move 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 formation, 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 by 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 remarkable 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 surgery, results which, a few years ago, would have been looked upon as Utopian. 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 injudicious and dangerous to interfere with the brain itself, not, as in earlier times, for 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 sepa

rate and distinct functions. It was found that if these areas in the surface of the convolutions were stimulated electrically, distinct movements were excited in certain groups of muscles on the opposite side of the body. These facts were not discovered all at once, but were the result of prolonged 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 disease. The lesions have not only been successfully diagnosed, but the brain and its membranes have been incised without resulting 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 exhibited no tendency to inflammatory action as long as the tissues were kept aseptic; hence, he said, if such injuries can be recovered 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; operation having been refused during life, he was permitted to trephine 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 tumour 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 tempero-sphenoidal lobe. In December, 1884, the first case of tumour of the

brain was operated on in London, having been previously diagnosed by Dr. Hughes Bennet, and removed successfully 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. MacEwen and Ferrier took part. Dr. MacEwen related several cases in which he had successfully operated, and mentioned his method of re-implanting 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 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 tumour, 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 tumours. 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 re-implanted, in one piece, the bone removed by the trephine.

At the second 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 surgical science. He says: "Of twenty-one cerebral cases (exclusive 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 pyæmia and septic pneumonia. 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 edema of the brain. Of the eighteen who recovered, 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 after operation from tubercular enteritis."

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 diagnosis of the lesion was made from sensory phenomena 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 case should be studied on its own merits, and the surgeons who attempt these operations, need not only experience of general surgery, but an accurate knowledge of motor and sensory phenomena in connection 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 vertebræ were removed; four to relieve paraplegia, caused by pressure from connective tissue, neoplasms and displacement of the vertebræ, due to caries or traumatism. Out of the six cases operated on four were successful 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 posterier end of nerve opposite the third dorsal vertebra. The patient suffered from paraplegia. He completely recovered and was shown to the London Medico-Chirurgical Society, January 24th, 1888. I have frequently trephined the spine in the dead subject, and I can say that the operation itself presents no great difficulties. 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: intubations of the larynx, re-implantation of bone, transplantation of the eyeball and conjunctiva, new theories as to the cause of inflammation, tetanus, etc., surgery of bronchocele, surgery of lungs, joints and many others, but time will not allow me to more than mention them.

RARE CARDIAC MALFORMATION.

BY G. A. BINGHAM, M. D.,

Pathologist to Toronto General Hospital.

Albert C., æt. 4 years 11 months, convalescing from measles and running about the room, dropped in a fit and died after a few minutes, on the evening of June 30th.

About one week prior to this I had been called to see him and found an unusually stout lad distinctly cyanosed, breathing in an asthmatic manner, and whose rapid and violent heart-beats I was able to count by sight, even when he stood some distance away. Following was the history obtained: "Ever since he was three years old

has been troubled with fits,' sometimes two in three weeks and sometimes once a fortnight. Before this time was a healthy boy, with no cyanosis and no heart trouble suspected.

He

The

No apparent cause for the attacks; they would come on even when he was perfectly quiet. would cry out that he felt ill and would then fall suddenly; would remain sensible during the attack; would scream and fight for breath. tits lasted from ten minutes to one hour. Seven weeks ago had a fit during which he was perfectly insensible and stiff, with eyes open and foaming at the mouth, since that time he has appeared worse. Has only been in Canada three weeks. While in England (Birmingham), the hospital physicians had used him frequently as the subject of a clinic, and they had said that a certain opening in the heart had not closed as it should have done."

On examining the heart I found a perfect babel of sounds, but among them all I detected a systolic sound which I thought to be aortic obstructive.

His finger-nails and lips were blue-black and face and extremities mottled of the same color.

Dr. Richardson, jr., and myself were only allowed to make a very imperfect post-mortem exam

ination, and on the morning of July 1st we hurriedly ligated the cardiac vessels and removed the heart, which was all we were permitted to examine.

The heart as a whole was hypertrophied, especially the right ventricle.

On opening the right auricle the foramen ovale was found to be closed, except a small valvular opening on one side. In the right ventricle the columnæ carnæ were enormously hypertrophied and there was no apparent opening into the pulmonary artery. On passing a probe down into the distal end of the pulmonary artery (which was normally patent) it was made to pass with some difficulty beneath the network of columnæ carnae between which it was seen. There was then a decidedly limited pulmonary circulation from the right heart.

How then did the venous blood escape from the right ventricle? On examining the ventricle more closely we were surprised to find up behind one of the semi-lunar valves, a large direct opening into the aorta; indeed the aorta appeared to take its origin equally from the right and left ventricles. On looking into the aorta from the distal end, the inter-ventricular wall was seen as a line forming the diameter of the cardiac orifice of the vessel.

Several questions naturally suggest themselves in connection with this case :

1. How was sufficient blood aeration carried on, to prolong life for nearly five years? Certainly not through the insignificant and almost imperceptible crevice between the columnæ carnæ in the right ventricle.

2. Why the hypertrophied right ventricle? 3. What was the cause of the systolic sound heard?

4. What is the pathology of the "fits"? 5. Why did the "fits" only begin about two years ago?

6. What was the cause of the cyanosis?

(1) Unfortunately we had not secured the aortic arch in our post-mortem excision of the heart, but there can be little doubt that the following was the condition present. A ductus arteriosus was given off as usual, from the pulmonary artery to the aorta; and this had remained patent; now when the venous blood from the right

heart passed into the aorta, a portion of it was forced into the d. arteriosus and from thence through the pulmonary artery into the lungs. Thus, by a reversed current, the work of aeration was carried on.

(2) The amount of extra work thrown upon the right ventricle, in forcing the current through the abnormal aortic opening and attempting to force it into the normal passage, would account for its hypertrophy.

(3) The systolic sound heard was undoubtedly pulmonary, obstructive at least in part.

(4) The attacks (in which he fought for breath) were probably due to a pulmonary stasis, caused by the temporary arrest of heart action, which always accompanied these attacks. The attack sevens week before death was evidently epileptoid in character and due in part to the excess of venous blood in the brain and the action of this impure blood on the nervous system.

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(5) Why the child remained free from the attacks early in life I am not prepared to say. believe that at an earlier period the pulmonary orifice in the right ventricle was very much more patent than at present. The orifice as now seen is occluded by hypertrophied columnæ carnæ and ventricular walls, and it may be readily understood, that if this hypertrophy were absent (as in earlier life) we would have a more patent artery. This may probably account for the non-appearance of the attacks before the third year of the child's age.

(6) Morgagni has said that in these cases the cyanosis is probably due to the general congestion which is present. Hunter, on the other hand, has claimed it to be the result of the admixture of venous with arterial blood, which is constantly going on. Probably both of these factors enter into the maintenance of that condition of peculiar discoloration, known as cyanosis.

CREOLIN AS AN ANTISEPTIC.-If creolin be as sure a germicide as the authorities now state, it must soon supersede the bichloride. It is harmless to the human organism; is cheap, and does corrode instruments. It is used in one half to 3 per cent. solutions.

A CASE OF THROMBOSIS OF THE UTEROVULVAR CAVAL RUPTURED DURING LABOUR.*

BY WM. S. MUIR, MD., L.R.C.P. AND 8. ED., TRURO, N.S. On the 22nd of March last, I was called to attend

Mary C., aged 17 years, primipara, a short, stout, full-blooded girl. She had been in labour for four

or five hours, as it was not the intention of her friends to have a doctor, her grandmother being a local midwife. I was told that her pains had been very hard and constant, that the waters had broken, but there had been no discharge of blood. Upon examination, I found things about as stated. The head was at the brim, and had been in the first or second position. I waited about for over an hour, and, as things did not appear to be any farther along, I decided to deliver her with forceps. I may say that during my wait I could not decide what was the cause of the delay, as the parts were natural and good-sized, and the head did not give one the idea that it was unnsually large. I chloroformed her, and had great difficulty in getting the left blade of the forceps introduced and in position. However, after some time, I got the forceps (Simpson's medium) locked. After giving a little more chloroform, I waited until I felt the uterus contract, then made gradual traction, using very little force. All at once came a gush of blood, which appeared to come from the upper part of the canal it fairly poured out. My first thought was a ruptured uterus; then a ruptured vagina; but that could not be. The blood was not dark and in clots, but as thick as ordinary venous blood, and it coagulated at once in the vessel I put below the edge of the bed to catch it. I put my hand on the uterus above, and found it contracting from time to time. The hemorrhage still continued; not in gushes, but slowly and steadily. My patient's face and pulse now began to tell a tale, so I decided to send for my friend, Dr. Page, who lived near at hand. Dr. Page came at once, bringing stimulants with him. Before this I had removed my forceps and discontinued the chloroform. decided to deliver her at once. I gave a small quantity of chloroform, and Dr. Page delivered her with his own forceps with very little difficulty.

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