superior iliac spine to the umbilicus. No actual swelling was felt. On examination the vagina was found to admit two fingers, there being a very small crescentic hymen. No discharge was visible. The cervix was nulliparous, the canal being closed. There was considerable tenderness in the right lateral fornix. Bimanual examination was difficult owing to the patient holding herself extremely rigid. The uterus was normal in position and size. In the anterior part of the right poster quadrant was a rounded, indefinite, elastic, tender swelling, which appeared to be about one and a half inches in diameter and was not continuous with the uterus. Per rectum there was tenderness in the region of Douglas's pouch but no actual swelling could be felt. The leucocyte count was 8000 per cubic millimetre and remained constant.

As regards the diagnosis, the patient was thought to be recovering from what was most probably a slight attack of appendicitis. Except for the continuous subnormal temperature the signs and the symptoms would do very well for the acute catarrhal form, occurring in a "south-east" appendix. But bearing in mind the missed period the possibility of an ectopic gestation was discussed, the symptoms fitting in with what would be expected in the case of an unruptured tubal pregnancy into the sac of which a small hemorrhage had occurred. In these circumstances, after a couple of days' obeservation, it was decided to operate at once and not to risk any further delay. The abdomen was opened by an incision rather lower than the usual appendicectomy one, the mucles being divided in the direction of their fibres. The appendix was found lying in the "south-east" position and appeared to be quite normal, except that at its tip it was attached to a swelling in the pelvis by a recent adhesion. In, and projecting from, the upper and back part of the right broad ligament was a globular purplish swelling about two inches in diameter. It was extremely tense and contained fluid. The tumor was identified as an enlarged right ovary over the apex of which ran the right tube with its fimbria ovarica attached to the swelling. A good pedicle was obtained, transfixed, and the tumor was removed; in so doing, however, the ovary ruptured and about one ounce of dark fluid blood escaped. The left ovary feeling normal the abdomen was closed. The patient made a good recovery.

The ruptured specimen on being hardened quickly contracted down to the shape and size of an ordinary ovary. Continuous sections showed the normal ovarian stroma to be infiltrated with blood and at one edge of the hematoma a mass of lutean tissue was seen. No trace of chorionic villi could be discovered.

During the last two years five somewhat similar cases of ovarian hemorrhage coming on at or about the time of a menstrual period have been admitted into this hospital. In two of these cases the

gland was found actually ruptured and there was a mass of blood in Douglas' pouch, giving rise to a localised peritonitis. These cases are of interest as once more illustrating the extreme importance of carefully going into a woman's menstrual history in cases of attacks of acute abdominal pain, even though the pain be not within the limits of the "genital sphere." Occasionally cases are seen closely resembling in many respects an acute abdominal condition, such as a perforated gastric ulcer. But on examination it is found that the patient is menstruating and if she is put to bed and kept at rest the condition, whatever it may be, completely clears up in a week or ten days.

I am indebted to Mr. Waring for his kindness in allowing me to publish this case.

Strangulated Femoral Hernia in a Man of Seventy-fiveResection-Recovery. CHARLES S. WHITE, M.D., House Surgeon Emergency Hospital, Washington, D.C., in the Jour. A.M.A.

The following case presents some unusual features that seem worthy of notice:

Patient.-C. P., aged seventy-five, male, white, farmer, widower, born in Virginia.

Family History.-Parents died, after short illness, of cerebral hemorrhages, but at an advanced age. One brother died of intestinal obstruction, one of sunstroke. Two sisters are dead, but cause of death unknown. Of six brothers, five had acquired hernias. None, except this patient, has been operated on. He has a nephew who is ruptured.

Previous History. The patient has had the usual infectious diseases of childhood. In 1895 he had cellulitis in his arm, following a wound of the hand, and he was disabled for four weeks. In 1898, he had a mild attack of pneumonia. With these exceptions, he has been unusually well, and until the present time he has been doing farm work every day.

Present Illness.-On May 17th, about 8 a.m., while lifting heavy logs, he had a sharp, severe pain in the right groin, but worked an hour longer. The pain increased and became unbearable so that he was obliged to return to his home, a distance of six miles, a half a mile of which he walked. He noticed the swelling over Poupart's ligament, and was seen by two physicians between 4 and 6 p.m., but neither was able to reduce the mass by taxis. He vomited once during the afternoon and spent a sleepless night. May 18th he was no better, and he was brought to this city. His bowels did not move any time after the initial pain until after the operation.

Examination.-When admitted to the hospital he was unable to walk and complained of pain in the groin; his pulse 90, full and strong, and temperature 97° F. He had not vomited during the previous twelve hours and was not nauseated. Near the lower attachment of Poupart's ligament there was a tumor about the size of a walnut, tense, not fluctuating and without impulse on coughing. It could not be reduced. The external inguinal ring could be felt and the swelling was below it. The skin was not inflamed. The abdomen was slightly distended.

Operation. The patient was etherized and an incision about five inches long was made parallel and just below Poupart's ligament. The sac was exposed and was found gangrenous and constricted at Gimbernat's ligament. A knife was introduced on a grooved director and the stricture incised and torn sufficiently to release the hernia. The sac contained about two drams of bloody serum and a knuckle of sphacelated intestine. The abdomen was opened through the right rectus, and one and a half inches of ileum. removed and an anastomosis made by a Murphy button. A wedge-shaped piece of omentum was excised. The sac was next transfixed by sutures, snipped off, and the stump returned to the abdominal cavity through the femoral ring. Then a radical operation for femoral hernia was done after the method of Bassini; kangaroo tendon was used for the buried sutures. The abdominal wound was next closed with catgut and silkworm gut. The operation consumed one hour and fifteen minutes.

Result. The patient made a good recovery, sat up on the twenty-second day and left the hospital one month from the day of admission. The button was passed on the tenth day.

Remarks.-Only a very small percentage of hernias in men are of the femoral variety, and the occurrence of rupture in five of six brothers, while only a coincidence, naturally suggests an inherited weakness. In those cases of strangulated hernia in which the active reflex symptoms, nausea and vomiting, are replaced by a quiet, even painless period, we are sometimes deceived and imagine our patient is better. It is a condition which often precedes a fatal termination, and this can not be emphasized too strongly. The surgeon general's library contains the report of many cases of femoral hernia with complications, but few in which. a resection was done in an older patient than in the case here reported.

Traumatism of the Right Kidney. CHARLES B. DYDE, M.D., Greeley, Colo., in the Jour. A.M.A.

History.-G. C. F. came under my care April 28th, 1905. Ten days previously he had been kicked by a horse, in the right lumbar region, while at work in a livery barn. During these ten

days he had been cared for at Kersey, Colo., where the accident occurred. He was prostrated by the force and shock of the injury and for some days suffered intensely. Six or seven days later, as he was feeling much better, he dressed and walked for a few minutes. This was followed by considerable hemorrhage from the bladder, a slight trace of which was observed the day after the injury. As this complication continued, he was removed to Weld County Hospital, where I first saw him. His previous history presented some interesting and noteworthy points. Three years. earlier, while in the United States Navy at Norfolk, Va., he had been operated on for appendicitis. Peritonitis and a fecal fistula developed and posterior drainage was made. Later empyema appeared, and this was also drained. Before the integrity of the bowel was restored he underwent a series of six operations. In a year's time he was restored to health, receiving as a legacy an extensive system of adhesions on his right side from diaphragm to pelvis.

Examination. He was a young man, aged twenty-three, of good development, well nourished, and when not in pain looked well. His condition at this time was marked by severe pain in the right side of the abdomen and very bloody urine; temperature normal and pulse about 80. The right abdomen was very rigid and slightly swollen. The side on a level with and a little anterior to the quadratus lumborum showed the site of the impact, being still discolored.

Hospital History.-During the ten days succeeding his admittance to the Weld County Hospital he showed some improvement, the urine gradually cleared and the pain diminished. Morphia, of which he had been receiving thus far one to two grains daily, was now gradually omitted. The swelling, external to the adhesions, was slightly increased, and the rigidity remained. At this time of apparent improvement, contrary to instructions, he got out of bed and walked as far as the ward lavatory. This indiscretion was followed by a return of both pain and hemorrhage. The pain was very severe, extending from right kidney to testicle, and intermittent in character. He would lie on his right side, knees doubled up, one hand supporting his scrotum. The urine at this time became so bloody that a catheter was frequently required to relieve the bladder. In consultation with Drs. Church and Hughes it was agreed that the renal colic was due to blood clots passing down the right ureter, and that the tumor was probably a sac of extravasated blood. The advisability of operation was considered at this time, but he was strongly opposed to this, his previous experience giving him a strong distaste for the knife. This condition of pain and hemorrhage continued for several weeks, with occasionally a short amelioration of symptoms. As a rule from one to two grains of morphia were required during the twenty-four

hours to control the pain, the amount being gradually increased. By this time he had become thin and very anemic; his appetite was poor and bowels constipated. The tumor was very marked, and the rigidity was extending. The pain while sometimes that of renal colic, was usually a general pain through the abdomen, burning in character, and extending well over to the left side. The temperature presented an occasional rise of a degree or two; the pulse was the same as before, but somewhat weaker. During the first ten days of June, the hemorrhage continuing, his weakness increased, and his condition was rapidly becoming critical. At this time a consultation was held and we decided that operative measures presented the only sign of hope. This conclusion was communicated to him and his consent was obtained.

Operation. We operated on the morning of June 13, just eight weeks after his injury. Kocher's oblique incision was made, by means of which the kidney may be exposed and, if necessary, removed. After going through the layers of muscle and fascia, instead of perirenal fat or kidney presenting in the wound, we found we had opened a large cavity, which seemed full of blood clots. On removing those most superficial, which were partly organized, we encountered a profuse and active arterial hemorrhage. At this moment the anesthetic, Dr. Weaver, stated that the pulse suddenly increased to 140. Compression controlled the hemorrhage until a number of strips of gauze were tightly packed into the cavity; at the same time strychnine and normal saline solution tided the patient over and prevented death on the table. He lived eighteen hours.

Autopsy. This revealed what we considered an unusual and remarkable condition. The right kidney, entirely free in the cavity, which contained two quarts of blood clots, was broken into. three pieces, retaining not the slightest connection with vein, artery or ureter. We considered that his days had been prolonged by the system of adhesions, which walled off and limited the hemorrhage, and that the gradual stretching and tension of these, as the swelling increased, created a great deal of the abdominal pain.

A Peculiar Case-Perhaps Neurasthenia. WILLIAM HIMMELSBACH, M.D., San Francisco, in the Jour. A. M.A.

History.-Woman, aged thirty-five, single. When I first saw the patient, in June, 1903, her condition was that of a pronounced neurasthenic. There was mental depression, irritability alternating with apathy, pain in neck and along the spine, tremor of the hands, occasional twitching of muscles of the face, and dilated pupils.