each time both above and below, and at last tying firmly.

The conse

quences are that all parts are snugly held in place, the thread nowhere becomes loose, and the dressing is just as sure to retain is position as that the method is carried out with reasonable care.

Remarks. Judging from description it is fair to conclude that this procedure is complicated, whereas the fact is that it is the most simple possible. Using the greatest practical brevity in describing, the details of any method seem verbose and confusing, but once done, the whole is so plain, so easy and satisfactory, to both patient and surgeon, that neither will be likely to substitute it by any other.

It would also seem to be bungling and excessively warm, both of which inferences are wrong. The supporting absorbent cotton pledgets should be thin, and the portion that is applied over the whole may be quite thin also. A single layer of cheese cloth is then all that is added over the end of the stump. The bandage must also be thin, and used sparingly. The U-shaped protector described not only aids in supporting where support is needed, but may be used as an aid in molding the end into desired shape. The patient will not allow you to omit it after he has once had it applied, as it almost perfectly protects the tender surface from the little taps and blows it would otherwise receive, and thus saves him from the most vexatious kind of pain, while the method of using the thread as described is simply perfection.

Finally, this whole dressing is readily removed by cutting all the threads across and unrolling the bandages as they were applied and quietly raising the cotton from its place without soaking. It may be best sometimes to run the scissors under its lower edge and cut it through for some distance towards the end, but trifling care will enable the dresser to remove it without discomfort to the patient. The most tender finger stump may thus be dressed, undressed and redressed at will without the infliction of the most trifling pain. If these are ends to be desired, then is this detail worthy of attention and practical adoption.

A QUARTER OF A CENTURY'S SURGERY: ITS LESSONS, ITS FAILURES, ITS DISAPPOINTMENTS, ITS PROPHECIES. (From an address delivered before the Sheffield Medico-Chirurgical Society by Dr. A. Jackson.) "Surgery," said Mr. Erichsen at the International Medical Congress, "is never stationary. To be stationary while all around is in movement, would be practically to retrograde. But movement does not necessarily mean advance.

The general direction of the movement may undoubt

edly be forwards, but the factors of that movement do not equally tend to progress."

We have entered upon a new era in surgery; we have given up much that was laid down as law in years gone by; and I cannot help but think that a retrospect made from time to time would sift the wheat from the chaff, the good from the bad, and enable us to retain what is useful and to put aside what is worth nothing.

What, then, are the lessons we should learn by a consideration of this period of surgical history? To what are we indebted for the great commotion, or progress-whichever view be taken of it-in the surgical art ? To anesthetics and antiseptics, taking the latter in the widest sense of the term.

No one can realize, except those who have witnessed it, the great increase in the number of cases in which anesthetics are employed, not only for operative, but still more for diagnostic purposes, and a great

improvement in accurate diagnosis is the result. For this purpose I

think we should do well to have recourse to it oftener. How different tumors and joint diseases appear when muscles are completely relaxed! How many mistakes have consequently been avoided; and how many more might have been avoided, if, after the administration of the anesthetic, a careful examination had been made.

But is there nothing to be said on the other side which we might well lay to heart with advantage to our patients? Familiarity with them has led us too be too careless in our examination of patients before their administration. Instead of the careful examination of patients before the day of operation as well as at the time, the latter is made often in a very hasty manner, with considerable bustle and noise going on in the theatre. To this fact, I think, may be ascribed the more frequent deaths from chloroform which have occurred in recent years. Another danger of anesthetics has been, and still is, that operations are now dawdled over, and not so quickly performed as they used to be; and we have not sufficiently realized the part result of this in the success or failure of our operations. A clear and accurate diagnosis is not now thought as necessary as it was formerly, and operators have consequently not as definite an idea of what they are going to do. So far as it is possible, an operation should be well conceived and clearly sketched in the mind of the operator.

In considering the influence of antiseptics upon the surgery of our time, it should be considered in its widest sense; not in the limited sense

to which the term "Listerism" is applied. Mr. Lawson Tait, Mr. Savory and Dr. William Roberts, have proved clearly that healthy living tissues cannot be successfully inoculated with septic bacteria-they cannot grow in them; and clinical experience has proved the same. From the so-called antiseptic treatment has come increased cleanliness of instruments, hands, wards, and air; increased attention to drainage; but these points were already being successfully carried out when the antiseptic treatment was floated, under, what I believe to have been, a false idea of safety. We have, however, learned that we may go further than was done in former days, and in many cases with advantage. We have learned to dress our wounds less frequently; to expose them less.

But while chloroform and antiseptics have had their advantages, have they done no harm? I think they have. What a terrible tale would abdominal sections tell, were they all recorded accurately, after the able method of Sir Spencer Wells! How often have they been done unsuccessfully! I am not alluding to ovariotomy, for that is one of the few successes of the last twenty-five years-a success founded upon a rock, which neither the winds of fashion nor the fickleness of the English people will ever shake. I am alluding more particularly to the exploratory operations for the relief of internal strangulation; for the relief of pain; for caries of the spine; and also to those cases where portions of the stomach and intestines have been removed, gastrostomies performed, etc., etc. As Mr. Erichsen puts it, "Will the surgery of our time record 'surgical triumphs or operative audacities?" May I substitute the word "atrocities?"

Far be it from me to say that these operations are wholly unjusti fiable. I have sinned-in my opinion-many times. But is it not time to pause and consider whether they are justifiable; whether they are suc cessful sufficiently often to continue them; and to try and perfect our diagnosis, before we make this a permanent operation. Syme, fifty years ago, used the word gastrostomy and condemned the operation; and I think we are bound to have stronger reasons than we have at present for running counter to the judgment of one of the greatest surgeons of the century.

The St. Bartholomew's Hospital Reports (1884) record twenty-one abdominal sections, with nineteen deaths, exclusive of ovariotomies.

Osteotomies are another result of anesthetics and antiseptics. They have, without doubt, been wonderfully successful; time will show whether they are permanently so. Time will show whether McEwen's or

Ogston's operation is the better; whether we had better let crooked tibiæ alone, or what we had better do with them. But are there no accidents, sometimes leading to death, of which we hear nothing? Mr. Langton, of St. Bartholomew's, has, all honor to him, published one. I know of others; and it is highly probable that the popliteal has been wounded both in Ogston's and McEwen's operations on the femur. I have had two ununited compound fractures of the tibiæ in the same child-made by myself with necrosis (they have united since I wrote this paper), which have caused me the greatest misery. A boy on whom I performed Ogston's operation, with the strictest Listerian precautions, is still under my care, having had pyemia and an empyema. Would not both these children have had happier lives and better prospects of success in life with their crooked legs and without the operation? Have we realized the extent of the calamity which it is to growing children to have a serious illness and prolonged confinement in bed?

With regard to the treatment of diseases of bones and joints, more particularly the hip, the knee, and the tarsal bones, are we where we were twenty years ago? With regard to the hip-joint and the tarsal bones, I think we are. The recognized modes of treatment of the hipjoint have failed. I do not mean in every case, but in the majority. I think excision of the head of the femur has failed because enough bone has not been removed, and it has not been resorted to early enough; but so far as I know at present, it is the only mode of treatment with any chance of success, except in the early stages. Excision of tarsal bones or gouging them out may also be classed amongst our failures; and I would urge a more frequent resort to Syme's operation.

Excision of the knee-joint has established its position in spite of the prophecies of Syme and others. I am inclined to think we ought to try more frequently for a movable joint and removal of the diseased portions of the bone only. I see occasionally a girl, whose knee-joint I excised four or five years ago, who has got good movement, and can walk comfortably several miles a day. I am inclined to think that in the rage for conservative surgery years ago, we lost sight of the fact that prolonged illness in youth often leads to serious constitutional mischief in after life even though the local ailments may be cured, whereas, if amputation had been performed, a moderately active life might have been pursued. If it is right to amputate the thigh in a case of disease of the knee-joint, why not at the hip and ankle for similar diseases? I believe the first Hey was more succassful in these cases than we are now.

The same failure seems to me to have occurred in cases of strangulated hernia. We are often still without any certain guide as to whether to operate or not. Unnecessary operations are still performed, and

thousands of operations must have taken place in that time.

While in the treatment of internal cancer, we have been called upon to witness great commotion, if not progress—while in the treatment of mammary cancer, we are urged to clear out all the glands of the axilla, so that nothing be left likely to be infected-a strange inconsistency has arisen with regard to osteoid cancer, especially with regard to the lower end of the femur; and an attempt is being made to run down the timehonored rule of amputating at the hip joint.

The current literature of the day has begun to harrass the treatment of wounded arteries, and we gather thence no fixed rules for treating wounded posterior tibials, ruptured popliteals. The laws of G. J. Guthrie have been questioned, and an attempt has been made to urge the ligature of the main artery at a distance from the wound, a treatment fraught with danger to the patient and disappointment to the surgeon, and only very rarely successful.

What a deal of commotion, without progress, has there been about the ligature of arteries, the temporary ligature of Dix, the temporary forceps of Nunnelly, acupressure, torsion: all have had their day, and all have practically given way to the ligature. Ambrose Pare is still triumphant.

Every department in surgery has been harrassed and unsettled; no one knows better how much has been done in this way than the unfortu nate man who has to lay down laws for the students in lectures: for in the very outset, with regard to the treatment and dressing of an incised wound, the treatment of a fracture, there are no rules, no laws; each man does that which is right in his own eyes, and there are almost as many different methods of treatment as there are clinical teachers.

Each hospital has its own particular way of treating broken bones. We have the same miserable sequelæ, ankylosed joints, edematous legs, pain, thickening, want of power, as formerly; and no one stops to think if anything can be done to prevent their occurrence.

Oh, that several workhouse medical officers would write a book on the Sequelae of Hospital Surgery! Such a book, with a hospital surgeon's account of his mistakes, would do more to advance surgery than the publication of so many successful cases. The treatment of empyema is now one of the burning questions of the day; and we find men advocating