have raised the standard of pathology as a science, but, with all respect, I beg to think that it has not maintained the zeal for pathological knowledge or extended the study of this most important branch of our training. Robert William Smith has left no successor. In thinking out an address of this kind the mind instinctively turns to a retrospect of improvements in surgery or a critical inquiry into the nature of the work which is actually being done amongst us. A theme so suggestive has many attractions, and yet much of all this has been anticipated in the annual digests to be found in our periodical literature, while the exhaustive and eloquent review of our work by Mr. Marshall at the Cardiff meeting, still fresh in our memories, leaves little to be done in this direction. Engaged in the constant work of a general hospital and the daily routine of metropolitan practice, I cannot lay claim to any special opportunities, nor is there any subject on which I have attained that degree of proficiency which would justify me in undertaking the instruction of the many able thinkers whom I have the honor to address.

He who writes the history of the surgery of this Victorian era will find one or two cardinal facts of such vast and stupendous proportions as to dwarf all others in the influence which they have exercised on our surgical work. Facile princeps among these is the method known as the antiseptic system, still enveloped in clouds of uncertainty and mis conception, notwithstanding the work which so many eager and enthusiastic inquirers have bestowed upon it, and far indeed removed from any approach to finality.

It may not be unprofitable to determine what is the present actual condition of this system, and setting aside bogus theories and unsubstantial hypotheses, to ascertain its exact relation to our everyday work. For, after all, it must come to this important questionWhat help does antisepticism afford to the daily practice of surgery? No honest or impartial observer can fail to recognize, with a deep sense of gratitude, the magnificent results and the brilliant success which have attended the Listerian system-results which have led to its adoption throughout the civilized world-results which have reorganized surgical methods, and given a startling impulse to the operative treatment of injury and disease. The system may be wrong in practice, and founded on an erroneous theory, but that wonderful results have followed since its introduction is an historical fact beyond contradiction. And yet, with this triumphant record, we find some of its most devoted ad

herents now relaxing the stringency of its application and abandoning parts of the system which were long regarded as essential, and that, too, without any diminution of successful results.

Again, we find antiseptic precautions so little regarded-nay, almost set at nought-as to prompt the ovariotomist to flush the peritoneum with water containing "germs and spores and thirty different kinds of beasts," and yet point to a continuous record of success little, if at all, inferior to the more complex method. In this burning controversy, to what conclusion can the simple inquirer after truth arrive at-he who is anxious to decide what is best for those who entrust to his judgment and skill the safety of their limbs and their lives? Let us, without prejudice or personal bias, endeavor to grasp the actual facts and see what they teach us when exam ined by the light of truth.

It may be conceded as proved by actual observation conducted and recorded by competent authority, that the atmosphere which surrounds our globe is infested with myriads of minute organisms-calls them by whatever name you please; that they belong, some to the vegetable, some to the animal kingdom; that they possess vitality, either potential or actual, from which it follows that they are subject to constant and restless change the heirloom of organization. These changes are largely influenced, if not altogether caused, by the surroundings among which they are situated, and they in their turn reciprocate and produce disturbance in the material which environs them. It has also been established beyond controversy that some of those are incapable of development or growth in the tissues or fluids of the living body, and can only undergo their life-changes when surrounded by material which is dead, and, therefore, amenable to the physico-chemical laws. Others again are capable of maintaining their independent vitality in living tissues, where from a minute beginning they increase and multiply, disarranging and vitiating the entire organism into which they have found their way, waging a deadly war against the tissue cells, who, nobly acting on the defensive, throw out breastworks to resist to the utmost the encroachments of these merciless invaders. In the first variety the effect produced is in direct proportion to the actual amount of the ferment introduced. In the second, the amount of disturbance is out of all proportion to the minute quantity of the noxa which produces it; that these latter bodies are an efficient and potent cause of suppuration and infective inflammation would appear to be

proved by actual demanstration. I shall not weary you with details, but simply state the experiments which have brought conviction to my own mind. We have experiments which prove beyond doubt that injury may be inflicted on the deep tissues of the living body, either by mechanical, physical or chemical noxæ, and if due cleanliness of the instruments is observed, and atmospheric air absolutely excluded, no effect whatever is produced beyond the injured spot. Hueter, of Griefswald, injected a 5 per cent. solution of chloride of zinc, killing the tissue with which it came in immediate contact, the necrosed mass producing no ill effect upon the surrounding structures; like results followed the action of the hot iron.

Chauvau adopted for his experiments the Continental mode of castration by torsion of the spermatic vessels, bistournage, by which the organ becomes completely detached from its living connection without inflammation, suppuration, or sepsis in thousands of cases, but if the minutest portion of fluid containing these atmospheric atoms is injected under the skin so that they enter the clood-current, severe inflammation is at once developed, a seething focus of disease where all was peace, and subsequent examination will show the organ and its surroundings infiltrated with infecting germs.

These experiments and observations prove conclusively by positive and negative evidence that these aerial entities are capable of producing suppuration and infective inflammation. It has not, to my mind, been established that they are the sole and only origin of such phe nomena. But the facts determined by Ogston, Koecher, and others, that they may enter the interstitial tissues through the respiratory or digestive tract, are gradually narrowing the ground uncovered by their influence, and explain away the apparent spontaneity of such diseases as ulcerative endocarditis and infec tive periostitis when these atoms are found crowding the deepest organs without any wound or breach of surface to account for their entrance. If the history which I have endeavored to sketch be true, it must commend itself to the ordinary understanding that it is our duty to destroy and exclude them from the body with all the care we possibly can, and if the means adopted for that purpose-call them Listerism, antisepticism, surgical cleanliness, or by whatever name you will-turn the scale a feather weight in favor ef restoration to health or saving the life of a single human being, the man who refuses to employ them through prejudice or apathy incurs a responsibility

nothing short of criminal. The difficulty which is now exercising the minds of practical pathologists and chemists is to find the most suitable germicide-one which will act efficiently without being poisonous to the tis sues or the system at large; and it is interesting to watch how one after another they have been lauded and proclaimed, only to be superseded by another and another, and here at all events we are very far removed from finality. Carbolic acid, corrosive sublimate, iodoform, thymol, have each for a time enjoyed the crown for a few months, only in their turn to be deposed and dismissed as impostors with ignominy. It is even now proposed to attack one set of these atoms by an opposing army of a different specses of atoms and thus effect their annihilation-reminding us of the quaint couplet of Butler

"These fleas have other fleas to bite 'em, These fleas, fleas-ad infinitum."

Does not all this warn us that there is another side of antisepticism which has been almost entirely neglected? It would appear as if, up to the present, the attention has been exclusively fixed on infective germs. Sufficient regard not being had to the important influence of environment, every effort has been strained to discover the most effective and deadly germicide, when we know that these atoms, no matter how virulent they may be, cannot undergo their life-changes, cannot produce these infective results, unless the environment, like the cultivation liquids of the histo-pathologist, is capable of developing and sustaining these changes. Deposited on clean metal, glass, or porcelain, they die of inanition; they exercise no influence whatever, and are amenable to none. In contact with dead organic matter, or living matter in certain conditions of altered or reduced vitality, they become a teeming source of infection, decomposition, and decay. If pathological surfaces could possibly be brought to and maintained in such a condition that they would not afford a suitable cultivation ground, do we not accomplish almost as much as when we destroy them? And surely the perfection of antisepticism must be attained when these two conditions are fully developed and enforced.

I need hardly quote examples of this infiuence of environment, such as the protectiou afforded by vaccination againts the germ smallpox, the protection of the blood by previons action of exanthemata.

of

The bacilli of splenic fever, so destructive to the herbivorous animals, take little effect on carnivora, and none at all on the pachydermata. The bacteria which will cause sep

ticemia in the mouse are wholly inert against the field mouse.

We can learn much that will enlarge our views if we study human by comparative pathology. Look at the flood of light there has been shed by the study of the bacilli of splenic fever, chicken cholera, and glanders. Look at the wonderful preservation of a valuable industry accomplished by Pasteur's discovery of the febrine in the silkworm. And we must not confine our researches within the narrow limits of even the animal kingdom. We can learn much by the pathology of the vegetable kingdom. Some of the most trsubleoome diseases which the sur geon has to deal with are derived from the invasion of vegetable parasites.

In connection with the influence of environment, a remarkable fact was communicated to me by a friend who devoted much time and patient industry to the cultivation of fruit, and the fact made a great impressiou on me, and I think it explains many facts in human pathology In exhibiting fruit for prize competition they have to be brought to a certain degree of ripeness to a day, almost to an hour. He told me he could hasten the ripening with almost mathematical precision by interposing between the prize specimens fruit of the same species which were already ripe, as if the emanation from the ripe fruit produced a ripening impression upon the apples in its immediate vicinity. I think we see this principle of environment frequently illustrated in human pathology when disease extends to adjacent but not continuous surfaces.

This twofold aspect of infective inflammation was forced on my attention when trying to think out the best mode of dealing with chronic abscess-a subject which has for a long time taxed the ingenuity of the surgeon, and often defeated his most ingenious plans, no matter how carefully they may have been carried out. This may be gathered from the long list of methods paraded in our system. atic works on surgery. There is nothing which indicates the uncertainty of our knowledge so much as the multiplication of modes of treat ment witness the wundred and one ways in which it is proposed to deal with so simple an accident as a broken collar bone or a factured femur. It would waste your time and weary your patience to quote the various authors who have, from time to time, suggested special modes of treatment, which have held their ground for a time, to give place in turn to some new idea. The structure of the immediate wall of a chronic abscess has been the subject of much diversity of opinion, and

there is considerable doubt as to the existence of any such structure as the so-called pyogenic membrane or cyst-wall. The idea of Billroth, that an abscess is but a hollow ulcer, conveys probably an accurate description of its structure. Its action as an absorbent surface is frequently brought under our notice, but its power of pyogenesis is not in accord with modern pathology.

There is a fact of very great interest in this connection. The discharge from a recentlyopened chronic abscess does not contain these microzymes, which are so characteristic of purulent matter in acute suppuration. Ogston and others have failed to detect them by the most carefully conducted observations, or to produce septic results by them; and hence it is that the collections produce little or no constitutional disturbance until they are opened. They may remain for years without any effect other than mere local inconvenience until the matter is discharged-either by the efforts of Nature, or by the knife of the surgeon-and the repeated obervation of this fact has induced the surgeon to postpone any interference, waiting often too long for the slow process of natural opening. The clinical records of these cases would lead us to believe that, in some remarkable way, the system would appear to be somehow prepared for this event; and I am satisfied in my own mind that far less constitutional disturbance follows the natural opening than that effected by the surgeon. There can be no doubt the use of antiseptics has done much to reduce this difference, but I cannot say, as the result of my own experience, that they have completely removed it.

I have given fair trial, such as my opportunities afforded me, of the different modes of treating chronic abscesses which have come to my knowledge; even the tinfoil and antiseptic putty, which I saw applied by the illustrious Lister himself in a case at the Richmond Hospital, under the lamented Christopher Fleming. Somewhere about the year 1868, the late Campbell De Morgan, whose untimely death cut short his useful career just as he was about to attain the eminence to which he was so justly entitled, entitled, visited Dublin, and going over Steevens Hospital, he explained and demonstrated to us his mode of treating open wounds with a solution of chloride of zinc, a plan which afforded so much satisfaction, that it has been universally adopted by my colleagues and myself, and we have thus for over twenty years been carrying out, without any rational foundation in histo-pathology, what I conceive to be the most essential and

ample room and verge enough for work-many untrodden fields of discovery-so that we can make the future of Queen Victoria's reign as glorious in the annals of scientific discovery, as full of help to the sick and wounded sufferer, as has been its past.-Brit. Med. Jour.

THERAPEUTICS OF FEMALE STERILITY.

From the advance sheets of the unpublished book of Prof Kish (Prague-Marienbad), entitled "Sterility of Women."

The therapeutics of female sterility has as its object the removal of such causes as have brought about this pathological condition. But this testifies at once to the difficulty and uncertainty of the therapeutic interferences. The first step toward a cure of this defect is a scrupulous and minute anamnesis of the genital and mariturnal relations not only of the wife but also of the husband, provided such be possible. We have to consider the sexual development of the woman, the age of her maturity, and naturity of menses, with all details. We have to search for a scrofulous, syphilitic, or other hereditary taint, to inquire as to her past state of health, diseases of childhood, and the history of her family and relations, especially in view of an absent or scanty procreative ability. The delicate question concerning the coitus, its relations, nature and consequences, can unfortunately be not avoided. It is necessary for the physician to know whether it occasioned pain or the normal gratification, whether the introduction of the penis into the destined parts is impeded or not, aud whether the sperma rapidly flows out again from the vagina. (A case is reported to Kisch where a lady consulted him for her sterility, which was afterwards traced to a condom use by the husband without her knowledge.) If possible, the sperma of the husband is to be examined microscopically. It is gathered in a condom, and brought for inspection immediately after the coitus. Several drops of vaginal or cervical mucus are likewise taken from the parts immediately after a coitus, the sperma placed in it, and the possible influence of the female secretions on the male noted. Occasionally we observe numerous spermatozoids moving to and fro in the semen; but, when placed in the secretion of the female genitals, they lose as once their mobility. This of course shows that the materia peccans in this instauce does not rest with the man. Some men object to the examination of their semen as an insult; they regard potentia coeundi as identical potntia generandi.

We have to find out whether germ-forma tion is impeded, or whether inherited or constitutional alterations are present in the ovulum, which render the same unimpregnable. Besidei, we have to search for organic affections of the ovaries or their neighborhood, which either prevent the formation or the descendence of the egg. The tubes of the cervix may be at fault on account of a congenital or acquired narrowness. Perhaps the secretions of the vagina are morbidly affected, so as to render the sperma inert. Numerous other questions of this kind are all deserving of our consideration, and we see that only by the most careful and minute scrutiny is it possible to reveal, of the numerous possibl ecauses, the reason of the sterility in a givencase.

Sim's assertion that the cure of sterility can only be accomplished by surgical interference is untenable. The principal factor is a medication which raises the nutrition of the entire organism, improves the blood formation, and favors the resorption of pathological products in the sexual organs. For in a large majority of cases presented for treatment we have to deal with anemia, chlorosis, and scrofulosis. Local alterations in the parts of course require their rectification, such as the various forms of flexion and ver sion. Occasionally surgical interference is called for in cases of abnormal conditions of the hymen, or of abnormal communications between vaginal and neighboring organs, or, finally, on account of neoplasms.

The prophylaxis of sterility deserves the fullest attention of every practitioner. The first requisite, of course, is a complete sexual maturity in both the husband and wife, which, as everybody knows, is not always the case at the present day, especially in so-called high life. Another important factor is the avoidance of marrying relatives. The results of this principle, as practised for centuries among the Spanish nobility, are two well known to require any illustration. In certain savage races, on the other hand, the exogamic principle-i. e., to marry only women from another tribe-is strictly observed. Next in importance as prophylactic measures stand proper diet, regimen, and occupation of the girl, especially during the period of menstruation, and in case of a married woman additional prudence in her confinement. Jumpicg, dancing, riding on horseback or in sleigh, often lead to inflammations of ovaries, peritoneum, and pelvic connective tissue, especially during menstruation, with the ultimate result of sterility. There are girls who for modesty's sake do not wish to acknowledge