A METhOD OF TREATING GENERAL PERITONITIS. Imsorcu r 519 probability tend to increase. the bleeding; we therfore limit the pre-operative stimulation to getting the patient tlhoroughlly warm and administering-1 c.cm. pituitary extract. During the operation every precaution is taken to minitnize thle degree of siocok; tlie theatre is thoroughly lieated, tho table is provided witlh Er hot-water bed; lately we have found it advantageous to operate on these cases wlile they are in the Trendelenburg

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... sition. Immediately before the operation commences the administration of subcutaneous saline by a Lane's bag is begun, and it is continued tiroughiout the operation; three to four pints of fluid are frequently given in this way. We have tried several different metlhods of anaesthesia. We lhave had goodl tesults from the use of spinal anaestlhesia, but there is difficulty in obtaining the freslhly prepared anaesthetic, and it would appear that this is an important detail. In two instances we have had patients collapse suddenly after-the administration of-this anaesthetic. More lately, and on the suggestion of a paper by Yandeil Henderson, we have employed closed ether anaestlhesia. Tlhe paper above mentioned adduces evidence to show that by this method of anaesthesia shock is considerably lessened. The method lhas given us great satisfaction. Briefly the operative technique which we have employed is as follows: The albdomen is opened in what would appear to be the most suitable situation, and generally in the middle line. A large incision is employed. If the abdominal cavity contains a large quantity of blood, sufficient of this is rapidly -swabbed away with a long roll of dry gauze to clear the ts iew. A systematic examination of the various viscer is now carried out. We begin by picking up the caecum and recognizing the ileo-caecal junction; we work back rapidly along the whole lengtlh of small intestine, examining not only the gut but also its mesentery. The large intestine is reviewed, special attention being paid to the various flexures. If necessity arises the stomach on both aspects, tlhe-duodenum, the liver, and spleen are examined. It is a wise precaution to palpate bolh kidneys, especially the left kidney, in cases of dnmage to the spleen. The pancreas is reviewed during the examination of the posterior wall of the stomach. Tlle pelvic viscera are examined last, and to facilitate their examination the residual haemorrhage is more completely cleared away. The question arises whetlher or not the abdominal cavity should be washed out. In early cass with extensive -soiling of the peritoneal cavity we have done so; in later cases, and in those which slhowed evidences of peritonitis we liave not done so. We latefound it sufficient to establish drainage by a single Keith's tube, passin-g into the pouch of Douglas. In special instances such as have already been mentioned we lhave fonnd it necessary to drain locally or in the flanks. -AVe invariably close the abdominal wall witlh thioughand through sutures of silkworm gut, guarded where they pass over the wound junction with small pieces of capillary rubber tubing. A Doyen's bandled needle is the ideal instrument for inserting these sutures. Throughout the operation speed is an important factor, coupled with every possible avoidance of shock. As regards the post-operative treatment, there is very little which we wish to add; it is similar to that of every othier abdominal operation. Special attention is paid to the administration of fluids-for choice by the administration of continuous rectal salines and by subcutaneous infusions. One is frequently asked regarding the prognosis of these cases. There is this fact to be recognized, that one must be prepared for repeated most bitter disappointments, but whien one comes to view a series of cases, the gains seem infinitely greater than the losses. The prognosis, of course, very largely depends on the degree of the injury sustained, but an even more important factor is the length of time which has elapsed since the injury was sustained. Early operation offers the best and surest clhance of ultim-ate success. In reviewing the statistics of the results of suclh operations as these it is impossibe to consider the queestion ofl masse. Eachl individual case must be considered, for the8 chances Of succe3ss depend upon SO many factors th1at it -varies enormoF8ilY in different instances. .We Wish1 to ackowledge ur inSdebednss to Colonel (:uthlbert Wallace 3A.M;C4t, br--iseucouragemcnt. and advice.; also ta Lieutenant ..Colonel Wear, C.M1G., R.A.M.C.(T.),. .for .permission. to record these,cases. Tne, illustratioqs are the work of Serg.eant Wilson and Private. Warr, R.A.M.CM4T.). CAPTAIN R.A.M.C.(T.); SURcEON WITH CARE: Or OUT-PATIENTS TO THE MIDDLESEX HOSPITAL. My interest in the subject of obstruction secondary to peritonitis dates back for ten years. Du-ring this period I have been collecting cas in wlhichl, as the result of peritonitis confined to the pelvis, obstruction has supervened. My conclusions were presented in a Hunterian Lecture last year. I showed that the guts below the horizontal level of the symplhysis were paralysed, while the bowels above, thotugh distended, retained their contratile power. As the pelvis contains botlh a length of large and a length of small intestine, there are two obstructions to be dealt with, aiid the name " ileus duplex" was suggested for the condition. The success of the treatment I adopted in cases of ileus duple* led me to attack on the same lines -the more difficult problem of pwialytic obstruLction in cases of general peritonitis. It must here be remarked that not all cases of general peritonitis go on to tlhe stage of obstruction. 'I'his is especialy thw case in clhildren, and I have operated upon a boy of 12 with absolutely universal peritonitis extending up to the diaphragm in whom no sign of obstruction was presnt. Recovery followed free drainage of the peritoneal cavity. Furthermore, in the early stages of general peritonitis peritoneal drainage is often successful in arresting the spread of the peritonitis and in preventing the onset of obstruction. There are, too, numerous eases of mild paresis of the bowel in peritonitis which can be successfully treated by subeutaneous injections of eserne, by turpentine or ammonia enemata, or by purgatives. This paper deals exclusively with cases in whiclh the accepted modes of treatment have failed to avert or relieve paralytic obstruction of the bowels. If thee -is a coudition in surgery which is stamped with the word lhopeless, it is that stage of a getneral peritonitis where, in spite of pelvic drainage, cessation of the passage of flatus and persistent foul vomit indicate tha complete obstruction has supervened. The rigid abdominal muscles have been forced to yield by the pressure of fluid poared out into th. paraly:d intestine, and the abdomen is uniformly and tightly distended like a drum. The pulse becomes running, the extremities cold, and tlie patient, measuring his condition by the abnormal clearness of his faculties, only-within -a few hours of tl<e end realizes with a horrible certainty that he is in the inexorable grasp of death. This would be aciepted as a true clinical picture of the later stages of general peritonitis. But in abdominal surgery typical "clinical pictures " are of pathological interest only. They imply that the surgeon's chance has gone. Is it inevitable that cases of general peritonitis should reaclh the condition tius depicted? There is a preceding stage in which the obstruction is comple-te, but the pulse is still relatively good, and the vomit hasnot become offensive. The abdomen is generally distended, but it is absolutely rigid only below the tubilicus. The uipper half of both recti is softer than the lower half, and above the umbilicus slight respiratory excursions of the abdomen can still be seen. This is a stage of general peritonitis which is not recognized in the textbooks, but is known to all surgeons of mucli clinical experience. It is tlhe stage of the clinical skeptch, not of the clinical pictuire; thle stage of deadly struggle, not yet of decisive defeat. Is the proble presented by such cases relly hppeless of -solutiQu _ -B.y tio,resen methods. of -surgery it