diac action. I have never injected a quart of normal saline solution in the flank, before undertaking operation, but what this fluid has disappeared like magic, and along with it we have had an improvement in the pulse so as to enable us to proceed with the operation. I would give up all remedies, if necessary, in preference to doing away with the normal saline solution in cases of shock.

As regards the doctor's idea of whisky, I believe it is not original with him, and he did not so claim, but Dr. Link, I understand, has operated entirely with the anaesthetic effects of whisky and claims to get good results. When you give a stimulant you do essentially what yould should not do-you make the heart beat itself to death. If my theory of shock is correct, and it is the accepted theory at the present time, and the doctor fills his heart up with normal saline solution, probably it, along with the stimulants, may accomplish the result (that is, with the whisky) and get rid of the anesthetic. The doctor has given us a good principle and we should at least try and see if there is anything in it.

Dr. Martin: With reference to chloroform and ether anæsthesia, ever since I have been practicing medicine, I have been congratulating myself that I could perform operations without torturing my patients, as my fathers and your fathers did, and I would dislike to accept the recommendations set forth in the paper in a general way.

Dr. John L. Eddy: I have used chloroform for a great many years, and have had quite a number of cases of suspended animation. Only last week a strong, healthy man stopped breathing shortly after the administration of chloroform, although his pulse was beating steadily all the time, but his respiration stopped for a long time. My experience has been that in nearly all cases where trouble has followed the administration of chloroform, it has been the result of paralysis of the muscles of respiration and not of the heart. In cases of profound shock there is nothing that will arouse a man so thoroughly and quickly as to insert both thumbs in the anus and dilate the sphincter ani. Every man who has done considerable. rectal surgery knows that, and if you do not believe it, the next case you have of suspended animation, try it.

I was a little surprised to hear Dr. Pierce's

statement, that down in Boston a coroner's jury indicted a man for manslaughter, because a woman had died in his chair from the administration of chloroform. In the section of country where I came from, we should indict them for womanslaughter. (Laughter.)

When we come to see the difference in the opinions of eminent surgeons, one using this and the other that, we are led to wonder why it is that so many people live in spite of the doc

tor.

If I had a case where I had any suspicion of heart failure or weak heart, I would use chloroform with pure oxygen gas. One drachm of it inhaled with pure oxygen is sufficient for any operation. Pure oxygen gas alone is one of the greatest restoratives we have. I invariably use the Esmarch inhaler. It is the safest one. The great trouble in chloroform is in getting too large a quantity at one time, but with the Esmarch inhaler we get it drop by drop. In the case I spoke of that occurred last week, where the man stopped breathing, I used the Esmarch inhaler. It is the only inhaler that the surgeon should use in giving chloroform.

Dr. Trainer: A word in regard to stimulation in shock. I fully agree with Dr. Buchanan as to the use of saline solutions. We all realize their efficacy and the doctor who spoke from the platform a moment since struck the keynote when he called our attention to the fact that many times we have this condition owing to dilatation of the heart, but he did not mention the fact, but took it for granted. that we knew, that the arteries were also dilated at the same time, so that they are not properly filled by the impulse of the heart. In connection with the saline injection, about the only heart stimulant I use is strychnia.

In regard to the choice of anæsthetic, if a man is accustomed to using chloroform in preference to ether, he can use it more satisfactorily and more safely that he can ether, and vice versa. Personally, I prefer chloroform. When we have a death from chloroform it is a common observation that it occurs at once, while the patient is on the table; whereas, with ether, many of the deaths attributed to the operation, perhaps a week or two weeks after the patient was operated upon, are due to the after-effects of the ether.

Dr. T. B. Greenley: Speaking of resuscitation from the effects of chloroform and stop

page of respiration, my plan is to throw cold water in the face of the patient, and as a rule he catches his breath and goes on breathing. This is a good way to bring about reflex action of the respiratory muscles. I have done that in two instances with satisfactory results. Many years ago I used chloroform as an anæsthetic more frequently than I do now. I agree with the doctor, who spoke of it that stretching of the sphincter ani with the two thumbs excites reflex action as quickly an anything.

Dr. Buchanan (closing): I had no idea that my paper would be the means of eliciting a discussion of such magnitude. The essence of it was confined to three propositions, one of which has not been touched. The first was that very large saline infusions--at least two quarts, repeated two or three times in the course of a few hours-were beneficial in cases of shock from loss of blood. Secondly, there were rare cases where the patient stood a better chance for life from a rapid amputation without any general anæsthetic, either chloroform or ether. Thirdly, that the disinfection of these terribly dirty and mangled limbs could not be carried out so that the limb would remain septic for days.

I must confess that I was a little astonished at the result of the vote brought out by Dr. Hoy. Some of the old men here remember the time when amputations were done without an anæsthetic, and I have no doubt that if they recall the condition of patients whose limbs were amputated without an anæsthetic, and the condition of similar patients to whom either chloroform or ether was administered, they will

find it to be materially different. The patients whose limbs I have amputated without a general anesthetic have had a dry skin, not any more moist than before the operation, and with no additional evidences of shock. Whereas, we are all familiar with the very low condition of the ordinary patient whose limb is amputated under an anæsthetic, when the amputation is done under very adverse conditions, so that the only way that this matter can be settled is to compare cases of amputation with anæsthesia and those without anæsthesia. That I have done, and I am satisfied that in those cases in which the anæsthetic has either been withdrawn or omitted, the benefit to the patient has been very much greater.

I have been misunderstood with reference to

the use of whisky as an anesthetic. I am familiar with the work of Dr. Link. He makes his patient absolutely drunk. It is not my desire to get the full effect of the whisky to the stage of drunkenness.

"A CASE OF STRANGULATED INGUINAL HERNIA, WITH UNUSUAL MEDICO-LEGAL ASPECT."*

BY DR. ALLEN STAPLES, DUBUQUE, IOWA.

On March 6, 1896, early in the morning, I was summoned to see H. B., brakeman, aged 28, who had been severely injured in the abdomen. He said that while following his regular occupation he had been passing from one car to another, and by a sudden jerking of the train had been thrown violently against the hand-rail. The injury had occurred about I o'clock in the afternoon previous, and he stated that there had never been any trouble with his groin before.

When I saw him he was somewhat pale, but a well nourished and vigorous looking man, and did not look very ill or anxious. In his right inguinal canal there was a large swelling, ten inches by three by one, not very tender, and with no impulse on coughing. The abdomen was soft, flat and comparatively free from pain. There was but one testicle, the left, in the scrotum. While there was no contusion visible, there were evident signs of strangulation. For several hours he had been showing these symptoms, such as shock, persistent vomiting, and some spasmodic pain. Several enemata had been given to him without any result. Assisted by a physician who had been called, I attempted taxis as long as I thought advisable, under ether, but in vain.

As all his symptoms steadily grew worse I took him at once to Finley Hospital and operated at 10 a. m. the same day, assisted by Drs. Boothby and Walton.

The pubes were shaved and washed and I cut down upon the large swelling in the right groin. Very quickly a dark colored tense sac was disclosed. My incision was about four inches long, coinciding with the long axis of the tumor. On opening the sac about a drachm of blood or bloody serum came away.

*Read by title at the ninth annual meeting of the National Association of Railway Surgeons, at St. Louis, May, 1896.

The next thing that came to view was a tense blackish, shining, ovoid mass, about as large as a fair sized orange. This mass was evidently altered omentum; behind and below it was a testicle of considerable size which appeared to be inclosed in a sort of mesorchium, which contained moreover an apology for a cord and an imperfectly developed epididymis. Below the latter and severely constricted by the pillars of the ring was a large loop of the colon. On introducing the finger into the canal it was seen to be enormously dilated, the protrusion being backward into the abdominal cavity. This had obviously resulted from distension of the vaginal process. The gut was very intensely injected and dark and covered by adherent layers of clot. With considerable difficulty, as the bowel seemed to be in a recoverable condition, a very tight cartilaginous constriction in the peritoneal neck of the sac was divided and the gut returned. The testicle, as it seemed impossible to place it in the scrotum, was removed and the spermatic artery tied with catgut. An examination of it showed that in addition to some adhesions to the omentum, the cord seemed to be twisted upon itself and the epididymis transformed into a small fibrous mass.

The testis proper was small and had suffered cystic degeneration. The large oriental mass spoken of, which seemed more or less gangrenous, was ligated with catgut and removed. What seemed to be the remains of a doublenecked sac was cut off flush with the peritoneum, after being tied. The opening into the abdomen was closed by catgut, lacing up the inguinal canal as recommended in Wood's operation.

The after history of the case was uneventful. There was no rise of temperature and no bad symptoms developed. In two weeks the patient was able to sit up, in three weeks to get about and in four weeks to leave the hospital. But the patient and his friends still insist that he never had any lump in his abdomen or trouble with it previous to the alleged accident on the day before the operation. It was reported to me by an outsider, however, that the patient had some time previously been treated by a physician for a swelling in his groin. The treatment had consisted of hypodermic injections into the tumor. On

being questioned upon the matter by myself the patient denied ever having had any such treatment, and with his friends began to make vague statements about the indemnity he expected from the company for his severe injury. Obviously in settling the question as to indemnity, considerable stress would be laid upon the fact as to whether the hernia was a recent one or an old one, and it is to this point that I desire to call your attention.

In the first place I regard it as improbable, though not at all impossible, that so large a hernia could take place in so short a time.

In the second place, the large amount and the density of the adhesions would strongly negative the idea of a recent hernia, and in the third place, such extensive gangrene, which, together with the adhesions, I strongly suspect to be partly due, at least, to the injection treatment, could hardly have taken place in so short a time as had elapsed between the receipt of the injury and the operation. Lastly, and most important of all, the cryptorchism which I found would most positively disprove the statement of the patient and his friends. To bring this out clearly I purpose to discuss the subject briefly.

Englisch, in treating the general topic of congenital cryptorchism describes precisely the condition in which we found the patient's testicle. According to him, in adult life the seminal canals have disappeared, the cellular tissue has increased and a fibrous mass finally takes the place of the seminal canals. This change takes place more often when the testicle lies in the inguinal canal than when it remains in the abdomen. At first the organ in the canal is movable, but finally, in consequence of inflammatory adhesions, its movability decreases year by year. The vaginal process of the testicle is rarely a closed sac but is usually open toward the abdomen, especially when the epididymis is present. The latter is usually, as in our case, degenerated into a small fibrous mass. The vas deferens and testis itself are frequently the seat of cystic degeneration, as we noted in our patient.

Another feature also remarked by us in our case, and occasionally the cause itself of strangulation, was the twisting of the cord and epididymis (mesorchium).

The cause of the retention and twisting of the testicle is very difficult to discover. It

has been thought to have been due to some intra-abdominal adhesion, which had retarded the descent of the epididymis and spread it out between the layers of the mesorchium. This would also account for the tilting of the body of the testicle, which we found, which caused its upper part to be directed downward and forward, for whatever it was that retarded the epididymis would probably act first upon the lower part of it. The twisting was probably caused by the continual downward pull of the gubernaculum testis, modified by the resistance of the adhesion, spoken of above. A testicle retained in the inguinal canal is moreover exceedingly apt to be complicated with hernia, and not unfrequnetly with strangulation. As in our case, the hernia both of omentum and bowel passed beyond the testicle through the inguinal canal, and being unable to descend into the imperfectly developed scrotum, rose toward the ilium, and formed the enormous mass that we described.

König, in writing of the subject of congenital adhesion of the testis with the omentum, as we found in our case, says that the testicle always becomes adherent in fœtal life and especially with that portion of the omentum called "omentum colilcum Halleri." Moreover, he states that this class of hernias is much more common on the left side than on the right. Indeed, one author, Luihart, states that he has never known any hernias complicated with undescended testicle save those upon the left side. In this particular our patient was a novelty.

Mr. John Wood, in his classical work, "Lectures on Hernia and its Radical Cure," states that hernias complicated with retained testes are invariably of the congenital variety, and Mr. Curling says if the testicle does not come down by the end of the first year it will certainly sooner or later be accompanied by a hernia. All of the authorities whom I have

consulted advise that if the organ has degenerated it should be removed, and if it still apparently is able to perform its function, it should be placed in the scrotum. In either of these alternatives the reason given is to avoid subsequent hernia with its dangers.

I think you will all agree with me from what I have said above, that if the question were asked me on the stand as to whether to the

best of my knowledge and belief the hernia from which my patient suffered was a new one or an old one, I would have no hesitation in affirming the latter to be the case.

The Extension of the Practical Application of Röntgen Rays.

The following editorial comment appears in a recent issue of the University Medical Magazine.

In the March issue of the Magazine we briefly described the practical application of the discovery of Professor Röntgen as far as it had been developed at that time. Since our report the use of the new radiation has been greatly extended. The June number of the Magazine contains the reproduction of a skiagraph showing a "jackstone" in the esophagus of a child, two and one-half years of age. This case came under the care of Dr. J. William White, at the University Hospital, and is, we believe, the first instance in which a foreign body has been detected in the trunk of the body by this means. A glance at the plate impresses the immense value of this new aid in diagnosis.

The August number of the American Journal of the Medical Sciences contains an article on the "Practical Application of the Röntgen Rays in Surgery," illustrated by a number of excellent plates representing interesting surgical conditions that could not be so lucidly portrayed in any other manner.

The application of the new ray in medicine up to the present time has been much more restricted. The shadows of the heart and liver are well seen, and the outlines of other organs are faintly perceptible. It is by no means to be considered, however, that the full utility of the radiation has as yet been discovered, and both surgeons and physicians are confidently looking forward to developments that will lend still more general assistance in diagnosis.

The construction of the flouroscope is being perfected, so that, at present, the necessary information may be obtained without the trouble and delay of making a skiagraph.

The Laboratory of Clinical Medicine of the University Hospital is already equipped with a plete plant will be installed in the Department Röntgen plant, and by October I another comof Clinical Surgery.

Medical Service of the Paris Exposition.

Dr. Gilles de la Tourette has been appointed physician-in-chief to the Paris Exposition, to be held in 1900. There will be an exhibit of objects illustrating the progress of medicine and surgery.

Very recently a largely attended meeting of The British Association occurred at Liverpool, and at a banquet in honor of Sir Joseph Lister, who was accompanied by many other notable medical men, it was said by the one proposing the toast to the distinguished guest of honor: "He (Lister) had the keen, scientific insight to observe the relation between the myriad germs, which Pasteur discerned, and surgical fever. He carried these investigations further by scientific investigations of the utmost beauty and skill. It was clear to him that the entry of these poisonous particles, and the changes they produced had all along been the source of the evil, and he revolved in his mind the problem of excluding them. Year after year this inquiry was the great object of his life. The difficulties were successively overcome, and he found that surgical fever no longer attacked his patients. The great truth was duly made known, and encountered the skepticism and opposition which all new

truth and all new untruth rightly meet. But by degrees doubt and opposition vanished, and to-day the skilled opinion of the world has accepted aseptic or Listerian surgery as a priceless boon to mankind. It is difficult to overestimate the benefit thus conferred on mankind in every part of the world. From Western California all around our globe, in America, Europe, the civilized parts of Africa and Asia, to Eastern Japan; from north to south, wherever trained skill is attainable, the splendid discovery of our guest is daily saving life and preventing suffering, and this it will do as long as knowledge and civilization remain. His reward is a great one, since he must know that he has probably saved more human life and prevented more suffering than any other man now living."

To be deserving of such words as these is truly the highest reward of human activity. Fame has no more to bestow.

The event above mentioned is full of meaning to the mind of the every-day working surgeon; full of significance in an historical sense, full of worth in a thoroughly practical direction. To Lister does the world indeed owe much. It stands indebted to him not alone for his patient research, and his discovery, but for the long years of ceaseless championship in support of his position, until he is able to-day, before time has dimmed his memory or blocked his powers of reason and discernment, to appreciate the universal acceptance of his teachings, the incomprehensible benefit to mankind and the restfulness that belongs to the conqueror as well in mental and logical, as in physical realms. To the general surgeon asepsis now means almost everything in the accomplishment of success, and it probably means more to the railway surgeon than to one following any other line of distinctive surgical work, for he has but little chance to prevent infection. The emergency surgeon must take it for granted that infection has preceded him, and he, therefore, is required to oppose forces already arrayed against him. In such cases force must combat force, and the knowledge gained by the sagacity and determination of Lister is the key to the situation, while the perseverance and practicability of the disciple becomes the means through which that knowledge works to the desired end. This is, in all instances,