wound and by following this down I found a band of adhesion that was easily cut through with a pair of scissors. Salines were given under each breast as well as a rectal saline. The pulse could now be scarcely felt. The operation consumed about fifteen minutes in all. There was evidence of general peritonitis.

Patient died six hours after.

The case

CASE 9.-Boy at Victoria Industrial School, under care of Dr. Godfrey. Was taken ill with griping pains, chiefly in the left inguinal region. He vomited twice. No rigidity was to be made out at that time. There was obstinate constipation.. Then symptoms of intestinal obstruction, vomiting, tympanites, together with tenesmus that was very marked, came on. There was no tenderness on pressure, no great elevation of temperature, but the pulse was gradually going up. No blood in the stools. Forty hours after the onset of the illness I saw him, and then found the abdomen distended and hard. looked very much like one of peritonitis following perforation of the appendix, but the absence of fever and the presence of tenesmus rather pointed against against this diagnosis. The case was obscure, but urgently demanded surgical interference. At about one o'clock in the morning, without any assistant, I opened the abdomen in the median line, Dr. Godfrey administering the anesthetic. The median line was chosen owing to the doubt that existed as to the nature of the disease. The appendix was looked for, but could not be found. The cecum could not be found at first. There was no cecum to be found in the right iliac pouch. Intestines being considerably distended the manipulation of the parts was rendered more difficult. Nothing could be found in the pelvis nor in the left iliac pouch. Patient's pulse was now very rapid, and I was afraid he would succumb before a diagnosis could be made, when suddenly a coil of dark colored intestine was encountered above the umbilicus. On careful examination it proved to be a loop of intestine about eighteen inches long that had slipped through under a band. The band was formed by the vermiform appendix, the tip of which had become adherent to a spot on the mesentery of the small intestine. The appendix and cecum had been drawn up out of the iliac fossa. In other words, it was a case of internal strangulation produced by an adhesion of the tip of the appendix. The appendix was removed, the bowel freed, the abdomen closed. The bowels did not move after operation until the fourteenth day. The patient vomited for about nine days, and the pulse at times reached 170 per minute. A small abscess formed in front of and another behind one ear. The patient made a good recovery. CASE 10.-Mr. S. On December 16th while on a Pullman car he was taken with an awful pain in the abdomen. The pain was

so severe that his face was blanched, according to his friends' ac

count of the condition. When the train reached Buffalo he was taken to the Emergency Hospital, and remained there for three days; was then brought home to Toronto when his physician, Dr. Harrington, saw him. His pulse and temperature were about normal, but he complained that he bloated up very suddenly with gas. There was some sickness at the stomach present at the time, but this passed off. Christmas and New Year's were uneventful, but about the 11th of January he was taken with severe pain in the abdomen and vomiting. This occurred at night. The vomiting continued so that nothing would remain on the stomach. I saw him in consultation with Dr. Harrington three days later, and the stethoscope revealed distinct borborygmy with increased peristaltic action of the intestines. The gurgling was very marked. We concluded that there was partial obstruction of the intestine, very probably due to adhesions. Operation was advised, and on the 15th of January, 1903, at the Toronto General Hospital, I opened the abdomen in the median line. The small intestine was reddened and dilated. It was followed down and found to be obstructed at one place. After the obstruction had been removed by breaking through a band, perforation of the intestine through the part compressed by the band that was now gangrenous, showed itself. Fecal matter escaped freely, but was caught on sponges. The hole was temporarily closed, while further investigation was carried out. It was very difficult to make out what the exact condition was. The intestine was found to be matted in the pelvis, two or three coils being bound down at one point. After a great deal of difficulty it was thoroughly loosened and all the affected portion of intestine, about five feet, drawn out on to the abdomen. Sponges were now carefully packed in to protect the remaining coils inside the abdominal cavity. intestine brought outside was kept bathed with a running stream of normal saline and hot towels. Several perforations were found. These were rapidly closed in the usual way. One portion of intestine was so damaged from pressure that it was found necessary to resect it. About twelve inches of intestine were removed. The Murphy button was used. The patient was very much shocked. Pulse reached 132. The abdomen was rapidly closed. While this was being done a subcutaneous saline was given under each breast. The patient made a slow but satisfactory recovery.

The

In reviewing these cases I find there were ten in number with three deaths and seven recoveries. Two of the cases followed operation for salpingitis; two followed operation for ectopic gestation; two for appendicitis; one for the removal of a dermoid tumor; while, in three cases, there had been no previous operation. Of these three one was produced by adhesion of the vermiform appendix, one by inflammation following tubercular disease, and

in one case the cause of the adhesion could not be definitely ascertained.

The lesson to be learned from the fatal cases is this: That operation must not be delayed. I am satisfied that these patients lost their lives owing to delay. In each case the delay was due to the obstinacy of the sufferer.

In conclusion, I would like to draw the attention of this society to one important point in connection with the diagnosis of partial or complete intestinal obstruction, namely, the presence of gurgling, especially when accompanied by intermittent peristalsis that is increased in its intensity far beyond the normal. stethoscope in this way becomes a valuable aid.

The

The downward

and then the reverse wave of muscular contraction of the bowel wall can be readily made out and the gurgling comes, as a rule, with the reverse peristalsis.

ERYTHEMA CIRCINATUM-ACNE VARIOLIFORMIS.

BY ALEXANDER MCPHEDRAN, M.B.,
Professor of Medicine, etc., University of Toronto.

I. ERYTHEMA CIRCINATUM.

THE following case is a rare variety of erythema, and presents characteristics of marked interest:

ill.

W. N., aged 19, an upholsterer. He was not robust, but never In April, 1900, a rash appeared on the backs of the hands. It began as small reddish-pink papules, that enlarged rapidly, and a vesicle formed in the centre deeply in the skin, closely resembling the vesicles of pompholyx. The vesicles did not rupture unless injured. The contents were clear and non-albuminous, and soon became absorbed, leaving a depressed violaceous centre

in the small circular eruption. In later eruptions no vesicles were formed, but the centre of each spot became somewhat depressed, similar to those in which the vesicles formed, and many of them were of a violet color. (Fig. 1.) The eruption was extremely itchy, and somewhat burning. There were over one hundred spots on the hands and forearms, a few on the neck, and two on the mucous surface of the lips.

The eruption lasted about two weeks, and then gradually faded. A fresh crop broke out about every four weeks, so that he was quite free of them for only five or six days between successive

crops. There was no desquamation, but the scratching sometimes led to the formation of pustules. The spots varied in size from a pin-head to a circinate spot half an inch in diameter, the majority being about one-eighth of an inch. The margin was well defined and slightly elevated. Many of the spots in the less severe eruptions were simple, slightly irregular macules.

The eruptions recurred at intervals until the late autumn. During the winter he was quite free of it, but in the following June it broke out again, being preceded by a burning sensation, and many vesicles were again formed. It was less abundant and recurred at longer intervals during this second summer. The general health had materially improved. He has not been seen since then.

He derived some benefit from strontium salicylate with alkalies internally, and the local application of 5 per cent. ichthyol in Pick's gelatine preparation. In this case there was an unusual degree of irritation for erythema. It had a strong resemblance to urticaria, which is, however, much more evanescent. It is also to be noted that this rash occurred chiefly on the exposed parts, while that of urticaria is usually upon the covered parts, and, while general, is more irregular in distribution.

II. ACNE VARIOLIFORMIS.

The following case of this rare affection came under observation recently:

Miss A., aged 35, had never been strong. She had marked splanchnoptosis with poor digestion and assimilation, and a marked degree of constipation.

The attack of acne varioliformis began as an eruption of small red papules on the forehead and temples. There were no papules on the scalp or cheeks. In a week many of the papules became capped with vesicles containing opalescent serum or thin pus. In the centre of the vesicle a small grayish scab formed, which increased in size as the pus dried up, and its centre showed decided umbilication. It required about three weeks for the scabbing to become complete. As the scab separated, a pit about one-eighth inch in diameter was left, resembling very closely the pitting from true smallpox. The eruption was scattered irregularly over the forehead and temples. A number of small comedones were also to be seen on these parts, and there were a few acne papules on the nose and cheeks.

Many of the papules were small; on these a small scab formed without any pus formation, and the pitting that resulted was slight. In the six months that have elapsed since the eruption. there has been no recurrence. The local treatment consisted in the application of a lotion composed of fifteen grains of resorcin in an ounce of saturated boric acid solution.