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Tous las autras axamplairaa originaux sont filmte an comman9ant par la pramlAra paga qui comporta una amprainta d'impraaaion ou d'illustration at an tarminant par la darnlAra paga qui comporta una talia amprainta. Un daa symbolas suivants apparaftra sur la darniAra imaga da chaqua mieroficha, salon la cas: la symbols -^ signifla "A SUIVRE", la aymboia V signifla "FIN". Laa cartaa. pianchaa, tabiaaux, ate, pauvant Atra filmte A daa taux da rMuction diffirants. Lorsqua la documant ast trop grand pour Atra raproduit an un saul clichA, il ast fiimA A partir da I'angia sup^riaur gaucha, da gaucha A droita, at da haut an bas, an pranant la nombra d'imagas nteaasaira. Las diagrammas suivants illustrant la mithoda. 32X 1 2 3 1 1 2 3 4 5 6 REPRINTED PROM THE " MONTREAL MEDICAL J0URN;.L," NOV., 1888. / ■^y ADDEESS ON BOMB OF THE] RECENT ADVANCES IN SURGERY. By Francis J. Shei'HKRD, M.D., Surgeon to the Montreal Qeneral Hospital ; Professor of Anatomy and Lecturer on Operative Surgery, McGill University. {Read brfore the Canadiun Medical Aviociation, at Ottawa, September, 1888.) Mr. President and Gentlemen : — When informed by our worthy President that I was appointed to deliver the address on Surgery before this Association, I felt that the duty might have devolved on one much more competent to treat this great subject satisfactorily ; one who had the faculty of making his address interesting to every one of you. When writing me, Dr. Graham said that the address should be limited to a period of — well, say that of an ordinary sermon, and hinted that the members of the Association did not want to be lectured to. I shall endeavor, to the best of my ability, to carry out these in- structions. It is not so many years ago that Boyer, after the French war, said that " surgery seems to have attained the highest degree of perfection of which it is capable." The history of surgery, which during the past fifty years has been one of continuous advance, has proved the falsity of Boyer's opinion. During the last decade this advance has been almost phenomenal, and now scarcely a month passes without the introduction of some new operative procedure or some daring operation on cavities and il 2 organs which have from time immemorial been regarded as sacred. The causes of this advance have been two in number — the dis- covery of anaesthesia and the introduction of antiseptic surgery, with which the name of Lister will ever be associated. Formerly, surgery was regarded as a mere mechanical art, and practitioners of medicine looked down upon the surgeon as one who practised a trade. How different is the relationship now. Surgery now takes the lead, and the surgeon has wrested from the physician many regions which he thought to be essentially his own. The abdomen, for a long time the hunting ground of the physician, has been almost completely surrendered to the surgeon, and with what brilliant results you all know. Certain diseases of the kid- ney, liver, ovaries, lungs, brain, etc., which were formerly purely medical, have become chiefly surgical ; and owing to modern methods of operative tieatment, many lives have been saved which heretofore the physicians let slip through their fingers as being beyond their skill to cure, though they endeavored by a copious and, it is to be hoped, judicious use of the various pre- parations in the parmacopoeia to alleviate the sufferings of their unfortunate patients. The brain, within the last few years, has yielded not a few results to surgery which medicine has striven for in vain. The victorious advance of surgery has been positive, and the success which follows its onward course stimulates to further exertions. Still medicine and surgery are not opposed to one another, and should go hand in hand. Without the aid of the physician, many cases would escape the beneficent treat- ment of the surgeon ; and one cannot afford to do without the other. In an address given by Prof. Bergmann before the German Scientific Medical Association in 1887, he says : " There is more or less rivalry between medicine and surgery in the cure of disease, but further progress in surgery can only take place through an increased knowledge of internal medicine. Surgeons must now avail themselves more of the accurate means of inves- tigation which we owe to physicians — auscultation and percussion, thermometry, chemical, microscopical, and electrical investiga- tion. As long as internal medicine remains the guardian of scientific methods and scientific principles, so long will it remain r n s tl n d SI g< CO to on lir to / on th th( th( ohi wil Wl or Ho lati dis no^ wri ] anc ma oft ■ 1 " ;iga- of 8 the parent tree of which surgery is only a branch." Again : " It follows from what has been said that surgery owes all its recent development to clinical medicine, and just as antiseptic treatment is the product of careful observation in etiology, so the energetic procedures of internal surgery will have successful results only when firmly established by the methods of clinical medicine ; otherwise surgery will sink, in the hands of expert specialists, to a mere display of manual dexterity." Such are the opinions of one of Germany's greatest surgeons. His warning note that surgery may degenerate into a mere display of manual dexterity is timely, for what strikes one most in reading the sur- gical literature of the day is, that it treats almost entirely of surgery in its operative aspects, and those departments of sur- gery which are not operative seem to be treated with but scant consideration. There is great danger of the surgeon becoming too limited ; already there are men who profess to perform but one or two operations ; they certainly do them well, but such limitation must induce a narrowness of mind which is detrimental to surgery in general, and will in the end have a dwarfing effect on the more scientific branches of surgery. It is to be hoped that this is merely a temporary condition which is induced by the novelty of invading territories hitherto but little known to the surgical traveller. However, even if it must be admitted that surgery to-day is chiefly operative, still it is more conservative than formerly, as witness the great advance made in the surgery of the joints. Where formerly a limb was amputated, now the joint is excised or the diseased ^matter removed with scissors and a sharp spoon. How rarely is the foot now amputated for disease of the articu- lations. I have only once amputated a foot for tuberculous disease of the joints, and have always regretted it. Who would now amputate an arm for disease of the elbow, or a hand for wrist-joint disease ? But, gentlemen, I fear I am tiring you with my platitudes and generalizations, so I shall pass on and give in as brief a manner as possible an account of the recent advances in some of the more important departments of surgery. At the Toronto I meeting of the Association in 1882 it was my privilege to read the report on surgery. At that time, among other subjects, I discussed the modern treatment of wounds ; since then, not much progress has been made in the treatment of wounds. The same principles laid down then are still in force — cleanliness, rest and asepticity. The dressings applied to wounds have become much simpler, and the antiseptics most relied on are soap, water and a good nail brush. Not only should the hands of the operator be cleansed with soap and water, but the parts operated on and their vicinity should also be similarly treated. Faith in germi- cideei is being lost, and although irrigation has supplanted the spray, the solutions used have become weaker and weaker, until some surgeons use water only, especially in operations on the abdomen and thorax, where antiseptics have been proved to be absolutely injurious and often dangerous.* Sponges have become objects of suspicion ; their place is now taken by the irrigator, linen, or pieces of washed gauze. The spray, which formerly was a trusted friend, a valued ally, and with some the sheet- anchor of antiseptic surgery, has been all but abandoned, and is now seen as a mere survival of a past condition. Whilst in Ger- many last summer, I saw in every surgical klinik the magnificent ruins of the spray-producer, looking like some old castle which marked the customs and conditions of other days. Lister him- self was one of the first to give it up, and last summer at King^s College Hospital he spent some time in explaining to me how especially useless the spray was in those operations on the thorax and abdomen, where it is still retained in a sort of superstitious way by some enthusiastic men. Whilst on the subject of the treatment of wounds, I might allude to one point where it seems to me practitioners in reporting cases might be more explicit. We read of a successful case of abdominal or other operation where the result was, of course, a brilliant success (how few un- successful cases do we read of), and the author states that tho operation was performed with full antiseptic precautions. Now, what does this mean ? " Full antiseptic precautions," with one •See Senger's paper road at a recent meeting of the Berliner MoUicinisolior Geaell- Bohaft. surgeon, may mean an elaborate ritual, and with another simple cleanliness. It would be a great improvement if, when report- ing cases of remarkable recoveries from astonishing operations, the reporter would state exactly the method of treatment em- ployed to which he attributes his great success. The patient gets but little credit for the part he plays in bringing about a favorable result, and nature gets still less. In the Burgery of the abdomen much progress has been made. In ovariotomies and extirpations of the uterus, the mortality is being steadily diminished, chiefly by the simpliiication of the methods of performing the operation. Rapidity of operation and a not too elaborate •* toilette of the peri- toneum," with drainage if there be bleeding, have been most successful in reducing the mortality in these operations. Fol- lowing the lead of such men as Tait, Bantock, etc., antiseptic solutions are being discarded for plain water. In cases of acute intestinal obstruction it is now becoming a recognized custom for the physician to call a surgeon in consul- tation, and the result has been that many lives have been saved. In my opinion these cases should be placed in the hands of the surgeon from the first, as in the grea*, majority of cases there is little hope of relief being afforded by medical means alone. Not i. few cases of intussusception have been cured by early opera- tions, and also many cases of strangulation due to bands, twists, etc. It is now an axiom of surgery not to let any case of acute intestinal obstruction die without at least an exploratory incision. Soon patients will be as anxious for operations in these cases as they are nov/ in cases of strangulated hernice. Physicians still procrastinate in cases of intestinal obstruction. They often do not advise operation until all hope of recovery has been aban- doned, and operation is looked upon as a dernier ressort. The treatment by rest, starvation and opium has still charms for most practitioners, who are always hoping that " something will turn up." Cases of operation are reported where no cause could be found for the obstruction, and where an opening was made in the distended bowel with the best results. The artificial anus which resulted being, after some time, spontaneously closed. This 'I I I :i I t I |i e affection, in spite of operation, will always be a very fatal one until some better means of diagnosis are available before collapse sets in. On many occasions the gravity of the case is overlooked until the patient is almost moribund. In inflammation of the ceeoum and appendix^ surgical inter- ference has been attended in numbers of cases by remarkable succcess. It is now held by many surgeons that all cases of so- called typhlitis ending in suppuration are due to perforation of the caecum (rare) or appendix, and that early operation in this most fatal affection is the proper procedure. In some cases the perforated bowel has been closed with sutures or the diseased appendix has been excised. The results have been most satis- factory. It has been attempted to close by operation perfora- tions due to the ulcers in typhoid fever, with but little result ; the condition of the patient and the state of the bowel itself render it improbable that much progress will be made in this direction. The operation has been performed by Kiissmaul of Strassburg, Bartleet of Birmingham, and Morton of Philadelphia, with fatal result in each case. In tubercular peritonitis, most brilliant results have been effected by operation. The early operations were chiefly cases of mistaken diagnosis for ovarian disease, or were doubtful cases in which an exploratory operation was called for ; the good results following these mistakes led to the adoption of incision and drainage as a recognized treatment for this affection. Many remarkable cures are reported, but in the majority of cases this treatment is only palliative. In suppurative peritonitis, the treatment by incision and drainage has also afforded some remarkable results, and in all cases this method should be adopted even if the cause, which is usually perforation of the intestines or appendix, cannot be dis- covered. In perforating gunshot wounds of the abdomen, good results have been obtained by immediate operation. W. T. Bull and Dennis of New York, and Parkes of Chicago, on this side of the Atlantic, have led the way in showing the profession what excel- lent results may be obtained by immediate operation. Prof. N. Senn of Milwaukee, at the International Congress held last year in Washington, road a remarkable paper on " Intestinal Surgery." His experiments were made on dogs, and ho showed how gun- shot wounds of the intestines could be healed by omental graft- ing, with or without scarification of the serous surfaces.* Dr. Senn has also quite recently devised a method for the detection of perforating wounds of the intestines, by means of hydrogen gas insufflated per rectum ; the escape of the gas from the ab- dominal wound can be recognized by its inflammability, and this, of course, is proof positive that the intestine has been perforated. At the meeting of the British Medical Association held in Dublin last year, some admirable papers on the radical cure of hernia were read by such surgeons as Macewen of Glasgow, Mitchell Banks of Liverpool, Ball of Dublin, Barker of London, etc. The results of operations by excision of the sac a d stitch- ing up the wound were most encouraging. Macewen reported sixty-tive cases operated on by his method, without a death, and only one failure. Banks, who was one of the first advocates of this method of operation, reported 106 cases ; Ball, 22 cases without a death, and Barker 35. Macewen does not excise the sac, but after reducing the hernia makes use of the sac as a pad, by drawing it up through the internal ring and fixing it there. Banks, Barker, and others advise excision of the sao and fixing the stump at the internal ring, whilst Ball's method consists in torsion of the sac before excising. The open method has been advocated on this continent by McBurney of New York. French surgeons, after ligature and excision of the sac, do not advocate closing the inguinal canal by sutures, as is done by English and German surgeons. My experience in this operation has been small, but some months ago I operated on a very for- midable case, the details of which I shall venture to mention. A blacksmith, aged 62, had an enormous, irreducible, scrotal hernia of the left side, from which he had suffered for many years. The tumor had become so large that he could not wear trousers or follow his occupation. He was, besides, a rather corpulent man and a hard drinker. I performed the operation for radical cure of the hernia on the 25th of April last. The sao was dissected out and opened, and the contents reduced with the greatest difficulty. The sac contained all the small intestines, the transverse and descending colon, and the sigmoid flexure, together with a large mass of omentum. Nearly two pounds Oi" the latter were excised, and it was only by suspending the patient by his heels (a suggestion of Dr. Bell's) that I was enabled to reduce the protruded bowel. The intestines had not been in the abdomen for some years, and that cavity now seemed too small to contain them ; and when, after an hour and a half's exertion, the intestines were all returned, the abdomen was as tense as a drum. The sac was excised and the stump fixed to the internal ring according to Barker's method, and the canal closed by suturing the conjoined tendon to Poupart's ligament. The patient made an excellent and uninterrupted recovery, and is now pursuing his occupation as a blacksmith with comfort. I saw him a week ago, and there was not the slightest tendency to a return of the hernia. In the victorious advance of surgery the liver has not escaped. Langenbuch of Berlin has successfully resected the greater part of the left lobe, and Dr. Dalton of St. Louis, and Prof. Postemp- ski of Italy, have successfully sutured the liver for gunshot wound and stab wound respectively. Hydatid cysts have been frequently and successfully evacuated. The surgery of the gall bladder has been making steady and uninterrupted progress. Lawson Tait has reported no less than thirty cases of operation on the gall bladder, with one death. He differs from Langenbuch of Berlin, who prefers excision of the gall bladder to incision and drainage. Mr. Tait says* : " The more experience I have in dealing with these cases the less necessity, it seems to mo, arises for anything more than the simple process of cholecystotomy, and the extremely favorable results obtained from it put it in the first rank of modern opera- tive procedures." Diseases of the gall bladder are among those affections which should be looked upon as surgical, and which the judicious practitioner should treat as such. In some cases • Lancet, April 14th, 18^. of obstruction from gall-stonos, tho gall bladder is shrunken and can be with difficulty brought to the surface. It is often diffi- cult to say whether a case of obstruction of tho common duct is due to impacted calculus or malignant disease ; when the cystic duct alone is obstructed there is no jaundice. In doubt- ful cases an exploratory incision is now considered justifiable. When the gall-stone has escaped from the common duct it may still prove a source of danger. Obstruction of the intestine due to gall-stone is more common than is supposed ; a small stone may cause symptoms of complete obstruction and consequent death. Such cases should be treated by early laparotomy. It is not necessary to incise the bowel to free tho stone, for it may be passed on through the ileo-ciecai opening by external manipula- tion, as has been done by Mr. Clutton of London, or broken up in situ with a needle, as recommended by Mr. Tait. The stomach has been frequently successfully opened for the removal of foreign bodies, or the performance of Loreta's opera- tion of dilating a contracted pylorus ; operations of excision of malignant growths of the stomach are not growing in favor, the game, as a rule, is not worth the candle. The pancreas has been successfully operated on for cystic disease, and the spleen has been so frequently successfully excised that the subject is no longer a matter for wonderment. Wo come now to the surgery of the kidney. Since Simon first extirpated a kidney in 1809, great advances have been made. Tho surgery of no other abdominal organ has been so rapidly developed and perfected. No doubt many kidneys have been removed unnecessarily, and too often, unfortunately, with a fatal result ; but surgeons are now beginning to see their way more clearly in this, until recently, little known brar 'h of sur- gery. It is now a well established rule that no kidney should be removed without a previous nephrotomy or exploratory in- cision. Again, no kidney should be removed until the condition of its fellow is ascertained. Several cases are on record where the surgeon has removed the only kidney in the patient's pos- session. A preliminary nephrotomy enables the surgeon to avoid this fatal mistake. The most brilliant results have been obtained 10 '^'^' in the operation of nephro-lithotomy. During the past year Mr. Jordan Lloyd* of Leeds, England, has introduced a method of exploration of the kidney which is a great improvement on the old needle puncture. He advises puncture of the lower end of the kidney with a long-bladed tenotome in a direction upwards and inwards till the lowest of the calyces is reached ; a small, short beaked child's bladder sound is then introduced, and the calyces and pelvis explored. In June last I had an opportunity of putting Mr. Lloyd's method into practice, and found it a simple and admirable one. The patient had been subject for several years to attacks of renal culic ; latterly the pain had been con- tinuous, and was located in the left lumbar region and down the course of the ureter ; great pain was felt on pressing over the left kidney. He had never had any blood or pus in his urine. Knowing the comparative harmlessness of the operation of neph- rotomy, and having had experience in several other cases, I determined tc out down on the painful kidney and examine it. When the kid.icy was reached the exploration was made with the greatest facility and with but little disturbance of the parts. After incising the lower end of the kidney with a bistoury, the short-beaked sound was introduced and the pelvis and calyces of the kidney thoroughly explored, but without result ; no stone was found. The hemorrhage from the kidney, which was free, was easily controlled by pressure. The wound was closed and a drainage tube placed at its lower end. Urine ceased to come from the wound after the second day. In ten days the patient was out on the gallery, and in two weeks the wound had soundly healed. The pain which previously had been most intense was much relieved, and has since almost entirely disappeared. When last seen the patient was attending to his work and looked strong and healthy. I might mention that a woman from whom I re- moved a kidney in September, 1884, for calculous pyelitis, is still alive and in good health, and since the operation has given birth to three healthy children. Another operation which is find- ing favor in the eyes of surgeons is nephrorrhaphy or fixation of a floating kidney. Removal of the kidney was formerly prac- n tised for the relief of the pain and inconvenience of a floating kidney ; the substitution of nephrorrhaphy for nephrectomy in these cases is a decided advance, for the former operation is a much safer as well as a more scientific one. In the %urgery of the bladder progress has also been made, though not to the same extent as in that of other abdominal organs. Tumors of the bladder are now successfully removed, and Guyon of Paris and Thompson of London have done excel- lent work in this direction. The introduction of the electro- endoscope has much facilitated diagnosis. The old supra-pubic operation is now the fashionable one for the removal of stone from the bladder, and it is being practised largely everywhere. The operation has been much improved by the introduction of Petersen's rectal bags and the practice of moderately distending the bladder before operation with an antiseptic solution. The operation is suitable for cases of large and hard stones, and for the removal of tumors and foreign bodies, but it will no more supplant the old operation of lateral lithotomy than did lithotrity. In some cases of stone in the bladder, Mr. Reginald Harrison* of Liverpool justly remarks, " it is necessary to do something more than merely remove the stone. In cases of cystitis with enlarged prostate where stone has formed, removal of the stone is necessary, but it is also necessary to prevent further forma- tion by getting the bladder into better condition." The bladder, says Mr. Harrison, is like a chronic abscess with a stone in it, and it is quite as necessary to drain the one as the other. These cases are unfit either for supra-pubic lithotomy or lithotrity ; but the lateral operation provides an excellent means not only for the removal of the stone but of after-drainage of the bladder. Ruptured bladders have recently been successfully treated hy abdominal section and suture of the bladder rent. An early diagnosis is, of course, important in these cases. I fear I have already exceeded my allotted time, and although many other subjects of intense interest to the surgeon might be touched upon, yet I feel constrained, for the remainder of my address, to confine myself to giving a short account of the re- * Lettsumiaa Leotures, 1838. \ !l 12 markable advance which has been made during the past two or three years in the treatment of various diseases and injuries of the brain and spinal cord by surgical operation. Brilliant results have been obtained in this department of sur '^ry — results which, a few years ago, would have been looked upon as T'^opian. The operation of trephining the skull is a very old one, and was frequently and often unnecessarily performed by surgeons in the early part of this century. I have heard that it was quite the fashion for Dublin surgeons to have their pockets full of buttons of bone which had been removed with the trephine from the skulls of pugnacious Irishmen. However, the surgeons at that time only trephined for injury, and their explorations did not extend further than the dura mater ; it was considered in- judicious and dangerous to interfere with the brain itself, not, as in earlier times, from superstitious motives, but owing to such interference being followed by fatal inflammation. It is only with the introduction of antiseptic surgery, and a more accurate knowledge of the localization of brain functions that the brain itself has been interfered with. Our knowledge of the functions of the brain has been greatly extended by the researches of such men as Broca, Hughlings Jackson, Fritsch and Hitzig, Goltz, David Ferrier, Yeo and others. The observations of these investigators chiefly go to prove that many areas in the brain are connected with separate and distinct functions. It was found that if these areas on the surface of the convolutions were stimulated electrically, distinct movements were excited in cei'- tain groups of muscles on the opposite side of the body. These facts were not discovered all at once, but were the result of pro- longed clinical observation and careful experiments on the brains of animals. Many cases of severe injury to the brain have been saved in the past by early trephining. Abscesses of the brain following injury have been frequently opened successfully. Again, many cases of epilepsy due to injury have been cured by trephining over the spot injured ; but it is only quite recently, in fact only since the truth of the theory of Broca's localization has been established on a firm basis, that operations have been undertaken where there was no external indication of injury or 18 disease. The lesions have not only been successfully diagnosed, but the brain and its membranes have been incised without re- sulting in fatal inflammation. It has been clearly shown that inflammatory conditions following operations are due to sepsis. If the wound be kept aseptic the case does well. Dr. Macewen of Glasgow, an old pupil and house-surgeon of Lister's, noticed that cases of severe injury to the skull, with extensive loss of cerebral substance, were quite amenable to treatment, and ex- hibited no tendency to inflammatory action as long as the tissues were kept aseptic ; hence, he said, if such injuries can be re- covered from, how much more likely is recovery from a carefully planned operation. His first case was in 1876 for abscess, which he diagnosed to be in the vicinity of Broca's convolution ; oper- ation having been refused during life, he was permitted to tre- phine over Broca's convolution after death ; the abscess was found as diagnosed and easily evacuated. In 1879 Dr. Macewen successfully evacuated from beneath the dura mater of a boy, who had previously received an injury of the head, some fluid which had collected there and had given rise to convulsive seizure of arm and leg. In the same year a tumor of the brain was diagnosed and successfully removed from the frontal lobe of a woman, who lived for eight years after and then died of Bright's disease of the kidneys. Up to 1884 Macewen had operated on seven brain cases, with one death, a case of abscess of the temporo-sphenoidal lobe. In December, 1884, the first case of tumor of the brain was operated on in London, having been pre- viously diagnosed by Dr. Hughes Bennet, and removed success- fully by Mr. Rickman Godlee ; the patient lived four weeks relieved of his previous symptoms, and then died from septic complications. The report of this case, at a meeting of the London Medico-Chirurgical Society in May, 1885, gave rise to a most interesting and important discussion, in which Drs. Mac- ewen and Ferrier took part. Dr. Macewen related several cases on which he had successfully operated, and mentioned his method of reimplanting the removed disc of bone. Up to this time MacEwen had operated on seventeen cases for the relief of cerebral pressure and other brain lesions. At the Brighton 14 meeting of the British Association in 1886, Mr. Victor Horsley excited the admiration of the meeting by his remarkable paper on the Advances in the surgery of the central nervous system. In this paper he minutely detailed his method of operating, and showed how, if performed carefully, the brain might be incised and tumors removed without any great risk to the patient. His experience was chiefly derived from operations on monkeys. He also showed three patients on whom he had successfully operated (one for tumor and two others for scarring of the convolutions, causing epileptiform fits). Since this time operations on the brain have become comparatively frequent for epilepsy following injury, for abscess of the brain (especially that form connected with suppurative disease of the ear), and for tumors. On this side of the Atlantic, Drs. Keen and Roberts of Philadelphia, and Drs. Weir and Seguin of New York, have done good work. Dr. Keen has recently successfully reimplanted, in one piece, the bone removed by the trephine. At the recent meeting of the British Medical Association in Glasgow, Dr. Macewen read an epoch-marking paper in the surgery of the " Brain and Spinal Cord." He related how for years he had been working at this subject, and with what great results. His paper is certainly a wonderful contribution to sur- gical science. He says : " Of twenty-one cerebral cases (ex- clusive of fractures of the skull and other immediate effects of injury), in which operations have been performed by me, there have been three deaths and eighteen recoveries. Of those who died all were in extremis when operated upon. Two were for abscess of the brain, in one of which pus had already burst into the lateral ventricles ; in the other, suppurative thrombosis of the lateral sinus had previously led to pyaemia and septic pneu- monia. The third case was one in which, besides a subdural cyst over one of the hemispheres, there was extensive softening at the seat of the cerebral contusion in the opposite hemisphere, accompanied by oedema of the brain. Of the eighteen who re- covered, sixteen are still alive, in good health, and most are at work ; leaving two, who have since died, one eight years after the operation from Bright's disease, the other forty-seven days afte" operation from tubercular enteritis." r -ife 15 I These results are certainly remarkable, and very encouraging as to the future of the surgery of the brain. I had the pleasure last year, while in Glasgow, of seeing some of Dr. Macewen's cases, and some were most interesting. In one case the diag- nosis of the lesion was made from sensory phv..iomena alone, and successfully operated upon. Notwithstanding the success of such men as Macewen and Victor Horsley, operations on the brain should not be rashly undertaken. Each c&^e should be studied on its own merits, and the surgeons who attempt these operations need not only experience in general surgery, but an accurate knowledge of motor and sensory phenomena in connec- tion with the localization of the functions of the brain. Dr. Macewen's name is also associated with the surgery of the spinal cord ; he has operated on no less than six cases. In all, the posterior arches of the vertebrae were removed ; four to relieve paraplegia, caused by pressure from connective tissue neoplasms and displacements of the vertebrae due to caries or traumatism. Out of the six cases operated on four were suc- cessful and two died. The first case was operated upon as early as 1882. Mr. Victor Horsley successfully removed a tumor, diagnosed by Dr. Gowers, from the posterior end of the nerve op- posite^ the third dorsal vertebra. The patient suffered from para- plegia. He completely recovered, and was shown to the London Medico-Chirurgical Society, .'^anuary 24th, 1888. I have fre- quently trephined the spine in the dead subject, and I can say that the operation itself presents no great diflBculties. The cases which call for this operation are, however, rarely met with. There are many other interesting subjects on which it might be profitable to dwell, such as intubation of the larynx, re-im- plantation of bone, transplantation of the eyeball and conjunctiva, new theories as to the cause of inflammation, tetanus, etc., sur- gery of bronchocele, surgery of lungs, joints and many others, but time will not allow me to more than mention them.