rium in about four weeks and had a perfect result, witly no recurrence up until the time of his death, which was two and one-half years later.

Case 1173, J. L. T., aged 66, admitted December 13, 1904, strangulated femoral hernia. Health has always been good. Has been an alcoholic drinker. About twenty years ago, while riding a wild horse, a small elastic tumor appeared just below Poupart's ligament on right side. On account of a severe strain the tumor increased in size and he has never been able to have it reduced. About eight years ago a right inguinal indirect hernia appeared; this was easily reducible. On Saturday, December 10, 1904, began to have griping pain in abdomen in right inguinal region; bowels did not move that day. Took calomel, oil, salts and enemas with no effect. Pain had never been severe but was always present. No vomiting. Sunday, condition same. Monday, vomited first time; still no movement from bowels, although had taken repeated doses of salts, calomel and oil. Tuesday, pain increased in severity; still no movement from the bowels. Pulse good, no fever. Examination on admission to the sanatorium showed abdomen distended, no pain nor tenderness, tongue coated heavily, brown and moist, temperature 99, pulse 92 and good, respiration 26. Operation: An incision one inch below and parallel with Poupart's ligament over the most prominent part of the tumor, and by careful dissection the sac was readily exposed. The tumor was about the size of two fists. The contents of the sac consisted of the omentum and smalli intestine. The omentum and the intestines were intimately adherent to the femoral ring. Much difficulty was experienced in breaking up these adhesions and relieving the constrictions. The strangulation had existed so long that the intestine was necrotic for some distance,

requiring the resection of about eighteen inches of the gut. An end-to-end anastomosis was made by means of a Murphy's button and the operation completed. The patient was extremely ill for more than a week, and during this time his life was despaired of. About eight or nine days after the operation we succeeded in getting his bowels to move freely, and from this day on the patient continued to improve. Previous to this there had been stercoraceous vomiting and great nausea and depression. The Murphy's button was passed on the seventeenth day following the operation. There was some infection of the wound, which healed gradually by granulation, and the result in effecting a permanent cure has been perfect. This same patient returned to the sanatorium about a week ago, and we made a Bassini's radical operation on the left side for a reducible inguinal hernia. This case is interesting from the fact that more than eighteen inches of the gut was resected and the strangulation had existed four days previous to the operation. I do not believe that I ever saw a patient's condition so extreme and get well. We had present with this patient stercoraceous vomiting, black vomit and a septic condition, from which it seemed impossible to survive. The patient was an alcoholic drinker, which added also to the severity of the case.

I have merely reported these two cases to impress upon the members of this Association that often in extremeold age and with conditions that seem beyond help, we may be able to get good results.

In conclusion, I wish to state that I believe the day is at hand when we should advise all our patients that are suffering from hernia to submit to an operation. The statistics collected by Bull and Coley, who have probably done more work in this line than any other surgeons in this country, show the very low mortality rate of not more

than one and one-fourth to one and one-half per cent. The cases that I have reported above show in nonstrangulated operations no mortality, and about six per cent. of recurrences. Taking these facts into consideration, it seems to me that every case of hernia should be operated

on.

DISCUSSION ON DR. ELKIN'S PAPER.

Dr. J. B. Morgan: I have listened with a great deal of interest to the able paper by Dr. Elkin, and I heartily agree with him as to the general conclusions. I think that by all means the Bassini operation for the radical cure of hernia is the best. I do not agree with him that the kangaroo tendon is suitable material to apply. What I have gotten hold of has not been uniform in size, and it will break.

I do not think the mattress suture should be used to bring together the edges with Poupart's ligament. For this I should use No. 2 round chromacized catgut. I do not use the suture to go around and through, as it will constringe the tissues and cuts off the blood, and causes local necrosis. The interrupted suture of good quality, No. 4 chromacized catgut, is best. A suture should always be applied above the internal ring. I have seen two occurrences of failure as a result of not applying the suture above the internal ring.

Another thing, there is tension on the skin after the radical operation for inguinal hernia. The tissues have been stretched and they rapidly regain their elasticity and pull on the sutures.

To relieve the tension, I place pieces of plaster parallel to the wound and plaster them down good and firm, and then I lay a piece of gauze over the wound, and take a needle and thread and stitch across from one plaster to the other, and this relieves the tension on the wound. If you do not do this the tension is liable to result in slight infection.

RECURRENT PARALYSIS OF OCULAR MUS

CLES ASSOCIATED WITH PAIN.

BY ALEX. W. STIRLING, M.D., ATLANTA.

This paper was written in October, 1903, but never published, as I wished to watch the case longer.

The following is a good example of a case, of which only some forty have up till now been reported.

When I first saw the patient in February, 1902, he was twenty-eight years old. He then told me that ten years previously he had had a slight attack, lasting for only a few days, but it was not till seven years later that he experienced the full force of his trouble, which has consisted in recurrences of excruciating pain in the left eye and temple, followed by paralysis of the third nerve. I shall first describe his condition as I found it at his first visit. He had been partaking freely of acetanelid, codein and morphine for the relief of his pain, and in consequence was pale and slightly cyanosed, with a very weak pulse. The attack had begun the night before with pain, which had come to a height in an hour or two. The diameter of his right pupil was now 2 mm. That of his left, 6-5 mm. Vision of both right and left eyes was full 6-5, without hm. Left accommodation was paralyzed, and he required a plus 3-D lens to read at twelve inches. The movements of the globe were still normal, and there was no ptosis. Left T was normal, and the interior of the eye was healthy. I prescribed croton chloral hydrate and gelsemium, to be begun when the effects of the other

drugs had diminished, and two leeches. I saw him again on the third day and found that the prescription had been of no benefit, and that soon after being here the external muscles had begun to be affected. He had now absolute ptosis, and, though the eye did not then diverge, he could turn it outward, but in no other direction beyond the middle line. No movement of the sup. oblique was observed. The pupil was fully dilated. The pain had somewhat lessened. I advised arsenic, quinine and strychnine. When I next saw the patient, six months later, the left pupil was still too large, but acted fairly well to light and to convergence. There was no ptosis and the ocular movements were normal. He had occasional pain, and he now tells me that on waking his vision was poor for near objects, and that then he used, and still uses, eserine, each application enabling him to read for two or three hours, and making the pupil as small as the other, or smaller. Without eserine he had required a plus 3-D lens. There was a slight, but apparent, exophthalmos. I saw him a month afterwards, in September, when an acute attack of pain was just beginning, and prescribed dionin with, as I expected, no benefit. Between then and now he has had attacks of pain every two to four weeks, with slight paresis once, in December, 1902. Looking back over the history of the affection, as it has been in his. case, we find in many points a close similarity to the majority of the others, which have been published. On neither the father's nor the mother's side was there any nervous affection, and among seven brothers and four sisters only one, the sister just older than himself, whohas migraine every fortnight. It is not usual to find the family history so free from nervous cases. His own general health seemed to be good; no malaria, no rheumatism, no specific history nor symptoms, no albuminuria, no dia