I have had occasion to observe a number of cases that suffered more from pain after the operation than before and where some of the symptoms were increased. It was not because of the operation, but because they had not taken into consideration certain factors and certain technique. I refer to including in the stitches branches of the ilio-inguinal and ilio-hypergastric nerves. I like the muscle-splitting operation here, as I think there is very little necessity for cutting any important structures. I read a paper in Louisville in which I described an operation for this. It was a modification of the operation suggested by Mayo-Robson. I use the capsule for holding the kidney in position, suturing the nephrocolic ligament and then apply sutures through the posterior flap. The essentials are sufficient exposure and delivery of the kidney and then avoidance of the ilio-inguinal and ilio-hypergastric nerves in the incision.

I do not think that there is any question but that this trouble is often associated with chronic appendicitis. As to dealing with the appendix and the gall-bladder through a lumbar incision, I devised this operation but did only two operations, as I did not consider it a good procedure. It is much better surgery to make two incisions. I do not know of any surgeons now who advocate this operation.

Dr. G. R. White, Savannah: I met with a little accident a few days ago in doing an operation something similar to that described by Dr. Kime, and I want to mention it as a warning to others in a like condition.

This patient had floating kidneys with Dietl's crisis. The kidney would swell up during those attacks, then subside. I operated during the interval and found the kidney divided into globules. In attempting to decapsulate I opened into the dilated pelvis of the kidney, which

extended up one of the sulci to within an inch of the median line.

Dr. Kime (in closing): I am glad that Dr. McRae brought out the point of the incision and the inclusion. of the nerve in the suturing. I usually make the incision below and parallel to the twelfth rib and cut as few structures as possible. If you do not watch this point you will have the neuralgic symptoms.

In regard to the trouble with the appendix, this is not uncommonly associated with this condition. This is due to a dropping down of the kidney prolapse of ascending colon and flexure, thus producing pressure on the cecum, causing a damming back of the feces into the appendix and the chronic trouble results. We should therefore always watch out for all these complications, if we want to be successful with all our cases.

A CASE OF SUPERFICIAL INGUINAL HERNIA.

BY EDWARD G. JONES, M.D., SAVANNAH.

Mr., age twenty, unmarried, presented himself to me on account of a swelling in his left groin. He stated before examination that his testicles were not in the proper position. Upon examination quite a considerable enlargement was found on his left side, entirely above Poupart's ligament and reaching outward as far as the anterior superior spinous process. It evidently contained fluid as well as intestine. When he was made to assume the recumbent posture, the fluid gradually disappeared and the gut was reduced without difficulty. It was then easily apparent that his testicle was situated superficially, having passed through the inguinal canal and external ring, then upward and outward in front of the external oblique aponeurosis. The hernia had never been incarcerated or strangulated. It had given him little discomfort, but the swelling had lately begun to increase perceptibly in size.

On the right side the testicle occupied a similar position, but there was no enlargement other than that caused by the testicle itself.

Upon operating on the left side, a serous sac was discovered, communicating with the general peritoneal cavity and extending from the internal ring, through the inguinal canal, through the external ring and thence upward and outward as far as the anterior superior spinous process. Its vertical diameter in its superficial position was some four or five inches. It contained at the time of operatin peritoneal fluid, intestine and the testicle. This sac was

detached from its superficial position and split longitudinally as high as the internal ring in order to allow the exit of the cord. The remaining portion was tied off as in ordinary hernia operations. The testicle was about one-third the normal size. With the finger, an opening was made between the parietal peritoneum and the left rectum, just above the symphysis, and the testicle placed in the cavity so made. The wound was repaired as in a hernia operation, except that no account had to be taken of the spermatic cord.

On the right side, a similar serous sac was discovered in a corresponding superficial position. Though somewhat smaller than the sac on the left side, its cavity was still considerably larger than the cavity of the ordinary tunica vaginalis. It contained the testicle, likewise illdeveloped. This sac had been obliterated above and consequently, in it there was neither a hydrocele nor a hernia. It was dissected away up to the point at which its walls had previously fused, and the testicle was placed in a position similar to the one on the other side.

The wound was repaired as on the left. The patient recovered without complications of any kind.

It appears, therefore, that the defect in this case was not what it usually is in cases of undescended testicle. It was not too short a cord or a closed external ring. The cord was amply long and the testicle had descended in actual distance as far from its original position near the kidney as is usual in normal cases. It had also brought down the customary peritoneal fold in a perfectly normal way to act as a tunica vaginalis. Preparatory to the descent of the testis there is a pouch-like bulging of the lower abdominal wall in either inguinal region. A shallow groove is thus formed which gradually becomes deeper and finally the two join in the mid-line to form the scrotum. Each of these pouches is normally.

lined on the inner side of a sac prolonged from the transversalis fascia-the infundibuliform process. These pouches are empty and ready to receive the testicles. Evidently in this instance no such sac had been formed, or else its walls had become fused before the gland presented itself for entrance. I am unable to find out whether it was late in passing the external ring. The patient thinks it has been superficial ever since he can remember.

Neither before nor since the operation has this patient been in any way neurasthenic. He feels sexually competent, but has led a virtuous life. He has an occasional emission at night, but it is hardly probable that true semen is ejaculated. He knows no difference between himself and other men except the mere position of his testicles. His mind does not dwell on his condition morbidly. He is physically well developed in every other way. His mental endowments are in no respect below

par.

Though his testicles had been located superficially for a long time, they have never been injured accidentally or otherwise. They were fixed extra-peritoneally at the time of operation on account of the reputed tendency of such ill-developed organs to undergo sarcomatous or other degeneration subsequently. It was thought best not to make an attempt to bring them into the scrotum, because there was so very little scrotum present and because, since the man was twenty years old, there was little likelihood of their physiologic development, my idea being that neurasthenic symptoms would be more likely to supervene if the undersized organs were placed in the scrotum, than if a comparison with the testicles of other men were made impossible.

This case seems of interest for the following reasons: 1. The hernia on the left side had passed out of the