A thrice-weekly, pharmacist-driven ASP can decrease antimicrobial expenditure, shorten duration of therapy and decrease the utilization of carbapenems, vancomycin and levofloxacin.

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by the injections is all that is required, buit I thtink that physiological rest for the parts for somiie dtays is neceissary, and can best be obtained by induced temporary paralysis or abolition of toniicitv by stretchlinog t1e sphliiicter ai1i. For the cuire *of sim)Ile non-complicated fissures thlis Ilmalw" be all thlat is req1uired. Frequiently 1 h-ave performed a dilatationl opelration at a niursing homiie ill the molrnitiO, tlhe patient ret-trning to his own homne the sanme eventing, with-iouit complaining of paine, and, c-lieii A 5 c.crn. syringe with a very fine needle 2 inches long is used.The skin at the point of injection is anaesthetized by injecting a few drops subcutaneously, and, by pushing the needle along unde-the skiin, the points for further deep injectioiis aic awiaesthetized so tlhat only the initial needle-prick is felt. At a point on the skin half an inch from the anal opening, the needle is inserted downwards aiid slightly inwards throuigh the sphincter to a depthl of 1D in., care being taken not to penetrate the bowel-wall anid iniject 2anaesthetic into the rectum. A gloved finiger in the bowel should obviate this by guiiding the needle to its destination.Having reaclhed the tissues underlying the haemorrhoid the solution is injected slowly drop by drop as -the needle is gradually witlhdrawn. After tlhree to five minutes anaesthesia will be complete. I lhave never folund it necessary to apply the solution to the sirface of the liaemorrlioid nor to inject the anaesthetic into the body of tde pile. Qui-nine and urea, whilst excellent for deep inifiltratioln, slhouild not be employed to anaesthetize the skin, as it canses tlhickeninig and induratioin of the cut edg,e. Abouit 2 c.

ACUTE pancreatitis is the most acute, agonizing, and one of the most fatal conditions which we are called upon t o treat inside the abdomen. The severity of the pain and its sudden onset cause the sufferer to seek immediate advice. I n a number of cases the label 'acute abdomen' is loosely applied, not because the disease presents any difficulty in diagnosis, but because it is not kept in mind by the observer. Deaver says, "Unless a surgeon has seen previously two or three cases of acute pancreatitis, or unless he keeps the condition constantly in mind, it is seldom that a correct diagnosis is made before opening the abdomen".Diagnosis.-I do not wish to go over the symptoms of the disease, as they are fuIIy and accurately recorded elsewhere, but desire t o emphasize their severity and the acuteness of their onset. There are two signs to which I must refer later on. The first is the marked cyanosis which was first recorded by Halstead, and the second is the discoloration in the flank due t o a direct retroperitoneal digestion by the pancreatic ferments to which Grey Turner has drawn attention. If it is thought necessary to confirm the diagnosis of acute pancreatitis, Lowe's test and the diastatic value of the urine are both confirmatory. Other and more elaborate tests are not usually available in an emergency, and moreover are quite uncalled for.Statistics.-Acute pancreatitis is an uncommon disease, only 21 cases having been treated a t the General Infirmary at Leeds in the decade 1915-24. This is equivalent to one in every 5000 surgical admissions. The average age of these patients was 50, and females were attacked more frequently than males, the figures being 62 per cent and 38 per cent. Of the whole series of 21 cases, 8 died, which is equivalent to a mortality of 38 per cent. Three cases were not operated on, and two of them died. That the third case was suffering from acute pancreatitis seems almost certain, as the diastatic value of his urine was found to be 200 units. It has been stated that cases do recover without operation. We must admit this possibility, as patients are sometimes seen a t operation after a supposed acute cholecystitis, when the pancreas is swollen, and large areas of fat necrosis are present. These cases have obviously recovered spontaneously from their acute attack, but we see that there is a mortality of 66 per cent for patients treated medically.In these the lesser sac was opened, usually between the stomach and transverse colon, and the peritoneuin covering the pancreas was incised. The pancreas was explored with the finger, and free sloughs, if present, were removed. This exploration should be very gentle, and should never be attempted with a sharp instrument, as the splenic or other vessels may be opened and give rise I n 13 cases the treatment was drainage of the lesser sac.