The wound looked

shocked, and died within thirty-six hours. well, all fecal discharge had ceased, and there was nothing in the outward appearance of the child to give any clue to the cause of this shocked condition in which she was found. The post-mortem examination, however, revealed the fact that a small pus-pocket existed, at the time of operation, deep down between the mesentery of the colon and the spine on the right side, and that during the separation of the colon from its surrounding attachments a few drops of this pus had been permitted to ooze into the general cavity of the peritoneum unnoticed. Sterilized Sterilized gauze had been carefully packed around the seat of the operation to prevent fecal contamination of the peritoneum. This extra care prevented the observation of what was taking place deeper down, and as a consequence death resulted.

I give this as but one instance of the relief of conscience that may frequently be afforded to the surgeon by a post-mortem examination. He is relieved from the charge of having introduced the poison from without.

The questions of operations upon the appendix and the diagnosis and treatment of ectopic gestation have been fairly well settled. The method of dealing with the pedicle in ovariotomy has been settled, except for the fact that some operators prefer silk, while others are assured of the safety of catgut. Operations upon the gall-bladder and gall-ducts have been performed many times during the past ten years, and they are now well recognized as proper surgical procedures. The operations of nephrectomy and nephrotomy are Looked upon as everyday procedures justified by the consensus of surgical opinion. Abdominal hysterectomy is an operation that has been much improved and simplified, some operators being still wedded to the clamp, while others prefer some of the other methods. The advisability of oöphorectomy for some fibroids cannot be doubted. But there are several procedures about which my mind is as yet in an unsettled state. There are two operations performed that I think are of doubtful value-namely, the fastening of the kidney to the side, and the fastening of a uterus anywhere. I consider that these operations have been recklessly performed and unnecessarily done. Whether they should ever be performed will be decided by future generations if not by the present one. I have satisfied myself of the fact that a kidney can be firmly fixed

if suppuration is produced, but I do not believe that the uterus can be permanently fixed unless a severe grade of inflammation, that may be dangerous to life, is produced. By fixing the uterus I consider that the physical laws of nature are outraged. The arguments for and against this operation will be presented to you later by Fellows of the Association.

Nephrorrhaphy was discussed last year, but to my mind the discussion was not a satisfactory one. I have read it carefully. Regarding the advisability of removing the uterus in septic diseases of the pelvis, there will be a good deal said about this subject. There may be considerable misunderstanding; the advocates of total ablation by the vaginal route have not expressed themselves with that amount of clearness that could have been desired. They have written as enthusiasts write. There are undoubtedly cases in which the uterus may be riddled with abscesses, but such cases are rare. That the uterus has been unnecessarily removed in many of these cases will, I think, be the common verdict. That the vaginal route has certain advantages cannot be denied ; this route has been used for years for opening pelvic abscess, suppurating ectopic gestation, ovarian abscess in which the patients have been so debilitated by prolonged suppuration that they are unable to withstand the shock of any attempt to remove the diseased mass through the anterior abdominal wall. These cul-de-sac operations, however, have been improved as a consequence of the attention that has been drawn to them. A bold operation is now done in place of the timid puncture with a curved trocar.

Operations to which more thought must be given are those for intra-abdominal and intrapelvic cancer. When peritoneal cancer has been diagnosticated, surely exploratory operation is uncalled for. Exploratory operation should become less and less frequent as we perfect our methods of diagnosis.

Operations for other forms of cancer are of questionable utility. Take, for instance, resection of cancerous intestine, gastro-enterostomy for pyloric cancer, removal of the uterus for uterine cancer. Gastro-enterostomy and resection of intestine are poor makeshifts. For carcinoma uteri, vaginal hysterectomy is the only operation that should be contemplated; but at best it prolongs life but for a short time.

I am afraid that many rash statements in regard to the after

results of this operation have gone forth to the profession from many associations. I have frequently performed vaginal hysterectomy for cancer of the cervix uteri. On two occasions I have removed the uterus for malignant adenoma confined to the body, without any implication of more than the mucous and a small portion of the muscular coat, without any appearance of implication of the peritoneum, and in each case the disease has returned within less than eighteen months after the original operation.

I must thank you for the patient hearing you have given me, and I trust that in the meeting, though the President's address is not open for discussion, the questions I have mentioned will be given careful consideration.

PRINCIPLES OF TREATMENT IN PUERPERAL

ECLAMPSIA.

BY WILLIAM WARREN POTTER, M.D.,

BUFFALO.

AT the Geneva Congress last year M. Charpentier, a distinguished Honorary Fellow of this Association and a recognized authority of high standing, gave utterance to views regarding the treatment of puerperal eclampsia, especially as to the applicability of the induction of premature labor for its relief, so at variance with those that I have been accustomed to harbor, and the verity of which, having so frequently tested, I have not doubted, that I confess to my surprise thereat. Moreover, I have been somewhat amazed that M. Charpentier's opinions, so forcefully announced on the occasion referred to, have been allowed to pass practically unchallenged for so long a time.

It is not in any spirit of controversy that I shall venture at this time to oppose M. Charpentier's teachings, but simply in the interest of professional progress and science. Let me, therefore, asseverate at the outset that in this paper I am giving merely my own views, briefly set forth, no matter how opposite to those referred to they may seem, nor yet how devoid of novelty or barren of suggestion they may prove. Howeversomuch this may appear to be the case, they are yet fortified by an experience and observation extending over a period of many years; moreover, in the application of the principles advocated a measure of success has been obtained at my hands that did not present itself under a contrary method previously pursued.

While it is my purpose chiefly to discuss principles of treatment, yet in order to do so intelligently it always becomes necessary to inquire into etiology and pathology. In the present instance,

however, only such brief reference to each will be given as will contribute to a more lucid understanding of my argument.

In the beginning it may be pertinently remarked that it is a matter of regret, notwithstanding the frequent discussion of this disease in societies and magazines, that we are still in doubt as to its pathogenesis. Nay, more; we are even forced to deny that it is a pathologic entity, and to affirm that it is but a group of symptoms which has been named eclampsia for the sake of convenience or for the want of a better term. We are prepared to further assert, as a result of progress already made, that it is not of hysterical, epileptic, or apoplectic origin-i. e., it is not produced in the human economy except in the pregnant or puerperal state..

Let us, too, go a little further and see if we cannot agree that the convulsions are reflexes excited by cerebro-spinal or medullary irritation of toxemic origin—a toxemia peculiar to pregnancy, that has no parallel except during gestation. I wish it were possible for us to go still further and formulate the precise nature and fix definitely the source of the toxins that play such havoc with a goodly number of pregnant women.

In searching for the causes of eclampsia the kidney has always been regarded with extreme suspicion by most physicians of experience. It is the duty of the kidneys to eliminate toxins, and if these organs fail in their office unmistakable symptoms may be promptly presented in the pregnant woman. These prodromes are manifested in various ways, the leading or most pronounced being headache, puffiness of the eyelids, local and general edema, scanty and albuminous urine. Renal insufficiency, either in quantity or quality, or both, is an almost universal accompaniment of the pre-eclamptic state. Indeed, anuria is often a forerunner of the fits. But the kidney is only a servant-in the majority of instanecs, too healthy in itself—but performing its duties in a faulty manner. It has perhaps been asked to perform excessive labor because of an over-production of toxic material; again, by reason of mechanical pressure on its emulgent veins, it finds itself embarrassed in its work; or, finally, it may be the seat of parenchymatous change. In any event the kidney plays an important part in the economy of the eclamptic; it is a sentinel stationed at an important gateway which must challenge every toxic element that approaches, and eliminate it with promptitude.