more or less complete obstruction. Enemata given through a long rectal tube produced no effect, so the patient was removed without delay to a surgical home. The operation was carried out in the evening. The abdomen was opened in the middle line below the umbilicus. Enormous distension of the small intestines and cecum was met with, and as the transverse and descending colon appeared less distended and the indication to drain the bowel with as little delay as possible was urgent, the wound was closed and another small incision was made over the cecum, which was drawn out, opened, and a Paul's tube tied in. Following the operation there was a little vomiting of a stercoraceous character, but the cecal opening gave great relief and the acute symptoms subsided. At the end of a fortnight the patient was able to be removed home. Enemata were subsequently given from time to time and occasionally brought away small scybalous masses.

On the afternoon of June 11th the patient was suddenly taken ill with intense pain in the left inguinal region, and when I saw her was extremely collapsed, with drawn features, cold extremities and thready pulse. Subcutaneous injections of strychnine, with a little morphine, were given, and she gradually rallied, symptoms of an acute localized peritonitis quickly manifesting themselves. A. diagnosis of intestinal perforation was made, and on the 15th an incision similar to that for inguinal colotomy was made over the area of pain and resistance. On opening the abdomen some very foul-smelling pus welled up, and the abscess cavity having been thoroughly swabbed out, the sigmoid flexure was seen plastered over with thick lymph and with a perforation on its anterior surface of the size of a shilling. The coats of the bowel were softened, black, and gangrenous, and in bringing it forward it tore almost across. The wound was therefore enlarged in an upward direction and the bowel was slit up with scissors till its walls appeared: unaffected by the changes below and would allow of its being stitched to the skin, which was then done. The whole condition. seemed to be an acutely inflammatory one. The abscess cavity: was again swabbed out and then packed with iodoform gauze, an indiarubber tube of large calibre being passed into the colon.

The patient stood the operation well. The discharge was most offensive for some days, but the cavity contracted quickly and at the end of a month the opening differed but little from an ordinary colotomy opening, and it acted well. As the cecal opening became an annoyance to the patient when she began to get about again, owing to the liquidity of the discharge, on August 11th, under ether, the mucous membrane was separated from the skin and the opening closed. At the time of writing (March, 1905) the patient finds no difficulty in controlling the artificial anus, and she is able to get about out of doors and to resume her ordinary domestic duties at home.

A Case of Chorea, Fatal, Apparently, from Excessive Muscular Action. J. P. CROZER GRIFFITH, M.D., of Philadelphia, in American Medicine.

Although chorea is of such common occurrence, instances of death directly dependent upon the disease or its complications, though not actually rare, are still far from frequent. The Collective Investigation Committee of the British Medical Association found nine deaths in 439 cases of chorea, i.e., 2 per cent. Sinkler found but sixty-four cases of death from chorea reported in Philadelphia during seventy-four years, and textbooks in general refer to the disease as having a most favorable prognosis, so far as recovery from the actual attack is concerned. We cannot know how many of the recorded deaths depended upon some complication, such as a rapidly fatal endocarditis. Undoubtedly the majority are due to such causes, and it is extremely likely that Baginsky is entirely correct in saying that death as a result of the fearful muscular action which continues night and day is seen but seldom.

In view of these facts the report of the following case is not without interest :

R. B., male, aged eleven years, was admitted to the Children's Hospital of Philadelphia, under my care, January 3rd, 1905. The family history was entirely negative as far as could be ascertained. The patient had had good health except for the occurrence of measles when five years old, and for an attack of what was called "nervousness" at the age of nine years, which lasted seven or eight weeks, and was said to be similar in nature to, although less severe than, the present one. He was treated in a hospital and recovered completely. Since that time he had been well until a month before admission, when the parents noticed that he was becoming restless, could not sit long in a chair, and twisted his hands and fingers about. At night-time he was quiet. Soon grimaces and rolling of the eyes developed, and later general choreic movements of the arms, legs and body. In the last week these movements had become excessive, the slightest excitement causing general and very violent tossing about of the extremities and of the trunk.

On admission the child appeared pale and ill. Nothing abnormal was found in the throat or the lungs, but a systolic murmur was audible over the heart in the mitral region. The abdomen was retracted, and some of the inguinal glands were enlarged. There appeared to be no control over the tongue, but the mouth could be opened fairly well. Speech was so much affected that it was almost incomprehensible. The child appeared, however, to understand, although he could not well do what he was told, nor did he seem able to make his desires known satisfactorily. There

was frequent loud crying and moaning. The choreic movements were widespread, constant and very violent. Respiration was jerky and irregular, the diaphragm acting irregularly and sometimes one side of this or of the thorax appearing to move while the other side did not. Rigidity of the arms alternated with violent tossing of them about from the shoulder-joint. The grip in both hands was weak. The movements of the right leg were somewhat greater than those of the left, and the patient was able to flex the left leg only after great exertion and excitement. The patellar reflexes were slightly increased. There was no ankleclonus. The movements were so constant and severe that the skin showed widespread excoriations and bruises.

The child was given a purgative, and administration of Fowler's solution was started, while for immediate relief he received chloral hydrate and potassium bromid in full doses. Later a hypodermic injection of morphin was given, but as this had little effect it was repeated twice during the night. In spite of this treatment he slept very little-not more than half an hour on the night of January 3rd. On the night of January 4th, he slept about three hours, but on the morning of January 5th he became extremely restless again and was now violently delirious and threw himself about to such an extent that he broke the straight-jacket by which he was restrained. His mental state was clearly distinctly worse and it is questionable whether he would have been able to understand and answer questions, even had the muscular inability not prevented it. The administration of chloral and of potassium bromid was continued, but with little effect. Morphin, too, having proved of no avail, a hypodermic injection of .1 mg. ( gr.) of hyoscin hydrobromate was administered in the afternoon and again during the night, and broken sleep amounting to eight hours in all was secured. January 6th found him quieter, but very stupid. When disturbed he showed at once the extreme choreic movements, attended by violent delirium. On this date the chloral and bromid were stopped, and the boy was kept quiet by hyoscin.

Examination on January 6th showed the child had emaciated very decidedly. The color was pale with some degree of cyanosis. The cardiac dulness extended upward to the third rib and reached the right border of the sternum, but did not seem to be specially increased. The apex beat was in the nipple line in the fifth interspace and was of fair strength, but rather diffuse. The mitral systolic murmur could be heard all over the precordium, was transmitted well to the axilla and to the angle of the capula behind, and was certainly louder than when the child was admitted to the hospital. Control over the bladder and rectum had been lost on the preceding day and there was now some difficulty in swallowing; solid food not being taken at all, and liquid only very slowly.

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A blood count made on this date showed red blood cells 5,730,000, leukocytes 22,400, hemoglobin 85 per cent. The urine had shown neither albumin, sugar nor casts on examination, although some acetone was present.

The patient was quieter during the greater part of January 8th, this being partly the result of hyoscin and partly apparently due to failing strength and increasing mental torpor. He was fed at times with a nasal tube and occasionally was able to swallow well. He apparently tried to talk, but was unable to do so. In the afternoon of January 9th his color became very bad, his pulse almost imperceptible, coma deepened, weakness increased, and he died shortly after 8 p.m.

The temperature was slightly over 101° on admission and had ranged from 101° to 103 until the afternoon of death, when it reached 104.8°. A blood culture was taken by C. Y. White on the morning of the day of death, but no conclusions could be drawn, as the result showed there had been decided contamination.

An autopsy was performed by Dr. Wadsworth, the coroner's physician, on January 10th, but circumstances prevented this from being entirely satisfactory, no microscopic study of the brain or spinal cord being possible, and the cultures which were attempted from different parts of the body being necessarily made under such circumstances that contamination was unavoidable. The report given me by H. C. Carpenter is as follows:

MICROSCOPIC APPEARANCES.

Skin is a purplish yellow, as in septic conditions. Bronzing over body, especially over abdomen and hips. Abrasions over all the bony prominences. Finger-nails blue, and sordes on lips and nose. Black mark over right eye. The pericardium is slightly thickened. Heart muscle is pale, and the mitral valve has a fringe of granular vegetations from I mm. to 2 mm. in diameter, all along the edge. Small spots of yellow atheroma are seen running transversely across the beginning of the aorta. Over left lung, posteriorly, are seen the remains of an old pleurisy. The lungs show some hypostatic congestion and edema posteriorly. Liver: Section slightly yellowish. Spleen somewhat softer than normal, slight increase of fibrous tissue of capsule. Kidney: Lobulated, capsule slightly adherent; stellate congestion of cortex, parenchyma swollen. Adrenals are very large; right, 12 cm., 2.5 cm., 1.5 cm. Left, 10 cm., 3 cm., 1.5 cm., otherwise normal. Stomach is very large and distended. Intestines are markedly congested in places. Pancreas is slightly congested, and very firm. Lymphglands of mesentery and retroperitoneum are enlarged, but not congested or caseous. Brains Increase of fibrous tissue about vessels of arachnoid, cerebrum congested, cortex normal, no flattening of convolutions.

HISTOLOGIC EXAMINATION.

Heart Muscle.-The connective tissue is increased, and there is considerable round-cell infiltration around the vessels, and, in isolated areas, round-cell infiltration between the muscle bundles. In places heaps of cells. Muscle fibers in close proximity to vessels show interfibrillary infiltrations. Some few muscle fibers hypertrophied. Section from mitral valve shows cellular infiltration with moderate amount of congestion.

Lungs.-Moderate congestion. Alveoli filled with fluid. Slight anthracosis. Some parts of the lung show round-cell infiltration into the alveoli.

Lymphatic Glands.-Moderately congested.

Diaphragm.-Muscle bundles in good condition with the exception of a few individual muscle fibers, which stain paler than normal. Some increase of connective tissue between the muscle bundles.

Liver-Slight fatty infiltration. Slight amount of congestion throughout.

Kidney. Moderate amount of congestion. The cells of the tubules normal, except, in a few isolated tubules, where there is cloudy swelling.

Pancreas.- Normal.

Suprarenal Gland.--Peripheral zone congested slightly, otherwise the gland is entirely normal.

Intestines.- Moderate congestion. Slight increase of intertubular tissue.

Appendix.-Same condition as bowel.

Spleen.-Congestion, vessels thickened. Malpighian bodies few and small.

BACTERICLOGIC EXAMINATION OF TISSUES.

Heart muscle contains a small coccus. In the cellular infiltration there is a mixed infection, bacilli, cocci, diplococci, and streptococci.

Lymphatic glands contain a small coccus in groups, and also a diplococcus.

Only one who has seen a case of the kind 'described can conceive of its terrible nature. I may, in passing, mention that I have never before witnessed any one at all parallel to it, and hope never to do so again. While it is impossible to state absolutely in this instance that the death did not depend upon the complicating endocarditis or the general toxic state of the system the result of the infection, yet the fatal issue had all the appearance of being the direct result of the movement. Certainly a long continuance of life was incompatible with the excessive muscular action.