from the groin to the toe, or from the shoulder to the finger, is swollen to half the size of the body; a violent phlegmonous inflammation pervades the whole; serous effu sion has taken place in the whole limb; and abscesses are forming in the great beds of cellular texture throughout the whole extent of the extremity. In three months, if the patient have labored through the agony, the bones are carious; the abscesses are interminable sinuses; the limb is undermined and everywhere unsound; and the constitutional strength ebbs to the lowest degree.

It was no wonder therefore that military surgeons as late as in the Crimean War went largely by "the good old rule, the simple plan" of amputating for all wounds of the limbs involving injury to bone at once, "while the soldier was in mettle." In recent wars, by the use of antiseptic "first field dressings" and by subsequent treatment with jealous regard for surgical cleanliness, it has been found possible to save a large proportion of limbs. In civil hospitals pyæmia is now almost unknown, and hospital gangrene, formerly a justly dreaded scourge, is extinct.

As illustrations of the improvement which has taken place in the results of amputations it need only be mentioned

that the average mortality rate after amputations in a London hospital which from a structural and sanitary point of view leaves much to be desired, fell from twenty-seven in 1871 to about Of six hundred and eleven in 1890. eighty-seven cases of amputation performed in a hospital in the North of England from 1878 to 1891 there was only eight per cent. of deaths; in the uncomplicated cases, taken separately, the mortality rate was no more than four per cent. In a series of cases operated on by several German surgeons of the first rank, in the pre-Listerian era, the average death rate was between thirtyeight and thirty-nine per cent.; in a corresponding series, in which the antiseptic method was used, the mortality was seventeen per cent. I have taken these statistics because they happen to be ready to my hand. A more brilliant array of figures in favor of the antiseptic treatment could, I have no doubt, be made by careful selection of cases. The facts which I have quoted, however, probably represent the plain truth.

In the operation for the radical cure of hernia the results have been even more striking. Twenty years ago this procedure was, on account of its fatality, considered to be almost outside the pale of legitimate surgery; now it is one of the most successful of operations. One English surgeon has performed it seventy-two times, with two deaths; another one hundred and thirty-seven times, with five deaths. An Italian operator has a record of two hundred and sixty-two cases, with one death; a French surgeon one of three hundred and seventy-six, with two deaths. Quite recently an American surgeon has reported a series of three hundred and sixty antiseptic operations for the radical cure of hernia, with only one death; and in that case the fatal result was found to be due, not to the surgical procedure, but to the anesthetic. In the operative treatment of cancer of the breast Lord Lister's disciple, Professor Watson Cheyne, not long ago published a series of cases showing a measure of success in dealing with that formidable affection altogether unparalleled. Tak

ing the received limit of three years without recurrence of the disease as the standard, he has been able to show a result of not less than fifty-seven per cent, of cures. Old statistics give the proportion of "cures" after these operations as five per cent., and even ten or twelve years ago it was no higher than twelve or fifteen per cent. Part of Mr. Cheyne's remarkable success is doubtless due to his very thorough removal of the disease; but when due allowance is made for this, a large part remains to be placed to the credit of the antiseptic treatment as making such drastic measures feasible. It may here be stated that, generally speaking, operations for cancer are more successful now than they were in the earlier part of her Majesty's reign; this is due not only to the rigid observance of surgical cleanliness, but to a better understanding, and in particular an earlier recognition, of the disease, which gives the surgeon the opportunity of interfering while there is yet time to prevent its spreading.

In no department of surgery has greater progress been made than in the treatment of diseases of the abdominal organs, and here, too, the way was prepared, and the advance has been powerfully helped, by the doctrine of surgical cleanliness. The development of abdominal surgery is, however, directly due to the late Sir Spencer Wells more than to any other man. Wells began his professional career as a surgeon in the navy, and during the Crimean War he had opportunities of seeing men recover from injuries caused by shot and shell which, according to the canons of surgery then generally received, ought to have proved fatal. Till that time and for several years afterwards surgeons had an almost superstitious dread of wounding or handling the peritoneum, the membrane which invests the organs contained within the abdomen. Wells saw, as others had seen, men who had been stabbed in the abdomen so that their bowels gushed out brought to the hospital, where their intestines were washed and replaced, and the wound stitched up, and in a short time all was well again. He, how

ever, saw what others had not seennamely, the true significance of these facts. They taught him that the peritoneum was much more tolerant than it was believed to be, and in particular that a clean incised wound of that membrane was as simple a matter and as free from danger as a like wound of any other tissue.

This simple observation had farreaching consequences. Wells took upon himself the task of bringing the operation of ovariotomy, which, owing to its terrible fatality, had fallen into utter discredit, within the sphere of orthodox surgery. Not long before he turned his attention to the subject a well-known surgeon had been threatened by a colleague with a coroner's inquest on any patient of his that should die after the operation. Wells's first ovariotomy was performed in 1858, and the patient recovered. During the ensuing six years he operated one hundred times, with thirty-four deaths-a rate of mortality that would now be thought appalling. He succeeded, however, in placing the operation on a firm basis, and as he gained experience he perfected his procedure, so that his mortality rate fell steadily till it almost reached the vanishing point. It has been estimated that by this particular operation alone he added ten thousand years in the aggregate to the lives of women who had the benefit of his skill. By his teaching and example, moreover, he did much more than this. He proved that the abdomen could, with proper precautions, be opened freely without fear, and thus laid the foundations of abdominal surgery in its modern development. The success of ovariotomy opened men's eyes to the feasibility of operations on other abdominal organs, and to the possibility of dealing with injuries which before were believed to be beyond the resources of surgical art. Soon the peritoneum, which had aforetime been held in such awe, came to be treated with familiarity-sometimes, it is to be feared, with contempt. celebrated operator is said to have declared that he thought no more of opening the peritoneum than of putting his

One

hand into his pocket. At the present time no abdominal organ is sacred from the surgeon's knife. Bowels riddled with bullet-holes are stitched up successfully; large pieces of gangrenous or cancerous intestine are cut out, the ends of the severed tube being brought into continuity by means of ingenious appliances; the stomach is opened for the removal of a foreign body, for the excision of a cancer, or for the administration of nourishment to a patient unable to swallow; stones are extracted from the substance of the kidneys, and these organs when hopelessly diseased are extirpated; the spleen, when enlarged or otherwise diseased, is removed bodily; gall-stones are cut out, and even tumors of the liver are excised. The kidney, the spleen, and the liver, when they cause trouble by unnatural mobility, are anchored by stitches to the abdominal wall; and the stomach has been dealt with successfully in the same way for the cure of indigestion. Besides all this, many cases of obstruction of the bowels, which in days not very long gone by would have been doomed to inevitable death, are now cured by a touch of the surgeon's knife. The perforation of the intestine, which is one of the most formidable complications of typhoid fever, has in a few cases been successfully closed by operation; and inflammation of the peritoneum, caused by the growth of tuberculous masses upon it, had been apparently cured by opening the abdominal cavity. Among the most useful advances of this department of surgery must be accounted the treatment of the condition known as "appendicitis," which has been largely rescued from the physician, with his policy of laisser faire, and placed under the more resolute and more efficient government of the surgeon. A New York surgeon not long ago reported a series of one hundred cases of operation for appendicitis, with only two deaths. In the develop ment of the surgery of the appendix and the intestine generally, a prominent part has been taken by Mr. Frederick Treves, whose researches on the anatomy of the abdomen shed a new light on

a region that was thought to offer no room for further investigation, and thus showed the way to new methods of dealing with its diseases. To him, Mr. Lawson Tait, Mr. Harrison Cripps, and Mr. Mayo Robson in this country; to Czerny and Wölfler in Germany; and to Senn and Murphy in America, it is largely owing that the abdomen, which but a few years ago was the territory of the physician, has been transferred to the surgeon-to the great advantage of mankind.

That surgery could ever deal with the abdominal organs in the manner just described would have seemed to our predecessors in the earlier part of the queen's reign the baseless fabric of a vision. But the modern surgeon, clad in antisepsis, as the Lady in "Comus" was "clothed round with chastity," defies the "rabble rout" of microbes, and dares things which only a short time ago were looked upon as beyond the wildest dreams of scientific enthusiasm. It is scarcely twenty years since the late Sir John Erichsen declared in a public address that operative surgery had nearly reached its furthest possible limits of development. He pointed out that there were certain regions of the body into which the surgeon's knife could never penetrate, naming the brain, the heart, and the lung as the most obvious examples of such inviolable sanctuaries of life.

Within the last fifteen years

the surgeon has brought each of these organs, which constitute what Bichat called the "tripod of life," within his sphere of conquest. In the brain the researches of physiologists such as Broca, Hitzig, Hughlings Jackson, and Ferrier made it possible in many cases to determine the exact seat of abscesses and tumors, and it was found that with the use of antiseptic precautions the brain substance could be dealt with as freely as any other structure. In 1883 Professor Macewen of Glasgow operated with success in two cases of paralysis and other nervous disorders caused by pressure on the brain. A tumor was removed from the brain by Mr. Godlee in the ensuing year. Since then portions of the brain have been removed, and

growths have been excised from its substance by Mr. Victor Horsley, who has done much to develop this branch of surgery, and Professor von Bergmann and other foreign surgeons have been busy in the same field. It must, however, be admitted that the results of brain surgery, though brilliant from the operative point of view, have so far been somewhat disappointing as regards the ultimate cure of the disease. In certain forms of epilepsy, in particular, which at first seemed to be curable by removal of the "cortical discharging centre" in the brain which is the source of the mischief, the tendency to fits has been found to return after a time, and the last state of the patient has been worse than the first. Still, the mere fact that the brain has been proved to be capable of being dealt with surgically with perfect safety is in itself a very distinct progress; and as Our means of recognizing the situation, nature, and extent of disease in that organ improve, there is ground for hope that the results of operative treatment will be more satisfactory. It is by no means impossible that some forms of apoplexy may yet come within the province of the surgeon.

Other parts of the nervous system have been brought within the range of surgical art. The vertebral column has been successfully trephined, and fragments of bone pressing on the cord have been taken away in cases of fractured spine; tumors have also been removed from the spinal cord by Mr. Horsley and others. There is a steadily increasing record of cures of intractable neuralgia, especially of the face, by division or removal of the affected nerve trunks; the Gasserian ganglion has been successfully extirpated in desperate cases by Mr. William Rose, Professors Thiersch, Angerer, and Krause, M. Doyen, and others. The ends of cut nerves have also been re-united, and solutions of their continuity have been filled up with portions of nerve taken from animals.

In the lung, tumors, including local ized tuberculous masses, have been removed, but these achievements can

hardly be counted among the legitimate triumphs of surgery. Wounds of the lung can, however, be dealt with successfully on orumary surgical principles. Tuberculous cavities in the lung substance have been laid open for the purposes of drainage, but the results have not so far been particularly good. In a series of one hundred cases of which a report is before me, five of the patients died as the immediate result of the operation, seventy died within two weeks, and fifteen more in the next fortnight; "only in ten of the cases was any benefit derived," and as to these the judicious reader will probably conclude that the principal "benefit" was that the operation was survived. In cysts and abscesses of the lung and in pulmonary gangrene surgical treatment is more successful. It does not seem likely, however, that the surgeon will ever be able to annex the lung to his dominion, however far he may extend his territory in other directions.

The heart naturally cannot be made so free with, even by the most enterprising surgeon, as the brain or the lung. Yet within the past twelve months a Norwegian practitioner has reported a case which encourages a hope that even wounds of the heart may not be beyond surgical treatment. A man was stabbed in the region of the heart, the weapon entering the substance of that organ, but not penetrating its cavity. The wound in the heart wall was nearly an inch in length. The patient was almost at the last gasp, but he was revived. The heart was then exposed by an operation which involved the removal of portions of the third and fourth ribs, and the wound was stitched. The patient lived for two days and a half. On examination after death the wound was found to be healing. It is clear, therefore, that in more favorable circumstances the man might have recovered.

Of the advance in some other departments of surgery, only a passing mention can be made here. Thus "cutting." which sixty years ago was the only means of dealing with stone, has now, thanks to Bigelow, Thompson, and

De

others, been almost superseded by milder methods. Tuberculous and inflammatory diseases of bones and joints, formerly intractable except by the ultima ratio of the amputating knife, are now cured without mutilation. formities are corrected by division of tendons, the excision of portions of bone, and the physiological exercise of muscles, without complicated apparatus. The healing of large wounds is assisted by the grafting of healthy skin on the raw surface; wide gaps in bones and tendons are filled up with portions of similar structures obtained from animals. The labors of Bowman, Critchett, von Graefe, and Donders have made ophthalmology one of the most scientific departments of surgery. The treatment of affections of the nose, ear, and windpipe has been improved and extended to a degree that makes the scanty literature on these subjects which existed in 1837 mere medical antiquarianism.

Enough has been said to show that in the vast progress of scientific discovery, and in the immense development of the arts that have taken place during her Majesty's reign, surgery has for a considerable number of years been in the van. It is a matter of legitimate satisfaction to all men of English speech, that both the memorable discoveries which have done most to further progress were made by men of Anglo-Saxon race; and the fact that so large and important a part in the advancement of surgery has been played by subjects of the queen is not the least among the many glories of the Victorian age.

In the domain of obstetric medicine, a very great diminution has taken place in the mortality of child-bed. Lying-in hospitals used to be hotbeds of septic disease; now puerperal fever is actually less common in properly conducted institutions of the kind than in private practice. This, too, is a result of the application of the antiseptic method of treatment to midwifery, and it was in recognition of this fact that the late Dr. Matthews Duncan dedicated his work on "Puerperal Fever" to Joseph Lister. The following figures, which I take from an address delivered some years

ago at St. Thomas's Hospital by Dr. Cullingworth, show in a striking manner the effect of the antiseptic treatment in reducing the death rate among parturient women:

Until the year 1877 this hospital [the General Lying-in Hospital] was scarcely ever free from puerperal fever, and the mortality, always high, occasionally became fearful. In 1838, of 71 women delivered 19 died; in 1861, 14 died out of 165; and in 1877, 9 out of 63. On several occasions the hospital had to be closed for long periods, and thousands of pounds were spent on the sanitary improvement of the building. In October 1879, this institution, having been closed for two years, was reopened, and has since been conducted on antiseptic principles, the details varying from time to time as increased knowledge and experience have dictated.

The result is shown in the table here appended:

Similar testimony is borne by Dr. Clement Godson as to the City of London Lying-in Hospital. In an address delivered before the "British Gynæcological Society in January of the present year he stated that in 1870, when he took over the medical charge of that institution, the patients were dying in the proportion of one in nineteen. The hospital was closed several times in the course of the ensuing sixteen years for sanitary lustrations of one kind or another, but still the fiend of blood-poisoning was not exocised. In 1886 a fresh start was made under antiseptic auspices. The result was that from the 1st of July, 1886, to the 30th of September, 1887, there were 420 confinements without a single death. From the 1st of July, 1886, to the 31st of December, 1896, there were 4,608 deliveries with 11 deaths, a mortality of one in 419 or 2.387 per 1,000. During the five years from the 1st of January, 1892. to the