The germ-theory of putrefaction is based upon the labors of Pasteur, and has been described by Professor Lister in the following words: "That putrefaction is not occasioned by the chemical action of oxygen or any other gas, but is a species of fermentation analogous to that of sugar under the influence of the growing yeast plant, being brought about by the development of microscopical organisms, the germs of which, from their extreme minuteness, float in abundance in the air as constituents of its dust." This theory has not yet been proven to the satisfaction of all. The success of the practice does not depend upon the truth of the theory. We must judge the success of the practice by comparing the results obtained by it with those obtained by other methods. This can in part be done by every operator for himself. It has been alleged by some that the improved results are due to greater cleanliness and increased personal attention of the operator. This, I am sure, does not account for the difference. In the wards of the Pennsylvania Hospital and in his private practice, my old and honored teacher, Dr. George W. Norris, taught his pupils, both by precept and by example, that "cleanliness was next to godliness," and that the surgeon should himself attend personally and carefully to the cases upon which he had operated. This practice I have always faithfully followed, and believe that to it is due in a large measure the success which I have secured. Yet, although my results were already highly satisfactory, I am convinced that in those cases in which I have employed Lister's treatment, I have obtained better results than I had ever obtained before. The accompanying temperature and pulse sheets from two recent cases, show how slight may be the fever following important surgical operations when done by the antiseptic method. The first is from a case after amputation of the mammary gland on account of carcinoma, in which the disease had extended to the axilla and beneath the pectoral muscle. The wound healed nearly throughout the whole of its extent by primary union, and from the rest there was only a slight serous discharge until it healed.

The second is from a case of coxalgia in which a large abscess of the thigh was opened, and the contents-pus and fibrinous shreds— were freely removed. From the time of the operation no more pus was formed, and the walls of the abscess rapidly consolidated, and the health greatly improved.

The antiseptic treatment is not as difficult or complicated as is generally supposed. It does not take much longer to dress a case

1 Lancet, March 13, 1875.

2 Professor von Nussbaum, Erztliches Intelligenz-Blatt, March 13, 1877. London Medical Record, May 15, 1877.

1000

990

than by other methods, and the dressings need not be so frequently changed. All that is necessary is carbolic acid' in solution (1 to 40),

980

are before you, have been imported from Edinburgh, and have been made under the direction and supervision of Professor Lister.

Various substitutes for carbolic acid in the antiseptic treatment have been proposed and are now on trial. Prominent among these are boracic acid,' salicylic acid, and a mixture of the sulphite of soda and glycerin.

1 Prof. Lister prefers phenol, a pure form of carbolic acid, because it is more soluble, and much less disagreeable in odor. Lister's Address before the Section on Surgery at the International Medical Congress, held in Philadelphia, Sept. 1876. 2 Dr. Leonard Cane. Lancet, May 20, 1876

3 Clinical Results of the Lister treatment of wounds, and on the substitution of salicylic acid for carbolic acid, by Prof. C. Thiersch. Clinical Lectures, selected by permission from the series published by Prof. Richard Volkmann, of Halle. New Sydenham Society, 1877.

Dr. Minnick of the Venice Hospital. Gaz. des Hôp., Sept. 7, 1876.

Another important topic in the progress of operative surgery is the means proposed to render operations bloodless. The prevention of any loss of blood may be of great importance in patients already reduced by hemorrhage or long-continued sickness. Therefore, in amputations, operations on bones, etc., a bloodless operation may often be the means of saving life. It also is of great value in operations of nicety, which require careful dissection, as neurotomy, ligation of arteries, etc. The apparatus for securing a bloodless operation, as originally proposed by Professor Esmarch, of Kiel, consists of an elastic bandage to press the blood and lymph out of the limb, and of an elastic tube to be applied instead of a tourniquet. This apparatus, which I hold in my hand, was made in Paris, and is the form generally used abroad. The elastic bandage is made of India-rubber and silk, and is very elegant in appearance, but not so useful as a plain strip of pure gum-sheeting, as it will absorb blood and pus and soon become foul. The circular tube has attached to it a steel chain and hook which is apt to cause at times injurious pressure on account of the unyielding nature of the metallic portion. I much prefer a simple elastic tube passed several times around the limb and then tied in a knot. The apparatus answers its purpose perfectly and no blood need be lost in an amputation. The value of the apparatus lies not in the elastic bandage but in the elastic tube or tourniquet. This is not generally recognized and too much stress has been laid upon the value of the elastic bandage. After various experiments and practical experience in its use in operations, I am sure that the bloodless operation depends upon the perfection of an elastic tube as a tourniquet. An ordinary bandage or merely elevating the limb will take the place in part at least of the elastic bandage; but nothing substitutes the elastic tourniquet. It is my constant practice to use it alone, and thus I obtain all the advantages of the bloodless operation without any risk of pressing injurious fluids into the circulation.

It has been objected to the use of Esmarch's apparatus that more blood than usual is lost in ligating the vessels, because the smaller ones cannot be detected until the elastic tube is removed altogether, and then the hemorrhage is not controlled and much blood is lost before the vessels can be ligated. There is no need for this, the tube can be loosened as gradually as the screw tourniquet, and as readily tightened by an assistant holding the ends in his hands after he has removed all but a single coil around the limb.

Another use of the Esmarch apparatus has been proposed by Dr.

Walter Reid.

By it he has reported the cure in fifty minutes of a case of popliteal aneurism. He applied the elastic bandage to the limb, the turns over the aneurism being loosely made, and then placed the elastic ligature around the thigh. Since then Mr. Wagstaffe2

has reported a successful case at St. Thomas' Hospital, London, and Mr. F. A. Heath' another at the Manchester Royal Infirmary. Mr. T. Wright and Mr. Thomas Smith have each reported a successful case, and Mr. Bradley and Mr. Thomas Smith' unsuccessful cases. It is too soon yet to express an opinion of the merits of this practice. These cases, however, give fair promise of the future usefulness of the method.

Another of the advantages which may be obtained in surgical operations from India-rubber is the use of the elastic ligature. It is applicable to all the purposes of the ordinary silk ligature when the design is to cut through the tissues quickly. There is seldom any need of tightening it, its own elasticity keeps tightening it all the time. I have found it very useful in fistula in ano, nævi, and capillary aneurisms. Even the inverted uterus has been twice successfully removed by it. One case has been reported by Dr. Arles," and another by Prof. Courty.

The importance of having an accurate means of measuring the length of the lower extremities has long been acknowledged, and many methods to supply this want have been suggested. The most common method is to measure from the anterior superior spinous process of the ilium to the internal malleolus. Others prefer to measure from the umbilicus, and others from the sternum. Several apparatuses have been designed for this purpose. During the past year two new ones have been published, one by Dr. B. F. Gibbs" and one by Dr. T. G. Morton. Both of these are exceedingly ingenious,

10

1 Lancet, Sept. 25, 1875. Also, Address in Surgery, by W. F. Favell, M.R.C.S. Engl., before British Medical Association at meeting held in Sheffield. Brit. Med. Journ., Aug. 5, 1876.

2 Lancet, 1876, vol. ii. p. 461. Lancet, Feb. 3, 1877, vol. i. p. 163. 6 Brit. Med. Jour., 1876, p. 171.

3 Brit. Med. Journ., 1876, p. 570.
6 Lancet, May 26, 1877.

7 Revue Scientifique, Sept. 2, 1876.
Amer. Journ. of Med. Sci., Jan. 1877.

8 Annales de Gynecologie, Sept. 1876. 9 A new anthropometer, or a simple apparatus for determining the inequalities of the length of the legs, by B. F. Gibbs, M.D., Surgeon U. S. Navy. Amer. Journ. of Med. Sci., Jan. 1877.

10 Description of an apparatus, devised by Dr. Thomas G. Morton, for measuring any irregularity in the length of the lower extremities, by Stacy B. Collins, M.D., Assistant Surgeon of Orthopedic Hospital, Philadelphia. Amer. Journ. of Med. Sci., Jan. 1877.

and are designed to place the body perfectly straight, and keep it thus while the measurement is made with mathematical accuracy. In long-continued inclinations of the pelvis and in old diseases of the hip causing deformity, the inclination of the pelvis cannot be overcome, and anchylosis at the hip will prevent the body being placed as desired. It is better, simply, to make use of two measurements, one from the anterior superior spine of the ilium or great trochanter to the internal malleolus, and the other from the umbilicus to the internal malleolus. The two measurements will often be very different. But their very differences when rightly studied give additional information, and we may arrive at a full understanding of the case without any costly apparatus. In illustration of this, I cite the following case: A man came to me on account of very great lameness. He walked with great apparent shortening of the left limb. He had had coxalgia many years before, and until lately had been able to work as a carpenter, but the deformity was increasing and now prevented him from working. The left limb was greatly adducted. By measurement from the anterior superior spine of the ilium, the limb was found to be of the same length as the other. By measurement from the umbilicus there was a shortening of full three and a half inches. Were one of the measurements true and the other false? No! they were both true and both of value. The one told that there had been no alteration in the bones, that their length was normal; and the other showed that great obliquity of the pelvis had been induced in order to overcome the adduction of the limb so as to bring the foot to the ground and prevent it from resting on its fellow of the opposite side. The case was very instructive as showing the value of the two measurements; and the practice, based upon their results, of dividing the adductors subcutaneously and then forcibly abducting the limb, proved eminently successful.

There has been during the year an evident increased tendency to prefer ether to chloroform as an anesthetic. Indeed, although many trials have been made with various other substances, the confidence in ether seems to be gaining, while that in all other agents is comparatively declining. This is more especially evident in Great Britain. Many surgeons who formerly used chloroform are now using ether. Lately, Dr. Sawyer has published a paper showing the advantages of ether over chloroform,' and Dr. H. Macnaughton Jones, after carefully examining the effects of the different anæs

Advantages of Ether over Chloroform, Dr. James Sawyer. Brit. Med. Journ., Dec. 11, 1876.