546 THE BRITISH JOURNAL O F SURGERY

The old man did not appear to be any the worse for the operation a t the time, but on the following day he gradually passed into a state of unconsciousness and died towards evening.

Case Z.-Mrs. L. P., age 81, was admitted under my care to the Bristol Royal Infirmary on November 13, 1919, with the following history. For many years she liad had an irreducible right fenioral hernia. Two days before I saw her this had become larger and more painful. Abdominal pain and distention had followed, with inability to pass flatus.

Condition on Admission.-The abdomen was greatly distended ; coils of small intestine, arranged in typical ‘beehive’ pattern, were plainly visible through the attenuated abdominal wall. On the right side was a small tender irreducible fenioral hernia. On the left side a small femoral hernia was also found; but this, though irreducible, was quite painless.

Operation.-The right femoral sac was cleared and opened, and was found to contain a purplish object about the size of a cherry. This, when pulled upon, proved to be the end of the appendix. It was not tightly gripped, and t h e strangulation was evidently not caused by the neck of the sac, but by some intra- abdominal condition.

The extremity, being bulbous, was quite irreducible. I next opened tlic abdomen by a vertical incision passing through the lower part of the right rectus, and found the following state o f affairs : The appendix was bluish-black

No post-mortem examination was permitted.

Aperients and enemsta had been given without avail.

from base to tip, but its peritoneal coat was still shiny. Its tip was firmly fixed in the femoral sac. In this way it formed a band, and beneath it had passed a loop consisting of the terminal eight or ten inches of the ileum. This intestine was engorged and distended, and, by its pres-

sure upon the vessel? of the meto-appendix, had evidently cut off the blood-supply to the appendix.

I amputated the appendix, and withdrew it from the femoral sac, thus releasing the- strangulated ileum. The femoral sac was next inverted, and, after ligation of the neck. was removed via the abdominal incision. Both wounds were then closed.

The patient made an uneventful recovery, in spite of her advanced age, and left the Infirmary in good health.

AN UNCOMMON lNJURY OF THE CARPUS. BY C. P. G. WAKELEY, LONDON.

DISLOCATION of the carpal semilunar bone is very rare, and I think a short account o f such a case may be of interest.

W. A. H., a man, age 29, while driving a motor-bicycle and side-car near Birehing- ton, Kent, on Sept. 29, 1919, was run into by a heavy motor lorry and thrown from