that fakirs, so-called specialists and mountebanks, shall be forever banished from the land. One more suggestion and I have finished. In order that the improvement of sanitary and health conditions in this country under the plan suggested may be accomplished, and in order that the medical profession shall reap the benefit of such work, it is necessary that the members of the profession to a man join in the work. If the medical profession is to be put on the high plane that we all hope for and is to be supported by the legislation which is necessary in the establishment and maintenance of its ideals, it is equally true that the efforts and heart of this greåt profession of ours must be in that work. I, therefore, appeal to you as members of the medical profession facing difficulties and conditions that are discouraging, to put aside minor criticisms, personal preferences, petty prejudices and all other feelings that retard the attainment of great ideas and come one and all to some adequate determination to do something for the accomplishment of the highest ideals of our profession. Gentlemen, I thank you. TWENTIETH CENTURY. SURGERY. By LEONARD FREEMAN, M.D., The executive committee has requested me to discuss the subject of "Twentieth Century Surgery," with the understanding that my remarks shall be neither too technical nor too scientific-that they shall be addressed to the laity rather than to the faculty. Hence, I trust that the physicians here will pardon me if I dwell upon subjects with which they are already sufficiently familiar. Believing that things present are best appreciated by contrasting them with things past, I shall speak of ancient surgery before considering that of to-day. My address, however, being limited to twenty minutes, I shall confine myself largely to the subject of amputations, using this as an illustration of surgery as a whole. Let us imagine an amputation during the tenth century. While half a dozen assistants sat upon the patient and subdued his wild struggles, a surgeon, with a great knife shaped like a sickle, cut straight down through the skin and muscles of an injured leg, like slicing a sausage or a cucumber. There was no chloroform then. Chloroform is a modern luxury and was not discovered until the middle of the nineteenth century. A man in those days had to shut his eyes, dig his nails into the palms of his hands, and bear the torture as best he could. An operating room was truly a hell of anguish. No flaps of any kind were made in amputating-simply a great, gaping, bleeding wound, with the bone protruding from its center. And the bleeding was something awful, the blood spurting from severed vessels in drenching streams. Nothing was known of stopping the circulation by constriction of the limb with a tourniquet, and it was no uncommon thing to see a poor, shrieking wretch bleed to death upon the operating table. What a memory that must have been to keep close to one during a dark night! No wonder surgeons were often afraid to operate. As soon as the bone had been hastily divided by a saw (how a saw grates on a bone), a red-hot iron was rubbed again and again across the raw and quivering muscles-think of the agony of it-in order to sear the open vessels and stop the terrible hemorrhage; for the art of tying arteries with ligatures of thread did not come into general use until the sixteenth century. Instead of using a hot iron, the stump was sometimes plunged into boiling oil, melted sulphur, liquid fead or boiling water. You could take your choice. The ancient Hindus covered the raw and bleeding part with molten pitch. Always give me an ancient Hindu for a cheerful idea. Such was the fear of hemorrhage that many ingenious expedients were employed to control it. A favorite remedy among learned men was to hold a toad in the hand until the animal became warm. But toads have an unreasonable tendency to remain cold, so the advocates of this attractive method had always an excuse ready in case the patient failed to receive that benefit which he had a right to expect. It was claimed in support of this theory that if a toad were hung about the neck of a rooster for a day or two the head of that rooster could be cut off without the loss of a drop of blood. Roosters are different now. Another method was to thrust the bleeding part into the vitals of a hen. But while the surgeon was out in the yard chasing a hen, most patients would bleed to death. The moss that grows within dead men's skulls was a favorite, if somewhat gruesome, application. If they used the moss that grew upon their surgeon's backs, there would have been less trouble in obtaining it, and the results might have been just as good. Various mysterious powders and liquids were employed, which were as efficacious as so much sand, but which were nevertheless bought for fabulous sums, occasionally by kings and princes. Some of these powders were so potent that they would even prevent hemorrhage when applied to the weapon which produced the wound. All the timid duelist had to do was to get a little powder secretly smeared upon his antagonist's sword, and the results after that might take care of themselves. We cannot wonder that a reaction set in, many surgeons becoming afraid to amputate at all. Limbs were no longer cut off, but were permitted to rot off, during months of fever and suffering. Other operators amputated with red-hot knives, while some past masters in the arts of torture used wooden or ivory knives dipped repeatedly in nitric acid. The more quickly a leg was removed the sooner could bleeding be controlled, hence a pious man invented a machine resembling a guillotine, in which the limb was placed on the edge of a knife-blade, while a second knife, heavily weighted, fell upon it from a considerable height. Bones were, of course, terribly splintered, but no one seemed to pay much attention to a few splinters. What a delightful time the victim must have had waiting for that knife to fall. Another eminent practitioner of the gentle art of surgery tied a cord about the seat of the amputation, and, by means of a stick, slowly twisted that cord tighter and tighter during the course of several abnormally long days, until the leg was twisted off. That surgeon is now shoveling sulphur in the warmest corner of purgatory. Those who calmly chopped off legs with a meat-ax were not so cruel after all, considering the performances of their brothers in iniquity; but there is no excuse for the villains who used a chisel and mallet, cutting slowly through flesh and bone as though doing a job of carpentering. As late as the middle of the present century, a Parisian surgeon first fractured the bones of his patient's limbs and then twisted off the rest of the tissues with a wire rope. A pity such men must die. They should live forever and enrich the world. with their valuable discoveries. It is strange that surgery made so little progress for centuries-from the time of the Roman Empire to within two or three hundred years of the present date. Throughout these dark ages of medicine many surgeons feared to amputate through living tissues, but first permitted injured extremities to become foul and gangrenous, and then cut them off through the dead parts. This was the only procedure followed during the time of Hippocrates. Hemorrhage was avoided with certainty, even though the patient died. Under these old methods it required from six to eighteen months to recover, during which dreary eternity the end of the bone, which always protruded from the open wound, had to exfoliate and drop off. As an aid to this process the bone was repeatedly burned with a red-hot iron. This kept the patient in good heart, and made him realize that something was being done. Even if the sufferer was unlucky enough to recover, which seldom happened, his stump was covered with a tender and delicate scar which was always ulcerating and giving rise to pain and annoyance. When the tourniquet came into general use and the fear of hemorrhage was lost, amputation experienced a boom—everybody wanted to amputate, and everybody amputated. A surgeon's reputation was largely measured by the number of mutilated cripples hobbling in his wake. If a man hurt his leg at all severely, that was the end of that leg. Amputations were made even for simple fractures. The craze, however, soon subsided, and the present rule became fairly established-to save whenever saving is possible. Not so very many decades ago, to enter a hospital was almost equivalent to entering the jaws of death. Gangrene, erysipelas and blood poisoning stalked unhindered through the overcrowded and poorly ventilated wards. So prevalent became the most horrible and hopeless forms of wound-disease that the hospitals of Paris and Vienna were formally closed and patients housed in tents in the open fields. The fear of hospitals which still exists in the minds of many probably dates largely from this period. Nothing was known of surgical cleanliness until some thirty-five years ago, when Lister, of London, announced his momentous discoveries. Suppuration was regarded as not only un |