years later, in the middle of the night, had a similar attack which was again relieved by massage. Nearly a year after had another attack which was not as long, and it passed away on his keeping quiet in a reclining position. Last Summer had an attack which was relieved by Jamaica ginger and massage, but lasted about onehalf hour. When these attacks have occurred they have been sudden in their onset, and immediately before and after them, he has been apparently in perfect health.

On September 10th, he played a hard game of golf in Norwich and then drove twelve miles to his home; retired that night feeling perfectely well, arose the next morning and prepared to go hunting. In a little while was taken with an exceedingly severe pain which centered in the umbilical region; took some brandy, returned to bed, massaged his abdomen thoroughly and in a short time was entirely free from pain and slept about one hour. On arising his pain commenced again, even more severe than before; massage was of no avail; had a large movement but pain was not diminished.

Dr. E. F. Ashley, of Colchester, was called at 9 A.M., and administered one-quarter grain of morphia sulphate hypodermatically, and repeated the dose at 9:30. Mr. P. gave the history of having eaten a number of half-ripe peaches the night before.

Upon examination of the abdomen the doctor found an area of extreme tenderness about the size of a hand, to the left and above the umbilicus. No tumor evident. The patient had vomited, but the vomited matter consisted only of fluid with mucus. Large enemata of hot water were given with no result; the fluid returning clear with the exception of some small particles of fecal matter and some mucus spotted with blood. Hot applications were made to the abdomen, but the pain still continued.

At 11 A.M., his temperature was 97.4; his pulse was normal.

P.M.

I was called in consultation and arrived at about 3:30 On examination found the abdomen fairly soft, and with no special tender spots, except on pressure in the neighborhood of the umbilicus. Patient said there was some increased pain. On percussion could get nothing decisive, except over this tender area there seemed to be tympanitic resonance of high-pitched metallic quality.

Patient's pain, which was considerable, was referred to the umbilicus. He was now given several large enemata of hot water, but with absolutely no result, the water returning perfectly clear. It was now decided to do an exploratory operation, and there being no conveniences for such an operation at hand, he was sent to the Backus Hospital in Norwich, where he arrived about 1:30 A.M.

On his arrival at the Hospital the patient said that his pain was not nearly as severe as when I saw him at 5 P.M., also said that what pain he did have was in a new place, being to the right of median line and in the region of the appendix. He complained very strongly of a severe pain in his right shoulder; could account for this in no way except that in coming to the city he laid on his right side in the ambulance all the way, about twelve miles, and the road was very rough. His pulse, however, was considerably quicker and weaker, being 120, and his temperature had gone up to 100.6. His face had a dark flush, his eyes were very bright and sunken, and he was very nervous and thirsty.

He was put on the table and the abdomen examined. It was now very hard and tense, with no specially tender points. Could get nothing definite on palpation or percussion, although there did seem to be some slight dullness in the extreme right upper iliac region. The tympanites had disappeared. The abdomen was thoroughly cleansed and, being influenced by the patient's statement as to the location of the pain together with the slight dullness found there, a small incision, sufficiently large to admit index finger, was made over the appendix.

As soon as the abdomen was opened there was a tremendous gush of blood stained serum, the stream rising fully ten inches from the surface of the wound and continuing for several seconds. A very large amount of fluid escaped. The fluid was serum, containing a large amount of blood and lymph, showing that an acute peritonitis was in progress.

On exploring with the index finger, found a large mass of intestines which were bound down in the right iliac region, and something entirely different from appendicitis; so the wound was closed and the abdomen reopened in the median line, when a very large mass of black and gangrenous intestines appeared. These, as stated above, were bound down in the right iliac fossa close to the caecum, which was drawn towards the median line. This mass was about seven inches in the transverse diameter and the coils of which it was composed ran for the most part transversely; a few, however, were parallel with the long diameter of the abdomen. The point of constriction was close to the posterior abdominal wall and to the caecum.

Some time was lost trying to uncoil the intestines, but this being found impossible, the constricting band, which was dense and heavy and about the size of a lead pencil, was divided and the intestines spread out in hot towels and allowed to remain for over twenty minutes. The band, in the meantime, was examined; it could be unrolled and stretched out, and appeared to be mesentery with inner border quite thickened and firm, and the rest of it membraneous.

The intestine was now examined and found to be ileum. The color had not improved; the gangrenous portions, commencing at the caecum and extending for a long distance up the ileum. The mesentery in many places was sloughing and entirely gone. There was one spot in intestine where a perforation had taken place, but do not think there was much extravasation.

The intestines were covered with lymph and some slight adhesions had taken place between coils. The ileum, having been previously clamped, was divided close to the spine, and above the ileum was divided one inch from the upper limit of the gangrene, an assistant holding the upper end.

The whole mass of gangrenous intestines, with adherent strips of mesentery was now removed from the abdomen. The abdomen was thoroughly flushed out with hot salt solution and preparations made for joining the intestines. The opening in caecum was closed, the edges being inverted and closed with a double row of Lembert sutures, one-half of a Murphy Button being first put into the caecum. This button was then pushed against the caecum on the other side of the caecum besides the appendix and an opening made, the button brought through and held by an assistant.

The end of the ileum was inverted and closed by a double row of Lembert sutures, the second half of the button having been previously placed in the bowel. This was brought through in same way as the other and the intestine was joined to the caecum by a lateral anastomosis. No additional sutures were required except a row in the mesentery.

The abdomen was now again thoroughly flushed out and closed; the different layers being closed separately, and wound dressed with wet bi-chloride dressing.

Patient stood operation very well considering the amount of intestine removed. At one time during the operation his pulse became weak and he was given a hypodermic of 1-30 grain strychnine sulphate and also a hypodermoclysis of salt solution beneath the breasts.

Patient was placed in bed and surrounded by hotwater bottles, and saline enema given, and ordered to be repeated every two hours. Pulse was 134, R. 22, T. 100. He was very restless on coming out of the ether and very

weak; vomited very often small quantities of dark brown fluid which continued throughout night.

Following day T. R. P. were as follows:

He vomited continually the same brownish green fluid. Enemata were expelled clear, no gas. Strychnia continued and heroin gr. 11⁄2 every three hours was tried to quiet him and control vomiting, but no effect. Ingluvin gr. x. and bismuth subnitrate gr. xx. every hour were also tried with the same result.

2d Day-Same medication continued and in addition the stomach was washed out with saline solution and washing continued until return flow was perfectly clear. He was also given two nutritous enemata during the day, consisting of whites of two eggs, brandy one ounce, peptonized milk eight ounces, and these were retained. T. R. P. second day were as follows:

The lavage seemed to exercise a very favorable influence over the vomiting, the patient often going for over an hour without vomiting. The peptonized milk was put into the stomach by a tube after the lavage and was retained for an hour when vomiting commenced again. Slept one hour during the day. Previous to this time