She had been in bed two weeks. Her previous history was that of a well-balanced, active woman, fond of outdoor recreations of all kinds and passionately devoted to music. Her weight previous to her illness was 135 pounds. Like most neurasthenics, she had an obsession; hers was that food is injurious. From the relatives the following facts were elicited: She had gradually abandoned all her pursuits, complained of tiring easily, and had lost flesh gradually, until at my visit she weighed but 85 pounds. There were no indications of an acquired neurasthenia through the usual exciting causes, neither was there any family history that pointed to an inherited neuropathic tendency. Examination of pelvic and other organs was negative.

Treatment. No medical treatment was instituted, but, after gaining her complete confidence through various suggestions, she again took up her former pursuits, and within three weeks developed a voracious appetite, accumulating fat at such a rate that in March, 1904 (a period of nine months), she weighed 240 pounds, an increase of 155 pounds, accompanied by an amount of physical energy that was startling. Any attempt to restrain either. her appetite or her movements was met with violent opposition.

Subsequent History.-So she remained till June, 1904, when, just as unaccountably, she stopped eating and the adipose tissue visibly melted away, so that in October, four months later, she dropped from 240 to 135 pounds. Her pulse became feeble and rapid, at times almost imperceptible, requiring considerable stimulation. There was likewise an edema of the feet and legs. Examination of urine was negative. She would take to bed for weeks at a time. In January, 1905, her long-lost appetite reappeared and with an increased voraciousness, mostly confined to cereals and milk. The quantities consumed were simply enormous. I have watched her eat for two hours at a stretch, actually shovelling in the food. To-day she again weighs 245 pounds, an increase of 110 pounds in six months, with every prospect of a still further increase in weight, I trust not in appetite. I am daily looking for a "tack" in the opposite direction. Her mind remains clear.

A Large Hydrocele of the Tunica Vaginalis. C. LLOYD WORRall, L.R.C.P. London, L.S.A., District Surgeon, Barberton, Transvaal, in The Lancet.

On May 30th I was called to see a native (at the office of the Commissioner of Native Affairs) who was reported to be "suffering from an extraordinary enlargement of the testicles." Visions of elephantiasis of the scrotum flashed across my mind, but these

were soon dispelled on examining the case. The history briefly was that the tumor had been gradually developing for four years and that it had never given much pain except that on walking there was a general ache. The patient had no recollection of any injury whatsoever to the parts.

I found on examination an enormous scrotal tumor of fairly regular outline, the left side being considerably the larger-it was quite dull all over on percussion and had that elastic feel which strongly suggested fluid. An examination for translucency proved quite negative. There was no impulse on coughing and the spermatic cord could easily be traced to the external rings. The penis was merged into the tumor in such a way that the prepuce alone was in evidence. As I was convinced that the tumor could be no other than an enormous hydrocele I decided to tap it and drew off in all slightly over seventy-eight ounces of fluid. This was contained in two sacs. In the larger one the fluid was dark from what appeared to be disintegrated blood, and in the other sac it was the ordinary straw colored hydrocele fluid.

I venture to report this case as it has one or two points of interest-its enormous size and yet causing little pain or discomfort. Again, it was noteworthy that notwithstanding the fact that this hydrocele had been forming for something like four years and reached such a size, the testicles seemed quite normal in size and apparently showed no sign of atrophy. One would have thought that the abnormal pressure of the fluid would have tended to make these organs degenerate and shrink. Another little point worth mentioning is that this native had come in to see the commissioner to report his wife having run away with another native. What a dom stic tragedy could possibly have been avoided had this wretched man thought fit in good time to call in the services of a surgeon.

I regret that I am not in reach of any special work on the diseases of the generative organs and therefore am not able to determine the frequency or otherwise of these enormous hydroceles. I note that Erichsen quotes "that Gibbon, the historian, had an enormous hydrocele, which was tapped by Cline, who drew off six quarts of fluid."

A Freak Case of Appendicitis. Louis L. NICHOLS, M.D., in the Brooklin Medical Journal.

My patient is a newspaper man about thirty years of age. He inherited a nervous temperament, but has been in fair health with the exception of an attack of typhoid fever some six years ago. He recovered from this without complications. There was no history of indigestion or colicky pains preceding his acute attack.

of appendicitis, which came on gradually Sunday morning, October 25th, 1904. I saw him first about 7 o'clock the same evening. He had been vomiting all day and his pain was spasmodic in character and distributed over the whole abdomen. There was no distention and no especial point of tenderness. There had been three or four attempts to go to stool, but with little result. There was no irritation of the bladder. The pulse was 100, and the temperature 99°. With these symptoms I was apprehensive of appendicitis and warned the family as to what to expect. The patient was ordered 1-10 gr. doses of calomel half hourly, to be followed in the morning by magnesia sulphate.

When I saw him on the following morning there was slight local tenderness in the right iliac region, with some distention and rigidity of the right rectus muscle. Vomiting had ceased, but the bowels had not moved. The temperature was 991⁄2° and pulse 106, and of good character. An ice bag was ordered, applied over the tender point, and magnesia sulphate continued till free catharsis was established. My patient had passed a restless night with but little sleep and he had a worried expression. A consultation was advised and held that afternoon with Dr. Walter Wood. During the interval which elapsed between my morning visit and the hour of the consultation the patient's bowels had been freely evacuated and he appeared much better in many ways. The pain had practically subsided; there was very little tenderness or rigidity, the most tender point being well over against the crest of the ilium; there had been no return of the vomiting during the day and the distention was gone; my patient had lost his worried expression, was hungry and wanted to sit up. In fact, the improvement was so marked that I began to doubt the accuracy of my diagnosis. Dr. Wood confirmed the diagnosis, however, but it was believed at this time that we were dealing with one of those catarrhal cases of appendicitis which so often shows improvement after the free use of salines, and that the case would gradually go on to recovery without surgical intervention.

How remote from the actual facts in the case our conclusions were, became evident from subsequent events. To be sure my patient, from this hour, went on to complete recovery, but in a way quite different from what we anticipated. The more severe symptoms gradually abated, the temperature and pulse slowly returned to normal, but in the meantime a mass in the right iliac region became clearly defined. There was slight tenderness to pressure over this mass and indisposition to move about in bed because of the board-like feeling over the region and pain caused by such motion. The patient's tongue did not clear nor the appetite improve as they should do with a case getting well. While I was speculating over the final outcome in a case presenting these unfavorable symptoms, and trying to decide upon the safest course

to pursue, Nature solved the problem for me in a most novel and unexpected manner. One week from the beginning of the attack my patient passed a very restless night, complaining of discomfort and tenesmus in the bowels. In the morning there were several loose stools and in one of them something which attracted the nurse's attention. On examining it I found what appeared to be a very much attenuated appendix about two and a half inches long, with a perfcration at the distal end. I submitted the specimen to Dr. Wood and he was skeptical about its true character. I then sent it to Dr. Archibald Murray for examination, and his report follows.

After his auto-operation my patient's recovery was rapid and without complication. The mass in the right iliac region gradually disappeared, and three weeks from the onset of the attack he was perfectly well, and has remained so to this day. Had not a very watchful nurse rescued this appendix from the bed pan we should still labor under the delusion that my patient's anatomy remains intact as it was originally created and that he simply suffered from an attack of catarrhal appendicitis.

This case was rare, but there have been other similar cases recorded. How many unrecorded cases there may have been where a sloughing and unrecognized appendix has passed from the bowel into the sewer we shall never know.

My object in presenting a freak case of this sort was not because of any particular interest attaching to its novelty, but to draw out discussion on the following points:

1. Should we have operated upon my own case at the time of the consultation or subsequently; and can we formulate any safe rule to guide us in the management of similar cases?

2. Should every case of appendicitis be treated surgically and operated upon as soon as a diagnosis can be made, other conditions being favorable?

3. Or should we adopt the expectant plan and treat each case according to the symptoms as they arise?

By which plan can we effect the greatest number of cures ?

Dr. L. L. Nichols, Brooklyn, N. Y.

BROOKLYN, October 9th, 1904.

My dear Doctor:-I have made sections from the tissue sent me, but it is absolutely necrotic and refuses to stain. Still, outlines of what were probably once glands, lymphoid elements and a muscular and fibrous coat can be made out and I should not hesitate to call the specimen an appendix. I have put it aside for you. Very truly,

386 Stuyvesant Avenue, Brooklyn.

ARCHIBALD MURRAY,

In his recent work on the "Vermiform Appendix" Dr. Howard Kelly has collected the history of four similar cases.

Bronchoscopy for the Removal of a Collar Button from the Lung. E. FLETCHER INGALS, M.D., Chicago, in The J. A. M. A.

Patient.-C. D. H. was sent to me May 23, 1904, by Dr. F. W. Wilcox, of Minonk, Ill. He was a man 22 years of age, who had formerly weighed 142 pounds, but who then weighed 1071⁄2 pounds.

History. He told me that fourteen months previously he had accidentally drawn a collar button, presumably of vegetable ivory, into the air passages. He at once felt the sensations caused by it near the upper part of the sternum on a level with the second rib; subsequently he had some soreness in the same place. He expectorated a little blood a few minutes after the accident, and he said. that there quickly appeared a peculiar squeak in the breath sounds. Pneumonia developed on the left side within twenty-four hours and lasted for one month. He had coughed ever since. He had sometimes felt something moving up and down in the lower portion of the trachea and a valve-like action with choking for a few seconds. His father stated afterward that the patient frequently had these choking attacks, coming on without apparent cause and without cough. The last time this sensation had been noticed was four months before he came to see me. He said he had been coughing continuously ever since, mostly at night. This was probably due to a change in position of the foreign body. During the summer immediately following the accident he had had an aggravation of the symptoms with daily fever in the afternoon, during which time he had been kept in bed for a week or two. His recovery from that attack had been very slow. When I first saw him he complained of occasional pain in the left side, referred to the second interspace about an inch to the left of the sternum and occupying an area about two inches in diameter. He had felt no pain in any other portion of the chest, except low down on the left side, at the time he had the attack of pneumonia. His previous history was negative. The heredity was good, there being no tuberculosis on either side of the family. He was a twin, and reported that his brother was strong and well.

Examination.-He had been much weakened by his prolonged illness, was pale and very anemic; he had dyspnea on any exertion and had some swelling of the feet. The voice was clear. I found the pulse 120, the temperature 99.6. He complained of coughing a good deal, mostly at night, and said that he raised occasionally a thin sputum of a brick-dust color, but there were only from two to four drams daily. There had occasionally been faint traces of blood in the sputum, but no distinct signs since immediately after the accident. His appetite was good, but digestion only fair; bowels loose, urine normal. There were no abnormal signs in