Apart from perforation, peritonitis is not very common, so that the following case is extremely interesting on account of its close simulation of perforation, though peritonitis without perforation was found when the abdomen was opened :

CASE XII.-W. W., æt. 33 years, was admitted to hospital on 24th December, 1901, having been ill for eleven days. Temperature on admission, 103.6° F.; pulse, 120; respirations, 24 per minute. The patient was extremely ill, and catarrhal râles were heard all over his chest. On the third day after admission a few subcutaneous hæmorrhages appeared, while on the sixth day (31st) patient complained of sudden acute pain in the abdomen, was sick, and vomited. Five minutes after he took a severe rigor, which lasted twenty minutes. His temperature rose from 103° to 105.8° F., and his pulse from 120 to 128. Examination of the abdomen revealed exquisite tenderness on palpation, with general rigidity, and the presence of fluid in the peritoneal cavity. Tympanites was a marked symptom throughout. Laparotomy was decided upon and the abdomen was opened within two hours after the first complaint of pain. A quantity of serous fluid escaped through the incision. The bowel was found to be deeply congested, wellmarked peritonitis being present, and much recent lymph covering the lower part of the ileum. No perforation was found, although the whole gut was examined. Two ulcers about a foot above the ileo-cæcal valve which had almost perforated were safeguarded with stitches, and the abdominal cavity flushed out. Patient did not rally well after the operation; he was sick and vomited frequently, while hiccough troubled him until death supervened. The autopsy showed extensive and deep ulceration in the last three inches of the ileum, and a few small ulcers higher up, but no perforation whatever. The gall bladder, mesenteric glands, and spleen were all carefully examined as probable causes of the peritonitis, but none of them showed any pathological indications in this direction. The probability is that in this case peritonitis was due to infection through the damaged but unperforated intestinal wall.

CASE XIII. The last case of the series is that of C. L., æt. 16 years, who had been ill for eleven days previous to admission on 24th August, 1902. She had been very ill from the onset, complaining of headache, general pains, and abdominal pain. On admission, her temperature was 104-6° F.; pulse, 128; and respirations, 36 per minute. Her

general condition was grave. There was muttering delirium, deafness, a dry tongue, a quick intermittent pulse of low tension, "taches bleuâtres," and an enlarged spleen. No abdominal distension was present, and tenderness on palpation was not evinced. Examination of the chest revealed a few cooing râles in front with some moist catarrhal râles at the bases of the lungs behind. Day by day patient gradually became weaker, and the catarrh in the lungs increased. The temperature remained high, ranging between 102.6° and 105 4° F., whilst the pulse varied between 120 and 140 per minute. She had a slight rigor on 31st August, but did not complain of pain, and there was but little disturbance of temperature or pulse. During the next three days she complained at intervals of attacks of abdominal pain, which, however, subsided in a short time after the application of warm fomentations. Physical examination of the abdomen. during these attacks gave no indication of perforation having occurred, nor were the pulse and temperature altered. 14th September, however, at 10 A.M., a marked change was noted in patient's condition; she became cold, livid, and very restless, whilst her face betrayed much anxiety. complaint of pain was made at this time. Her pulse was rapid and feeble, its rate 150 per minute. Temperature was unaltered. Examination of the abdomen revealed marked distension, the liver dulness being completely obscured. Her breathing was mainly thoracic. In the right flank there was some impairment of the percussion note, but otherwise the abdomen was quite tympanitic. There was distinct rigidity of the whole abdominal wall, but this was more marked in the right iliac fossa.

No

The surgeon was immediately summoned, but collapse occurred so quickly that operation was deemed inadvisable. The pulse gradually rose; the temperature fell during the first two hours, then rapidly rose until death supervened at 1.45 P.M. Two leucocyte counts made at 10:30 A.M. and 12 noon gave 4,000 and 3,000 per c.mm., respectively.

On post-mortem examination the abdomen was found to be filled with feculent fluid, whilst a large perforation was present in the ileum, about a foot above the ileo-cæcal valve. The gut around the perforation was covered with lymph. The interesting points in this case are the premonitory attacks of pain, the fact that no pain was complained of at the time of perforation, the abdominal rigidity and distension, and the sudden collapse. The unusual size of the perforation also calls for remark, a pencil easily passing through it.

Another case of perforation which has just occurred is peculiarly interesting, and worth recording along with the others :

CASE XIV.-G. A., æt. 7, was admitted to hospital on 29th January, 1903. He had been ill for fourteen days, and on admission presented the appearance of a typical case of enteric fever, with facial pallor, clear bright eyes, dilated pupils, and dry brownish tongue. The abdomen was distended, but there were no rose spots, and little enlargement of the spleen. There was nothing abnormal in the heart or lungs.

On the third day after admission to hospital the temperature became normal, and it remained so until 14th February, when a slight rise occurred, this being the beginning of a relapse. During the period of apyrexia, from 1st February to 14th February, the abdominal distension had persisted, but in all other respects the boy was perfectly well. The temperature during the relapse was never very high, fluctuating between 99 and 102° F. On 21st February the pulse, which before this had been running between 90 and 110 per minute, rose to 128, for no evident reason, and from this point onwards remained steadily between 120 and 130. There was no complaint of pain and no rigidity, but the distension became perhaps a little more marked about this date, and the boy was in consequence put upon 5 grs. of salol thrice daily; this had little effect, and about ten days later turpentine enemata and turpentine by the mouth were tried, but gave only temporary relief.

On the morning of 10th March, about 5:30, patient complained of sudden acute abdominal pain, and on examination the abdomen was found to be quite rigid, with exquisite pain on palpation in the suprapubic area. There was no alteration in the temperature or pulse-rate, but the patient's facies was very suggestive of perforation. A leucocyte count gave 8,000 per c.mm.

Laparotomy was performed at 8:30 A.M., and on opening the abdomen much gas and about half a pint of purulent fluid, which had a fæcal odour, escaped through the incision. A cavity was found, cut off from the general peritoneal sac by adhesions, and into this cavity the contents of the bowel were discharging through its perforated wall.

A fæcal fistula was therefore the cause of the distension, perforation having in all probability occurred on 21st Feb., when the distension became a little more marked, and the pulse-rate rose to 128 per minute.

The immediate cause of the sudden acute pain at 5:30 A.M. on 10th March is difficult to determine.

The cavity was washed out and a drainage-tube inserted. For some time after the operation the boy became thinner, but he is now beginning to pick up, and is likely to make a perfect recovery.

This case is quite unlike any of the others, inasmuch as symptoms of perforation were quite absent until some time after it must have occurred, and little disturbance was caused by the actual perforation, which presumably took place about 21st February, when the pulse-rate rose from 100 to 128 per minute. The perforation must have occurred gradually, so that sufficient time was allowed for the formation of adhesions, and a general peritonitis was thereby avoided.

To Dr. J. Brownlee, Physician-Superintendent of Belvidere Fever Hospital, and to Dr. F. Macrae the writer is indebted for personal explanations of various points in connection with many of the cases.

GLASGOW NORTHERN MEDICAL SOCIETY.-The first annual excursion of the Society took place on Tuesday, 2nd June, to Ardlui. The company started from the city at 11:30 A.M. by train, after which they sailed to the head of Loch Lomond. Dinner and tea were provided in Ardlui Hotel. The weather was fine throughout. A unique feature of the trip, and one which added much to the pleasure of the day, was that ladies. were present.

Speeches were made at dinner by the President, Dr. J. W. Allan, and others. The President spoke of the work done by the office-bearers of the Society during its first session, and also thanked the committee who had arranged the trip. He regretted that more ladies had not availed themselves of the day's outing. In answer to the speech by Dr. Allan, he said that Dr. Allan should have been made the first President, as he was the founder of the Society.

The return journey was by train via the West Highland Railway, arriving in Glasgow about 8 P.M.