active means of encouraging peristalsis, such as cathartics, or enemata. I know that in this respect, again, I am at variance with the views of the majority of physicians, who hold that the bowels must be moved early, in order to avoid intestinal paralysis. This practice may be very good after clean laparotomies, for it certainly makes the patient feel easier; but where the intestines are affected by an inflammation of their peritoneal covering, they should be allowed to rest for a few days, in order that they may recover, also, that adhesions may form around the stump of the appendix. After a lapse of three, or preferably four days, if the patient still suffers from an imperfect evacuation of gases, I employ a lavage of the rectum, the water being allowed to enter and flow out again, without any attempt to force it up the intestine. A regular enema is given about the fifth or sixth day. A study of my cases would substantiate the corrections of the view that the intestines should be permitted to rest during the first days. All of my successful cases, except the first one, were treated in accordance with this principle, no attempt being made to move the bowels. My first case had magnesium sulphate introduced when the stomach was washed. As regards the three fatal cases, No. 14, the moribund one, can be disregarded; No. 18, in which the progress of the sepsis was not even interrupted by the operation, also has no bearing on this question; Case 17, the remaining fatal case, received an enema daily, beginning with the day following the operation. Just at that time I had read articles by several writers on this subject, in which it was strongly recommended that peristalsis be induced as soon as possible after the operation. This caused me to waver from my usual method and to order the enemata in Case 17. The effect at first was surprisingly satisfactory, as the patient felt very well after his enemata; but on the sixth day he suddenly developed a septic peritonitis, which, within less than half a day, caused his temperture to rise 71⁄2 degrees, and terminated fatally. I cannot help thinking that the excitation of peristalsis prevented the formation of firm adhesions over the stump of the appendix, that on the sixth day the closure of the stump

became imperfect, and that fecal mater discharged itself over the peritoneal cavity. It was impossible to prove the correctness of this view, as an autopsy was not permitted. If it were within our power to bring on a movement of the bowels with a very slight amount of peristalsis, I should give my consent to the administration of such a remedy; but as long as the degree of peristalsis is not completely in our control, I prefer to leave the bowel alone.

(Since reading this paper I have had the opportunity of assisting another surgeon at an operation for diffuse suppurative peritonitis in a female child, a case about equal in severity to the milder ones in my series. Two days later I saw her again in consultation. In the meantime, calomel had been given, and her bowels were moving freely. She appeared to be in satisfactory condition and was feeling comfortable-like my Case 17. But on the following day she sank rapidly, the temperature rose, and she died of septic peritonitis. So my experience with exciting peristalsis after this operation leads me to consider it a dangerous procedure.)

For a similar reason I do not give rectal alimentation in these cases, as this is apt to excite peristalsis. I give small quantities of water, if the stomach will bear it, and later bouillon and strained gruel. If the stomach revolts and the patients vomits, the stomach is washed, and again nothing but water is given for a short time.

As regards the progress, it may be said in a general way that the earlier a case comes under treatment the better the chance for recovery; it will be best, if the pus has not yet spread far enough to classify the case under diffuse suppurative peritonitis. Nevertheless, the severity of the case cannot be measured by any routine method as the number of hours it has lasted. Some cases progress more slowly than others. If this were not so, it would not have been possible for me to save some cases operated on the fourth day, while one, operated at the end of the third day, succumbed. In cases that progress more slowly we find at the operation that here and there the peritoneum tried to set a barrier to the invasion by forming adhesions which

hold back the pus in one direction, but fail to do so in another direction. I have found that these adhesions are usually formed anteriorly, while posteriorly the pus travels onward. Thus we not infrequently find some adhesions in the neighborhood of the appendix which may have prevented the pus from at once finding its way upward; in such cases it frequently travels next into the pelvis; there, again, some adhesions may imperfectly close the pelvis, the pus, however, continuing to travel to the left iliac fossa, and so on. In one patient (Case 11) the adhesions in the region of the appendix and at the brim of the pelvis had even attained quite some firmness, yet they did not prevent, but they merely retarded the progress of the pus, as in that very case the abdomen was full of it up to the liver and spleen. Such a case in which the disease advanced more slowly may be more favorable on the third day than another case, with a more rapid invasion on the second day.

To sum up, the main points recommended in the treatment of diffuse suppurative peritonitis are: 1. Extensive incision, as a rule in the median line; 2. Lavage with saline solution poured in large quantities into the peritoneal cavity; 3. Closure without drainage.-Medical Record.

Extracts trom Home and Foreign Journals.

SURGICAL

TREATMENT OF PROSTATIC ENLARGEMENT.

James Pedersen declares that at the present state of knowledge he does not believe that it is possible to say absolutely when surgical intervention should be advised. More detailed, descriptive, and searching statistics, especially as to end results, on both the conservative and the radical sides are needed. The exclusive advocacy of one operation is unwarranted. Various factors should influence the physician in his treatment of these cases. The variation in the state, degree, and complication of the pathological condition must govern his method of caring for the case. From his study of these patients the writer believes that the teaching which advises surgical intervention as soon as catheter life fails, comes nearest to being correct. He believes in discriminate intervention as against indiscriminate oper. ating.-Medical Record.

POSTOPERATIVE GASTRIC PARALYSIS ACUTE DILATATION OE THE STOMACH.

W. A. Bastedo has recently seen three cases of acute dilatation of the stomach. One was the postoperative paralytic type; the other two were without paralysis, and were due, respectively, to the ingestion of a heavy meal in a chronically dilated stomach, and to the artificial dilatation with gas of a stomach which had an obstructed pylorus. In the first case paralysis of the stomach, pylorus, and probably part of the duodenum had quickly followed an operation for the removal of both tubes and one ovary. There was a large amount of secretion. It was noted that vomiting did not seem to lessen the distention to any great extent, nor did belching bring forth any large quantity of gas. In the second and third cases acute dilatation occurred without paralysis. The

writer concludes that acute dilatation of the stomach may be paralytic or nonparalytic and postoperative abdominal distention may be due to gastric paralysis as well as to intestinal paralysis.— Medical Record.

A CASE OF PERFORATION OF THE SOFT PALATE DUE TO TERTIARY SYPHILIS, STAPHYLORRHAPHY.

H. Fred Ziegel cites the history of a patient, a man twentyfour years old, who was suffering from tertiary syphilis. There was little doubt as to the diagnosis, which was gumma of the soft palate with subsequent degeneration, abscess formation, and rupture into the mouth. After two months of vigorous antisyphilitic treatment, both constitutionally and locally, the parts appeared sufficiently healthy for accomplishing the permanent correction of the palatal defect. Under cocain anesthesia, the edges of the cleft were freshened and five sutures were passed so as to approximate the edges. Most of the sutures had to be repassed more deeply on account of the friable condition of the tissues. After stimulation with silver nitrate, the opening closed completely and the patient was without symptoms.-Medical Record.

ETHER-AIR ANESTHESIA.

M. Metzenbaum, Cleveland, Ohio (Journal A. M. A., November 17), advocates the use of the open or drop method of ether administration, using the ordinary Esmarch or chloroform mask covered with six or eight layers of gauze, and held, at the beginning, 6 or 8 inches above the patient's nose. The patient is directed to count slowly after the anesthetist, or to breathe in and out or to blow the vapors away. The ether, in the ordinary chloroform bottle with dropper, is allowed to drop on the mask somewhat more rapidly than if it were chloroform, and the bottle is moved continually so that the drops fall on all portions of the mask, and the ether is inhaled as a warmed, well-diluted gas. The mask is gradually lowered till it nearly touches the face,