getting a ready-made shoe that is almost as difficult, if not quite as difficult, to get a shoe to fit the foot as it is to get a set of false teeth to fit the mouth, but the structures about the mouth will not yield as readily as the foot. In making a shoe that will fit the foot I believe the ideal method is to make a plaster cast of the foot and make the shoe from the plaster cast. Sampson, of Baltimore,

found that a very proper way.

I wish to thank the Society for the kindly manner in which the paper has been received.

ACUTE DIFFUSE SUPPURATIVE PERITONITIS.

BY S. J. YOUNG, OF VALPARAISO, IND.

Many men of many minds have written about peritonitis. The theme is old, but not exhausted-not while surgeons are reporting 100 per cent. of mortality. I shall confine myself to a discussion of the acute diffuse suppurative form of the disease, and will consider especially the treatment. For etiology and classification I will refer you to the publications of Senn1, and Bayard Holmes", whose monographs are exhaustive and scholarly.

In the study of this subject my purpose has been to secure the experiences, methods and opinions of a considerable number of surgeons, for comparison. This I have undertaken by correspondence and some references to literature. Fifty letters were addressed to surgeons in various sections of the country, information being sought on lines suggested by the following questions: 1. Do you make it a rule to operate acute diffuse suppurative peritonitis?

2. If not, what are the contraindications?

3. How many cases have you operated, and with what mortality?

4.

What is your method of operation and treatment?

5. Did you ever refuse to operate? If so, when and why? Not specific answers, but free discussion was invited. Twentyfive answered--some in detail. A dozen sent courteous regrets. From the remainder no answers were received. To all who so kindly responded I am under obligations, which I hereby acknowledge with sincere thanks. Many of the letters received were scholarly and instructive. I wish that I might publish them in full, but that is manifestly inexpedient. I therefore give you brief excerpts, as follows:

B. F. Curtis operates except when patient appears too weak to

withstand the ordeal. Stagnant venous circulation, coil extremities and poor pulse are contraindications. He advocates flushing, drainage, ice coil and opium.

H. L. Burrell, of Boston, makes it a rule to operate. He reports at least one hundred cases, and recalls "a few instances in which recovery has occurred." He irrigates, drains and puts the patient in the Fowler position. Occasionally, when in doubt as to how diffuse the peritonitis is, he uses Ochsner's treatment for a few days.

Van Buren Knott, of Sioux City, was among those who gave detailed information as to his methods of treatment. He always operates unless patient is moribund. He has kept records only since 1902. Since that date he has operated upon nineteen cases, with seventeen recoveries and two deaths. He employs the median incision, above or below the umbilicus as indicated, and at once repairs any leak or diseased part that may exist. Through a two-inch incision above the symphysis he places a tube 13 inches in diameter, carrying a gauze wick to the bottom of the pelvis. In females a similar tube, without the gauze wick, is placed in the culdesac. Gallons of hot salt solution are used to flush the abdomen, enough of which is left in to entirely fill the cavity. With an additional drainage tube in the pelvis similar to the first, but without the wick, the patient is raised to the Fowler attitude while yet on the table, transferred to the bed and kept in this position. Through this plain tube in the pelvis he pumps out, every two hours, such excess of fluids as are not carried off by the wick. This is done for twenty-four hours. He thinks by leaving in the abdominal cavity a large amount of saline solution a strong current is established toward the lower pelvis.

D. N. Eisendrath operates all cases where diagnosis has been made during the first twenty-four to seventy-two hours. As contraindications, he mentions extreme sepsis, as shown by a pulse of 180 to 200, excessive distention of the abdomen, which denotes a complete septic paralysis of the gut, as well as constant vomiting. He thinks these latter cases, however, are those in which a diagnosis has not been made until the fourth, fifth or sixth day

12-Ind. Med. Assn.

after the onset of perforation. Prior to his adoption of the Fowler position, he reports seven cases with a mortality of 100 per cent. Since using the Fowler position he has had three cases, all of which recovered. He washes the abdominal cavity with three or four gallons of hot salt solution and inserts a Mikulicz (or umbrella) drain of plain gauze. Where the drain goes through the skin it is surrounded with long strips of loosely folded gauze, which is frequently changed within the first few days after the operation.

Charles A. Powers, of Denver, says his mortality has been very high-over ninety per cent. Abdominal irrigation with hot saline solution, free drainage and the Fowler position are the essentials of his technic. He thinks the mortality will diminish as time goes by. He commends the treatment of Blake, "whose statistics on this subject are the best that we have thus far."

Joseph Rilus and Thomas B. Eastman make it a rule to operate all cases unless moribund. They report seven cases, with one death. Their method is celiotomy, lavage, very gentle manipulation of the intestines in search for abscess or perforation, and tube drainage from bottom of pelvis, with patient in Fowler's position.

George Tully Vaughan reports sixteen cases, with four recov eries and twelve deaths. He uses irrigation and drainage, and refuses to operate only when patient is moribund.

John A. Wyeth does not operate all cases. In cases of seemingly diffuse mild peritonitis, progressing slowly from the first indications of the disease, he adopts the Fowler position, gives calomel and flushes the colon from below with salines. He reports two cases within two years of general diffuse peritonitis in children which had developed in connection with colitis due to intestinal indigestion, and both were relieved, without operation, by this method. Rapidly developing general peritonitis, from symptoms of gangrene of the appendix or perforation, he says, require operation, and the seat of the infection should be sought out and removed. He flushes with sterile water, 100 to 105 degrees, with a long tube, beginning above the liver, spleen and stomach,

and underneath these organs, and around on either side, carefully, under high pressure, using volumes of water until the fluid comes out clear. In women he opens the culdesac and drains, and in men through an opening above the pubes he puts in a pelvic pack.

Among those who take a pessimistic view of operative treatment is Roswell Park. He says: "I have had such small measure of success in attacking diffuse suppurative peritonitis that I avoid operation on it if I possibly can. I feel that the contraindication is the fact of its being suppurative and diffuse."

Byron Robinson prefers to wait. He says in answer to my first question: "I operate on any peritonitis which does not appear to check by anatomic and physiologic rest. If anatomic and physiologic rest checks the distribution of sepsis, I wait a while. I do not operate on the dying." His method is incision and drainage, with incision into the colon for the relief of distending gases.

Dr. Binnie, of Kansas City, says operation is the only logical method of treatment, but he has seen more cases recover unexpectedly without operation than with. He is convinced that almost all cases where the abdomen is much distended and diffuse suppuration is present will die, no matter what the treatment.

Hunter Robb does not think it necessary to carry out any immediate operative procedure, except in three or four out of a hundred in which the pus that has escaped into the peritoneal cavity contains virulent organisms. He says: "If operative procedures are carried out during the acute stage the mortality is high, due in most instances to the shock of operation. Where I have opened the abdomen in the acute stage of the disease, the death rate has been about ten per cent. By waiting, however, until the acute symptoms have subsided, and then carrying out operative procedure, the death rate is under five per cent." Пе operates by a vaginal incision, irrigating and packing the pelvis with five per cent. iodoform gauze.

Parker Syms makes it a rule to operate on diffuse cases. He says: "I believe there should be a careful distinction made between diffuse and general acute suppurative peritonitis. I believe that general acute suppurative peritonitis is fatal in one hundred