Century. Two things gave surgical knowledge and skill in the 19th century a character of scientific or positive cumulativeness and a wide diffusion through all ranks 19th of the profession.1 The one was the founding of museums of anatomy and surgical pathology by the Hunters, Guillaume Dupuytren (1777-1835), Jules Cloquet (1790-1843), J. F. Blumenbach (1752-1840), John Barclay (17581826), and a great number of more modern anatomists and surgeons; the other was the method of clinical teaching, exemplified in its highest form of constant reference to principles by Thomas Lawrence (1711-1783) and James Syme (1799-1870). In surgical procedure the discovery of the anaesthetic properties of ether, chloroform, methylene, &c., was of incalculable service; while the conservative principle in operations upon diseased or injured parts, and especially what may be called the hygienic idea (or, more narrowly, the antiseptic and aseptic principles) in the conditions governing surgery, were strikingly beneficial. Faye (1701-1781), Ledran, Antoine Louis (1723-1792), Sauveur | of open wounds. Various means were also adopted to prevent Morand (1697-1773) and Pierre Percy (1754-1825) of Paris, the entrance of air, as, for instance, in the opening of abscesses by Bertrandi of Turin, Troja of Naples, Palleta of Milan, Schmucker the" valvular method" of Abernethy, and by the subcutaneous of the Prussian army, August Richter of Göttingen, Siebold of division of tendons in "club-foot." Balsams and turpentine Würzburg, Olaf Acrel of Stockholm and Callisen of Copen- and various forms of spirit were the basis of many varieties hagen. of dressing. These different dressings were frequently cumbersome and difficult of application, and they did not attain the object aimed at, while, at the same time, they shut in the discharges and gave rise to other evils which prevented rapid and painless healing. In the beginning of the 19th century these complicated dressings began to lose favour, and operating surgeons went to the opposite extreme and applied a simple dressing, the main object of which was to allow a free escape of discharge. Others applied no dressing at all, laying the stump of a limb after amputation on a piece of dry lint, avoiding thereby any unnecessary movement of the parts. Others, again, left the wound open for some hours after an operation, preventing in this way any accumulation, and brought its edges and surfaces together after all oozing of blood had ceased, and after the effusion, the result of injury to the tissues in the operation had to a great extent subsided. As a result of these measures many wounds healed kindly. But in other cases inflammation occurred, accompanied by pain and swelling, and the formation of pus. High fever also, due to the unhealthy state of the wound, was observed. These conditions often proved fatal, and surgeons attributed them to the constitution of the patient, or else thought that some poison had entered the wound, and, passing from it into the veins, had contaminated the blood and poisoned the patient. The close association between the formation of pus in wounds and the fatal "intoxication" of many of those cases encouraged the belief that the pus cells from the wound entered the circulation. Hence came the word pyaemia." It was also observed that a septic condition of the wound was usually associated with constitutional fever, and it was supposed that the septic matter passed into the blood-wher.ce the term "septicaemia." It was further observed that the crowding together of patients with open wounds increased the liability to these constitutional disasters, so every endeavour was made to separate the patients and to improve ventilation. In building hospitals the pavilion and other systems, with windows on both sides, with cross-ventilation in the wards, were adopted in order to give the utmost amount of fresh air. Hospital buildings were spread over as large an area as possible, and were restricted in height, if practicable, to two storeys. The term "hospitalism" was coined by Sir J. Y. Simpson, who collected statistics comparing hospital and private practice, by which he endeavoured to show that private patients were far less liable to such catastrophes than were those who were treated in hospitals. The following were among the more important additions to the resources of the surgical art: the thin thread ligature for arteries, introduced by Jones of Jersey (1805); the revival of torsion of arteries by Jean Amussat (1796-1856) [1829]; the practice of drainage by Pierre Marie Chassaignac (1805-1879) [1859]; aspiration by Philippe Pelletan (1747-1829) and recent improvers; the plaster-of-Paris bandage or other immovable application for simple fractures, clubfoot, &c. (an old Eastern practice recommended in Europe about 1814 by the English consul at Basra); the re-breaking of badly set fractures; galvano-caustics and écraseurs; the general introduction of resection of joints (Sir William Fergusson (1808-1877), Syme and others); tenotomy by Jacques Delpech (1777-1832) and Louis Stromeyer (1804-1876) [1831]; operation for squint by Johann Dieffenbach (1795-1847) [1842]; successful ligature of the external iliac for aneurism of the femoral by John Abernethy (1764-1831) [1806]; ligature of the subclavian in the third portion by Astley Cooper (1768-1841) [1806], and in its first portion by Colles; crushing of stone in the bladder by Gruithuisen of Munich (1819) and Jean Civiale (1792-1867) of Paris [1826]; cure of ovarian dropsy by removing the cyst (since greatly perfected); discovery of the ophthalmoscope, and many improvements in ophthalmic surgery by Alfred von Gräfe (1830-1899) and others; application of the laryngoscope in operations on the larynx by Jean Czermak (1828-1873) (1860) and others; together with additions to the resources of aural surgery and dentistry. The great names in the surgery of the first half of the century besides those mentioned are: Antonio Scarpa of Italy (1747-1832); Alexis Boyer (1757-1833), Félix Larrey (1766-1842) — to whom Napoleon left a legacy of a hundred thousand francs, with the eulogy: C'est l'homme le plus vertueux que j'aie connu,' Philibert Roux (1780-1854), Jacques Lisfranc (1790-1847), Alfred Louis Velpeau (1795-1868), Joseph Malgaigne (1806-1865). Auguste Nelaton (1807-1873)-all of the French school; of the British school, John Bell (1763-1820), Charles Bell (1774-1842), Allan Burns (1781-1813), Robert Liston (1794-1847), James Wardrop (17821869), Astley Cooper, Henry Cline (1750-1827), Benjamin Travers (1783-1858), Benjamin Brodie (1783-1862), Edward Stanley (17931862) and George Guthrie (1785-1856), in the United States, V. Mott, S. D. Gross and others; in Germany, Kern and Schuh of Vienna, Von Walther and Textor of Würzburg, Chelius, Hesselbach and the two Langenbecks-Konrad (1776-1851) and Bernhard (1810-1887). AUTHORITIES.-Wise, History of Medicine among the Astahes (2 vols., London, 1868); Paulus Aegineta, translated with commentary on the knowledge of the Greeks, Romans and Arabians in medicine and surgery, by Francis Adams (3 vols., London, 1844-1847), Häser, Gesch. d. Medicin (3rd ed., 1875-1881), vols. i. and ii. (C. C.) Modern Practice of Surgery.-A great change has taken place in the practice of surgery since the middle of the 19th century, in consequence of the new science of bacteriology, and the introduc- For the surgery of any particular region or organ, reference should be made to the article on that region or organ. Antiseptic Surgery. This was the condition of affairs when Lister in 1860, from a study of the experimental researches of Pasteur into the causes of putrefaction, stated that the evils observed in open wounds were due to the admission into them of organisms which exist in the air, in water, on instruments, on sponges, and on the hands of the surgeon or the skin of the patient. Having accepted the germ theory of putrefaction, Lister applied himself to discover the best way of preventing all harmful organisms from reaching the wound from the moment that it was made until it was healed. In the germ he had to deal with a microscopic plant, and he desired to render its growth impossible. This, he thought, could be chance of entering the wound or after it had entered, or by done either by destroying the plant itself before it had the facilitating the removal of the discharges and preventing their accumulation in the wound, and by doing everything to prevent the lowering of the vitality of the wounded tissues, because unhealthy tissues are the most liable to attack. Several substances were then known as possessing properties antagonistic to sepsis or putrefaction, and hence called " antiseptic." Acting on a suggestion of Lemaire, Lister chose for his experiments carbolic acid, which he used at first in a crude form. He had many difficulties to contend with-the impurity of the substance. As its irritating properties and the difficulty of finding the exact strength in which to use it: he feared to use it too strong, lest it should impair the vitality of the tissues and thus prevent healing; and he feared to use it too weak, lest its antiseptic qualities should be insufficient for the object in view. dressings for wounds he used various chemical substances, which, being mixed with carbolic acid, were intended to give off a certain quantity of carbolic acid in the form of vapour, so that the wound might be constantly surrounded by an antiseptic which would destroy any organisms approaching it, and, at the same time, not interfere with its healing. At first, although he prevented pyaemia in a marked degree, he, to a certain extent, irritated the wounds and prevented rapid healing. He began his historic experiments in Glasgow and continued them on his removal to the chair of clinical surgery in Edinburgh. After many disappointments, he gradually perfected his method of performing operations and dressing wounds, which was somewhat as follows. A patient was suffering, for instance, from disease of the foot necessitating amputation at the ankle joint. The part to be operated on was enveloped in a towel soaked with a 5% solution of carbolic acid. The towel was applied two hours before the operation, with the object of destroying the putrefactive organisms present in the skin. The patient was placed on the operating table, and brought under the influence of chloroform; the limb was then elevated to empty it of blood, and a tourniquet was applied round the limb below the knee. The instruments to be used during the operation had been previously purified by lying for half an hour in a flat porcelain dish containing carbolic acid (1 in 20). The sponges lay in a similar carbolic lotion. Towels soaked in the same solution were laid over the table and blankets near the part to be operated upon. The hands of the operator, as well as those of his assistants, were thoroughly cleansed by washing them in carbolic lotion, free use being made of a nail brush for this purpose. The operation was performed under a cloud of carbolized watery vapour (1 in 30) from a steam spray-producer. The visible bleeding points were first ligated; the tourniquet was removed; and any vessels that had escaped notice were secured. The wound was stitched, a drainage-tube made of red rubber being introduced at one corner to prevent accumulation of discharge; a strip of "protective "-oiled silk coated with carbolized dextrin was washed in carbolic lotion and applied over the wound. A double ply of carbolic gauze was soaked in the lotion laid over the protective, overlapping it freely. A dressing consisting of eight layers of dry gauze was placed over all, covering the stump and passing up the leg for about six inches. Over that a piece of thin mackintosh cloth was placed, and the whole arrangement was fixed with a gauze bandage. The mackintosh cloth prevented the carbolic acid from escaping and at the same time caused the discharge from the wound to spread through the gauze. The wound itself was shielded by the protective from the vapour given off by the carbolic gauze, whilst the surrounding parts, being constantly exposed to its activity, were protected from the intrusion of septic contamination. And these conditions were maintained until sound healing took place. Whenever the discharge reached the edge of the mackintosh the case required to be dressed, and a new supply of gauze was applied round the stump. Whenever the wound was exposed for dressing the stump was enveloped in the vapour of carbolic acid by means of the steam spray-producer. At first a syringe was used to keep the surface constantly wet with lotion and then a hand-spray. These dressings were repeated at intervals until the wound was healed. The drainage-tube was gradually shortened, and was ultimately removed altogether. The object Lister had in view from the beginning of his experiments was to place the open wound in a condition as regards the entrance of organisms as nearly as possible like a truly subcutaneous wound, such as a contusion or a simple fracture, in which the unbroken skin acted as a protection to the wounded tissues beneath. The introduction of this practice by Lister effected a complete change in operative surgery. The dark times of suppurating wounds, of foul discharges, of secondary haemorrhage, of pyaemic abscesses and hospital gangrene constitute what is now spoken of in surgery as the pre-Listerian era. As years went on, surgeons tried to simplify and improve the somewhat complicated and expensive measures and dressings and chemists were at pains to supply carbolic acid in a pure form and to discover new antiseptics, the great object being to get a non-irritating antiseptic which should at the same time be a powerful germicide. Iodoform, oil of eucalyptus, salicylic acid, boracic acid, mercuric iodide, and corrosive sublimate were used. For some years Lister irrigated a wound with carbolic lotion during the operation and at the dressings when it was exposed, but the introduction of the spray displaced the irrigation method. All these different procedures, however, as regards both the antiseptic used and the best method of its application in oily and watery solutions and in dressings, were subsidiary to the great principle involved-namely, that putrefaction in a wound is an evil which can be prevented, and that, if it is prevented, local irritation, in so far as it is due to putrefaction, is obviated and septicaemia and pyaemia cannot occur. Alongside of this great improvement the immense advantage of free drainage was universally acknowledged. Moreover, surgeons at once began to take greater care in securing the cleanliness of wounds, and some of them, Lawson Tait and Bantock, for example, produced such excellent results by the adoption merely of methods of strict cleanliness, and became so aggressive in their championship of them, that many of the older practitioners were bewildered and unable to decide as to where truth began and where it ended in the new doctrine. But though the actual methods, as taught and practised by Lister, have, with the spray-producers, passed away and given place to new, still the great light which he shed in the surgical world burns as brightly as ever it did, and all the methods which are practised to-day are the direct results of his teaching. By 1885 the carbolic acid spray, which to some practitioners had apparently been the embodiment of the Listerian theory and practice, was beginning to pass into desuetude, though for a good many years after that time certain surgeons continued to employ it during operation, and during the subsequent dressings of the wound. Surgeons who, having had practical experience of the unhappy course which their operation-cases had been apt to run in the pre-Listerian days, and of the vast improvements which ensued on their adoption of the spray-and-gauze method in its entirety, were, not unnaturally, reluctant to operate except in a cloud of carbolic vapour. So, even after Lister himself had given up the spray, its use was continued by many of his disciples. It was in the course of 1888 that operating surgeons began to neglect the letter of the antiseptic treatment and to bring themselves more under the broadening influence of its spirit. Certain adventurous and partially unconvinced surgeons began to give up the carbolic spray gradually, by imparting a smaller percentage of carbolic acid to the vapour, until at last the antiseptic disappeared altogether, apparently without detriment to the excellence of the results obtained. But while some surgeons were thus ceasing to apply the antiseptic spray to the wound during operation, others were pouring mild carbolic lotion, or a very weak solution of corrosive sublimate (an extremely potent germicide) over the freshly-cut surfaces. These measures were in turn given up, to the advantage of the patient; for it was hardly to be expected that a chemical agent which was strong enough to destroy or render inert septic micro-organisms in and about a wound would fail to injure exposed and living tissues. Eventually it became generally admitted that if a surgeon was going to operate upon the depths of an open abdomen for an hour or more, the chilling and the chemical influences of the spray must certainly lower the vitality of the parts exposed, as well as interfere with the prompt healing of the wounded surfaces. With the spray went also the "protective," the paraffin gauze, and the mackintosh sheeting which enveloped the bulky dressing. Aseptic fluid which it has drained from the wound affords clear evidence that its use has saved the patient discomfort and has probably expedited his recovery. For septic cavities drainage-tubes are still used, but it must be remembered that the tube cannot remain long in position without causing and keeping up irritation; hence, even in septic cases, the modern surgeon discards the tube at the earliest possible moment. If after he has taken it out septic fluids collect, and the patient's temperature rises, it can easily be reinserted. But it is better to take out the tube too soon than to leave it in too long; this remark applies with special force to the treatment of abscess of the pleural cavity (empyema), in the treatment of which a drainage-tube has almost certainly to be employed. Poultices are now never used: they were apt to be foul and offensive, and were certainly septic and dangerous. If moisture and warmth are needed for a wound they can be obtained by the use of a fold of clean lint, or by some aseptic wool which has been wrung out in a hot solution of boracic or carbolic acid, and applied under some waterproof material, which effectually prevents evaporation and chilling. There was no special virtue in poultices made of linseed meal or even of scraped carrot: they simply stored up the moisture and heat. They possessed no possible advantage over the modern fomentation under oilsilk. Years before this happened, in the address on surgery given | can have done no harm and sometimes the large amount of at the Cork meeting of the British Medical Association, Sir William (then Mr) Savory had somewhat severely criticized the rigid exclusiveness of the members of the spray-and-gauze school: the sum and substance of the address was that every careful surgeon was an antiseptic surgeon, and that the success of the Listerian surgeon did not depend upon the spray or the gauze, or the two together, but upon cleanliness-that the surgeon's fingers and instruments and the area operated on must be surgically clean. Though precise experiments show that it is impossible for the surgeon to remove every trace of septicity from his own hands and from the skin of his patient, still with nail-brush, soap and water, and alcohol or turpentine, with possibly the help of some mercuric germicide, he can, for all practical purposes, render his hands safe. Recognizing this difficulty many surgeons prefer to operate in thin rubber gloves which can, for certain, by boiling, be rendered free of all germs; others, in addition, put on a mask, sterile overalls, and india-rubber shoes. But these excessive refinements do not seem to be generally acceptable, whilst the results of practice show that they are by no means necessary. The careful, the antiseptic surgeon of 1885 is to-day represented by the careful, the aseptic surgeon. The antiseptic surgeon was waging a constant warfare against germs which his creed told him were on his hands, in the wound, in the air, everywhereand these he attacked with potent chemicals which beyond question often did real damage to the healthy tissues laid bare during the operation. If, as was frequently the case, his own hands became sore and rough from contact with the antiseptics he employed, it was not to be wondered at if a peritoneal surface or an incised tissue became more seriously affected. The surgeon of to-day has much less commerce with antiseptics: he operates with hands which, for all practical purposes, may be considered as germless; he uses instruments which are certainly germless, for they have just been boiled for twenty minutes in water (to which a little common soda has been added to prevent tarnishing of the steel), and he operates on tissues which have been duly made clean in a surgical sense. If he were asked what he considers the chief essentials for securing success in his operative practice, he would probably reply," Soap and water and a nailbrush." He uses no antiseptics during the operations, he keeps the wound dry by gently swabbing it with aseptic, absorbent cotton-wool, and he dresses it with a pad of aseptic gauze. This is the simple aseptic method which has been gradually evolved from the Listerian antiseptic system. But though the pendulum has swung so far in the direction of aseptic surgery, a very large proportion of operators still adhere to the antiseptic measures which had proved so highly beneficial. The judicious employment of weak solutions of carbolic acid, or of mercuric salts, and the application of unirritating dressings of an antiseptic nature cannot do any harm, and, on the other hand, they may be of great service in the case of there having been some flaw in the carrying out of what should have been an absolutely aseptic operation. A great change has taken place in connexion with the use of soft india-rubber drainage-tubes. In former years most surgeons placed one or more of these in the dependent Drainagetubes. parts of the area of operation, so that the blood or serum oozing from the injured tissues might find a ready escape. But to-day, except in dealing with a large abscess or other septic cavity, many surgeons make no provision for drainage, but, bandaging the part beneath a pad of aseptic wool, put on so much pressure that any little leakage into the tissues is quickly absorbed. If a drainage-tube can be dispensed with, so much the better, for if it is not actually needed its presence keeps up irritation and delays prompt healing. But inasmuch as a tube if rightly placed in a deep wound is an insurance against the occurrence of " tension," and as it can easily be withdrawn at the end of twenty-four hours (even if it has served no useful purpose), it is improbable that the practice of drainage of freshly made cavities will ever be entirely given up. If the tube is removed after twenty-four hours its presence Much less is heard now of so-called "bloodless " operations. The bloodlessness was secured by the part to be operated onan arm, for instance-being raised and compressed Bloodless from the fingers to the shoulder by successive turns Operations. of an india-rubber roller-bandage (Esmarch's), the main artery of the limb being then compressed by the application of an elastic cord above the highest turn of the bandage. The bandage being removed, the operation was performed through bloodless tissues. But when it was completed and the elastic cord removed from around the upper part of the limb, a reactionary flow of blood took place into every small vessel which had been previously squeezed empty, so that though the operation itself had actually been bloodless, the wound could not be closed because of the occurrence of unusually free haemorrhage or troublesome oozing. A further objection to the application of such an elastic roller-bandage was that septic or tuberculous material might by chance be squeezed from the tissues in which it was perhaps harmlessly lying, forced into the blood vessels, and so widely disseminated through the body. Esmarch's bandage is therefore but little used now in operative surgery. Instead, each bleeding point at an operation is promptly secured by a small pair of nickel-plated clip-forceps, which generally have the effect, after being left on for a few minutes, of completely and permanently arresting the bleeding. These clips were specially introduced into practice by Sir Spencer Wells, and it is no unusual thing for a surgeon to have twenty or thirty pairs of them at hand during an extensive operation. Seeing how convenient, not to say indispensable, they are. in such circumstances, the surgeon of to-day wonders how he formerly managed to get on at all without them. Biers's treatment by passive congestion is carried out by gently assisting the return of venous blood from a part of the body without in any way checking the arterial flow. In the case of tuberculous disease of the knee-joint, for instance, an elastic band is gently placed round the thigh for several hours a day, and in disease of the wrist or elbow the girth is applied round the arm. The skin below becomes flushed, and the arterial blood which, as shown by the pulse, is still flowing into the affected part, is compelled to linger in the affected tissues, giving the serum and the white corpuscles time to exert their beneficial influence upon the disease. In the case of tuberculous, or septic, affections of the lymphatic glands of the neck, or of other parts where the constriction cannot be conveniently obtained, effective congestion can be secured by the use of cupping glasses. And if so be that suppuration is taking place in the interior of an inflamed gland, the cupping-glasses can be applied after a small puncture has whole of the broken-down material can be got away without the necessity of making an actual incision or of resorting to scraping. The method of inducing hyperaemia should be so conducted as to give the patient no pain whatever: it must not be carried out with excessive energy. By means of the Röntgen or X-rays (see X-RAY TREATMENT) the surgeon is able to procure a distinct shadow-portrait of deeply-placed bones, so that he can be assured as Röntgen to the presence or absence of fracture or dislocation, or Rays. of outgrowth of bone, or of bone-containing tumours. By this means also he is able to locate with absolute precision the situation of a foreign body in the tissues-of a coin in the windpipe or gullet, of a broken piece of a needle in the hand, of a splinter of glass in the foot, or of a bullet deeply embedded in soft tissues or bone. This effect may be obtained upon a fluorescent screen or printed in a permanent form upon glass or paper. The shadow is cast by a 10- or 12-in. spark from a Crookes vacuum tube. The rays of Röntgen find their way through dead and living tissues which are far beyond the reach of the rays of ordinary light, and they are thus able even to reveal changes in the deeply placed hip-joint which have been produced by tuberculous disease. In examining an injured limb it is not necessary to take off wooden splints or bandages except in cases where the latter have been treated with plaster of paris, lime-salts obstructing the rays and throwing a shadow. Thus the rays may pass through an ordinary uric acid calculus in the kidney or bladder; but if it contains salts of lime, as does the mulberry calculus (oxalate of lime), a definite shadow is cast upon the screen. The value of the X-rays is not limited to the elucidation of obscure problems such as those just indicated: they are also of therapeutic value; for example, in the treatment of certain forms of skin disease, as well as of cancer. Too much, however, must not be expected from them. For the treatment of a patch of tuberculous ulceration (lupus), or for a superficial cancerous sore (epithelioma), they may be of service, but in the treatment of a deeply-seated malignant growth-as a cancer of the breast-they have not proved of value. Moreover, the X-rays sometimes cause serious burns of the skin; and although this happens less often now than was previously the case, still the frequent application of the rays is apt to be followed by cutaneous warty growths which are apt in turn to develop into cancer. In many cases in which the X-rays are used a more prompt and efficient means of treatment would probably be by excision. One great advantage which operative treatment by the knife must always have over the treatment by X-rays is that the secondary implication of the lymphatic glands can be dealt with at the same time. And this, in many cases, is a matter of almost equal importance to that of removal of the cancer itself. Radium. The employment of radium in surgery is still in its infancy. Doubtless radium is a very powerful agent, but even if it were found of peculiar value in treatment its cost would, for the present, put it out of the reach of most practitioners. Probably it will be found useful in the treatment of naevus, rodent ulcers and superficial malignant growths. As to what influence radium may have in the treatment of deeply-seated cancers it is as yet impossible even to guess. For those sad cases, however, which the practical surgeon is reluctantly compelled to admit as being beyond the reach of his operative skill, the influence of radium should be tried with determination and thoroughness. The therapeutic influence of radium may eventually be found to be great, or it may be disappointing. The fact that under direct royal patronage an institution has been established in London for the investigation of the physical and therapeutic value of this newly discovered agent should satisfy every one that its properties will be duly inquired into and made known without mystery or charlatanism and absolutely in the interest of the people. But in the meanwhile too much must not be expected irom it as a surgical agent. (E. O.*) SURGICAL INSTRUMENTS AND APPLIANCES. The purpose of this article is to give an account of the more important surgical instruments that are now in general use, and to show by what modifications, and from what discoveries in science, the present methods of an operation have come to be what they are. The good surgeon is careful to use the right sort and pattern of instrument, and the chief fact about the surgery of the present day, that it is aseptic or antiseptic, is recorded in the make of surgical instruments and in all the installation of an operating. theatre. Take, for instance, a scalpel and a saw that are figured in Ambroise Paré's (1510-1590) surgical writings. The scalpel folds into a handle like an ordinary pocket-knife, which alone was enough in those days to keep it from being aseptic. The handle is most elegantly adorned with a little winged female figure, but it does not commend itself as likely to be surgically A B C FIG. 1.-Needle-holders. A, Hagedorn's; B, Macphail's; C, Allen and Hanbury's, for Hagedorn or ordinary needles. clean. The saw, after the same fashion, has a richly chased metal frame, and, at the end of the handle, a lion's head in bold relief, with a ring through its mouth to hang it up by. It may be admirable art, but it would harbour all sorts of germs. If one contrasts with these artistic weapons the FIG. 2.-Tenotomy Knives forged in one piece. instruments of 1850, one finds no such adornment, and for general finish Savigny's instruments would be hard to beat; but the wooden or ivory handles, cut with finely scored lines like the cross-hatching of an engraving, are not more likely to be aseptic than the handles of Paré's instruments. At the present time, instead of such handles as these, with blades riveted into them, scalpels are forged out of one piece of steel, their handles are nickel-plated and perfectly smooth, that they may afford no crevices, and may be boiled and immersed in carbolic lotion without tarnishing or rusting; the scalpel has become just a single, smooth, plain piece of metal, having this one purpose that it shall make an aseptic wound. In the same way the saw is made in one piece, if this be possible; anyhow, it must be, so far as possible, a simple, smooth, unrusting metal instrument, that can be boiled and laid in lotion; it is a foreign body that must be introduced into tissues susceptible of infection, and it must not carry infection with it. Or we may take, at different periods of surgery, the various kinds of ligature for the arrest of bleeding from a divided bloodvessel. In Paré's time (he was the first to use the ligature in amputation, but the existence of some sort of ligature is as old as Galen) the ligature was a double thread, bon fil qui soil en double; and he employed a forceps to draw forward the cut end of the vessel to be ligatured. From the time of Ambroise Paré to the time of Lord Lister no great improvement was made. In the middle of last century it was no uncommon thing for the house-surgeon at an operation to hang a leash of waxed threads, silk or flax, through his button-hole, that they might | now available, that which is chiefly used is one impregnated with a double cyanide of zinc and mercury. Its pleasant amethystine tint has no healing virtue, but is used to distinguish it from other gauzes-carbolized gauze, tinted straw-colour; iodoform gauze, tinted yellow; sublimate, blue; chinosol, green. The chinosol gauze is especially used in ophthalmic surgery; for general surgery the cyanide gauze is chiefly employed. The various preparations of absorbent wool (ie. wool that has been freed of its grease, so that it readily takes up moisture) are used not only for outside dressings, but also as sponges at the time of operation, and have to a great extent done away with the use of real sponges. The gauzes in most cases are used not dry, but just wrung out of carbolic lotion, that their antiseptic influence may act at once. The whole subject of surgical instruments may be considered in more ways than one. It may be well, for the sake of clearing the ground, to take first some of the more common instruments of general FIG. 3.-Amputating Saws. be handy during the operation. Then came Lord Lister's work on the absorbable ligature; and out of this and much other experimental work has come the present use of the ligature in its utmost perfection-a thread that can be tied, cut short, and left in the depth of the wound, with absolute certainty that the wound may at once be closed from end to end and nothing more will ever be heard of the ligatures left buried in the tissues. The choice of materials for the ligature is wide. Some surgeons prefer catgut, variously prepared; others prefer silk; for certain purposes, as for the obliteration of a vessel not divided but tied in its course for the cure of aneurism, use is made of kangaroo-tendon, or some other animal substance. But what ever is chosen is made aseptic by boiling, and is guarded vigilantly from contamination on its way from the sterilizer into the body of the patient. The old ligatures were a common cause of suppuration. Therefore the wound was not closed along its whole length, but the ligatures were left long, hanging out of one end of the wound, and from day to day were gently pulled until they came away. Certainly they served thus to drain the wound, but they were themselves a chief cause of the suppuration that required drainage. Sutures, like ligatures, were a common cause of suppuration in or around the edges of the wound. Therefore, in the hope of avoiding this trouble, they were made of silver wire, which was inconvenient to handle, and gave pain at the time of removal of the sutures. At the present time they are of silkworm-gut, catgut, silk or horsehair; they are made aseptic by boiling, and can be left any number of days without causing suppuration and can then be removed without pain. Next may come the consideration of surgical dressings. In the days when inflammation and suppuration were almost inevitable, the dressings were usually something very simple, that could be easily and frequently changed-ointment, or wet compresses, to begin with, and poultices when suppuration was established. It is reported of the great Sir William Fergusson that he once told his students, "You may say what you like, gentlemen, but after all, there's no better dressing than cold water." This is not the place to try to tell the long history of the quest after a perfect surgical dressing, and the advance that was begun when Lord Lister invented his carbolic paste. The work was done slowly in the international unity of science during many years. The perfect antiseptic dressing must fulfil many requirements: it must be absorbent, yet not let its medicament be too quickly soaked out of it; and it must be antiseptic, yet not virulent or poisonous. Of the many gauzes B FIG. 4.-Artery Forceps. A, Péan's; B, Spencer Wells's. surgery, and then to note the working out, in the operations of the use of antiseptic or aseptic methods, and the surgical uses of surgery, of the three great principles-the use of anaesthetics, electricity. FIG. 5.-Retractors. Of the essential instruments that are common to all operations, we may well believe that they have now become, by gradual development, perfect. Take, for instance, the ordinary surgical needle. In the older forms the eye was slit-shaped, not easily threaded, and the needle was often made of a triangular outline, like a miniature bayonet. At the present time the needles used in general surgery are mostly Hagedorn's, which have a full-sized round eye, easy for threading, are flat for their whole length and have a fine cutting edge |