At the Dawn of the Century.—In the year 1579 the celebrated French surgeon, Ambroise Paré, probably the greatest of his day, in completing his work on “Chirurgery,” made the following statement, which to us of to-day is both amusing and pathetic. He says: “For God is my witness, and all good men know, that I have labored fifty years with all care and pains in the illustration and amplification of Chirurgery; and that I have so certainly touched the work whereat I aimed that antiquity may seem to have nothing wherein it may exceed as beside the glory of invention, nor posterity anything left but a certain small hope to add some things.” This great man had scarcely passed away when the practice of surgery of his day was a thing of the past, due to the realization of that “certain small hope” which he allowed as possible to posterity. Every reader, when he reflects upon the crude surgery practiced in those days, when the operations were those of necessity and not election,—that is, were done for injuries and not for disease, done to relieve and not to cure; when he remembers that not only antiseptics but also anæsthetics were unknown, must be filled with sympathy for this old gentleman, and wonder what he would think now were he to see what progress posterity has made and is still making.

It is not our purpose, however, to carry our researches so far back as Paré’s time, but to begin with our own century and bring before the reader the advances in surgery since the day of our grandfathers.

In the beginning of this century surgery was practiced by many great men, men who did not enjoy the self-satisfaction of their predecessor, Paré, but who accomplished much by constant endeavor and faithful application to advance this art and science. They, too, realized manifold “hopes,” and their children and grandchildren have moved on, and to-day are still pressing forward in the line of invention and discovery. But to us, the art of an hundred years ago appears widely different from that of our day. Anæsthesia had not then been discovered, no germ theory had been evolved, and, consequently, no such thing as antiseptic or aseptic surgery was known. The abdomen was opened for disease only, and rarely; and brain surgery consisted solely in trepanning for fractures of the skull. Surgery was not regarded as a specialty, but every surgeon was also an obstetrician and a practitioner of general medicine. Outside of the treatment of broken bones, dislocations, gunshot wounds and injuries, the surgeon at that time operated for strangulated hernia, for stone in the bladder—“cutting for stone,” as it was called; for cataract and for cancer. Dentistry was just beginning to be taken up as a specialty, and all medical men extracted teeth, and many filled their cavities. Ophthalmic surgery consisted largely in operations for cataract, and was done by the general surgeon. One department of the surgeon’s education at this time was well attended to, and that was his anatomic knowledge. Our bodies were the same then as now; and although the surgeon dared not trespass in anatomical fields which are familiar ground to the student of to-day, he did study the body after death, and was quite as well informed regarding the gross anatomy of the human body as the surgeon of to-day; and, had anæsthesia been known to him, he would probably have accomplished nearly all that was done during the middle of the century by his successors.

During the first quarter of the century no great advance was made in surgery, that is, nothing revolutionizing; but many minds and hands were at work perfecting old methods of operation and devising new ones. They had to trust to whiskey and opium to control the pain of the patient, and consequently operations requiring much time in their performance were avoided when possible, and, when necessary, had to be performed with such rapidity that the essential object aimed at was often missed. The patient was given a large dose of laudanum and a huge drink of whiskey or brandy, and was then held or tied on the table while the surgeon proceeded with his work. One can readily understand the torturing pain the poor patient had to endure, and the hurried and often unsatisfactory operation which the surgeon had to perform. The endurance of pain was not the worst part of the patient’s lot, for afterward he ran the greatest risk of blood-poisoning and gangrene, which were common complications in those days. It was the rarest thing for even the simplest operation wounds to heal by “primary union,” as it was called,—that is, without the formation of pus. Every wounded surface was expected to go through a certain amount of suppuration. Many patients lost their lives from compound fractures of their bones; and a compound fracture, that is, where there was a wound connecting the seat of fracture with the skin, usually meant many months in bed, and very often the loss of the limb.

Excepting for the purposes of removing a fœtus from the womb (the so-called Cæsarian operation, because Cæsar was from “his mother’s womb untimely ripped”), the abdominal cavity was practically never opened, and when it was the patient nearly always died. The operation for the radical cure of hernia was seldom resorted to, excepting when strangulation of the intestine necessitated operative interference to save the patient’s life. During the latter part of the eighteenth century the quacks, calling themselves “rupture cutters,” were not scarce; but the great mortality of their practice produced a wholesome fear among the people. The operation was so often fatal that most of the best surgeons would only perform it under unusually urgent circumstances. What caused the deaths was peritonitis, or gangrene of the intestine, and not the method of operating; for at this time nearly every method of operating had been devised that was in vogue fifty years later.

Bone surgery, the treatment of fractures, dislocations, and diseases of the bones, was greatly improved in the first half of the century, this subject receiving more attention at the hands of surgical writers than any other.

Anæsthesia.—Anæsthesia may, certainly from the patient’s point of view, be looked upon as the greatest advancement ever made in surgery. It was great not only for the reason that it gave the patient absolute unconsciousness during the time of the operation, but because it enabled the surgeon to work with greater exactness and less hurry. The conception of the anæsthetic state did not, however, come into being for the first time in our century, for, like most great ideas, it agitated the minds of medical and scientific men for centuries. Gross tells us that Theodoric, in the thirteenth century, recommended the inhalation of a certain combination of opium, hemlock, and other vegetable derivatives for the purpose of producing sleep, and that in India similar combinations were for centuries in use. It is needless, however, to say that the effect produced was nothing like that following the use of nitrous oxide, “laughing gas,” ether, or chloroform, and that their use never became general. Toward the close of the last century Sir Humphry Davy and others performed repeated experiments with nitrous oxide gas, but finally gave up in despair. In the early part of our own century several methods of producing insensibility to pain were recommended, such as pressure on nerves and bleeding to the degree of producing unconsciousness, but none of them was ever sufficiently successful to render their adoption general; and it remained for a New England dentist, Dr. Horace Wells, in 1844, to first use satisfactorily upon himself and his patients the complete state of unconsciousness produced by nitrous oxide gas. This poor man, however, failed signally when he endeavored to demonstrate its powers before a body of medical men, and was subjected to the most unwarranted ridicule. However, a pupil of this man, another dentist, named Morton, two years later, experimented with ether, and finally proved upon himself and on patients the wonderful power of the vapor. He exhibited his discovery at the Massachusetts General Hospital at Boston, where Dr. Warren performed an operation upon a patient etherized by Dr. Morton. The fame of this man and his great discovery spread rapidly over the continent and into the Eastern Hemisphere, and in 1847 Sir James Y. Simpson in Edinburgh discovered the anæsthetic powers of chloroform. These two agents, ether and chloroform, have existed as rivals for professional favor for nearly half a century, one being more popular and more generally used in one country and the other in another. There is, however, a field for the use of both, the operator choosing the anæsthetic to suit the individual case. In our own country ether is more generally used in the North and East and chloroform in the South and West. Chloroform has had more deaths attributed to its use, but in many cases is a much safer anæsthetic than ether. It is most amusing to observe the attitude of the so-called conservative surgeon toward the use of anæsthetics soon after their discovery; this is particularly true of their employment in obstetric practice, many eminent obstetricians maintaining that the parturient woman was intended to suffer, and referring triumphantly to the Bible for authority. It is, however, needless to say that although many men were at first uneasy in the use of these new-found agents, those who did not take advantage of their wonderful powers found themselves rapidly becoming out of date and deserted by their patients, who preferred unconsciousness to the older method of using opium and whiskey.

Notwithstanding the great step made by the introduction of ether and chloroform, the medical man is to-day still dissatisfied and is continually endeavoring to discover some agent or combination of agents which will produce insensibility to pain without unconsciousness and without the slight danger and the uncomfortable after effects of chloroform and ether. An ideal anæsthetic then must be a local anæsthetic, one that will render the field of operation insensible and be without the slightest danger to the patient.

Local Anæsthesia.—At the beginning of our century freezing with ice alone, or with ice and salt, was the only method employed for producing local insensibility. Freezing as a local anæsthetic was, however, not extensively used until fifty years later, when Dr. Richardson of London showed the anæsthetic effect of spraying the surface of the tissues with ether. During the late sixties this method of freezing became quite popular for producing local anæsthesia for small operations such as extraction of teeth, removing nails, opening abscesses, etc., and occasionally was employed for more protracted operations, Cæsarian section having been performed a number of times by the aid of this agent. The rhigolene spray was found later to be more satisfactory than ether in many respects, and the two together were frequently used.

Another freezing agent which is now used very extensively and has entirely supplanted those just mentioned is the chloride of ethyl. This, when applied to the dry skin, produces in a few seconds complete freezing, and renders the surface comparatively painless for many of the minor surgical operations.

The properties of cocaine as a local anæsthetic were known thirty years ago, but it was not until 1884 that Dr. Kohler of Germany demonstrated its practical applicability. To-day most of the operations on the eye, nose, and throat are performed under the pain prevention afforded by this drug, and in general surgery it has an extensive field, being found satisfactory where freezing is inapplicable or general anæsthesia not desired, as, for instance, in removing small tumors, splinters, ingrowing nails, etc. In the eye, nose, and throat it is applied simply in solution to the mucous membrane, but where anæsthesia of the skin is desired, it is necessary to inject it under the skin with a hypodermic syringe. When used in strong solutions this remedy is dangerous, and it has lately been shown that weaker solutions when used in larger quantities are just as satisfactory and less dangerous.

A recent substitute for cocaine is eucaine; but, although less dangerous, it is less satisfactory and not harmless to the tissues themselves.

Antiseptic and Aseptic Surgery.—Excepting the introduction of anæsthesia, no greater step has ever been made in surgery than that which was brought into use by the antiseptic and aseptic method of treating wounds. It is now about thirty years since Sir Joseph Lister, believing in the so-called “germ theory,” evolved by Pasteur, Virchow, and others, advocated the use of agents which were destructive to germ life in the treatment of wounds. At first the great antiseptic, and the one used most generally by Lister, was carbolic acid, which was applied to the wound in solution, and used as a spray during the performance of operations, to protect the wound from infection by germs in the atmosphere. It was not long, however, before it was discovered that the danger lay not in the atmosphere but in the skin of the patient and in the hands of the surgeon and in the condition of his instruments and dressings; and to these sources attention was given with results known to us all. Other antiseptics, such as bichloride of mercury and boric acid, afterward came into use, and within the past ten years the first of these two has largely supplanted carbolic acid, and is the one reliable and practical destroyer of germs. The antiseptic treatment of wounds was probably not in full swing until about 1885–1890, and was quickly followed by the more recent aseptic method. These two can, however, never be successfully separate, as the latter is dependent entirely upon the former; that is, in order to render the field of operation and the hands of the surgeon aseptic, the antiseptics must be used. Asepsis means without poisonous germs, and, as applied to surgical treatment, it is essential that, after the instruments, the dressings, the patient’s skin, the surgeon’s and his assistants’ hands have been thoroughly cleaned with soap and water and rendered free from germs, there be use of antiseptic solutions in the wound or on the dressings. This has been a great step forward, this discovery that it was in the skin that the germs lurked, and that soap and water and a scrubbing brush were as necessary as antiseptics. Few surgeons to-day employ antiseptic solutions in wounds unless the wound itself is already infected, when it becomes necessary. In wounds which are clean and made by the surgeon under aseptic conditions, no antiseptic drug is required which may indeed be actually harmful, for these chemicals which destroy germs are not altogether harmless to healthy tissue, particularly when used in strong solution.

The discovery of anæsthesia and the promulgation of the germ theory of inflammation, together with the subsequent perfection of the means of destroying microbes, all within the memory of many now living, have revolutionized surgery to such an extent that the surgeon reaches fearlessly into regions which before were impracticable, and undertakes operations which were never even dreamed of a generation ago. One can readily imagine that no surgeon would care to undertake, and no patient would endure, the agony of an operation lasting for several hours without an anæsthetic; and that it must have been only an immediate and certain danger of death that compelled a surgeon, in pre-antiseptic days, to open an abdomen or brain when he realized the great probability of subsequent inflammation and death.

Let us look at some of the individual advances of surgery since the introduction of anæsthesia and of the use of germ-destroying agents, considering first, simple fractures.

Of Simple Fractures.—Anæsthesia was the means of permitting surgeons to “set” fractures in a satisfactory manner and without pain; and the use of antiseptics has prevented many of these fractures from becoming compound fractures. Lately there has been a change in the general treatment of fractures which is proving a great advancement. Formerly it was the custom to keep not only the broken bone itself perfectly quiet on a splint until union had taken place, but also to immobilize all the neighboring structures, joints, muscles, and tendons. This meant that when the limb was taken off the splint, not only would the bone be “solid,” but there was also a tendency to fixation of the muscles and joints, so that it took the patient as long to get back the use of the limb as it did to unite the broken bone. This is now obviated in many fractures by beginning both the passive and active motion of the neighboring muscles and joints at a much earlier period than heretofore; in fact, in many fractures, such as those near the wrist, by never allowing these adjacent structures to get stiff at all, but keeping up the passive motion (while the fragments are held firmly together) from the very first dressing. In other more complicated and serious fractures where motion is contra-indicated, the use of carefully applied massage prevents largely the stiffness and the wasting of the muscles which results from long confinement on splints.

Compound Fractures.—In pre-antiseptic days compound fractures were one of the greatest causes of the amputation of limbs; and yet, to-day, these same breaks, which twenty-five years ago would have cost the patient his limb, are, by means of antiseptics, rendered aseptic and converted into a simple fracture by the closing of the wound, and the part is not only saved but fully restored to function.

Bone Diseases.—Diseases of the bones, as inflammation, caries, and necrosis, are now dealt with very differently from of old. The diseased structures are now thoroughly removed; and the inflammation which at one time kept the patient in misery and danger for a long time is subdued from the start.

Osteotomy.—This term, which means the division of a bone, is generally applied to the correction of deformities, such as bow-legs. This operation fifty years ago was not frequently resorted to, and then only in severe cases, the milder ones being left alone or treated with braces, which at best could do little more than prevent increase in deformity. When the operation was performed on the bone, it was then divided, usually with a saw. The operation nowadays for this condition is what is called subcutaneous osteotomy; that is, the wound made is only as large as the chisel used for severing the bone, about one half inch, and owing to our knowledge of microbes and our means of destroying them and preventing their ravages, hundreds of legs are made straight every year which a generation ago could not have been safely touched.

Amputations.—The first successful amputation at the hip joint, for either injury or disease, in the United States, was done in 1806 by Dr. Brasheur; the next was not accomplished until 1824. As late as 1882, the great American surgeon, Gross, wrote in his “System of Surgery:” “To no operation that can be performed on the human body is the oft-repeated maxim, ‘Ad extremos morbus extrema remedia,’ more justly applicable than to amputation at the hip joint. The operation may become necessary both on account of disease and accident; but it is of so formidable a nature and so fraught with danger, that it should never be undertaken unless the patient has no other chance of escape. The great risk which attends it is chiefly due to shock, loss of blood, suppuration, erysipelas, and pyaemia.... Under highly favorable circumstances, much of the enormous wound may unite by the first intention; but, in general, more or less suppuration takes place, and in some instances the discharge is so copious as to lead to fatal exhaustion. The greatest danger of all, however, is the occurrence of pyaemia, or secondary abscess, especially in amputations at the hip joint in consequence of injury, as a compound fracture or a gunshot wound.” This gives the attitude of the profession toward this operation a little more than fifteen years ago, and the dangers which attended its performance. Let us add that the mortality at this time may be expressed in the following figures. (Dr. F. C. Sheppard prepared these statistics for Dr. Ashhurst.) Of 613 cases in which the results are known, “237 occurred in army practice, of which 30 recovered and 207, or 87.3 per cent died; 71 were performed in civil life for injury, with the result of 47 deaths, or a mortality of 66.1 per cent; 261 were practiced for disease, with 105 deaths, or a mortality rate of 40.2 per cent; and of 44 amputations for unknown causes 34, or 77.2 per cent were fatal.”

In 1890, Dr. John A. Wyeth of New York introduced his “bloodless method” of amputation at the hip joint, and he recently reports 69 operations performed after this manner by himself and others, in which there were 11 deaths, 5 of which occurred in cases of extreme injury, where the patients had lost a large amount of blood and vigor before operation. In 40 cases the operation was done for malignant growth, and 4 deaths occurred, 10 per cent. In 22 the amputation was made for inflammatory disease of the bone, and 3 died, 13.6 per cent. One has but to contrast these statistics to understand what antiseptic methods and recent improvements in the control of hemorrhage have done to lessen the mortality of amputations. The still more recent use of salt solution injected into the circulation of patients suffering from profuse hemorrhage has lately been the means of saving many lives which would have otherwise succumbed to the loss of blood and the shock subsequent to injury and operation. As illustrating the contrast between the septic and antiseptic methods, let us consider the surgery of our Civil War and compare with that of to-day, and we shall see the enormous differences in methods, and particularly in economy of limbs and organs as well as mortality.

Hemorrhage.—The arrest and control of hemorrhage has greatly improved within the past twenty-five years. The making of an aseptic wound does away largely with the much dreaded secondary hemorrhage of a generation ago, by preventing suppuration, which is usually the cause of secondary hemorrhage. The clumsy and complicated apparatus of former days for controlling hemorrhage has been superseded by the use of the Esmarch rubber tourniquet, the neat hemostatic forceps, and the sterile animal ligature. No surgeon thinks to-day of applying a silk ligature to a blood vessel and allowing it to hang out of the wound until it separates, so that in case of secondary bleeding he could readily find the vessel; but he applies an absorbable ligature, usually of catgut, which is sterile, and which is entirely absorbed by the tissues after it has done its work. Much suffering has been saved patients by the introduction of absorbable materials for ligation of vessels and sewing of wounds. Formerly one of the great dreads of wounds was the “taking out of the stitches.” To-day where the wounds are not inflamed this is little complained of, and where the animal suture is used there is no discomfort whatever. Many means have, during the past century, been employed for the resuscitation of patients suffering from profuse hemorrhage and shock. The idea of injecting into the veins of the patient thus affected blood from another person or from an animal is not new, and has at times been quite successful. The most generally used method was to draw the blood from a healthy person or animal and inject it into the vein of the patient with a syringe: however, so-called “direct transfusion” was also employed, and consisted in pumping the blood direct from the vein of the healthy individual into that of the patient. Other materials than blood have been injected into the blood vessels of persons suffering from great loss of blood, notably milk. All of these methods have been put upon the shelf, never to be called into use again. The ingenuity of the nineteenth century suggested the substitution of a solution of common salt for blood and, to-day, the intra-venous injection of normal salt solution saves hundreds of lives. The solution is made to resemble as closely as possible the liquid portion of the human blood (the liquor sanguinis), especially as to specific gravity; and as it is always sterilized by boiling before being used, it is free from all the dangers which accompany the transfusion of one person’s blood into another. No well-appointed operating room is without its transfusion apparatus and its salt solution ready for use.

Wounds.—Reference to the remarks on asepsis and antisepsis will show the reader that the treatment of wounds has undergone a complete change in the past quarter of a century; but probably the modern treatment of gunshot wounds illustrates this better than anything else. Until 1885, only six cases were recorded where the abdominal cavity was opened for gunshot wounds, but since that time hundreds of cases have been treated in this way every year. The injuries were formerly considered almost certainly fatal, and if the intestine was injured the patient assuredly died. Now the abdomen is opened, hemorrhage controlled, wounds—often to the number of six or eight or even thirty or more—of the intestines closed, or an injured section of the intestines removed and the abdominal cavity cleansed and closed, with many favorable terminations to make the operation not only a justifiable one, but one of necessity and safety. There is no comparison with the present-day results of gunshot wounds of either abdomen or chest and those of a generation ago. It is the duty of the surgeon, in case of gunshot wound of abdomen, to open, explore, and repair, whereas formerly it was considered the part of wisdom to leave the patient without radical treatment and only to make him comfortable with opiates. Thus cases of damage to the intestines and viscera did occasionally recover in pre-antiseptic days, but it was the rarest occurrence.

What has been said of gunshot wounds applies also to stab wounds of the chest and abdomen.

The Alimentary Canal.—Probably the surgery of no portion of the body, unless it be the brain, has been so much improved during the past fifteen years as that of the alimentary canal. The esophagus or gullet is now opened with impunity for both disease and injury. This organ is not only approachable through the neck but also through the back part of the chest, by resection of the ribs; and the latter operation is frequently made necessary by the lodgment of foreign bodies,—buttons, false teeth, etc.—so low down in the esophagus that they cannot be reached through the mouth or through an opening made in the neck.

The Stomach.—This organ, which was formerly a forbidden field to the surgeon, is now subjected to the most varied surgical operations, from simple opening for the purpose of removing a foreign body or establishing a fistulous tract to the resection of a portion of it or to its complete resection, as has been successfully accomplished several times within the past year or two for malignant disease. The removal of the smaller end of the stomach for cancer is now a frequent operation. During the war of the rebellion there were sixty-four cases of wounds of the stomach, and only one recovered. In over six hundred and fifty cases of wounds of the intestines there were recorded only five cases of recovery from wounds of the small and fifty-nine from wounds of the large intestine.

The Intestinal Tract.—What has been said of the stomach applies also to this portion of the alimentary canal. No surgeon can nowadays call himself such if he is incapable of removing a diseased portion of intestine, it may be only a few inches or several feet, and bringing the dividing ends of remaining intestine into such apposition that healing takes place and the function is restored. Until recently, when the means of anastomosing the intestinal canal were perfected, it was the custom of the surgeon to bring the severed ends of the intestines into the abdominal incision and suture them there, establishing in this way an artificial anus with all its accompanying discomforts. This was certainly better than allowing the patient to perish from his disease, but how infinitely preferable is the present method of bringing the healthy cut ends of the intestine into apposition and reëstablishing the calibre. It is this operation which has so much reduced the mortality of intra-abdominal injuries, gunshot wounds, stabs, etc., and has made hundreds of sufferers from intestinal cancer either well again or comfortable for years. The perfection of the operation of joining one part of the alimentary canal to another has been due largely to the ingenuity and perseverance of American surgeons, who have devoted years to experimentation and practice upon the cadaver and upon animals.

The Kidneys.—The kidney has not been behind the other organs of the body in reaping the benefits of modern surgery. The first case of removal of the kidney was done in 1869 by Simon, and was successful. It was done only after a number of dogs were operated on successfully to demonstrate that life and health are compatible with only one kidney. Since this time the removal of a kidney for disease or injury, when its fellow of the opposite side is healthy and performing its function, has been looked upon as an entirely justifiable operation. The surgery of this organ has lately so far advanced, however, that many kidneys are now treated by more curative operations. In 1880 the first operation was done for the removal of a stone from the kidney, an operation which now nearly every surgeon of much experience has performed. The operation for the fixation of a floating kidney, which is now so common, was first done in 1881. Now, since Simon’s bold experiment the lives of between two thousand and three thousand persons have been thus saved who had otherwise certainly died.

The Bladder.—For generations the bladder has been considered a legitimate field for surgery, but modern methods and technique have greatly extended the domain. One of the greatest advances in bladder surgery has been the crushing of stone and its immediate removal. Until 1825 the treatment of all stones in the bladder was their removal through an incision made in the organ. At that time Civiale first performed the operation of passing a bladed instrument into the bladder and crushing the stone, then allowing the patient to pass it subsequently at urination. The operation became quite popular with certain surgeons as early as the middle of the century. The cutting operation has, however, never been entirely put aside, and even to-day it is, in many cases, the best and only procedure. In 1878 Bigelow, of Boston, devised the method which is now universally used, of crushing the stone and washing it out at once through a silver tube. This was a great stride ahead of the old method.

One of the great difficulties in deciding upon the removal of a kidney has been the trouble of finding out whether the other kidney is doing its work, and this Kelly, of Johns Hopkins University, has done much to overcome in devising his method of examining by looking at the openings of the tubes of the kidneys where they empty into the bladder. If the kidney is performing its function the urine will be seen flowing from its tube into the bladder.

Hernia or Rupture.—Probably the treatment of no condition has received more consideration from the surgeon of the nineteenth century than that of rupture, and it was not until 1891 that an operation was devised, simultaneously by an Italian and an American surgeon, which has proved for itself all that its originators claimed. Hundreds of operative methods have been brought forward for the cure of this troublesome and dangerous condition; but, until the operations of Halstead and Bossini were brought forward, little prospect of an absolute cure could be promised a patient, and the conservative surgeon would only undertake to operate upon very troublesome cases such as could not be controlled by a truss. Now nearly every case of hernia may be looked upon as curable by an operation.

Operative Gynæcology.—The operative treatment of the disease of the female generative organs has been revolutionized in our century, and its revolution has been largely due to American surgeons. The first ovariotomy ever performed was done in Kentucky, by Dr. Ephraim McDowell, in 1809. In the fifties, Marion Sims won great renown for himself and his country by his wonderful ingenuity and boldness in this line of work. The greatest advance here, as in all departments of surgery, has been made since the introduction of antiseptic and aseptic principles. To-day there is no disease or condition which, if seen early enough, cannot be cured, or essentially relieved at the hands of an expert abdominal surgeon. Thousands of women are now saved every year by these means who formerly would have certainly died or remained hopeless invalids.

Appendicitis.—This condition must seem to the ordinary reader to be either a new disease or one much more prevalent than in days gone by, but it is not the case. The cause of this appearance is the fact that in former times the condition was not recognized in its incipiency, and the exact cause of the trouble was unknown. The condition then advanced until it was called typhlitis, peritonitis, and obstruction of the bowels, etc., all of which would to-day occur if the conditions were not recognized early and treatment immediately instituted before the inflammation and infection extended from the appendix to neighboring tissues.

Brain Surgery.—This branch of surgery is practically a triumph of recent years. Formerly the brain was never interfered with except for injury (traumatic), and even then nothing was done excepting for the removal of pressure, as from a piece of depressed bone, and the institution of drainage. To-day the skull is opened for epilepsy; abscesses of the brain are opened and drained successfully, and tumors of the brain are removed, thus not only in numberless instances saving life but—what is equally important—saving the usefulness of the life and mind. The first actual successes in this line are recorded by Bennett and Godlee in 1884, who localized and operated on and ultimately found a tumor. The patient died, but the bold beginning was followed by a number of other surgeons, till this new region for exploration, hitherto untouched, has become a fertile ground for successful efforts. Abscess of the brain, until twenty years ago, was almost invariably fatal. MacEwen in 1879 located an abscess of the brain and begged to be allowed to operate, but was refused by the family of the patient. After the death of the patient he operated precisely as he would have done in life, evacuated the pus and demonstrated that had he been permitted to do so he could have saved life.

Where the cranium is wounded surgeons nowadays will not hesitate to open the skull, secure the bleeding vessels, remove clots, and thus many lives are saved. Even comparatively slight injuries to the skull, where the brain is damaged, involve oftentimes destruction to the arteries and blood is effused, producing such destructive pressure as causes very serious symptoms or even death. In other instances, the results of a blow or a fall without injuring the skull may cause profound damage and subsequent hemorrhage. In all these cases operative interference, now extremely safe and easy, may readily save life. Gunshot wounds of the brain are now only occasionally fatal, provided opportunity offers for prompt and clean operative work. Even where the ball has traversed the entire length of the cerebrum, recovery has followed operation. The results of brain surgery in relieving certain forms of epilepsy are occasionally most brilliant and frequently much relief is afforded. Where the epilepsy is of the character known as focal, and where there is evidence of irritation of the brain, due to a local pressure, whether of the cranial walls or of some new growth within the brain tissue, the removal of these sources of irritation has in many reported instances been most satisfactory. Again, certain cases of protracted headache, so severe as to render life insupportable, have been cured by trepanning the skull. Certain forms of insanity have been modified and relieved where this had followed upon brain injuries. It is of great interest to reflect upon the methods by which students of brain disease are enabled to determine so exactly the location of tumors, abscesses, hemorrhages, clots, scars, and other alterations of tissue giving rise to epilepsy and brain disorders, and which afford no indication of the diseased locality by any changed condition of the surface. In dealing with other parts of the body, if the precise locality of the part to be operated on cannot be at first determined, there is no hesitation in the minds of the surgeons in cutting down upon, and searching for, that which he proposes to remove. In dealing with so delicate an organ as the brain, however, this cannot be permitted; for a variation of the very smallest dimension will sometimes change the manipulations from those of perfect safety to the most fatal results. Our knowledge of the location of the functions of the brain and the areas from whence arise governing influences has been derived almost solely from experiments upon living animals. Among the names of the great pioneers in this direction must be mentioned those of Ferrier and Horseley, of England; Fritsch, Hitzig, and Goltz, of Germany. The researches which have thus opened up a new realm of operative possibility are among the very greatest triumphs in our means of saving life and affording opportunity for relief of the most serious disablements known to modern times.

For illustration of how these studies are pursued, it may be of interest to review the method used by Horseley.

The brain of a monkey having been exposed at the part to be investigated, the poles of a battery are applied over squares one twelfth of an inch in diameter, and all the various movements which occur (if any) are minutely studied. One square having been studied, the next is stimulated, and the results are again noted, and so on from square to square. These movements are then tabulated. For example, all those adjacent squares which, when stimulated, produce movements of the thumb are called the region for representation of the thumb, or “the thumb centre;” and to all those squares which produce movements of the hand, the elbow, the shoulder, or the face, etc., are given corresponding names. In this way the brain has been mapped out, region by region, and the same minute, patient study given to each.

These animals are etherized so that they do not suffer the least pain. Such operations, with few exceptions, even without ether, are not painful. The brain itself can be handled, compressed, cut, or torn without the least pain. A number of cases have already been reported in which a considerable portion of the human brain has been removed by operation, and the patients have been about their ordinary avocations within a week or two.

Studying in this way the brain in the lower animals, it is now possible to get a very fair knowledge of the localization of many of its functions in man.

Moreover, portions of the body can be entirely severed, and, if suitably preserved, can be replaced, and they will adhere and grow as if nothing had happened. When a wound is slow in healing, we now take bits of skin, either from the patient’s own body or provided by the willing family or friends, or even from frogs, and “graft” them on the surface of the wound. They usually adhere, and as enlargement takes place at their margins, they coalesce by one half the time required for healing. Even a large disk of bone, one or two inches in diameter, when removed from the skull, can be so saved and utilized. It is placed in a vessel filled with a warm antiseptic solution, which is again placed in a basin of warm water, and it is the duty of a special assistant to see that the thermometer in this basin shall always mark 100° to 105° Fahr. The bone may be separated from the skull so long as one or two hours, but if properly cared for can be replaced, and will grow fast and fulfill its accustomed but interrupted duty of protecting the brain.

Röntgen Rays.—One of the most recent advances in the art of surgery is the discovery and use of the X-rays. In December, 1895, Professor Röntgen, of Würzburg, announced his discovery, and since then its utility has continually increased, until to-day no large hospital or properly equipped teaching institution, indeed no first-rate surgeon, is without the X-ray apparatus. By its use many doubtful cases of both injury and disease in surgical practice are thus entirely rendered clear. In the diagnosis and treatment of many fractures it is nearly indispensable, showing the exact location of the break and the position of the fragment before and after dressing. Probably in no other condition, unless it be in fractured bones, has the X-ray proved itself of so much value as in the location of foreign bodies lodged in any of the organs or tissues of the body. Before Professor Röntgen’s discovery it was not of infrequent occurrence that an exploratory operation was necessary to positively prove the presence of a foreign body, and even this was at times of necessity a failure. To-day the X-ray picture enables the surgeon to learn the exact location of the foreign body and indicates to him the best point from which it may be attacked. With repeated improvements in apparatus the time of exposure required for making the picture of the part has been greatly reduced. The advantage of this was made manifest when it was discovered that destruction of the skin, the so-called “X-ray burns,” might follow long and repeated exposure to the rays. It is not always necessary to make a plate of the part to be examined, since by simply studying the parts by the eyes through the fluoroscope or the fluoroscopic screen the surgeon can readily see everything that a photographic picture could show him. The fluoroscope or screen is now often used during the operation of removing foreign bodies; through it the surgeon can watch the various steps of his operation, his approach to the foreign body and its final removal.

If the field of its usefulness continues to expand at its present rate, it will not be long before its use as a diagnostic measure will be as valuable to the medical man as it now is to the surgeon.

By such instruments of precision as this, and others less conspicuous, the old elements of intelligent inference and argument by analogy and exclusion are rendered of less value, and a rapid approach is made to scientific exactitude in surgery as well as medicine. All this has attained a far higher quality and scope in the last quarter of this century than in any other period of the world’s history, and we may look to great advances in the coming century, in all life-conserving and remedial measures whereby the race may enjoy a larger measure of relief as well as immunity from the onslaught of disease and the results of accident.

There is shown here for illustration a photographic picture of a limb, taken by the X-ray now growing familiar to every one. It should be borne in mind that while it is a simple matter for the casual observer to note obvious solutions of continuity in bones, or the presence of foreign bodies, this is not the chief item of usefulness to the surgeon, and certainly not to the medical practitioner. A special training is required to study and interpret the findings and appearances of the tissues, their altered relationships, densities, and many other matters entirely insignificant to the uneducated among medical men or laity.

Again, the picture here shown is similar in outline to but a reversal of the shading seen through the fluoroscope by direct vision, when the greatest skill is required in noting the significance of altered states in the denser or softer tissues.

When suits for malpractice are instituted against surgeons it is not to be admitted that the evidence or findings of the “highly intelligent” but not technically skilled witness can have the slightest weight as proving the condition of tissues of which they are very ignorant, not only physiologically but more so pathologically.