pointed out, the paralysed muscles always contract well under the influence of electricity; but two new phenomena have appeared. A slight, but permanent, oedema occupies the lower limbs up to just beneath the knees, and the intestines are the seat of a considerable meteorism, due doubtless to paresis of the proper muscular coats of the intestines and the large muscles of the abdomen. The incontinence of urine and fæcal matter is always the same; there are no eschars. In the upper limbs the paralysis has not made progress; the deafness of the left side persists.

PROCEEDINGS OF SOCIETIES.
"Etsi non prosunt singula, juncta juvant."

HERNIOPUNCTURE. This Paper was read before the Louisville Medico-Chirurgical Society. By DOUGLAS MORTON, M. D. In the September number of this Journal there was published a report of two cases of strangulated hernia, treated respectively by Dr. David Cummins and myself, by what I characterized as "a new and easy mode.” In each of these cases the instrument used for evacuating the contents of the hernial tumor was a canula needle. A few days ago I had occasion to treat another case, in which I used a very small trocar and canula, and the object of my again appearing before the Profession on this subject is to call attention to the unfitness of this instrument for the purpose, giving rise, as I have found by experience, to a danger by no means inconsiderable.

In order that a trocar and its containing canula may pass easily through the tissues, the point of the former is made to cut an opening larger than will be completely filled by the canula at its smaller end. In the proper uses of the instrument this is no disadvantage; but we can readily see that when plunged into a hernial sac tightly distended by effused serum, the pass

age of the instrument will be attended by an escape of some of this fluid into the subcutaneous cellular tissue, and when the intestine distended by flatus is punctured there will be a still more ready escape of gas.

These matters are readily caught in the loose cellular tissue of the scrotum, and may provoke a dangerous degree of erisypelatous inflammation. In the case in which I used the trocar this event occurred, and necessitated my making extensive incisions into the scrotum, which have not yet healed.

I am prompted by a sense of duty to lay these facts before the Profession, especially as I spoke of having had a trocar and canula made for treating hernia.

While the danger referred to furnishes no occasion of qualifying the terms in which I spoke of the expediency of the operation, it is certainly suggestive as to the kind of instrument that should be used, and the manner of its use. I am satisfied that the proper instrument is a canula needle. Those used with the hypodermic syringe, as I have before stated, will serve the purpose very well, but I think there would be an advantage in having a slight and uniform taper from heel to point of the needle-giving it an acutely conical instead of a cylindrical form. The advantage of such a form of needle is obvious, having forced its point through the herniated intestine, the escape of gas through the puncture may be effectually prevented by pressing the instrument a little further, so as to introduce a portion of greater diameter.

The tumor ought to be firmly grasped and steadied with one hand, and the instrument plunged suddenly and boldly in with the other, at least to the extent of half the diameter of the hernia in the direction the needle is thrust, which should be toward the stricture, backward and upward. This latter point is important, as it often happens that a very large quantity of bloody serum is effused into the space between the limits of the sac and the contained loop of intestine, making it necessary to plunge the needle deeply in order to reach the latter at all.

The instrument must be allowed to remain until the gas ceases

to flow out, when the operator should gently press the tumor, and at the same time slowly withdraw the instrument; when the point emerges into the space surrounding the loop, which always contains more or less serum, this fluid commences to pour out. By continuing the pressure properly the sac may be pretty well emptied of its fluid contents.

If a large loop of intestine is involved in the hernia, and is not held down by adhesions, it will probably return spontaneously the moment the instrument is withdrawn; but if the extruded portion is only a small section, and the strangulation has existed for some hours, the removal of the gas will accomplish only a small relative diminution in the size of the protrusion, owing to the thickening of the intestinal coats by congestion, and some manipulating may be required for its reduction. As puncturing the scrotum gives some pain, and the patient has a horror of having a sharp instrument stuck into this region, which is by no means unnatural, chloroform ought to be administered. When the doctor sets about this little operation, however, he will find that expediency demands its use as well as humanity.

It may happen that a hernial sac is so very tightly distended by effused serum that the tumor will feel solid, and give rise in the mind, of a novice especially, to doubts about its true nature; and as far as its mere feel is concerned, in such a case, the most experienced may not be able to determine the true character of the hernial protrusion-whether it be bowel or omentum. Now although I believe the novice will do no harm if he sticks his needle in a tumor he is doubtful about (provided in his differential diagnosticating he has excluded the possibility of its being a testis), it is certainly very desirable to know beforehand what prospect there is for accomplishing good with the instrument. I would therefore advise that, in addition to the ordinary means for diagnosis, he would draw the integument tensely acrosss the tumor and percuss, after the manner that one thumps a watermelon. If the hernia contains gas, it will give out a sound, of course, more or less tympanitic; and presents a proper case for the use of the needle.

I go into these minutiæ because of being convinced that many failures occur in surgery, as well as in other matters, from insufficient observance of details, which may indeed appear at first sight inessential and nugatory.

I am reminded moreover by the motto on its back, that this Journal is designed for the "indocti" as well as the "periti," and I am writing for the former class, who must "discant," although the latter may be bored a little in the present instance in being called upon to "meminisse."

A few days ago, in conversation with a prominent physician of this city on the subject of this method of treating hernia, he told me that he thought the two cases reported some time ago afforded insufficient data to justify our conclusions as to the harmlessness of the operation. He appeared to entertain to a considerable degree the time-honored notion of the extreme danger attending peritoneal injuries. I would reply that, in forming an estimate of the danger of puncturing the serous investments of hernia, these two cases were not by any means our sole reliance. Our data consisted of the results very preponderantly favorable of a vast number and great variety of operations involving more or less extensively the peritoneum. In our discussion of the operation published in the September number of this Journal, I think the question as to the danger of peritonitis following directly the slight injury of the membrane, and that, as to the danger of extravasation, were satisfactorily disposed of, and I know of no other, except the one the notice of which is the main object of this paper.

The best light, however, in which to consider the utility of this operation, and the importance of minutely discussing its details, we get from the management of hernia cases as it is really very often conducted. I quote in the report referred to the views expressed by Mr. Birkett, as to the extent of injury that may be and is actually done in a large number of cases. Any medical man can appreciate the correctness of these views. When a case of hernia falls into the hands of a man who makes no pretension to surgical skill (and the majority of cases

fall into such hands, there being a great majority of medical men who are without surgical skill) taxis, which seems so simple in description, and so very easy in practice, will be tried in by far the greatest number of cases. Now, taxis is by no means the easy thing it appears, and a great many failures actually occur when success would have crowned efforts guided by skill and experience.

These failures are very significant, for they may leave the patient in an immeasurably worse condition. Every effort which effects no progress toward reduction must necessarily increase the difficulties to be overcome, inasmuch as it gives rise to irritation, of which increased congestion of the hernia is the result.

Let us consider what is apt to occur in the country: A case of hernia falls into the hands of a man who has never tried taxis before; thinking it a very easy thing, he will set to work at it, and if there is any real difficulty to be overcome, will probably fail; in this event he will send for the nearest doctor in the neighborhood; and he may know no more about the matter than himself, but he can share responsibility, and this may be the sole reason why he is wanted. But Doctor No. 2 will certainly try his hand at taxis, and having greater difficulties to overcome, will in greater probability fail and injure the patient still more. At this juncture Doctors No. 1 and 2 will have a consultation, the conclusion of which will be that the case demands that the stricture be divided, and that a surgeon must be sent for. Now, the nearest surgeon may be a long way off, and risk will be run of his not being found at home. In the meantime the patient's chances of recovery are growing more and more slim. When the surgeon at length arrives, tries taxis himself awhile, as he will very likely do, and then opens the sac, the probabilities are that he will find the intestine very much in the condition described in the quotation from Birkett referred to.

Now, the great utility of the operation of evacuating the contents of the hernia arises from the fact that it requires no