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The method practised by CIVIALE in 1824, and improved-by FBRQUSSON, SKEY, and HENRY THOMPSON, came

to be the method of treatment for selected cases of

vesical calculi; but it was not until 1878,. when BIGELOWintroduced litholapaxy or lithotrity at one sitting, thatlithotrity became the chief method of dealing with stonesof all sizes. In 1886 KEEGAN showed that children were

suitable cases for lithotrity. The introduction by LEITER ofthe cystoscope hag greatly facilitated the diagnosis and treat-ment of diseases of the bladder.In the surgery of the brain very great progress has

been made. No longer are fractures of the vertex ofthe skull considered to be of especially bad prognosis,for with care and antiseptic treatment they usually healreadily; but it is especially in inj aries and diseases of thebrain, where the localisation of the lesion would formerlyhave been impossible, that we cm appreciate most theadvance which has been made. There is still a large portionof the cortex the function of which is unknown to us, butdisease of most parts of the brain declares clearly its localityby the symptoms and signs to which it gives rise. As a

result of this knowledge surgeons have been much more

ready of late years to explore the cavity of the skull. In1883 MACEWEN, of Glasgow, trephined successfully for

haemorrhage ; and later in the same year he removeda soft mass from the Rolandic area. GODLEE, in 1884,removed a glioma from the position in which its presencehad been diagnosed. Others who have done much work inthis field are VICTOR HORSLEY and LUCAS CHAM-

PMNNIERE.

Though a form of the laryngoscope was invented in 1829,yet it was not until 1857 that a useful laryngoscope was devisedby CZER1’vIAK. Of the various operations which have beenperformed on the larynx space does not allow us to speak,but we may mention that excision of the larynx was first

performed in 1866 by’P. HERON WATSON. He was followedin 1873 by BILLROTH. Amongst the recent additions to aidsto diagnosis none can compare in importance with the

ROENTGEN rays, which were first described in January,1896 ; there can be but little doubt that their usefulness willincrease, and even at present they are of extreme value.

MIDWIFERY: THE PART PLAYED BY ANÆSTHETICSAND ANTISEPTICS.

THE changes that have, taken place in obstetric medicineduring the past sixty years, both in the region of theory andas regards the details of practice, are, as everyone knows,in most directions considerable, and in some directions evenwonderful. To chronicle these changes with any degreeof completeness would necessarily require several volumes,since they could be only fully dealt with by making anabstract of all the works on midwifery and gynaecology,text-books, monographs, pamphlets, and current literaturethat have been written on these subjects during the periodunder review. Here we shall only attempt to sketch in themerest outline some of the more important alterations that haveoccurred. We say advisedly "alterations," since, with allthe desire in the world to view matters from a judicial stand-point, we cannot altogether hope to free ourselves entirelyfrom the bias of our own day. Some of the alterations thathave occurred in both midwifery and gynaecology since theyear 1837 have been regarded at one time as changes in thedirection of true progress and at another time, and even bythe same generation, as deviations from the real highway intoby-paths that, after promising well for a time, led back-wards into the darkness which it was hoped had been leftbehind. In some things, after all allowance has been madefor the tendency of each generation to regard itself as

superior in knowledge and skill to those that have precededit, there can be no doubt that real progress has been made,

while it is not impossible that in some others the appearanceof progress has been fallacious ; and it may be that the widerknowledge and larger experience of those that are to comeafter us will lead them tojthe conclusion that the authoritiesof sixty years ago were in some ways not so far wrong afterall. We have only to turn for a moment to the region of art;to find convincing proof that the lapse of time is not neces-sarily equivalent to progress, and that indeed the knowledgeand skill of to-day may in certain directions be immeasurablyinferior to that of, say, a hundred years ago. Such arts as the-production of certain kinds of china and of silverwork aregood examples of what we mean. As to china, some of themethods and knowledge familiar to many not so very long-ago have been totally lost, and the silver-work of the modemworkman, with all his advantages and School Board educa-tion, is poor indeed compared to what his great-grandfather,who without, very likely, being able to write was in manyways an artist instead of a mere workman, was able to produce-The process by which the practitioner of sixty years ago-was evolved was essentially different from that which pro-duces the practitioner of to-day. The latter is no doubt in.

many respects the better man ; but probably something that.pertained to his predecessor has had to be sacrificed in orderto secure this superiority.

After these preliminary reflections we may come to

matters of detail. Tne changes in the department of

midwifery have not been so tremendous and strikingas those in gynaecology, no doubt because midwiferyis of necessity such a very ancient art. In midwifery,at all events, we do not think we can find any indication of ground having been lost. If we regard thematter from the standpoint of a woman who is pregnant.at the present time as compared with that of a woman.similarly situated in 1837 the former is undoubtedly in a.

more favourable position. We should say that should the-

pregnancy happen to be extra-uterine the advantage ofliving in 1897 rather than in 1837 is so great that-

probably no one would care to dispute it. In a standardtext-book published in 1341 extra-uterine pregnancy is.

spoken of as follows z" This singular deviation from’the usual course of conception is fortunately of rareoccur-rence, for few cases terminate favourably. If it be in the-

Fallopian tube ...... the patient usually dies from internalhsemorrhage." Modern investigation has, however, shown)that cases of extra-uterine pregnancy are by no means souncommon as was formerly supposed, and that even whena tubal pregnancy has rnptured, causing intra-peritonealhoemorrhage, the case is very amenable to operative treat-ment, if seen in time. Many cases have now been,

recorded where a definite diagnosis of tubal pregnancyhas been made before rupture, and where the gravid tube-has been successfully removed. There is, of course, inthe works on midwifery contemporary with that just re-ferred to nothing to be foand on the subject of anti-

septics or anaesthetics. We should regard the applica-tion of the antiseptic principle to midwifery as the greatest.improvement that has been made in obstetric practice within;-the last sixty years. When it is fully understood and faith--tally employed deaths from puerperal fever may be com-pletely or almost completely avoided, as the practice of ourbest-managed lying-in hospitils has sufficiently shown..Even at the present day, however, in general practice it.

would appear from the statistics recently published byCULLiNGWOETH that puerperal fever is still responsible fora relatively high percentage of fatalities which, it is to be:hoped, may be prevented as the details of the antiseptic

principle come to be more universally adopted. As regardspuerperal fever the same authority already quoted writing inI 1841 says :-" But we now come to a source of dangerwhich follows the most favourable as well as unfavourable

labours-which is extremely varied in its nature, fatal 1&

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its effects, and (what renders it so peculiarly formidable) bymo means uncommon in its occurrence. Of all the dangersto which a lying-in woman is exposed puerperal fever is by’far the most to be dreaded ; there are few or no difficultiesduring parturition which the practitioner has to contend withthat can be compared to it; there are none in which-he is frequently made to feel so helpless and his variousmeans of treatment so utterly inefficacious ; certain it isthat puerperal fever in its worst forms has occasionally com-mitted such ravages among patients of this class as to-rivalin destructiveness the most malignant pestilences: withwhich the human race has been afflicted." With this Iobviously true picture of the state of things in 1841 before ’,as, it is surely the most noteworthy achievement in"obstetric- practice of the last sixty years that the nature of’this pesti-lence has been arrived at, sufficiently at least to enable’us toprevent its occurrence provided the necessary precautions,which are now well known, be observed.As regards phlegmasia dolens, or rather as it is there"given

phlegmatia dolens," we quote from the same authority(1841): "Phlegmatia dolens rarely or never proves fatal of’itself; the patient either dies in consequence of the puerperalfever which has preceded or attended the affection, or fromthe system gradually sinking under the injury which it hassustained." Nothing was apparently known at.] that time ofthe connexion between phlegmasia dolens and pulmonaryembolism.To sum up the matter, broadly speaking the midwifery of

<sixty years ago did not differ so very materially from themidwifery of to-day, except-and the exceptions are of the’greatest importance-that it was conducted without theassistance of anasthesia and without the, employment of

antiseptics.

SIR JAMES SIMPSON. 1

It is when we come to consider the progress of gynaecology’during the period under review that we are confrontedwith changes of the most striking kind. Its progress has"been marked, however, by many false starts. Theories,as to the causation of many of the diseases peculiar to

1 Vignetted by permission from a woodcut in the "Practitioner."

women have been advanced, have become rapidly fashion.able, have dominated practice for a time, and have thenbeen proved unsound and have disappeared into a well-merited oblivion. There is, for instance, the period whengynaecological practice was largely influenced by the beliefthat the so-called 11 ulceration " of the cervix was account-able for most of the symptoms complained of in relation tothe pelvic organs. JOHN WILLIAMS has drawn a vivid

picture of the state of things that prevailed about this

time. He says: " During my early student days womensuffered mainly from two diseases-ulceration of the cervix,which was rubbed weekly with nitrate of silver, and

stricture of the cervix, which was dilated with bougiesat similar intervals." Then there came the time when the

malposition, so-called, of the uterus was supposed to be thekey to a right understanding of the majority of women’sailments. The uterus was considered to be pathologicallyflexed or "verted" in this or that direction, and instrumentsinnumerable were invented and used to correct the displace-ment. The worst offenders in this class were those who held

strong views as to the importance of flexions, and carriedtheir opinions to the logical conclusion in practice by intro-ducing a rigid stem into the cavity of the uterus. Theywere more mischievous than the pessaries, merely inventedfor insertion into the vagina. The latter, for the most part,merely acted as foreign bodies that did little harm, if theydid no good. But the intra-uterine stems were a source ofactual danger to those unhappy enough to be condemned towear them. Modern investigation has shown that the so-called "ulceration" of the cervix (by which is understood thevarious forms of erosion) occupies a position of little or no

pathological importance, and that the uterus may be allowedto have a very considerable choice as to the situation it mayoccupy without this freedom of choice in any way acting tothe prejudice of its possessor.

It is undoubtedly in the direction o the surgical treat-ment of the graver diseases peculiar to women that the

greatest triumphs have been won during the last sixty years.The rise and progress of ovariotomy till it has come to its

present position afford the most remarkable instance in thiscategory. The treatment of cases of ovarian tumour isdescribed in a standard work published in the year 1844 asfollows: ’’ Here then are the different modes of treatmentrecommended in ovarian dropsy: the abstraction of thewater with the cautions before described; the extirpationof the ovary in the earlier and later periods of its growth;the removal of a circular piece of the cyst so as to lay openthe cyst into the peritoneum ; and the prevention of thedilatation and growth by early paracentesis. In the presentill-success of our practice all these operations are wellworth your consideration ; and if you can bring one of themto such perfection as to cure some of the unhappy indi-viduals who now fall victims of the disease, you will indeedbe conferring an invaluable good on the fairest and leastoffending part of our species." Which of these operationshas been brought to the perfection just mentioned is now amatter of common knowledge; and all honour to those whosework established it in its present position. In the treatmentof cancer of the uterus practice has also undergone a revolu-tion during the past sixty years. In a standard authoritypublished at the beginning of this period we find both excisionof the cervix (the vaginal portion only) and removal of thewhole uterus mentioned as possible forms of treatment. The

mortality of both operations at that time was frightful.Nineteen cases of extirpation of the uterus are mentioned, ofwhich sixteen died ; and it is further stated on the authorityof VELPEAU that the operation had been performed twenty-one times in twenty years, and that in not one of the caseswas there any permanent benefit. The changes that haveoccurred since then in the results of such operations aresufficiently familiar to our readers. While the success of

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surgical treatment in the cases just referred to has been amatter for the warmest congratulation, it must not be

forgotten that there have been drawbacks attending it. Thesuccess of ovariotomy has undoubtedly led to the removal

of ovaries and uterine appendages in cases where such

an operation could not be justified in the opinionof men of moderate views. The measure of safety intro-

duced into all operations by the observance of asepsis hasundoubtedly had a tendency to cause a multiplication of

operations both major and minor in gynaecology, some ofwhich are regarded by competent observers as of doubtfulutility. Probably such a result is the necessary con-

sequence of the enthusiasm engendered by every successfulmovement - and it may be hoped that the lapse of timewill tend to correct any undue activity in the direction

indicated.To sum up, as regards gynaecological progress during

the last sixty years in the direction of treatment, the mostprominent achievements have been the establishment of

ovariotomy and of vaginal hysterectomy, omitting minoroperations, while in the way of diagnosis, the improve-ment of the speculum, the invention of the uterine

sound, the introduction of means for dilatation of thecervix uteri in order to examine the endometrium, and thebimanual method for examining the condition of the pelvicorgans, stand out as the chief gains to be recorded. The

accoucheur of to-day can hardly imagine what his practicewould be without anaesthetics and without antiseptics, andsimilarly the gynaecologist finds a difficulty in realising whathis art must have been without these, and with practicallyno way of investigating his cases except by digital exami-nation of the vagina. Among the instruments that it wouldseem difficult for any modern operator to dispense with, wethink SPENCER WELLS’S artery forceps should certainlybe named.

___

PREVENTIVE MEDICINE: THE PRODUCT OF THEREIGN.

WHEN, perhaps a century hence, the historian sets himselfto write of preventive medicine, the reign of QUEENVICTORIA will occupy a position of no mean degree in thepages of the woik. The era has been remarkable in thatwithin its limits preventive medicine has, as we have

pointed out, been born. When our beloved QUEEN ascendedthe Throne in 1837 the pages of the statute book were,from the point of view of preventive medicine, with oneexception, unwritten upon, and it is not a little significantthat the exception referred to, the Quarantine Act of

1825, should on the eve of the Diamond Jubilee havebeen erased from the statutes as a vexatious measure

no longer to be tolerated. The birth and growth of

sanitary science-for preventive medicine can now be

justly termed a science-have been in the main the

resultant of the concurrent operation of three importantfactors. These are the development of what must, for thewant of a better term, be called the spirit of humanity,which attaches year by year increasing value to

human life and well-being; a better appreciation of theeconomic fact that health is wealth ; and last, but in nosense least, an increased knowledge of the laws which

govern the spread of infectious diseases-laws which, rightlyapprehended, make for health and prolong life. To thesethree factors may, perhaps, be added a fourth-namely, arelative absence of the disturbing influences of war. Itwould be an attractive and congenial task to trace here, step

‘

by step and in chronological order, the progress which pre-ventive medicine has made during the sixty years of HERMAJESTY’S reign, but we must content ourselves witha brief general survey, which shall form, as it were,a sort of roll-call of the masters in the science

and of the works with which their names are andwill be associated. In the very year of the QUEEN’Saccession to the throne there came into operation an.

Act which provided for the registration of bitths, deaths,and marriages, and which formed the starting-point of those"statistical classics" with which the name of WILLIAM;FARR will always be gratefully identified. It was, however,the late EDWIN CHADWICK who first entered the lists in.the cause of public health, and it was his energetic andpersistent efforts which were largely responsible for thememorable Health of Towns Commission and for the placing.of the Public Health Act of 1848 upon the statutes, an Actwhich was quickly followed by others of sanitary import.In his labours CHADWICK was ably supported by such co-workers as SOUTHWOOD SMITH, SUTHERLAND, GUY, ARN02T,and KAY, and although his reign was but brief the student of’public health will always regard him and his coadjutors asthe pioneers of the science.

In the year 1847 the city of Liverpool set an excellentexample by appointing DUNCAN its first medical officer

of health, and to the City of London belongs the honour ofhaving secured in the following year the services of

SiMON, who, in 1855, was appointed the medical adviserto the Central Health Authority, for which he labouredwith such signal success for well-nigh twenty-one years

SIR JOHN SIMON.

It may be interesting, too, to call to mind that

amongst the first medical officers of health who were-

appointed and who helped to build up the publichealth service of this country were BALLARD, BUCHANAN,BRISTOWE, and BURDON SANDERSON; and it has been to thegeneralship of SIMON, SBATON, BUCHANAN, and nowTHORNE THOBNE, that we are indebted for those highlyvaluable annual reports of the Medical Department of thePrivy Council and of the Local Government Board whichhave added in so marked a degree to our knowledge of the*natural history of infectious diseases and of administrativemethods; while on the more philanthropic side of publichealth we must not neglect to make honourable mention ofthe work done by such men as SHAFTESBURY, B. W

RICHARDSON, and PEABODY, all of whom in an unofficial