cases of pelvic inflammation, and thirty-nine out of forty-two gall-bladder cases.

All cases of peritoneal infection from any cause whatever have been included and in all deaths occurring, either as a direct or remote result of the infection, are included in the statistics.

During the time since we have been adhering to the above plan of treatment, we have had under our care in the Ellis and Physicians Hospitals 180 cases of acute intra peritoneal infection, divided as follows:

In fifty-one cases of acute appendicitis the infection was either confined entirely to the appendix or the peritoneal lesion was local in character and did not show the presence of free pus. All of these cases made uneventful post operative recoveries. Thirty-three were operated on during the first fortyeight hours of the attack. Six between the third and seventh days, and twelve after the eighth day.

Two mild cases of appendicitis were not operated upon because business interests made it imperative that they have the speediest possible convalescence. One abscess case, complicated by pregnancy, recovered without operation. She was improving when first seen by us and we thought it better to trust to natural processes rather than to operate and risk a miscarriage with a drainage opening into the abdomen.

Twenty-one cases of perforative appendicitis, two cases of ruptured tubal abscess, one perforated empyema of the gallbladder, one typhoid perforation, one perforated duodenal ulcer, and one case of acute hemorrhage pancreatitis, making twenty-seven cases in all, were operated during the primary stage of the diffuse peritonitis with three deaths, two appendix

cases and one case of duodenal ulcer. All of these cases were operated within forty hours of the onset of the peritoneal infection and all (except the pancreatitis case, in which the fluid was hemorrhagic) showed large quantities of free sero purulent fluid in the peritoneal cavity. The twenty-four cases which recovered convalesced without alarming post operative trouble in any case.

The two fatal cases of appendicitis occurring in this group are worthy of reporting in detail, as they represent types of cases which will probably always give trouble to the surgeon. One was operated on the first day and the other on the second day of the attack.

The fatal case in the first day group was that of an old lady, of sixty-three, who for some time previous to the attack of appendicitis had had a very irregular intermittent pulse, and who looked like a desperately bad risk from the very first. The appendix in this case was perforated near the caeoum and there was a moderate amount of free fluid in the peritoneal cavity. The most noteworthy pathological feature was that of a gangrenous and perforated appendix, accompanied by only very slight evidence of reactive inflammatory changes in the remainder of the appendix. This we interpreted at the time of the operation as representing a very low grade of resistance on the part of the patient, which conclusion was subsequently confirmed by the post operative history of the case. The appendix was removed and the abdomen closed without drainage. The patient did well for two days and then began to develop symptoms of a localized peritonitis, with slight infection of the abdominal incision. There was only moderate distension and no vomiting, but the patient died four days after the operation of toxemia and heart failure. Probably we should have drained this case, but the abdominal conditions did not seem to warrant it at the time of the operation, and we thought it better to risk the absence of drainage rather than to subject the patient to the more tedious convalescence of a drainage case.

The fatal case in the second-day group is of special interest, in so far as it typically represents some of the difficulties

which will probably always be encountered and which tax to the utmost the judgment of the surgeon. A child, aged four, had been sick forty-eight hours. At first there was no evidence of peritonitis, but following the giving of a cathartic the symptoms of peritonitis promptly developed. On admission there was slight distention and the lower half of the abdomen was quite rigid, with very marked tenderness. The question of the advisability of operating was carefully considered and we decided to operate immediately, because in young children it is very difficult to carry out the rest treatment, the child insisting upon having water to drink, and if this be denied him, it is almost impossible to keep him quiet in bed. Then, too, the mother and all the rest of the relatives usually add their full quota to the difficulty of enforcing what is, at best, a rather strict regime.

Operation disclosed the entire peritoneal cavity filled with sero purulent fluid except within the region of the appendix, where the fluid was of a distinctly purulent character. The peritoneal surfaces were reddened, with here and there a few flakes of fibrin, the entire picture being that of a typical second day diffuse peritoneal lesion. The partially gangrenous appendix was removed and a viaform gauze and rubber tube drain was carried to the head of the caecum and an additional rubber tube drain to the bottom of the pelvis. After the operation the patient was placed in the Fowler position. There was no immediate shock from the operation, but the patient soon began to develop evidence of a very severe toxemia, and in seven hours the temperature had risen to 105 F., the pulse to 180, and there were muscular twitchings and clonic convulsions. The patient died of the toxemia thirteen hours after the operation. This is a case in which the operative manipulations, limited as they were, undoubtedly determined a very marked and fatal increase in the absorption of the toxins. Had this been an adult we would unhesitatingly have employed the Ochsner treatment.

The duodenal ulcer case, a woman of sixty, was operated on under the diagnosis of strangulated hernia, a large inguinal hernia having become irreducible at the onset of symptoms.

A diffuse peritonitis of unknown origin was found and drained through the inguinal ring after reducing the hernia. The condition of the patient did not warrant further search for the cause of the peritonitis. She was put on the routine post operative treatment, and much to our surprise, in forty-eight hours the abdomen was flat and the general condition was excellent. At this time liquids by mouth were ordered, with the result that within two hours the patient went into a sate of collapse, and died a few hours later, the autopsy showing a perforated duodenal ulcer.

Only seven cases were operated on during the intermediate stage of the peritoneal infection, with four deaths. One, a case of typhoid perforation, was moribund when admitted. Six were appendix cases, and four of these six were third-day cases, with peritoneal symptoms of only about forty-eight hours duration. At operation these four cases all presented diffuse, sero purulent intra peritoneal lesions with fairly abundant fibrin, and distinct roughening of the peritoneum. Although three of these cases recovered, it is quite probable that the safest procedure would have been to defer operating, according to the method of Ochsner. The peritoneal symptoms were little, if any, influenced by the operation and drainage, and three of the cases subsequently showed evidence of insufficient drainage by the development of secondary intra peritoneal abscesses, which finally opened into the operative drainage tract in two cases, while the third case died on the eighth day following the operation. One of the cases which recovered developed a metastatic peritonitis which considerably delayed the convalescence.

Certain it is, that in the writers experience similar cases have done better when treated by the Ochsner method until the localization of the peritoneal lesion. Subsidence of temperature, pulse and abdominal symptoms have been just as rapid without the operation and the danger of secondary abscesses, and the possible necessity for a secondary operation has been practically eliminated by waiting for the stage of localized abscess formation before operating.

A fatal case, operated on on the sixth day, is of interest

chiefly because of a number of misfortunes which might have been avoided had we used better surgical judgment at several periods during the time the case was under treatment. The history of this case is as follows:

H. T., aged 9, school girl. Attack began four days before admission, with only moderately severe pain, localized in the right side of the abdomen. The patient vomited once or twice during the first onset of the pains. Forty-eight hours before admission the pains became very severe, general in character, and the patient vomited frequently from this time until admission. Examination showed a well developed, fairly nourished child, facial expression anxious, temperature 103, pulse 120, chest negative, abdomen level, costal border tympanitic, everywhere rigid and tender.

The physical examination left no doubt as to the presence of a diffuse peritonitis and the history showed it to be at least forty-eight hours, and possibly three or four days old. The patient was put on the Ochsner treatment, and within thirtysix hours the temperature was 100 F., with a pulse of 100; there was no vomiting and the general condition was much improved. At this time the patient was transferred from one ward to another, and immediately following this the pulse rose to 120 and became of very poor quality. Co-incident with this, there was an increase in the abdominal distention and the general condition of the patient became very grave. Two days later the pulse and general condition were somewhat improved. but the abdominal distension was still marked, although rigidity was beginning to be localized to the right lower quadrant. We should have left well enough alone at this time, but, becoming impatient and hoping against our better judgment that incision and drainage might "relieve tension" and lessen the toxemia, we opened the abdomen through a right rectus incision and found a typical sixth day diffuse lesion, characterized by multiple small foci of pus, with all peritoneal surfaces, as far as examined, covered with a sticky, fibrine purulent exudate. One rubber tube and several gauze wicks were inserted and a large moist boric dressing applied. Except for a slight rise in temperature eight hours later, the