directed to the matter by noticing the easy manner in which simple fractures healed as compared with compound. Previously to the introduction of antiseptics the latter ended generally in amputation, it having been found by experience that the removal of the affected limb gave the best chance of ultimate recovery. The first experiments bearing on the subject were made by this eminent surgeon on compound fractures. Carbolic oil of one to twenty strength was poured into the wound, and to prevent its evaporation an external dressing of carbolised putty and tin was placed over it. It was not till the spring of 1871 that gauze was introduced. Being then a resident assistant in this house, I wrote Mr. Lister asking for a sample, and in a short time he kindly complied with my request, adding that he had delayed sending it until he could prove it thoroughly trustworthy. Sprays were at this time unknown, and the only method of protecting a wound from the influence of the air was by keeping a gentle stream of carbolic acid and water (one to twenty) playing over its surface by means of a syringe. About ten years ago foot sprays were introduced, but were found laborious as well as troublesome to work, the slightest neglect of the person in charge being liable to do mischief. Even with these rough methods results were got so highly satisfactory, as to warrant the belief that the system only needed further investigation to show that it was destined to play a most important part in the future of surgery; and all the world now knows how successfully Mr. Lister has accomplished this, and how gradually, step by step, he has improved the system, until at the present time results well nigh perfect are obtained. Well, gentlemen, when I first became a student of this hospital, sixteen years ago, the methods of treatment then in vogue were totally different from what you are now accustomed to see. In amputating In amputating a limb bloodless surgery was unknown, and the compression of the main artery was entrusted to the care of an assistant. In this way a good deal of hæmorrhage took place, for even granting that the chief vessel was firmly held the smaller anastomosing branches would remain patent until ligatured. The application of the tourniquet, which works by means of a screw and strap, was not much better, for though it arrested the flow so long as it was retained in position, a considerable quantity of blood was imprisoned below the seat of amputation, and thus practically "On a New Method of Treating Compound Fractures, Abscess, &c." By Joseph Lister, F.R.S., Lancet, 16th March, 1867. Page 327. lost. The tissues at the same time were gorged with it, and oozing, as a natural consequence, would take place for some hours after division of the muscles. In these cases, instead In of a serous serous or bloody discharge not usually extending beyond the first week, there was always heavy and long continued suppuration, and as pus, from its viscid consistency, does not obtain a speedy exit from stumps, the consequence was that healing took place somewhat slowly, at the same time weakening the patient and retarding recovery. addition to all this there was the danger of absorption of poisonous material into the system. Epidemics of pyæmia and hospital gangrene* were of frequent occurrence, and when these dread diseases entered a ward the ranks were decimated in an alarming manner, while fumigation and other hygienic remedies did not prevent their return. Even erysipelas made its appearance much more frequently than it does now, and as wounds were generally left open it quickly spread to others in its neighbourhood. At this time the drainage of wounds had received but scant attention, and in amputations the operator aimed at cutting his flaps in such a way that there was a natural or dependent outlet for the discharge, and by the method of Teale, with its various modifications, this to a certain extent is accomplished. Silk ligatures were used in securing blood-vessels. The ends were left long and brought out at either angle of the stump, so that when the process of ulceration was completed they could be removed piecemeal. In a way they acted as drains, but it is not difficult to see that a porous body such as silk, left for some time in a suppurating wound, must become thoroughly soaked with decomposing material, and as a natural consequence prove at the very least a source of irritation. The practice of passing a piece of rag between the flaps was equally bad, and instead of serving the purpose of a drain must rather have tended to retard the object for which it was introduced. Lint was the dressing used for stumps, † and in a short time after being applied it became soaked with pus, and consequently the wound was kept almost continually bathed in a foetid discharge. The smell of the wards in these days was "On the Effects of the Antiseptic System of Treatment upon the Salubrity of a Surgical Hospital." By Joseph Lister. Lancet, 1st January, 1870. Page 5. +"On the Effects of the Antiseptic System of Salubrity of a Surgical Hospital." By Joseph Lister. 1870. Page 40. Treatment upon the often overpowering, and if once felt was not likely to be forgotten. Let us compare all this with the practice adopted at the present day under the antiseptic regime. Bloodless operations are now generally carried out in order to husband the patient's strength, and give him every possible chance of recovery. In amputations the best way of accomplishing this is to roll an elastic bandage round the affected limb, beginning at the distal extremity and gradually extending as far up as is necessary, where it is held by an assistant until it can be uncoiled from its lower end and carried upwards to a sufficient extent for operating, when it is finally wound round its highest folds and fixed by a safety pin in the usual manner. In this way the vessels are completely emptied, and hæmorrhage during the operation is efficiently controlled. This method is vastly superior to the one adopted by some surgeons of stretching an elastic rod or band round the limb, and keeping it to the requisite amount of tension by means of the catch of Foulis, for not only does it fail to empty the parts of blood, but its compressing power is exercised over much too limited an area, and in one instance I know of, where the band was retained for several hours above the elbow during the transit of a patient from the country, so much injury was done to the tissues in the neighbourhood that amputation at the shoulder joint became necessary soon afterwards. Much greater care is spent in the arrest of bleeding than formerly, and the more thoroughly this is done the less discharge there will be, with a correspondingly diminished risk of tension, and, consequently, the more speedily will the wound heal. Nowhere is the old maxim, "The more haste, the worse speed," better verified than here, and a little time is well spent in arresting bleedings from even small arterial twigs. The catgut ligature is an immense improvement on the old fashioned silk one. It is bland and innocuous in its character, and capable of absorption by the tissues without injury to the patient. In the deligation of arterial trunks in their continuity in the operation for the relief of aneurism, it has proved itself reliable, and may be cut short and left in the wound. As a suture gut is preferable to all others. It permits of a nice adaptation of the parts, is not liable to catch on the dressings when these are being removed, and can be left to take care of itself with no fear as to ultimate results. In the radical cure of hernia the pillars of the ring can be brought together with strong threads of catgut, and it is much superior to the very thick wire used by some surgeons for this purpose. Having operated recently on a case of this kind in Ward 29, I am in a position to say that it answered my expectations thoroughly, and the difficulty in the way of removal of thick wire constitutes one of the most serious drawbacks to its use; while the practice recommended by Mitchell Banks* of Liverpool, of leaving it buried in the tissues must occasionally give rise to after discomfort, for it is impossible that a heavy metallic suture, retained in such a position, can at all times accommodate itself completely to the parts in its neighbourhood. For the apposition of periosteum gut is indispensable, while hæmorrhage from bone can be completely arrested by plugging the cavity with threads of this substance, and Lister's sinus forceps will be found the most efficient agents for accomplishing it. For all these purposes gut hardened in chromic acid should be used, and if prepared by the process recommended by Mace went it is thoroughly reliable, and will be found capable of resisting the action of the tissues for a considerable time. I have on more than one occasion found to my cost, that the material sold in shops, under the name of "chromic catgut," was in truth nothing of the sort, and gave way in the course of two or three days. The drainage of wounds is now recognised as one of the most important elements in their successful treatment, for if the discharge does not get a free exit tension must follow, which in its turn gives rise to inflammation, and if these remain unrelieved for a sufficient length of time suppuration is the inevitable result. The india-rubber drainage tubes of Chassaignac were the first agents employed for this purpose. The material of which they are composed is non-porous, and does not absorb the fluids which come in contact with it, and unless compressed there is always a patent channel through which fluid material of any kind can pass. Small holes are pierced in the tubing at short intervals in order to increase its action, and if necessary it can be removed at each dressing, thoroughly cleaned, and then replaced. More than two years ago decalcified drainage tubes, made from the tibiæ and femora of the common fowl, were introduced by Macewen. These fulfil their purpose very well, and taking advantage of the principle of capillarity are threaded * "On the Radical Cure of Hernia." By W. Mitchell Banks, M.D., F.R.C.S. British Medical Journal, 18th November, 1882. Page 985. For further information on this point, see British Medical Journal, 29th January, 1881. British Medical Journal, 5th February, 1881. with horse hair, which, while maintaining their calibre, forms at the same time an excellent conductor of a serous or sanguineous discharge. The hair is removed at the end of fortyeight hours, but the tube itself needs no further care, and is generally absorbed either whole or in part. FIG. 1. The above gives an excellent representation of a Decalcified Drainage A further improvement, which has been carried out in amputations by the same surgeon, is the piercing, by means of a pair of dressing forceps, of the posterior flap in one or more places, and the securing in these of the tubes by means of stitches of catgut. No method can be adopted which more effectually fulfils its purpose than this, and a wound is likely to be most completely drained when several exits are afforded for the escape of discharge. The same principle leads the agriculturist to put in a number of small drains in preference to one large one, when conducting operations for the removal of superfluous moisture from his fields. In bringing the edges of a wound together it is not only requisite to do so accurately, but to avoid tension on the parts. The introduction of button sutures has greatly tended to relieve this, and we have three different kinds to choose from, those of Ogilvie Will, of Lister, and of Macewen. The first two are for wire alone. The one devised by the last named surgeon is to my mind much the simplest and best, and while easily and cheaply made, is equally well adapted for either wire or catgut. In many situations gut is the most convenient thread to use, for the ends of one side can be left long without inconveniencing the patient, and when secured by a slip-knot, bb, Fig. 3, a greater or lesser amount of pressure, according as circumstances demand, can be applied at any time without disturbing the parts in an injurious degree. Those who have had to deal with wire in this relation know, that though fulfilling its function efficiently, it is not easily untied, and the ends, whether left long or cut short, do not adapt themselves to the parts in their neighbourhood with the pliancy of gut. The button suture should be made use of first, and as the edges of the wound are thus brought into contact, the subsequent |