patient gradually improved and finally recovered from the operation and lived about ten months. No tumor ever developed in the abdomen, and she had no recurrence of the acute symptoms. The appearance of the part of the gut affected was of acute inflammatory infiltration.

Was this a case of localized enteritis, caused by invasion. of the intestinal walls with bacteria from the interior of the intestine?

Case 2.-- Miss W., age 25, was prostrated Oct. 15, 1899, with obscure abdominal pain. In spite of treatment, it continued increasing in severity with elevation of temperature and pulse.

I saw her in consultation with Dr. Wm. G. Hanson, the evening of October 18. At that time the abdomen was exceedingly tender, without localization; pain was continuous and diffuse; temperature 102 2-5°, pulse 118. I could neither confirm or refute a diagnosis of appendicitis, but in view of the obscurity and menace, advised an exploratory incision. She was hurriedly removed to the hospital, and an incision made over the appendix, which, on exposure, was found unperforated and apparently was not the source of the trouble. On inspection of neighboring loops of intestines, they were found covered with patches of exudate, were dark red and distended. Another incision was made in the median line to facilitate wider exposure. The same yellowish exudate was found over nearly all the intestinal peritoneum and the pelvic organs. Intense inflammatory redness was apparent everywhere. All parts were carefully cleaned by gently rubbing with mops of soft gauze under a stream of sterile water. Lastly the abdomen was irrigated with saline solution and the wounds closed without drainage. Ice bags were packed over the abdomen. The patient gradually improved and recovered.

In this case there was no visible gate-way open for infection of the peritoneal cavity. The appendix was not at fault.

The appendages were normal.

There was no perforation of

the intestine.

tonitis?

What was the cause and source of the peri

Case 3. Mrs. C., age 38. Two children. General health good up to present illness. Friday, Feb. 23, 1900, suffered pain in the abdomen during night, accompanied by loose movement of bowels. Had been taking anti-fat pills for a few weeks, which produced some diarrhoea. Was seen by her physician, Dr. Hodgdon, Saturday afternoon. Temperature then 103°, pulse 130; pain diffuse over the whole abdomen, much distension. I saw the case March 1, and found distension still present and diffuse tenderness; temperature 102 2-5°, pulse 120. No further movements had occurred. The patient had vomited the preceding Monday. Here was another obscure case. I could make out no localization of pain or tenderness, no tumor. Again, in view of the obscurity and menace, exploration was advised. Incision. in the median line showed the intestine covered with a plastic exudate, foul fluid in the pelvis, but appendix and appendages normal. Further exploration along the small intestine disclosed a segment, about a foot long, greatly thickened, intensely red, with small areas of gray necrotic patches scattered over it. It was much like Case I only a more intense degree of involvement. The same treatment was adopted as in the preceding case, except that gauze drainage was adjusted. The patient succumbed in a few hours.

Was this again a case of penetration of the intestinal wall by the bacteria which inhabit the intestinal canal, and if so, what condition made such a dire disaster possible?

Case 4. Mrs. M., age 68, of Irish birth and strong constitution. Was prostrated Saturday, December 29, with feeling of sickness all over. Sunday morning vomited and had pain in the bowel, which became sore and tender all over. She felt hot and feverish. Took castor oil, and had four or five free movements. Her physician was summoned Monday. Temperature was then IOI 4-5°, pulse 104. Tenderness seemed localized toward the right side. Tues

day was more comfortable, temperature 99 2-5°, less tenderness. I saw her Wednesday, and was summoned because the bowels were more tender, painful and sore, and had become distended and vomiting had supervened. In this case appendicitis was suspected, but final diagnosis was held in abeyance, because of obscurity of symptoms. Exploratory incision was advised and accepted. The appendix was found normal, but the whole peritoneum was inflamed, covered with yellowish white deposit, and there was much foul purulent fluid in the pelvis and lumbar fossæ. No focus of inflammation nor defective area could be found. The abdomen was thoroughly flushed, mopped and irrigated and gauze drainage established. The patient lived about eighteen hours. A culture was made of the fluid found in the abdomen and an infection of pneumococci found. This latter, while it gives no hint of value for guidance in future cases, demonstrates that a fatal peritonitis may be established without physical lesion of the abdominal viscera, and from other source than the intestinal contents.

GENERALIZATION.

Cases 1 and 3 demonstrate fairly satisfactorily that peritonitis may be produced by direct penetration, through the intestinal wall, of pathogenic bacteria, which at all times inhabit the intestinal canal.

Cases 2 and 4 demonstrate that peritonitis may exist without evidence of such penetration and irrespective of the intestinal contents, i. e., it probably occasionally becomes infected directly through the blood current. In the last case, there was a recent history of some kind of a pneumonia or bronchial attack of mild character from which the patient was convalescent when the abdominal trouble came on. This was probably the source of the pneumococci.

We come back to the question, what is peritonitis? Modern pathological research has changed the views of all who have given the matter careful consideration. The time

has been when any disease which was characterized hy pain and tenderness in the peritoneal cavity was called peritonitis. It was a very common thing to speak of fibroid tumors as causing peritonitis. As bacteriological science has come to be more widely known, the question arises whether it is proper to call any inflammatory development, or anything that suggests inflammation, peritonitis, unless there are bacteria in the abdomen, or some bacteriological process is going on. There are many microbic organisms, which are capable, if they reach the peritoneal cavity, of producing a train of symptoms that we call peritonitis. Experiments have been made of injecting into the animal, bacteria which have been sterilized. They act as poisons, producing diarrhoea, but the animal will get well. But let pathological living bacteria be injected in the same quantity, and in the resistance of the animal there will be more or less fatal sequelæ.

It is interesting to look at the peritoneum as an anatomical structure. I would call your attention to the peritoneal tissue. It is something over one-third of the area of the anatomical covering of the body. It is provided on the upper portion, about the region of the middle tendon of the diaphragm, with little openings varying from 3-16 to 5-16 of an inch in diameter, and these connect with the lymphatics. To one dealing with the abdominal organs, and operating on them, flushing them, according to the modern method of using saline transfusion, it is of interest to note how quickly the peritoneum will absorb. It seems but a few minutes after the injection is given, when it is absorbed and taken. over the system, for the pulse, which has been weak, will improve in a very short time.

It is said that the peritoneum is very inactive in resistance of bacterial organisms. There is usually a strong effort early on the part of nature to ward off all infection by throwing out plastic exudate over the intestine, and cutting it off from the other portions of the cavity. This is nature's safeguard, and if she cannot do it, here comes the great menace

to the system. This will indicate to you my views of peritonitis, that it is a derangement of the peritoneum itself and a subsequent invasion of toxines. It is evident from clinical evidence that a great many cases of local peritonitis take care of themselves. The peritoneum is relieved by nature. and absorption occurs and repair takes place. We can reach but one conclusion, that the earlier the abdomen is opened and the material washed out and drainage established, the better the patient is prepared to withstand the attack. The use of copious solutions of poisonous substances has been given up and clear water is not used. Instead copious injections of saline solution are given to facilitate the washing away, through the drainage that has been established, and the drawing out of millions of bacteria, and rendering their toxines inert.

This is the history of cases of peritonitis that have come to my notice. They usually die, the mortality, in spite of all modern methods, is not very encouraging. Cases that come to the surgeon are almost always far advanced, after the inflammation is general, the abdomen is distended, and the patient septic through and through. Under these circumstances death is pretty likely to occur.

REPORT OF THE SURGICAL SERVICE OF THE MASSACHUSETTS HOMEOPATHIC HOSPITAL FOR JULY, AUGUST AND SEPTEMBER, 1900.

BY WINFIELD SMITH, M. D.

It is a great temptation in reporting a service at the Homœopathic Hospital to make a complete list of all the cases which have come under the supervision of the attending surgeon, and to add such a list to the general report, but as this unduly complicates the description of the more important cases occurring in the service, I shall refrain from such