Since the discovery of neomycin by Waksman in 1949,1 this antibiotic has been found useful in the prophylaxis and treatment of intra-abdominal infections. Poth2 and others3,4 demonstrated the effectiveness and safety of neomycin sulfate used orally as an intestinal antiseptic prior to bowel surgery. More recently, intraperitoneal instillation has been advocated in the treatment of peritonitis.5,6 Neomycin has also been given as prophylaxis against the complications associated with soilage of the peritoneal cavity. Pridgen7 in 1956 and Engel et al.8 in 1957 each reported four cases of respiratory arrest associated with neomycin administered intraperitoneally. Another case is reported in the case section of the American Society of Anesthesiologists' Newsletter.9 Ferrara et al.,10 Webber,11 Middleton et al.,12 and Doremus13 reported six additional cases. At this time we are aware of 16 patients including the one presented in this paper who