area of the peritoneal surface, and interfering with functional activity of one or more of the abdominal organs.

Here are some of the most important causes: Bacteria, or other products migrating through the damaged intestinal walls; infection of the appendix and bile-ducts; ulceration and perforation of some part of the gastro-intestinal tracts; The Fallopian tubes; Thrombosis, rupture of abscesses of co-related organs; wounds of the parieties, or viscera; or necrosis of contiguous tissues. Probably the most common cause of infection is the bacillus coli, then the streptococcus, staphylococcus, gonococcus, and sometimes pneumococcus.

The appearance of the peritoneum at first is red and injected, from which exudes serum, rapidly becoming purulent, from the presence of bacteric leukocytes, then fibrinous flakes, or masses are formed, causing adhesion of adjacent organs.

The tubercular variety comes on in the most insidious manner. The first symptom being that of pain, wandering in character, coming at frequent intervals, accompanied with rigidity and contraction of the abdominal wall, until effusion has taken place, when there will be a gradual and increasing distension. The appearance of the peritoneum will be red, very much thickened, and in the advanced cases completely studded with tubercles, not only of the parietal peritoneum, but also of that portion covering the intestines and other abdominal organs. The presence of a large amount of fluid in the cavity is likely to prevent adhesions, but may interfere with the functional activity of some of the abdominal organs, mostly the kidneys, or interfering with complete respiration and crowding upon the diaphragm. In this form of peritonitis the differential diagnosis must be made out as ulcer or carcinoma of the stomach, infection of the gall-bladder or kidneys, diffused carcinoma with ascitis, which, however, usually arises after middle life. The presence of tubercular focus in some location will suggest the probability of that as a cause. In this variety the onset is usually slow, whereas, in acute septic conditions the onset is rapid. The abdominal enlargements in the milder types may extend over a period of months. Later, in this condition, if effusion does not take place, and the tubercles become softened, which is usually the case, and the disease advances, there will be ulcerated adhesions and agglutination until the entire abdominal contents are adhered more or less through the entire surfaces.

Peritonitis due to puerperal infection.-In this disease the infec tion is brought about by the septic condition, first of the endometrium, the infection rapidly spreading through the diseased and crippled uterine body itself, or through the blood or lymph channels. After

the onset there is very little difference in the abdominal symptoms from any other peritoneal infection, the initial lesion frequently being ushered in with a severe chill.

Symptoms. The symptoms of septic peritonitis are usually very pronounced, especially pain, spasm, tenderness, nausea or vomiting, changes in the pulse or temperature. These constitute the most important. The nausea is often variable, with many a patient it being the principal symptom from the onset, and may consist of bile, grassgreen in character, caused by peritoneal irritation, and later becomin brown, or of a coffee-ground character. The pain may be severe or slight, and if this has been persistently distressing for some time, and suddenly ceases, it usually indicates severe progress of the disease, probably ruptured appendix, or abscess in some other organ;-pyosalpinx, for instance. Spasm of the abdominal muscles, is practically always present, and frequently even under anesthesia. Sometimes patients cannot bear even the slightest palpation over any portion of the abdomen, where as, on the other hand, if necrosis has already commenced when the patient is examined, this important symptom may be entirely lost. I have seen this condition a number of times. Once, with a young man, who had suffered with appendicitis for over a week, continuing to work through the whole time, and who absolutely refused to go to the hospital until he was in a state of collapse, and in which case the entire cecum and a large portion of the mesentery was found to be in a necrotic, sloughing condition.

Temperature. Usually elevated in the beginning. It is a bad sign when it drops suddenly below normal and all pain disappears. Probably rupture has taken place, and no time should be lost when this condition is present. The pulse is often a more reliable sign than temperature. There may be increase in rate, and decrease in volume. A pulse of 120 in an adult is usually a bad sign, if persistent.

Respiration. This is usually increased and becomes more shallow because of the crippled condition of the abdominal muscles. Abdominal distention is due largely to paralysis of the muscular coats of the intestinal tract, gases generated along its course being retained by the interference with normal peristalsis. This, and the persistent vomiting being brought about by the reversed peristaltic action. The face in extreme cases becomes pinched, lips drawn and of a bluish appearance, later on the extremities will become cold and clammy, indicating approaching dissolution.

Chill, usually present at the onset of peritoneal infection is not so apt to occur later on in the progress of the case. The characteristic position of the patient suffering from peritonitis is dorsal, with

knees flexed. At the same time the patient will be extremely restless, as evidenced by the motion of the arms and the upper part of the body, provided the pain is not too severe.

Prognosis. As cure depends upon early treatment so prognosis depends upon an early diagnosis, and in this connection it is well to remember what may be present in the septic variety. The points of danger are: Shock, pain, intestinal paresis and sepsis, which may cause death; obstructions of the stomach, bile passages or intestines from adhesion of fibrinous bands which interfere with the functional activity of the abdominal organs, causing long persisting discomfort. While the virulence of the infection is one of the most important matters to bear in mind, yet frequently of greater importance than that is the region infected and the extent of the area involved. These demand a greater consideration than the virulence. Then again, it is not alone the species of infection which demands our consideration, but the amount of infection which has been brought to bear upon the vitality of the patient. Where necrosis is limited, perforation having taken place, and the parts being protected by adhesions, it is a very different matter from that condition where the necrosis is more diffused and no protective wall has been raised up providing for the salvation of the surrounding parts. A proper understanding of pre-perforated protective inflammation is of the greatest importance, especially in appendicitis and typhoid, where ulceration finds its way through the intestinal wall. The prognosis will also depend largely upon the danger of spreading infections, due to the sudden. pouring out of septic material. When this condition is present in the upper portion of the abdominal cavity and the infection is liberated immediately below the diaphragm, the infection is more severe, and the danger to the patient largely increased. First, because the septic condition more easily and rapidly gets into the blood system, and also because the respiratory function is interfered with to a point of danger. We must constantly bear in mind that it is not so much the peritonitis or the crippling up of the functions of the peritoneum, as it is that the functional activity of important abdominal organs may be interfered with, and thereby the very source of life is cut off. Hence, the sources of danger and death are where the toxins are poured into the general circulation, which poison the vasomotor and respiratory centers and cause intestinal paralysis, thrombosis and gangrene, with re-infection, whether by osomosis, or cellular action. Septic absorption is exceedingly active in both diaphragmatic and omental regions.

Treatment.-Medical treatment is usually a waste of time, for

it may be the means of letting the moment of election for operation pass, without doing anything in the direction of averting an inevitably fatal termination. It is all a question of diagnosis. Is there, or is there not peritonitis, and if so, what is the cause of the infection, and can it be removed without increasing the danger of the patients. The treatment of this disease is essentially surgical, and the chief aim of all surgical work in this connection must be the removal of the infecting focus, with as little injury to the surrounding tissues as possible; therefore the early operation is the most desirable because the progress of the infection is arrested sooner, and further destruction is prevented. As to the danger of surgical intervention, that will depend upon the location of the infection and also what important organs are involved, and to what extent their functional activity is interfered with. No matter which of the several methods of procedure is followed in the surgical work, the manipulations should be of the gentlest character, because the inflamed peritoneum is very easily injured, and thus new channels for fresh infection are opened. In cases of appendicitis, especially when seen in the first few hours of the disease, when vomiting of grass-green fluid persists, and there are other evidences of peritoneal inflammation, an immediate operation is certainly urgently required, particularly so in cases occuring in children. I have many times seen cases in children of ten and twelve years of age, where rupture of the appendix has taken place in less than twenty-four hours after the onset of the attack. These cases are usually best managed by carefully removing the appendix, gently sponging out all infected material, using moist wicks for drainage, if any is required, otherwise closing the wound, placing the patient in the Fowler position and maintaining the instillation of the normal salt solution, per rectum, a la Murphy. No laxatives or cathartics should be given, and if nausea persists gastric lavage should be carefully followed until all backward flow from the upper intestines has been washed out.

There are cases of a more diffused infection where irrigation may be required, and when that is the case it is best accomplished with normal saline, and should be done thoroughly with the irrigating fluid at a temperature of 104° to 105°, until it returns perfectly clear, after which the peritoneum only should be closed, temporary drainage being maintained through the fat and muscle layers for the first two or three days, at the expiration of which time the external wound is closed by means of through and through sutures placed at time of operation; provided there is no necessity for maintaining drainage over a longer period. In those cases of septic peritonitis

arising from puerperal infection it is usually necessary to obtain and maintain drainage through the posterior cul-de-sac, and in addition to insert also two drainage tubes through lateral abdominal incision. In these cases all infectious fluids should be carefully mopped up, and thorough irrigation with normal saline; this can best be accomplished by means of a large glass canula, using ten to fifteen quarts at a temperature of 104° F., until the water comes away clear. The drainage must be free. Pass two parallel tubes through each lateral incision, and two of large calibre through the medium incision. The dressing must be very wide and thick and should be renewed every twelve hours. In tuberculous peritonitis, where ascites is present, the fluid must be evacuated and the cavity carefully sponged out, great care being exercised not to handle the abdominal. contents in a rough manner, or make the roughened peritoneum bleed. The cavity should be thoroughly ventilated, and then carefully closed. In a number of septic cases due to streptococcus infection, I have seen most decided improvement and eventual recovery from the use of the antistreptolitic serum. There can be little doubt but that whatever attracts the leukocytes increases the resistance of the patient to the infection by establishing a protective hyperaemia.

The remedies applicable to this condition are limited to those having a special effect on sepsis and are necessarily few in number, and cannot be expected to have an appreciable result in cases of extremely rapid progress. Those that I have noticed as giving any positive action are arnica, arsen iodid, secale cor.

NORMAL AND ABNORMAL AUSCULATORY RESPIRATION

SOUNDS.

BY W. A. HUMPHREY, M. D., TOLEDO, O.

Of the normal sounds we speak of the vesicular, bronchial, tracheal and the laryngeal, each having its own characteristic, viz.; pitch, intensity, quality, duration and rythm and its area over which it presents its characteristics in their most distinctive type. The left infra-clavicular region furnishes the best example of vesicular murmur. The inter-scapular the best normal bronchial and the stetscope applied over the trachea or larynx discloses their respective characteristic normal murmur.

The Vesicular is the most important. It is likened to a gentle.