It has been suggested to me that an abnormal shape of the uterus would account for some of the signs presented.

B

A

4. Left Fallopian Tube beyond the Sac; B. Dilated Portion of Tube where Fœtus was situated; C. Opening of Tube into Cavity of Uterus.

On February 8, 1878, I made an examination of the patient whose history I have given. It was perfectly easy, by bi-manual examination, to decide as to the shape of the uterus. Its entire contour could be felt, and I satisfied myself that there was not the slightest abnormality in the shape of this organ. The uterus seemed to be still very slightly displaced to the right of the median line, but I could feel nothing to the left of the median line of an abnormal character. The examination which I made was repeated by Drs. Thomas and Emmet.

II.-A Case of Femoral Aneurism successfully treated by Intermittent Pressure. By THEODORE R. VARICK, M. D., Surgeon to St. Francis's and Jersey City Charity Hospitals, Jersey City, N. J.

MRS. D., widow, aged forty-nine, native of Ireland, first observed a pulsating tumor in the right groin about two and a half years ago. For a period of two years it remained nearly stationary, giving no serious inconvenience, and, except for its pulsation, she would not have noticed any deviation from health. About six months since, while walking in the street,

she was conscious of a feeling of numbness extending down the limb, and observed an increase in the size of the tumor.

From this time it continued to enlarge until October 19, 1877, when she called at my office. On inspection, I discovered an aneurism of the common femoral artery, commencing immediately below and impinging upon Poupart's ligament, and extending three inches down the limb, including a portion of the superficial femoral, with a strong expansive pulsation and well-marked aneurismal bruit; the pulsation in the sac ceasing on compression above. The collapse of the sac, which occurred at this time, indicated a fluid condition of the blood, and an absence of all effort on the part of Nature to effect a cure by the deposition of laminated fibrin.

Having determined to resort to the treatment by pressure, I accordingly, on the 25th, applied a conical-shaped canvas bag, containing 14 pounds of shot, to the femoral as it passes over the ramus of the pubis, which had the effect to completely control the current of blood and allow the sac to collapse. The shot-bag was suspended from the ceiling by a cord, into which was inserted a piece of elastic, the better to admit of its accommodating itself to the motion of the body. Owing to the pain produced by the pressure, and the extreme irritability of the patient, it was necessary to have an assistant constantly with her in order to keep the weight in situ. Notwithstanding the utmost care, owing to the impossibility of keeping the patient quiet, the pressure would at times become entirely displaced, allowing a return of the current through the sac. The object of the pressure was simply to diminish, and not absolutely to cut off the flow, thereby favoring the processes of Nature in effecting a cure by the deposits of laminated fibrin, and although, for the reasons above stated, it was impossible to carry out this plan strictly in detail, yet a similar result was arrived at by the intermittent character of the compression. Occasionally the full force of the circulation coursing through the sac, now partially or completely arrested, allowed the fibrin to collect in the concavity of the sac, and at the same time to attach itself to any asperities that might exist, thereby forming nuclei for subsequent deposition. The time occupied by, and the manner of applica

tion of, compression, will be seen by reference to the subjoined

The sac at this time becoming manifestly more solid, and losing its expansive pulsation, the point of pressure having become excoriated, and the sac hot and tender, all pressure was removed, and ice-bags applied until November 3d, when Ricord's bubo compressor was substituted for the shot-bag, and answered an excellent purpose, maintaining its position and controlling the circulation at will.

At this time pulsation in the femoral below the sac ceased, not gradually, but abruptly, and the artery could be felt below the point of egress from the sac, pulseless and cord-like. The egress of blood being prevented in the main channel, and ultimate success being assured, all pressure was removed. The pulsation in the sac gradually diminished until the 14th, when it ceased entirely.

In addition to the details just cited, the patient was confined to an absolutely animal diet with a minimum allowance of liquids, perfect rest in bed, and bromide of potassium in sufficient doses at night to produce repose, morphine having been previously tried, but abandoned, as it occasioned nausea.

The patient, being a spare woman, with relaxed integument and feeble muscular development, was a particularly favorable subject for observing the course of the disease and the progress of cure. The aneurism, from its location, unless there existed an abnormal anatomical arterial distribution, must have given rise to five efferent branches, viz.: super

ficial epigastric, superficial circumflex ilii, two external pudic (superior and inferior), and the profunda femoris, which, taken in connection with the point of ingress, and point of egress of the main trunk, made in all seven openings into the sac-a condition exceedingly unfavorable to successful treatment. Owing to the general physical condition of the patient alluded to, the tumor could be grasped nearly to its entire posterior aspect, and the branches arising therefrom distinctly felt, violently vibrating. The femoral below the sac having become embolized, as must have been the case, as indicated by the abrupt subsidence of pulsation, the sac below the origin of the profunda (for a distance of about one inch and half) became reduced to the condition of a diverticulum, especially favorable for the deposition of laminated fibrin. From this time solidification progressed with increasing rapidity, as one by one from below upward the efferent branches became obliterated and the cure completed. Another point to be observed is, that the shot-bag pressure was applied to the artery within one-quarter of an inch of the upper portion of the sac, while that by Ricord's bubo compressor, on account of the size of the pad, was, in addition, exerted upon the upper portion of the sac itself.

January 8, 1878.-I visited the patient to-day, and found the tumor reduced to the size of a hickory-nut, perfectly solid, and free from pulsation; the patient suffering no inconvenience except from a somewhat diminished temperature of the part, with occasional cramps of the muscles of the limb.

Notes of Hospital Practice.

CHARITY HOSPITAL.

SERVICE OF DR. JOSEPH W. HOWE.

Exsection of the Head of the Femur in a case of Ununited Intracapsular Fracture.-An interesting case of excision of the hip-joint was recently performed on a patient suffering from old ununited intracapsular fracture of the head of the femur.

The patient, a woman fifty-eight years of age, had received the fracture eighteen months previously. She was treated by extension for fifteen months, but, as no signs of ligamentous or bony union were found at the end of that time, the limb was put up in plaster-of-Paris dressing. The plaster was renewed several times during a period of three months, but at the end of that time there was as much pain as at the time of injury. During the whole period of eighteen months the patient was unable to leave her bed. It was decided to perform exsection of the head of the femur.

A curved incision, three inches long, was made behind the trochanter, and the joint opened. It was then found that the only attempt at union was a ligamentous band an inch and a half long by an eighth of an inch thick, extending from the remains of the head to a spicula of bone running out from the base of the trochanter. The remainder of the neck had disappeared. In the cavity of the joint half a drachm of thick pus surrounded the remains of the head of the femur.

The ligamentous band was seemingly the remains of the capsule. The pain which the patient complained of was caused, in all probability, by the spicula of bone pressing upon the surrounding tissues.

The patient made a good recovery, and eight weeks after the operation she was able to sit up and move the limb without experiencing any pain. She seems to have every prospect of a useful leg.

The operation was believed to be indicated from the fact that the patient had been confined to her bed for eighteen months, and at the end of that time her condition was nearly as bad as at the time of injury.

Removal of Skin over a large Inguinal Hernia; Obliteration of the Sac.-A man aged thirty-five years had a large reducible hernia, which on one occasion became strangulated. He was operated on at Bellevue Hospital, and recovered. As a result of the operation, the opening in the abdominal wall became increased in size, and allowed of an increased protrusion of omentum and intestine into the scrotum. When the patient was standing, the hernia extended down for a distance of eight inches. The lower portion was ulcerated, and looked as if