but not for those in No. 2; fluid diet; hot fomentations locally or an ice-coil; morphine very sparingly.

What is the operative treatment ?

Abdominal section and removal of the appendix. When performed in cases such as are given under No. 2 or in recurring or relapsing appendicitis the prognosis is favorable.

Describe the operation.

Make a five-inch incision from the level of the umbilicus in the right linea semilunaris, or a similar incision nearer the anterior superior spine of the ilium, and more obliquely placed. Divide the peritoneum at the upper part of the wound, as adhesions are less liable here to be encountered. The small intestine is now pressed toward the median line, and the cæcum appears in the wound. This is turned outward, and the appendix either becomes visible or is felt for with the finger. If no adhesions are encountered, the appendix should be raised, and an aneurism needle armed with a double ligature passed through its mesentery close to its base. The ligature is divided at its loop, and one portion is tied about the mesentery, and the other around the appendix one-fourth of an inch from its junction with the cæcum. The appendix is then cut from its mesentery, and then divided just beyond the lig ature. The mucous membrane in the stump should be destroyed with the Paquelin cautery, or the method of turning in and suturing the opposing serous surfaces may be used.

Should adhesions have formed, they should be gently separated by blunt dissection in the direction of the appendix. A valuable guide to its location is the longitudinal bundle of muscular fibres on the anterior surface of the cæcum which terminates interiorly at the appendix. In separating adherent coils of intestines the operator should proceed as if an abscess existed, and a gush of pus may be encountered at any moment. The field of operation should be walled off from the rest of the abdominal cavity by sponges or gauze compresses. If pus is found, it should be caught on longhandled sponges and thoroughly wiped away before proceeding to the removal of the appendix.

When the appendix is in a large abscess-cavity and has been destroyed so that it cannot be removed, the operation reduces itself to the opening of the abscess. If a great deal of pus is present, a counter-opening may be made in the flank just above the crest of the

ilium, through which a drainage-tube is passed, in addition to packing the diseased area with iodoform gauze.

In a case where no pus has been found the abdominal wound is closed without drainage.

What is perityphlitis?

This is inflammation of the cellular tissue around the cæcum. If, as sometimes happens, the appendix is placed behind the cæcum, and thus has little or no peritoneal covering, it is also involved in this inflammation, which is usually suppurative. The symptoms resemble those of appendicitis, and in addition there are redness and visible swelling in the neighborhood of the right anterior superior iliac spine.

Treatment is by incision parallel to Poupart's ligament, irrigation, and packing the abscess-cavity with iodoform gauze. "Perityphlitic abscess" is a synonym for this affection.

PERITONITIS.

What are the varieties of peritonitis?

Only those will be mentioned which have surgical interest. They comprise the following:

Discuss suppurative peritonitis.

1. Diffuse or general;
2. Progressive focal;
3. Local.

To this are due the various adhesions that form. It may be local or general, and in either case it may be primary or as accompanying a corresponding suppurative peritonitis.

This is "ascites," which often accompanies cirrhosis of the liver, etc.; when excessive, tapping in the median line is indicated.

Peritoneum studded with miliary tubercles; serum in the cavity.

THE LOCAL VARIETIES.-The best example is suppurative appendicitis, already described. A similar local peritonitis may occur

anywhere. The lesions are the same: adhesions form, pus collects in the midst, the "walls" are coils of intestine, and perforation of the organ primarily involved may or may not occur. This "primary involvement" may mean an ulcer of the stomach or of the intestines resulting from inflammation or traumatism acting on the mucous membrane, or salpingitis, etc. Diagnosis is based on previous history and on any indications of local pain, tenderness, and swelling. Other symptoms resemble those of the following:

PROGRESSIVE FOCAL.-Various foci of pus, each walled in by adhesions between coils of intestine, develop one after another. Causes. The same as in the preceding variety. Symptoms.—Similar to the following:

DIFFUSE OR GENERAL.-Generally excited by penetrating wounds of the abdomen or by perforation of a viscus due to previous inflammation, traumatism, or malignant growth. Cases have occurred, however, in which failure to find such perforation is recorded. But there is really no more reason to argue against "idiopathic" general suppurative peritonitis than there is against "idiopathic" suppurative inflammation anywhere.

Symptoms.-Marked septicemia; rigidity and swelling of abdominal wall; legs drawn up; abdominal pain and tenderness severe; palpation may give fluctuation or dulness; if the latter, it is more in favor of progressive focal peritonitis; marked tympanitic resonance, especially if it hides liver-dulness, indicates gas, and hence perforation of the alimentary canal. The fever and tenderness are points in differential diagnosis from acute intestinal obstruction, which, when uncomplicated, presents no fever, and in which deep pressure, if made gently, often relieves the colicky pain; while even the lightest touch is often unendurable in peritonitis, whether local or general or "focal."

What is the treatment of suppurative peritonitis?

The local varieties should each be treated as nearly as possible according to the rules laid down under Appendicitis. In the other varieties abdominal section and drainage are indicated. If "focal," the incision should be made, if possible, over the focus, whose site may be judged from an area of dulness. In the general form the incision is in the median line and below the umbilicus. Flushing or washing out the general cavity is questionable. Good results have been obtained from simply wiping the cavity and intestines with gauze. In all cases of perforation suture should be applied.

What is the treatment of tubercular peritonitis?

Abdominal section, evacuation of the fluid, and closure of the abdominal wound without irrigation or drainage seem to exercise practically a curative effect in cases of purely peritoneal origin, and to have a decidedly ameliorative effect even in cases in which the lungs or other organs are involved.

WOUNDS OF THE ABDOMEN.

Give the varieties of wounds of the abdomen.

Essentially they are the same as wounds in general. Each may penetrate the abdominal cavity or not, may or may not involve an organ, and finally may or may not be complicated by protrusion through it of an organ which may itself be wounded or otherwise. Thus we have the following table:

Discuss the diagnosis between penetrating wounds with viscera not wounded and non-penetrating wounds.

With Protrusion.-The diagnosis is of course self-evident.

Without Protrusion. This question, considered without regard to perforation (to be discussed later) of the abdominal cavity, depends on whether the wound is large or small; if the latter, the condition of the patient must also be determined.

IN LARGE WOUNDS.-In these, whether they be incised, lacerated, or punctured, it is comparatively easy by direct examination to find out the state of the peritoneum. If this is untouched, the wound is "non-penetrating," and requires simply ordinary wound treatment. On the other hand, if the peritoneum is found to be severed, the wound is "penetrating," and, in the absence of visceral wounds (to be discussed later), should be sutured at once or after return of the viscera to the abdominal cavity if there is protrusion.

The presence or absence of internal hemorrhage is settled by direct inspection through the wound.

IN SMALL WOUNDS.-The far most common varieties are bullet(pistol-shot) and stab-wounds. In these the condition of the wound, pure and simple, offers no points on which to base a diagnosis, because there is no way of inspecting the peritoneum without enlarging the wound (which should never be done, nor should it be even probed merely for purposes of diagnosis). Nor is there any protrusion, because the wound is too small. Even the character of the hemorrhage, from purely the wound point of view, is not decisive, because it is known that many non-penetrating wounds bleed profusely, and that penetrating wounds may not, and vice versa. Hence in small wounds of the abdomen we must also consider the condition of the patient. For example: A pistol-shot wound of the abdomen is considered to be non-penetrating if there are no signs of shock nor of internal hemorrhage-i. e. collapse; fluctuation and dulness in the abdominal cavity—even if there be considerable hemorrhage from the wound itself.* On the other hand, such a wound, accompanied by shock, collapse, fluctuation, and dulness, is regarded as penetrating even if there be absence of local hemorrhage. Furthermore, shock alone is not conclusive, as it may occur with non-penetrating wounds; nor does the absence of the signs of internal hemorrhage positively indicate that the wound is non-penetrating, because such wounds, occurring without these signs, may be penetrating. This point, however, is unimportant clinically, as all such wounds are regarded as non-penetrating as far as treatment is concerned. Hence it is clear that for a positive diagnosis of a penetrating pistol-shot wound of the abdomen, without wounds of the viscera, the presence of the signs of internal hemorrhage is absolutely necessary.

What are perforating wounds of the abdomen?

Wounds which have both a point of entrance and of exit, and in which the inflicting instrument passes through the abdominal cavity. The vast majority of these wounds are caused by bullets. Nonpenetrating wounds may also have "points of entrance and exit." Hence a differential diagnosis is necessary, and it is made on the same principles as above described.

Shock and collapse are here necessarily intermingled. The former is supposed to be due to the impact of the bullet, severance of the peritoneum, injury to the viscera, etc.; the latter to the hemorrhage.