the last ten years gone back to the use of chloroform, unless there is some special reason why I should not use it. I do not believe that it adds to the depression in these serious cases.

Dr. P. Daugherty: Some years ago I met Dr. Link of Indiana. I asked him what anæsthetic he used and he replied "whisky." I said, "Don't give anything else," and he replied, "very seldom." I have never seen it tried myself, although I often give whisky before giving chloroform. I began to administer anæsthetics forty years ago, have never given ether in my life, and am too old to commence now, as long as we have chloroform.

Dr. Milton Jay: This is an interesting subject, and whether a major or capital operation should be done without an anæsthetic or not, is a point that cannot be decided except by the surgeon in charge of the case. There is something about the nervous system of individual cases that we do not understand. We find, at times, great sensibility to pain, and then again insensibility to pain. We find sensitiveness to touch, without sensibility to pain. I have seen. cases in which there was sensibility to touch, yet no ordinary amount of cuttting seemed to give pain. In cases of great shock we find that a stimulant alone will prevent the patient from suffering very much. Even a little whisky may do in certain cases, and an anæsthetic need not be used, but such cases are the exception.

Dr. Pierce: It has been my experience that the use of whisky increases the sensitiveness of patients. Giving the patient a drink of whisky makes it more difficult to bring him under the influence of chloroform, and increases the sensitiveness. Every surgeon will bear me out, that the most troublesome patients to treat are those who are half intoxicated. They are the most difficult to manage, most sensitive to pain, and make more trouble than patients not under the influence of liquor. I can conceive of no use to which whisky can be put in producing anæsthesia, unless you make the patient stone drunk. As to the relative merits of chloroform and ether, we are opening a very broad subject, and one that we cannot definitely settle. There is a wide difference of opinion on both sides. Some years ago, at a coroner's inquest in Boston, it was said that a lady had died in a dentist's chair from the use of chloroform. The coroner's

jury brought in a verdict of manslaughter against the dentist, because ether had not been used instead of chloroform. The weight of judgment of the profession now is largely toward the use of ether by reason of its safety. If a patient has kidney trouble and an examination of the urine indicates albuminuria, I would not use ether. Ordinarily, I think it is safer to use it. If any trouble should result, the weight of professional opinion would be on your side, not because it is easier to use. I agree with Dr. Daugherty in regard to chloroform as a preference. I have given it a hundred times where I have given ether once, and I prefer it to ether. I have seen no bad effects from its use.

Dr. W. S. Hoy: I did not expect to take part in this discussion, but since the matter of anæsthetics has come into the debate, I would like to get an expression of opinion from the members of this association as regards what anæsthetic they would use in the majority of cases. For twenty-one years I do not remember of having given ether in a single instance. (A rising vote was taken at his juncture and 105 members showed their preference for chloroform to ether, while 16 preferred ether to chloroform, when there was no special contraindication to its use.)

Dr. W. S. Hoy (resuming): I desire to say a few words regarding the paper of Dr. Buchanan. I shall only touch upon one or two of the valuable points the distinguished gentleman made. Realizing, as I do, that Dr. Buchanan comes from Pittsburg, and knowing the high esteem his co-laborers have for his ability as a surgeon, I can truthfully congratulate this association on the honor we enjoy in having him with us to-day. While many of us look with distrust and doubt upon the ideas the gentleman would attempt to inculcate, still we must of absolute necessity weigh carefully the ideas advanced, and by the usual instructive discussions arrive at a satisfactory conclusion regarding the merits of his paper. I am constrained to ask the question, are we advancing or retrograding? It looks like a bold step forward, and, on second sight, it is equally apparent that it is a step backward. The doctor explains, in his usually instructive manner, that in capital operations he executes the operation without the use of an anæsthetic, simply gives whisky. Now I shall not consume much of

your time in the discussion of this part of his paper, yet I do feel that it will be of paramount importance and interest to look at the action. of the "whisky" he proposes to administer and see just how he obtains the desired results from this source. What is the effect of alcohol and its compounds? I am free to confess that whisky is, beyond doubt, an anæsthetic and paralyzant, therefore the question simply resolves itself into the individual's constitutional ability to withstand its physiological effect. You all know that some persons will take only a small portion of spirits and lose the power of exact co-ordination. My experience leads me to the conclusion that in a vast majority of cases it acts at once as an anæsthetic, lessening the rapidity of impressions, the power of thought and the perfection of the senses.

Take, for instance, a single ounce of alcohol administered internally, and what do we find? Diminished nerve activity, diminished cerebral activity, impairment of the co-ordinating power of the brain, as well as marked lessening of muscular strength. Let me fully impress one idea, and that is this: I know of no substance in the entire materia medica which more rapidly wastes and destroyes brain cells and impairs the tissues, than alcohol and its compounds. The very first full realization of its effects is what? Do you call it a stimulant? Have you failed to fully realize the depressing effect upon the cardiac vaso-motor and respiratory nerve functions? Not to say anything of the attendant loss of tone in the heart and blood vessels.

Take, for instance, the case of a moderate drinker of whisky, and what do we find? At once a dilatation taking place in the vessels of the liver and spleen, and corresponding interference with all the natural metabolic processes taking place in these organs. I am sure of one thing; the Doctor, if he obtains the desired immunity from pain for his patient in these major operations, he must realize that the absolute effect of whisky, when it comes in contact with the nerve centers, is invariably that of a narcotic, paralyzant and anæsthetic, no matter what the dose may be, the effect only differing in degree according to the size of the dose. Now, I cannot for my part see the benefit the distinguished surgeon obtains from using whisky in preference to the grandest anæsthetic the world has ever known, chloro

form, and for my part I would oppose the whisky for several good reasons. Among a few I might say the rapidity of its absorption. from the stomach and circulation throughout the system. If used hypodermically, the very moment it gets into the blood it diminishes the interchange of oxygen and carbon deoxide through the lungs, and thus retards tissue metabolism generally. The very presence of whisky in the circulation impairs the natural affinities and functions of the red corpuscles. hemoglobin and albumen of the blood, thereby diminishing the internal distribution of oxygen and retarding molecular or metabolic changes, whether nutritive, disintegrative or secretory. I know that my very learned friend, Dr. Outten, will tell you that by the constant diminishing of the internal distribution of oxygen, and the activity of the leucocytes, whisky directly diminishes vital resistance to the action of all morbific causes. When does this action begin, if it be the result of long continued saturation of the system with whisky? Do we not have the starting point from the very first profound drink, that would be required to do the capital operation without pain?

Dr. Robert Barclay: I rise to make an inquiry. I would like to know whether there. are occasions when it is necessary for the railway surgeon to operate on patients in the sitting posture, and if so, what anæsthetic would he use for that work. It is the custom of aural surgeons to place patients in the sitting posture, in order that they may keep the field of operation free from blood, so as to finish it and see what they are about.

President Murphy: I will ask those who would change the anaesthetic, in order to operate upon a patient in the sitting posture, to rise. (Not one member rose.)

Dr. W. B. Outten: The chief element of Dr. Buchanan's paper has not been touched. I maintain that in the direction of shock, that of all the remedies that have ever been suggested (and I have watched them closely and carefully) none equals the normal saline injection. You can prate about whisky, strychnia, etc., all you please, but there is this condition which exists in shock, namely, a partial paralysis of one side of the heart which arises in consequence of lack of sufficient quantity of blood supplied to the heart. With the saline solution you fill the vessels and there is response of car

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 anæsthetic. 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.

We

Dr. Trainer: A word in regard to stimulation in shock. I fully agree with Dr. Buchanan as to the use of saline solutions. 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 anesthetic, 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 anaesthetic has either been withdrawn or omitted, the benefit to the patient has been very much greater.

I have been misunderstood with reference to

no

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 and with very tender, 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