operation, even when performed with the greatest care, is probably not free from danger. Most of our modern surgeons do not consider it advisable to wash out a septic wound, but they all desire free drainage. It seems probable that many obstetricians do not pay sufficient attention to the drainage from the uterus and vagina. Much can be done to promote free drainage from the organs by raising the shoulders of the patient, and turning her slightly to either side, at regular intervals.

In considering the surgical aspects of obstetrical procedures. we desire to acknowledge the great debt we owe to the surgeons; and our methods of treatment, as learned largely from them, may be briefly summarized as strict antisepsis for the external parts and strict asepsis for the internal parts. And let me say in conclusion that for the measure of success which now attends our efforts on behalf of woman in her hour of need-to Lister be all the honor and all the glory!

INGERSOLL OLMSTED, M.B., HAMILTON.

The honor of being chosen to deliver the address in surgery at the meeting of this Association is one I had not expected. After looking over the names of the distinguished gentlemen who have filled this honorable position, I feel any words of mine quite inadequate to express my gratitude to you, and it is with mingled feelings of pleasure and anxiety that I attempt to speak of the advances which surgery has made during the last few years. Not having had the extensive clinical experience of many of the gentlemen who have addressed you in the last few years, I shall only attempt to draw your attention to some of the most important work which has been done in different countries.

In surgery especially, has the English speaking people contributed more than their share of good work, and America particularly, should be proud to be favored by the visits of distinguished surgeons from abroad.

Great advances have been made in the surgical treatment of diseases, yet in many instances our hopes have not been realized. Thus when the tetanus bacillus was isolated, and a serum prepared, it was thought a treatment had been found that would ward off the usual fatal termination of this dis ease. This has now been found to be erroneous, and, in fact, the use of antitetanic serum has almost been abandoned in the treatment of cases of tetanus. Fortunately, however, the serum is almost a certain preventative of the disease. Thus, in 1903, in the United States there were 406 cases of tetanus reported, following accidents received during the Fourth of July. In the present year only 73 cases were reported. This marked improvement is attributed to more careful treatment of the wounds, and the administration of the antitoxin. In a recent discussion of this disease before the Surgical Society of Paris, Berger stated that during the last seven years all patients, with one exception, entering his wards with wounds in which there was a possible infection with the tetanus bacillus, received a small dose of antitetanic serum. The one patient who had not received the serum was the only one that developed tetanus. *

It is now the rule in many hospitals in America, to give the serum in all cases having wounds which could have become soiled by dirt, manure, or other foreign substances. The

*

Delivered at the meeting of the Canadian Medical Association, Montreal, 1907

serum should be repeated, as a single dose will not alwoys prevent the disease. Suter and James Bell have each reported a case where tetanus developed forty-seven days after a single prophylactic dose of the serum had been given.

Although hemophilia is a comparatively rare condition, it comes to our attention at times in a very realistic manner. It is very disagreeable for a surgeon to be called to operate on some acute surgical condition, when the patient is affected with this interesting blood state. The use of calcium chloride and subcutaneous injections of gelatine, although at times very useful, fail to check the copious oozing in subjects of this disease.

Hemophilia is presented in two distinct etiological conditions, first accidental, and second hereditary. In the accidental variety there is no history of heredity, or injury, or previous serious disease. Its course is more or less benign, and occurs at less frequent intervals, and requires a more serious injury for its production. In the hereditary variety, on the contrary, the tendency to hemorrhage follows the slightest wound, owing to the fact that coagulation is very much retarded. Emile Weil has shown that fresh human or animal serum introduced into the system of patients affected with hemophilia produces a marked increased coagulability of the blood in the hereditary variety, and in the accidental variety the coagulation becomes normal. This followed the intravenous injection of twenty cubic centimeters of animal blood serum. The change in the blood occurs about twenty-four hours after the introduction of the serum. Locally the serum has much the same action.

It appears that in the accidental form of hemophilia there is an absence or diminution of the ferment which causes coagulation, while in the hereditary form there seems to be some anti-coagulating substance. If the antidiphtheritic serum be used, and this is the one most easily obtained, it should be fresh. Numerous observers have confirmed the beneficial effects of this method of treatment, and it certainly should be given a trial. If the serum be given subcutaneously 20 or 30 cubic centimeters should be used.

With our present methods, the brain may be examined with comparative safety, yet there is still much to be desired. The unfortunate results which have formerly followed cerebral hemorrhage in the new-born, can, by the intermusculo temporal operation, be frequently relieved. In most of these cases the labor is protracted, and the child is asphyxiated as a

rule when born. Even the most desperate cases should be given a chance. There are usually localizing symptoms, yet one should not hesitate to open both sides of the skull if necessary. This is also indicated in fracture of the base. Undoubtedly many patients have died from compression, which would have been saved had the skull been opened. The convalescence is much quicker, and the recovery better. I can

recall several cases of fracture of the base with extensive hemorrhage that were relieved by this means.

In cases of papillary edema due to cerebral compression, a decompression operation will ward off the symptoms. In one case operated on for Dr. Osborne, the sight, which was rapidly failing, made rapid improvement after the operation. An early interference is necessary in order to forestall atrophic changes in the nerve, and a large sized disk should be removed. For severe cases of tie douloureux, the evulsion of the sensory root of the casserian ganglion removes the pain, and leaves no bad after effects. Cushing has operated on 54 cases of this disease with only two deaths. This operation is simpler than removing the ganglion and the results are really better. Where the attacks of pain are not so severe, Charles H. Mayo exposes the nerves at the points of exit from the foramina, extracts them by slow evulsion, cuts them off, and then plugs the bony openings by driving in small silver nails. This is an operation void of danger and easy to perform.

The injection of 70 per cent. alcohol into the nerves is also very effectual in many cases of intractable neuralgia. In spasmodic tic, the facial nerve may be resected and anastomosed with the spinal accessory. The result in a case I saw, which Cushing had operated on, was extremely satisfactory.

Since operations on the thyroid have become frequent during the last few years, attention has been drawn to the importance of the parathyroid bodies. Although these structures were first accurately described by Sandstroem in 1880, their function remained a secret for many years. It was then found that when these bodies were removed a true tetany developed, which led often to a fatal termination. These parathyroid bodies are often difficult to distinguish during the removal of the thyroid, being situated usually where the thyroid vessels enter the gland. They get their blood supply apparently from the thyroid vessels, and hence, if a complete thyroidectomy be made, the main trunk of the vessel should not be ligated, but rather the branches as they enter the gland. Halsted usually leaves the upper pole of the thyroid where the superior thy

roid enters. One of the dangers of this procedure is the liability of secondary hemorrhage. Dr. Charles H. Mayo leaves the posterior capsule of the gland, believing by this procedure that the parathyroids will be uninjured. Halsted, who had an unfortunate experience in one of his cases, does not think that Mayo's procedure will preserve the integrity of these important bodies. He has sucessfully transplanted parathyroids in the spleen of a dog, and also into the opposite half of the gland. Von Eiselberg had two cases of grave tetany following thyroidectomy during the past four years, and in both cases the administration of the dry parathyroids successfully relieved the condition. In one case of tetany of long standing, he transplanted into the abdominal wall, a parathyroid gland taken from a patient operated on for goitre. The result was very good indeed, as the tetanic symptoms were very much improved. The rectus muscle and spleen are eminently suitable structures for such transplantation.

If only one-half of the gland be removed, together with the isthmus, the destruction of the parathyroids on this side of the body will not influence the health of the patient, yet in this operation I believe these bodies should be preserved if possible, otherwise it would be dangerous to operate later on the other half, a condition, however, which fortunately, seldom occurs. Partial thyroidectomy has been very successful in the treatment. of exophthalmic goitre or Graves' disease, yet it is an operation difficult of execution, and quite dangerous.

The treatment of the gland with X-rays for some weeks before operation, will, it is said, toughen the tissues, thereby lessening the danger of hemorrhage, and perhaps also that of acute thyroidism. This latter danger, is, I believe, the greater of the two, and for this reason the gland should be freely exposed before attempting its removal, and free drainage should be provided.

The treatment of essential epilepsy by resection of the cervical sympathetics has not been attended by sufficient success to warrant the belief that much amelioration will result from it. The reports of cases operated on vary so much, that one uconsciously feels that the reporters in many cases, are not unbiased. In the cases that have been followed for years after the operation, a return of the attacks has been the rule, just in fact, what one would expect where the procedure is lacking in the pathegenic basis.

The excellent experimental work of Carrell has given rise to great advances in surgery of the arteries and veins. Many