Case IV. H. S., aged fifty-two, married; was admitted to the Eastern Michigan Asylum in 1899, suffering from chronic melancholia of two years' duration. In the spring of 1897 she thought herself pregnant, although her last child had been born twenty-seven years before and there was nothing on which to base her belief. The idea, however, persisted for a year or more, until long after the time when she should have been confined. Since then she has thought her abdomen full of live animals which are devouring her. She refused food because unwilling to feed these animals, and became greatly emaciated. The pulsation of the aorta which she felt conveyed the idea of the movement of the animals. On one occasion she mentioned to the attending physician an undue familiarity with the family cat and complained of kittens in the right hepatic region.

Operation.-Abdomen unusually rounded and prominent for a woman of her years; walls thin and devoid of fat. On entering the peritoneal cavity it was at once noted that the omentum was absent. Careful search located the missing apron rolled up and adherent under the right lobe of the liver. When released and spread out the omentum was thin and atrophied, and contained but little fat. An excellent recovery from operation was made, but, although the patient was less emotional and less inclined to groan, there was no change in her mental state up to the time of her death, which occurred some eight months later as the result of an acute intestinal disorder. In this case the visceral delusions were undoubtedly occasioned by the adherent omentum together with the inflammatory conditions (perihepatitis) which resulted in the adhesion of that viscus to the under surface of the liver. The condition had existed for a considerable period of time and the delusions had become fixed as the result of the constant irritation produced in the parts involved. It is not unreasonable to assume that had the operation been undertaken earlier and the source of irritation removed, the delusion, at least, might have been cured.

SIMULATED INTESTINAL OBSTRUCTION.

Case V. S. M., aged fifty-nine, married, the mother of six children, an inmate of the Eastern Michigan Asylum for nearly twenty years, and suffering from monomania; complained August 26, 1899, of pain in the abdomen, Examination revealed

some distention and marked tenderness present. The following day the distention became extreme, the abdomen tense, and the temperature rose to 99 2-5°. Attacks of vomiting occurred but were not stercoraceous in character. The bowels moved on the first day of the disorder, but not afterwards.

Operation was undertaken for the relief of the probable intestinal obstruction on August 28th. At this time the abdomen projected particularly in the lower portion, and resembled in appearance the contour produced by a large fibroid growth of the uterus (Fig. 3). The abdomen was tympanitic over the entire surface. On opening the peritoneum the greatly inflated intestines presented thinned, pale in color, with injected vessels, and the coats of the intestinum angustum contained many ecchymosed spots. There was no collapsed portion of the bowel, and careful inspection failed to reveal either constricting band or intussusception. The colon was punctured in two places to permit the escape of gas, and the openings afterwards closed with eye silk. Slight adhesions were found at the hepatic flexure of the colon and deep in the right iliac region.

The patient recovered well from the immediate effects of the cœliotomy, but on the following morning developed right hemiplegia which, however, did not involve the face. She was aphasic, but sensation was not impaired. During the following day she became more feeble, and, on account of the difficulty in deglutition, was unable to take nourishment. She died on the third day, coma having gradually developed. Trophic sores formed over the spots of pressure on the paralyzed side, and shortly before death the temperature rose to 103°.

A fine

Sectio cadaveris. Operation wound firmly healed and dry. Intestines, omentum and mesentery congested. Large intestine distended to sigmoid flexure. Small hemorrhages into mesentery. The right kidney weighed 3 ounces, the left kidney 31 ounces, the liver 374 ounces, and the brain 371⁄2 ounces. antemortem clot was found in the right internal carotid artery. Atheroma of all basilar, ganglionic and cortical vessels, especially post-cerebral. Small hemorrhage near left caudate nucleus with an area of softening around it. The whole brain and meninges congested, and there was a small hemorrhage into the primer. This case is particularly interesting from the fact that it shows the effect of cerebral disease in producing distant

physical conditions resembling in their symtoms morbid states usually of local origin.

APPENDICITIS AND GALL STONES.

The frequent finding of gall-stones at autopsies on the insane renders it a matter for speculation why, when so common, biliary calculi are so rarely productive of symptoms leading to their detection during life. Appendicitis appears, in my experience, to be an uncommon disorder among the mentally deranged, as I have met with only two or three mild cases during the past twelve years. The association of appendicitis and gall-stones has been often noted in the sane, but the following case is the only one of which I have knowledge occurring in the mentally alienated:

Case VI. R., aged thirty-four, the mother of three children; was admitted to the Eastern Michigan Asylum, December 5, 1898, suffering from mental deterioration with delusions and hallucinatory manifestations. On May 3, 1899, she was seized with abdominal pains and the temperature rose to 102 3-5°, with pulse 120 and respiration 30. The bowels failed to respond to either cathartics or enemata. On the following day there was nausea and vomiting, with an evening rise of temperature. On palpation an indurated mass was found in the right iliac region extending upward toward the liver. On May 5, the bowels moved freely with some pain, and the conditious continued with variations until the twenty-first, when operation was undertaken.

On entering the abdominal cavity the omentum, caput coli, and lower portion of the ascending colon were found involved in a mass of adhesions. The appendix could not at first be found, but after careful search was finally located, greatly attenuated, elongated and extending upward to a linguiform process of the right lobe of the liver, to the apex of which it was adherent. The adhesions were separated and the offending tube removed. Convalescence was rapid and uneventful until June 7th, seventeen days following the appendectomy, when shortly after an evacuation of the bowels the patient again complained of severe pain in the abdomen. This was followed by two attacks of vomiting, and the abdomen became considerably distended. On the following day there was less pain but