respirations, 20 per minute. Physical examination of the lungs revealed the presence of some friction sounds in the left lower lateral region. The heart was normal.

On 6th November the bowels moved five times about 6 A.M., but not till 10:30 A.M. was special attention directed to the patient, when the anxious expression of his face and some sweating on the forehead denoted something wrong. His pulse was found to have suddenly risen from 96 to 120 per minute, while his temperature had fallen from 101° to 99°. He made no complaint of pain, however. Examination of the abdomen revealed slight but distinct rigidity in the suprapubic region, mainly confined to the right side. Gentle palpation elicited a complaint of pain. A leucocyte count at 12:45 P.M. gave 21,000 per c.mm.

Perforation having been diagnosed, laparotomy was performed, and a small pinhead perforation found. The bowel was much injected, and there was a small amount of feculent fluid in the peritoneal cavity.

Patient recovered well from the anaesthetic, but the pulsecontinued to rise steadily, whilst the temperature ran about 103 F. There was a slight bloody discharge from the drainage tubes, fæcal in odour.

Gradually the patient sank; the pulse became so rapid that it could not be counted, and he died at midnight. Temperature before death was 104-4° F.; pulse, about 180; and respirations 32 per minute.

In this case the probable connection between the movement of the bowels at 6 A.M. and the perforation is to be noted, while the absence of any spontaneous complaint of pain is distinctly unusual, and of necessity rendered the diagnosis of perforation somewhat difficult.

The main points deserving attention in this case are the absence of sudden acute pain, the presence of unequivocal though only local rigidity of the abdominal wall, and pain on gentle pressure, along with the sudden rise in the pulserate and fall in the temperature. There was little or noincrease in the abdominal distension.

CASE II. The second case was that of G. A., æt. 16 years, who was admitted to hospital on 18th December, 1900, that being his twenty-second day of illness. On admission his. temperature was 101.8° F.; pulse, 100; respirations, 24 per minute. His facies was typically that of enteric fever. His tongue was moist, and thickly coated with whitish fur. No. rose spots were seen, and the abdomen was quite flaccid, and

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no tenderness was complained of on palpation, Examination of heart and lungs revealed nothing abnormal. Until 20th December nothing noteworthy occurred, the fever running its usual course; but on this date patient seemed rather uneasy and complained of slight abdominal pain. The temperature and pulse remained steady, however, and there was really nothing to indicate serious mischief. At 6 P.M. the patient complained of severe abdominal pain, and his face wore an anxious expression. His pulse was found to have risen a few beats per minute, while his temperature had fallen, between 6 and 7 P.M., from 102.6° to 1018 F. On examination of the abdomen some rigidity was detected, especially in the right iliac region, while in the flanks there was some dulness, and a distinct fluid wave was obtained from before backwards in the right flank.

In

By 8 P.M. the rigidity had increased, was well marked, and patient had a considerable amount of pain. At 9-20 P.M. laparotomy was performed and the perforation closed. the abdominal cavity a fair quantity of fluid (turbid) was found, whilst in the pelvis the coils of gut were matted together with flakes of lymph. The abdominal cavity was washed out, and two drainage tubes inserted. Patient did not stand the operation well, but, contrary to expectation, rallied during the night, and continued to do well, the temperature running between 99° and 100° F., and the pulse between 100 and 120 per minute, His bowels moved after enemata, and there were about 3 oz. of blood in the motion. The discharge continued purulent till, on the 11th January, a fæcal fistula became established, which was apparently high up in the gut, inasmuch as charcoal administered by the mouth passed through the wound three hours later. For a few days it looked as if patient might die from inability to absorb sufficient nutriment, but with the help of rectal feeding he was enabled to hold his own till the gradual closure of the fistula permitted the establishment of normal digestion. Convalescence after this was good, and the patient was dismissed well, and advised to wear an abdominal belt.

In this case the symptoms were fairly typical, and there was little difficulty in the diagnosis of perforation. As in the previous case, there was a fall in the temperature with a rise in the pulse-rate, while the rigidity of the abdominal wall was quite marked, and along with these signs was the sudden attack of abdominal pain. Unfortunately, no leucocyte counts were made. Recovery, though slow, was perfect, and this is hardly to be wondered at, considering that here all the factors

tended in that direction-a young stout lad of 16, only three weeks ill, and operation performed about three and a half hours after perforation had occurred. In all probability the early diagnosis, and consequent early operation, saved the

situation.

CASE III.-The next case of the series was that of a nurse who was engaged in an enteric ward at the time she became ill. She had been feeling ill and out of sorts for some time, but only became acutely ill on 26th December, 1900, when she was sick and vomited, and had severe headache. Her temperature at this time was normal, and no suspicion was entertained of her having contracted enteric fever. Four days later (29th December), she was warded. On admission her temperature was 1044 F.; pulse, 100; and respirations, 24 per minute. She presented the appearance of a severe case of enteric fever; with a pale and somewhat dusky face, sunken eyes, and hollow cheeks, but the spleen was not enlarged to percussion. The course of the disease after admission was fairly normal until the 2nd January, though the temperature was running high. On this date she complained of severe abdominal pain, and there was some slight rigidity of the lower part of the abdominal wall. The pulse remained strong and good, its rate 100 per minute. There was no sign in patient's face or general condition to indicate that a perforation had occurred, and the date of illness (eighth day) made this the more unlikely. A blood count gave 5,000 leucocytes. Until 9th January patient ran a normal course of enteric fever, with increasing weakness. There had been no return of the abdominal pain experienced on 2nd January. On 7th and 8th January a few small clots of blood appeared in the motions. At 4 A.M. on the morning of 9th January the patient complained of severe abdominal pain. Examination revealed some tenderness in the right iliac region. At this time the pulse was unchanged, and the temperature had neither risen nor fallen. A leucocyte count gave 7,500 per c.mm. At 10 A.M. more severe pain was complained of, and a blood count now gave 9,000 per c.mm. A rapid change for the worse took place about 11:30, and the symptoms increased markedly. Laparotomy was performed at 2 P.M., or ten hours after the first onset of symptoms, and the perforation (which was small) closed. The gut adjacent to the perforation was slightly coated with lymph, apparently of recent origin. Patient rallied well after the operation, and seemed comfortable. The next day she had

a good pulse and better colour than she had had since the onset of illness. The discharge from the wound was only slightly purulent. In the afternoon, however, she became worse, and again complained of abdominal pain, while at the same time she vomited two or three times. A marked change rapidly occurred in the pulse, which rose from 114 at mid-day to 148 at 6 P.M., the temperature falling meanwhile from 102-2° to 97-4° F. On the dressing the discharge from the wound was markedly feculent, and a second perforation was diagnosed. The condition of the patient, however, did not warrant a second operation, and from this point onwards she gradually sank, and died on 11th January at 9-20 A.M.

It is specially to be noted in this case that there was some hæmorrhage on the two days previous to perforation, that the leucocytes, which in an earlier count numbered 5,000, had risen to 7,500 and later to 9,000, and that the condition after operation was so favourable that in all probability she would have recovered but for the occurrence of a second perforation two days after the first. In connection with the second perforation, it is to be remarked that severe abdominal pain was complained of, that the temperature fell from 102.2° to 97.4° F., and that the pulse rose from 114 to 148 per minute, thus showing an almost perfect accordance with the two former cases.

CASE IV. The fourth case was that of A. C., æt. 19 years, who had been ill for fourteen days previous to admission, and confined to bed for ten days. On admission (2nd January, 1901) he presented the usual appearance of a moderately severe case of enteric fever. Physical examination of the chest revealed nothing abnormal. The abdomen was somewhat distended and there was some muscular rigidity, which, however, could be overcome without causing any pain. There was no special tenderness in the right iliac fossa. The spleen was enlarged, and numerous rose spots were present. Temperature was 102.6° F.; pulse, 90; respirations, 20 per minute. Diarrhoea was a troublesome feature in this case from the time of admission, and ten days after (12th) some blood clots were found in his motions. Again, on the 19th, blood-clots were found in one of his motions, and the following day patient passed about 40 oz. of blood in two motions. During all this time the temperature had been ranging between 101° and 103° F., and the pulse between 90 and 104 per minute. The boy, however, all along looked markedly poisoned. Perforation occurred with typical signs about 5:45 P.M. on 20th

January. Patient complained of severe abdominal pain, and on examination of the abdomen it was found to be tympanitic all over. No liver dulness could be detected. There was some dulness in both flanks, and marked rigidity of the abdominal wall. A few minutes later there was a second complaint of severe pain, but the symptoms otherwise remained unaltered. Laparotomy was performed three hours later. On opening the abdomen, much gas escaped, and afterwards feculent fluid. Two large perforations were found and closed. The abdominal cavity was washed out with saline fluid, and posterior drainage established. Patient did not

stand the operation well, and did not rally after it, but gradually sank, and died at 8:30 next morning (21st), the pulse before death being very rapid and almost imperceptible.

Here, again, hæmorrhage (serious in this instance) occurred a few days before perforation. There was nothing noteworthy about the temperature. The large amount of hæmorrhage, the marked poisoning, and the fact that the patient was in his fifth week of illness, greatly lessened his chance of recovery from so serious an operation.

CASE V. The next case, R. E., aged 17 years, who was admitted to hospital on 4th January, 1901, forms the fifth of those operated on, and is somewhat unusual on account of the peritonitis being due, not to perforation, but to rupture of a softened mesenteric gland. This patient recovered. When admitted, all the signs of enteric fever were present, with the exception of rose spots, none of which were seen. Physical examination of the chest revealed nothing more than the presence of a few moist râles at the bases of both lungs. behind. On the seventh day after admission (10th January) the temperature had reached normal, and continued so until 19th January, at 10 o'clock, when it suddenly shot up to 104° F. Patient at this time complained of having had slight abdominal pain since 8 A.M. His pulse had risen from 70 to 120 per minute. Examination of the abdomen disclosed some rigidity in the right iliac region, with tenderness there and in the suprapubic area. Two hours later the rigidity and tenderness were more marked and had extended across the middle line, there was some distension of the abdomen, and fluctuation was obtained in the flanks.

Three leucocyte counts were made, as follows:-At 12 noon, 11,000 per c.mm.; at 2 P.M., 7,600 per c.mm.; at 4 P.M., 12,400 per c.mm.

Laparotomy was performed at 5:45 P.M., about ten hours.