the dressing was found saturated with fecal matter, a fistula evidently having formed into the colon, but it healed in a couple of weeks.

On August 25th the patient was sitting up; the large cavity had contracted so that only a small granulating fistula was left. His weight had increased to 105 pounds; he felt perfectly well and was discharged to his home September 22d. Weight, 137 pounds, a gain of 36 pounds. Patient a picture of perfect robust health; urine normal; fistula closed.

October 1st, weight, 140 pounds. October 12th, weight, 147 pounds. The patient has gone to work in a machine shop.

The interest in this case is the ease with which the diagnosis was made by the aid of the electrical cystoscope, and particularly the demonstration that the right kidney was healthy and, therefore, an operation advisable. Only by operative means in two other ways -an explorative laparatomy or an explorative suprapubic cystotomy with catheterizing of ureters-could the diagnosis be cleared up, and there is no comparison between these methods and the simple cystoscopic examination, done without any danger to the exhausted patient. Cystoscopy necessitated, of course, that the bladder shall be able to contain five ounces of clear fluid, and that the cystoscope shall be able to enter the bladder. Luckily both indications were fulfilled in this case.

A second point of interest was the impossibility of feeling and palpating the enormous kidney before operation. I can only explain this by the strong adhesions of the lower segment of the kidney to the colon and surrounding tissue, by which the kidney was forced to enlarge upward and forward below the diaphragm. A third point of interest was the long time-seventeen years-in which the patient had suffered from nephrolithiasis without a distinct diagnosis having been made, and the rapid and perfect recovery that followed the removal of the diseased organ, the patient in seven weeks gaining forty-five pounds in weight. I have during the last three years performed nephrectomy four times. Two operations were done on account of tuberculous kidneys. One of these died on the fourth day of suppression of urine, and the post-mortem examination showed the remaining kidney to be tuberculous. A cystoscopic examination would in this case probably have shown that the operation was contra-indicated. The second case recovered, but died half a year later of general tuberculosis of the urinary organs. The third operation was per

formed in October, 1892, on account of a large sarcoma of the left kidney in a lady fifty years of age. The patient recovered, and so far, two years after the operation, no relapse has occurred and the patient is in perfect health.

REPORT OF A RECENT CASE OF ABDOMINAL PREGNANCY, COMPLICATED WITH PYO-SALPINX

LAPARATOMY, RECOVERY.

BY H. T. WILLIAMS, M. D., of Rochester, N. Y.

THE patient was referred to me by Dr. J. H. Finnessy, of Rochester, N. Y., in whose practice it occurred, and was admitted to St. Mary's hospital September 10, 1894, with the following history:

Mrs. Geo. L., born in Canada, 29 years of age; married nine years; one child, now 8 years of age.

Menses irregular ever since birth of child. Menses ceased last December; some morning sickness followed; she increased in flesh. This increase was more noticeable after the sixth month. The abdomen increased in size until fore part of last April, when she had a sudden flow of water from her vagina which continued all of one day. Since that time her abdomen has gradually diminished in size; but ever since the flow of water from the vagina, she had had occasional sharp, shooting pains through the abdomen. Last July, noticed that her breasts were very large and contained considerable milk for two weeks, when it gradually disappeared and breasts grew smaller until at the time of her admission to hospital they had reduced to their normal size.

In August last, for two days, had severe pains in abdomen, which resembled labor pains; since then she has been comparatively comfortable, with the exception of occasional slight pains. In the early part of August, a few days after the attacks of severe pain, she menstruated normally, the flow lasting four or five days; she menstruated again September 1st, one week before operation.

Vaginal examination reveals a tumor somewhat irregular in shape, lying above and to both sides of the uterus, but by far the greater part of it to the right of the womb.

She was operated upon September 10, 1894, about an hour and a half after her admission into the hospital. An incision three and one-half inches in length was made in the median line of the abdomen between the umbilicus and symphysis pubis. The fetus (a male) was found still covered with the amniotic sac (which was empty and firmly adherent to fetus) lying in the abdominal cavity

1 Read before the Central New York Medical Association, Buffalo, N. Y., October 16,

on top of the fundus of uterus, and in many places firmly adherent to intestines, which, however, were stripped off without much difficulty and the fetus easily removed. It was about the size of one of five months, but had evidently been dead for some time, and was considerably shrunken and macerated. One hand is adherent to top of cranium. The head is somewhat irregular in shape, rather triangular, and apparently there are no eyes, ears or nose, although this is undoubtedly due to the fact that the amniotic membrane is now so firmly adherent to the head and so much thickened as to obliterate them.

The placenta, which is of good size, was found in the expanded Fallopian tube, to the right of upper part of fundus of uterus. The umbilical cord passed through an opening in the tube to the umbilicus of the child. A part of the tube near the placental attachment was sacculated and contained several ounces of pus, which burst during removal, and some of the pus escaped into the abdominal cavity; the ovary on that side (the right) was healthy, but had to be removed with the tube. There were not many troublesome adhesions, and the tube with the placenta and ovary was ligated with silk ligature three-fourths of an inch from uterine attachment and removed, and the stump cauterized with paquelin cautery. Very little bleeding occurred during any part of the operation. The left ovary and tube were healthy and were not removed; the abdominal cavity was flushed with two or three quarts of warm sterilized water. The incision in peritoneum was closed with fine running catgut suture. The aponeuroses and small amount of muscular fibers closed with five silkworm gut sutures, which were tied with two knots, then cut short and allowed to remain; then a few intermediate medium-sized catgut sutures through anterior aponeurosis of muscles to perfectly approximate the two surfaces. Several large-sized catgut sutures were then passed through the skin and down to aponeurosis of muscle and the skin then closed over the silkworm-gut sutures, in this way completely burying them; a few intermediate fine catgut sutures through skin entirely closed incision, approximating the surfaces nicely. This method of closing the incision in laparatomies is one I have used in a number of cases recently, and have been greatly pleased with the results. In all but two cases union has taken place by first intention, and in these two cases (of which the above case is one) only the skin separated for a short distance, but no separation of the muscles took place; the silkworm gut remains strong

and unirritating, and it is almost impossible for a hernia to

occur.

The after-dressing consists in dusting the wound with a little powdered iodoform; then covered with iodoform and bi-chloride gauze held in place by two strips of adhesive plaster extending across abdomen, then a layer of absorbent cotton and a wide flannel bandage completes the dressing.

The patient made a rapid and uneventful recovery, with very little constitutional disturbance of any kind. The highest temperature, 100 4-5°, occurred on the fourth day after the operation, and dropped to 99° after a free movement of the bowels had taken place.

The incision healed by first intention with the exception of about an inch of the upper part, which separated through skin and fat only, and soon entirely closed again. She was allowed to get out of bed on the twelfth day, and at the end of the third week was able to walk about as she pleased, and was discharged from the hospital cured.

19 CLINTON PLACE.

TWO PECULIAR CASES OF HERNIA.'

BY CLAYTON M. DANIELS, M. D., Buffalo, N. Y.

IN THIS brief paper it is not my intention to go into a dissertation upon hernia, interesting as the subject is in all its bearings, but to put upon record two cases which are novel if not unique.

CASE I. On May 23, 1893, C. Munjella, 42 years old, married, an Italian laborer, while holding a " scraper drawn by horses in the erection of a railway earthwork, was forcibly struck in the left groin by one of the handles. The blow caused great pain at the time, and a prominent swelling at once appeared. He continued work for two or three hours until suffering forced him to go home, where he remained for three days without attention, except the application of some household remedies. At the end of the third day he came to my office, walking with difficulty and well bowed over at every step.

Upon examination I immediately noted the absence of testicles in the scrotum, and the patient stated that he "never had any," so far as he knew, although he was a married man and sexually strong, but without children.

1. Read before the Medical Society of the County of Erie, January 8, 1895.