CHAPTER XLVI

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THE PERITONEUM AND ITS DISEASES.

Were the peritoneum spread upon a flat surface it would be found to equal in area that of the skin which covers the body. In man it is a closed sac; in woman it is exposed to exterior contamination through the Fallopian tubes by way of the uterus and vagina. Hence the frequency with which infections of the latter are transmitted to the membrane itself. Thickened in some places, or duplicated, for the purpose of forming ligaments and membranous visceral supports, it is usually thin, connected with the structures which it lines or covers by a more or less delicate, cobweb-like connective tissue. In some of its duplications relatively large amounts of fat may be collected. While freely supplied with bloodvessels it may be regarded as an enormous lymph sac, its capabilities of absorption being relatively immense. It is because of this that human beings escape many of the possibly fatal consequences of infection. Along it infectious processes travel, sometimes with wonderful rapidity, while again it throw’s out exudates and rapidly walls off a serious disturbance, imprisoning it, as it were, and often effectually. Fluid may escape from it (fluid exudate) with great rapidity, or it may exude a fluid rich in fibrin which rapidly accumulates and forms a dense, firm exudate that serves to bind surfaces together and is often the surgeon’s best friend. In fact, the surgeon looks for a minimum and desirable amount of this exudate to ensure the result of whatever sutures he may pass through the peritoneum and the tissues which it covers. Thus after an ordinary intestinal suture it is expected that within some six hours the exudate thus formed will be of itself almost sufficient for the purpose of safety.

Peritoneum is said to possess the power of absorbing from 4 to 8 per cent. of the weight of the individual within an hour, but this only under normal circumstances, since inflammation or previous lesions delay or interfere with the process. Increased peristalsis hastens it, the reverse being also true. On the other hand, conditions may be easily reversed, and the presence of sugar or glycerin within the peritoneal cavity causes a diluting fluid to be thrown into it at about the same rate. It is by virtue of a firm, fibrinous exudate that foreign materials, _e. g._, ligatures, sutures, and even larger substances, are encapsulated, those which are capable of disintegration finally disappearing from within this investment. Occasional instances are on record of instruments, sponges, or pieces of gauze being left within the peritoneal cavity, in consequence of inadvertence during or when concluding an operation. Such bodies as these often encapsulate in this way and have been found years after at postmortem examination, or have been slowly extruded during life by natural processes. Such unfortunate occurrences as the latter afford the greatest reason for care during all such operations.

PERITONITIS.

The term peritonitis has been made to cover so many conditions, of widely differing pathological character, that it is intended here to consider only those which have a practical interest for the surgeon. It is unfair both to terminology and pathology to include under the same name conditions that may be brought about slowly, or without any

## participation of bacteria, with those which are due solely to bacterial

invasion. No attempt will be made here to go into a minute or complete classification of the various conditions included by different writers under this name. For instance, they have spoken of an idiopathic form of peritonitis, thus confessing by use of this adjective ignorance of the etiology of the condition. The surgeon has neither use for such an expression nor belief in such a possibility. The thickening of the peritoneum which may result from the proximity of an old hemorrhage, or the irritation produced by the circulating fluids in cases of Bright’s disease, is for him an entirely different entity, and is neither an idiopathic form nor peritonitis itself.

For surgical purposes we mention especially the following forms:

A. Consecutive;

B. Traumatic;

C. Perforative;

D. Tuberculous;

E. Malignant;

F. Intra-uterine and infantile.

Forms A, B, and C may merge into one another or be confused from the beginning, or they may themselves be consecutive to D, while E, the malignant form, is hardly a distinct type, but rather a peritoneal expression of a more widespread general condition.

Again writers have endeavored to make distinctions by the use of such terms as “virulent,” “septic,” “putrid,” between which, however, no lines can be clearly drawn nor sharp distinctions made. They depend to some extent on the nature of the bacterial invasion, and again upon the actual virulence of the bacteria involved. The most distinctive type of surgical peritonitis is the _tuberculous_, which is usually relatively slow and recognizable as such, but as between the cases produced by spreading erysipelas, gonorrhea, intestinal perforation or postoperative infection one can make few, if any, distinctions which are serviceable or useful.

Anatomically considered there are two types of great importance--the _circumscribed_ or _local_ and the _general or diffuse_--prognosis depending in no small degree upon the extent of limitation of the

## active process, while at any time the former may merge into the

latter. _Consecutive peritonitis_ may include that which is the result of direct extension, as from erysipelas, appendicitis, acute cholecystitis, pyosalpinx, or other acute infections which have spread to and involve this membrane. Under this head also may be included those cases due to thrombosis or embolism, of mesenteric or other vessels, which lead to speedy gangrene of a part or all of the intestine.

_Traumatic peritonitis_ refers rather to those cases where infection has been carried directly inward from the exterior. Traumatic peritonitis may be the result of extension of the same conditions which produce the first, the consecutive form, or only occur more directly, as, for instance, those cases produced by rupture of the stomach or duodenum after ulcerations of the same, or perforation of typhoidal ulcers, actual rupture and escape of the contents of a suppurating gall-bladder, appendix, tube, or any other collection of pus, or perforation due to the gradual extension of tuberculous, syphilitic, or malignant disease, with final rupture of a viscus.

The nature of the bacterial invasion is of more interest to the pathologist than to the surgeon as such. In general, however, it may be said that, in addition to the ordinary pyogenic organisms, the colon bacilli are perhaps the most frequently to blame, while the more putrid types are the result of actual escape of bacteria from the intestine, as through a perforated appendix, and the addition of a mixed type to one which began perhaps as a simple one. Thus in the so-called _putrid_ forms multiple bacterial contamination is usually discovered upon making cultures. The pneumococcus, the capsule bacillus, and the gonococcus are also not infrequently found, in cases of peritonitis whose nature and origin will be suggested by the discovery of the

## particular germ involved in each case.

=Symptoms.=--While varying much in time and intensity, and even completely changing their type during the successive stages of the disease, there are, nevertheless, certain cardinal symptoms which are universally recognized in cases of surgical peritonitis. These include _vomiting_, _pain_, _tenderness_, with more or less shock, followed sooner or later by abdominal _spasm_ and _distention_, while to these symptoms there is sure to be added _bowel obstruction_ of some type which becomes, toward the end, perhaps the most profound feature, and which may even mask the significance of other symptoms. According as the lesion is localized or generalized _pain_ may be referred to a particular area or may be general and intense. _Local pain_, with tenderness, usually implies, at least at first, a localized lesion, and is not so likely to be accompanied by vomiting as the more diffuse form. Depression is found to correspond largely to the type and degree of sepsis, while collapse is a prominent feature in the more severe cases. The pain, which is sometimes intense, subsides, and it should be emphasized that a speedy subsidence is not necessarily a favorable symptom. It too often marks the transition of an ordinarily acute case into one of intensely septic or even putrid type. _Tenderness_ may be acute and localized, or diffuse and only evoked on deep pressure. One of the most significant symptoms is _abdominal rigidity_, which persists throughout the active state of the disease, and which, when followed or accompanied by meteorism, may to some extent mask and obscure all conditions within. If the patient be not seen until this stage is reached diagnosis can be made only by history and conjecture, for it is almost impossible to determine anything by palpation.

_Temperature_ is an uncertain factor. It sometimes rises high at first, and then falls, while if it fall too low the prognosis is serious. The _pulse_ also shows very irregular variations, usually rising, however, as the disease becomes more severe, and being often almost uncountable at the end. A combination of rising pulse and falling temperature is of serious import.

In addition to the _vomiting_, which is a pronounced early feature of the disease, we have, as bowel obstruction comes on, an added _fecal character_ to the vomitus, which sometimes is most characteristic of complete obstruction. This obstruction is due in part to toxic paralysis of the muscular coat of the bowels, and in part to the result of adhesions or fixations by which bowel motility is completely prevented. Thus in many instances of peritonitis following acute appendicitis there are loops of intestine glued together by exudate in such a way as to practically occlude or disable them.

The depression, shock, and final collapse of the disease are characteristic, as is also the _facial appearance_, the cheeks becoming discolored and the orbits hollowed out, so that the eyes early sink back. Other expressions of diminished blood pressure are not lacking--coldness of the extremities; cold, clammy perspiration; lividity of the skin, and the like.

While this is a picture of the most common expressions of acute septic or surgical peritonitis, it is occasionally found that conditions equally serious arise without such marked symptoms, and that the patients become rapidly worse, finally dying, who neither vomit continuously nor show extreme meteorism nor abdominal rigidity. Such cases are thereby stamped as those of more extreme toxicity, where systemic reaction is paralyzed almost from the outset, and are accordingly the more hopeless on that account.

Ordinarily it is not difficult to recognize the onset and the course of peritonitis in surgical cases. The condition may be confounded with one of septic intoxication from some focus which has not involved the peritoneum; otherwise differentiation is rarely difficult. The occurrence of such a condition does not necessarily indicate faulty technique on the part of an operator, as the condition is too often present when the surgeon begins his work. On the other hand, it too often follows faulty technique and constitutes the strongest argument for vigilance both in preparation, performance, and after-treatment.

=Treatment.=--But little will be said here about non-operative treatment, although first it should be emphasized that treatment in the past was too often of the non-operative type. Many cases of peritonitis could be saved by operation were it performed while the infection is still localized, but this is at a period when they too rarely reach the surgeon’s hands, he being called in as such when the inefficacy of drug treatment has been already demonstrated. Without denying that the surgeon is not blameless in all these respects, blame should, nevertheless, be placed where it properly belongs, at the door of the man who fails to recognize and carry out plain surgical principles.

The opium treatment for peritonitis, with which the name of Clark will always be associated, was introduced at a time when many things were considered as peritonitis which were not necessarily such. It was furthermore an advance on previous methods and gave better results. That, however, is no excuse for adhering to it when better means are at hand. On the other hand it must not be denied that much can be done medicinally to give comfort and meet certain indications. In spite of the many disadvantages attaching to the use of opiates it seems unnatural to let patients suffer as they would without them. It is justifiable, then, to use them in cases which are hopeless, or in those which refuse operation; but given indiscriminately and early they often mask symptoms which, if properly appreciated, would lead to early diagnosis, and, it is to be hoped, early operative relief. Views also differ regarding catharsis. It is a great disadvantage to permit the intestines to retain fecal matter for days and add a consequent copremia to the other features of the disease. On the other hand, intestinal activity tends to disseminate infection, and is, consequently, most undesirable. If at the outset the intestinal canal could be emptied and then left at rest it would best meet the somewhat contrary indications.

Ordinarily, however, it is of small advantage to keep bombarding the stomach with repeated doses of laxatives which are more often rejected than retained, and which have little effect.

One of the most distressing features is _vomiting_, and here it is well to follow Berg’s suggestion and test the vomitus with litmus paper. If it be found alkaline small doses of morphine should be given, each with a drop or two of aromatic sulphuric acid, in a little chopped ice. If it be found acid small doses of milk of magnesia are advised or some such preparation, with minute doses of morphine, frequently repeated. The greatest relief in these cases, where the upper bowel is emptying itself into the stomach, will be obtained from _lavage_. In the same way tympanites and meteorism are best treated by passing a rectal tube high, leaving it in place, and utilizing it for lavage of the bowel, using warm water with a little sodium salicylate. Not the least distressing feature of such a case is the reflex hiccough which is produced by diaphragmatic spasm, since the phrenic nerve distributes sensitive fibers as well to the peritoneum. For this there is no really effective remedy. Small doses of Siberian musk, with or without morphine, beneath the skin will sometimes quickly relieve it. Depression and lowered blood pressure are best treated by adrenalin and digitalis, rather than by strychnine, which stimulates peristalsis. Fever, when high, should be treated by cold sponging rather than by antipyretics. The kidneys should be kept active, if necessary by hypodermoclysis, and the skin equally so by hot-air baths, as through both of these emunctories much elimination may be effected. The question of catharsis comes up again in considering what can be done to improve elimination of ptomains by watery stools, but these are hard to secure; it is, after all, questionable whether their effectiveness in this regard has not been greatly over-rated. Richardson, for instance, is inclined to believe that cases reported as cured by free catharsis would, in all probability, have recovered without it, it being doubtful whether the really infectious element be present.

_Surgical treatment of peritonitis_ includes a recognition of the cause, and, if possible, its removal. Richardson has grouped in the following suggestive manner the indications for operative intervention in the early stages, when cases are not without hope:

General pain, becoming local; or local, becoming general, according to cause;

Tenderness, showing the same indications;

Abdominal rigidity;

Green vomitus;

Rising pulse and temperature;

Diminished peristalsis without too much shock.

On the other hand, in cases of fully developed peritonitis, where the surgeon may still consider the possibility of intervention, but where prognosis is far less favorable, the conditions include:

Lessening or vanishing pain;

More general tenderness;

Great distention, replacing rigidity;

Excessive dark or fecal vomitus;

Obstipation;

Rapid and feeble pulse;

Pain extremely severe;

Low temperature and the ordinary evidences of reduced blood pressure.

In such cases the decision rests largely upon the degree of collapse. To operate upon a moribund patient is hopeless and brings discredit upon surgery. Before operating upon any serious case of this kind the circumstances should be fully explained to those concerned, and they should be impressed with the fact that should the patient die he dies _not in consequence of the operation but in spite of it_.

The _operation_ itself will in a large measure depend upon what can be learned of the etiology of the disease and the diffuseness of the resulting infection. To reach a localized focus the incision may be made at any point which will best afford access; but in dealing with a generalized process the middle line, and an extensive incision, will ordinarily afford the best opportunity for doing whatever is necessary.

The _preliminary incision_ may be made short, as for exploratory purposes. Unless a loop of distended bowel be at once blown into the opening there will be prompt escape of fluid, whose character will reveal much of what has gone wrong within. If reasonably clear the operator is fortunate. If it be purulent he has to combat a most serious condition; if it be offensive, it is probably due to contamination from a septic abscess or from intestinal gases, while if the fluid be nondescript and contain floating particles of fecal matter there is an intestinal or gastric perforation. So soon as one comes upon fixation or adhesion of viscera he will find lymph, in condition of greater or less organization. Inside the masses thus bound together he will probably find the greatest centre of pernicious activity.

The more one sees of these intra-abdominal conditions the more respect he, as a surgeon, feels for the _omentum_. Only recently have surgeons learned to appreciate the kindly activities of this duplicature of the peritoneum, with its slight or heavy load of contained fat. It manifests a tendency which may be almost regarded as a sagacity or instinct for shifting itself toward a local focus of infection, and there throwing out lymph by which it becomes attached and helps to form a protective barrier that often is most effective. Were it not for this tendency many cases of acute appendicitis, for instance, which now recover would be lost during the early days of the attack, in consequence of a quickly disseminated infection. Thus a gangrenous appendix, or hernia, or gall-bladder, is frequently so wrapped up in a protective layer of omentum that the operator has first to detach this, or go through it, before he comes upon the actual site of the trouble. Some such disposition of the omentum, then, may be easily discovered during the earliest moments of his exploration, and if later he conclude to remove a portion of it, because of actual or impending gangrene, he nevertheless sacrifices it with a feeling of regret because of the good it has already done.

The further treatment of these cases is essentially a matter of what can be done to remove the exciting cause. Questions of gravest import, and often difficult of immediate decision, will present in nearly every case; as, for instance, whether to resect a portion of intestine, to remove a gall-bladder, to hunt for an appendix when embarrassed with the difficulty of the effort and necessity for widely separating intestinal coils, or of the treatment of distended bowel, which it may perhaps be impossible to restore to place, of extensive and complete flushing of the abdominal cavity, or of mere local cleanliness. And after these questions have been decided, and action taken, there comes still the question of _drainage_, with the wisdom of or necessity for counteropening, as in the loin or in the cul-de-sac, and the character of drain to be used. As to what should be attempted _in general_ there will rarely be much room for doubt. As to how best to accomplish it should be decided according to the training, the experience, and the opportunities of the operator, and the nature of the environment. When the entire peritoneal cavity is invaded, and flooded with more or less infectious material the more thoroughly it can be washed out the better. At the same time to do this with any degree of even apparent thoroughness requires practical evisceration of the patient, and an amount of time spent and shock produced by handling the viscera, which are exceedingly depressing and may of themselves be more than can be borne. The meteorism, which is so conspicuous a feature of most of these cases, means the distention of the bowel to such a degree that when once the intestines lie upon the surface of the body they can usually be restored with the greatest difficulty; and this would raise the question of the desirability of either one or more punctures, through which gas should be allowed to escape, or a sufficiently wide opening, with the introduction of a Monk tube, and the complete emptying both of gas and putrefying fecal matter. The latter is certainly in theory the much more desirable measure, if the patient’s condition will only justify it. Probably after pelvic drainage the Fowler semi-sitting posture in bed would be desirable, while after high drainage the Trendelenburg position, with the pelvis higher than the thorax, would be preferable.

If free abdominal _irrigation_ is to be practised a large quantity of warm sterile saline solution should be used, to which may be added perhaps a small proportion of acetozone or of mercury bichloride. The silver salts also make equally effective and less irritating fluid, the nitrate being used in the proportion of 1 to 10,000, or the citrate or lactate in proportion of 1 to 500 or 1 to 1000. These metallic salts will coagulate the albuminoid fluids and give to the peritoneum an opaque appearance, which, however, need cause no alarm.

Another question of importance is that of _enterostomy_. In some of these cases the acute bowel obstruction is the most predominating and distressing late feature, and an enterostomy may be attempted, even though it be known it will serve but a temporary purpose, in order to relieve distress. There never can be more than sentimental objection to it, in such cases, with the possibility of something more than mere temporary relief. It can be effected under local cocaine anesthesia, by attaching to the parietal peritoneum the first loop of distended small intestine that presents, and, after firmly fixing it in place, making a small opening, and then preferably inserting a glass or other tube for better drainage purposes.

These constitute the precautions to be followed and the advice to be given in cases of septic or surgical peritonitis. How successful they may be, or how satisfactory the termination of the case, cannot be foretold by statistics nor by reports of cases in the hands of others. Success will depend in large measure upon the early or late period at which the case is thus treated, and upon the general surgical discretion and experience of the operator. It is probable that disappointment will result more often than success. Nevertheless every life thus saved is one snatched from a certainly fatal termination without it, and if successful but once in ten times one life has thereby been saved that may be worth saving, without saving the other nine. While I would advise to make the attempt in any case which offers a reasonable prospect of success, caution should be used against doing it without a full understanding with those concerned that it is an effort in the right direction, concerning which no promise can be made; death results not from the operation so much as in spite of it.

Summarizing, briefly, the best methods of treating a diffuse septic peritonitis we may agree with Le Conte,[53] that they consist of the following measures: The least possible handling of peritoneal contents, the elimination of time-consuming procedures, most perfect drainage of the pelvis by a special suprapubic opening, as well as free drainage through the operative incision, the semi-sitting posture of the patient after its conclusion, the prevention of peristaltic movements by withholding all fluids by the mouth, and perhaps by small amounts of opium, and the absorption of large quantities of water through the rectum, by which there may be produced a reversal of the current in the lymphatics of the peritoneum, making it a secreting rather than an absorbing surface and increasing urinary secretion. It is inexpedient to waste time sponging peritoneal surfaces or wiping away lymph, for danger of septic absorption is increased rather than diminished. Patients with diffuse septic peritonitis bear brief operations fairly well, but prolonged ones badly; therefore a minimum amount of work should be done.

[53] Annals of Surgery, February, 1906.

One of the most valuable procedures in carrying out the above advice is Murphy’s method of _slowly introducing large quantities of water into the rectum_. The rectal tube used for the purpose ends with a sort of nozzle containing three or four openings, and the reservoir containing the solution is elevated but a few inches above the level of the bed, the intent being that it shall simply trickle into the bowel no faster than absorption can occur. In this way from a pint to a quart may be absorbed each hour, the pressure being continuous, and the flow so regulated that no accumulation of fluid takes place in the bowel. Murphy claims that by this method the lymph current in the peritoneal lymphatics is so reversed that the peritoneum is bathed with free discharge and that this should be afforded escape by suitable drainage methods, coupled with Fowler’s (the sitting) posture.

TUBERCULOUS PERITONITIS.

_Acute or chronic tuberculosis of the peritoneum_ assumes usually, first, the _miliary_ form, after which, in the slow cases, infiltration and great thickening occur to such an extent as to alter the appearance, texture, and behavior of the peritoneum itself. It is rarely a primary condition, but is usually secondary to some other tuberculous focus, which may be one or more of the mesenteric nodes, these being involved in consequence of infection from the alimentary canal; or the peritoneum may be easily infected either from the genito-urinary tract or directly from the intestine. In children, the most common path of infection is through the mesenteric nodes; in females, through the Fallopian tubes, and in males, either through the intestine or the kidneys or ureters. The peritoneum, under these circumstances, behaves very much as does the pleura, in the presence of acute or chronic tuberculous lesions which extend to and involve it. Thus it may become so thickened, and even “leathery,” as to have lost all its original characteristics, and to appear more like a dense, firm membrane than in its original semblance.

_Peritoneal tuberculosis_ appears in three different types: A _fibrinoplastic_ type, characterized especially by adhesions; an _ulcerative and sometimes absolutely suppurative_ form, marked always by the presence of pus and pyoid; and an _ascitic_ type, characterized by leakage of increasing amounts of serum and the development of well-marked ascites.

The first, or _fibrinoplastic_, is a localized lesion, and leads to the formation of dense adhesions, as, for instance, between a Fallopian tube and the pelvic walls or the other viscera. As the disease spreads all the tissues become matted together in a mass which renders them almost indistinguishable, frequently much resembling malignant disease. In some instances it may be possible to remove the entire affected area. At other times it is best to let it alone.

The _ulcerative form_ is characterized by more general symptoms of conspicuous febrile type. It produces rapid loss of strength and weight, frequently attended with evidences of intestinal ulceration and with abdominal tenderness and pain. A certain proportion of these cases justify exploration, though but few of them will be found favorably disposed for radical surgical measures.

The _ascitic type_ is characterized by rapid accumulation of fluid, with accompanying malaise and debility. As the abdomen distends and the diaphragm is pushed upward respiration becomes more difficult and rapid. A certain _protrusion of the umbilicus_ also characterizes many of these cases. Their course is not so febrile, but it may be possible, especially in the early stages, to make out some enlargement of mesenteric nodes, or involvement of the viscera, which will aid in diagnosis. It is most common in children, but it may be met with at any age. In general such a collection of fluid, which cannot be accounted for by recognizable disease of the heart, liver, or kidneys may be suspected to be tuberculous.

=Treatment.=--Treatment of tuberculous peritonitis should be _surgical_ when possible. This statement is based partly upon the fact that it is so commonly a secondary condition. Such treatment will depend, in large measure, upon the extent to which it may be possible to remove any exciting foci of the disease; but experience shows that even this is not always necessary to bring about a cure, as in those cases of the ascitic type where it is desirable only to wash out the abdominal cavity and close it again, this simple procedure seeming to suffice.

It is the cases of the _ascitic type_ which seem most benefited by _incision and irrigation_, usually without drainage, and it is these which are perhaps as hopeless as any under non-operative treatment. It was Van de Warker, of Syracuse, who, in 1883, first recognized the value of simple irrigation in these cases, and while at present we find it impossible to explain the benefit which so often and so rapidly accrues, the measure is universally recognized as that offering the most hope. This, like every other surgical procedure, should be practised early rather than late, preferably so soon as diagnosis is made, or, when this is difficult, it should be made a part of an exploratory operation intended partly for diagnostic purposes. The measure itself is simple. A small opening in the middle line, between the pubis and the umbilicus, permits free escape of all contained fluid, which should be facilitated by changing the position of the patient, thus preventing plugging of the opening by presenting bowel. Every drop which can escape having been removed, the abdomen is then flushed repeatedly with either warm saline solution or a plain watery solution of acetozone, 1 to 1000, or silver lactate or citrate, in the same proportion or a little stronger. My own preference has always been for the latter, and with a silver solution I have obtained a large degree of success. There is no objection to leaving a small amount of either of these fluids in the abdominal cavity--_i. e._, no more than an ordinary effort to empty it before closing the wound. An incision one inch long, made for this purpose, will serve nearly every indication. Through it the parietal peritoneum, as well as that covering numerous loops of intestine, can be inspected, and through it also a finger may be inserted for exploratory purposes, for the detection of mesenteric nodular disease or of any other focus. Should any serious local condition be revealed which might be benefited by radical measures, this would be the time to practise them.

Before closing the wound margins it would be well to thoroughly disinfect them, for over them has flowed infected fluid, and we sometimes see tuberculous foci develop at this point. This fact explains also the disadvantage obtaining in these cases of making drainage openings. They serve their purpose admirably for a short time, but, becoming thus infected, lead to the establishment of tuberculous fistulas and sinuses, which may call for subsequent operation. Fecal fistula may even be a more remote consequence. As the peritoneum is approached it will be found more or less altered, and there may even be observed bowel or omentum adherent behind it; therefore caution must be observed.

A final caution should also be given in order that we may avoid mistaking that form of ascites which is frequently seen in connection with cancer of the abdominal viscera extended to the peritoneum, and

## particularly that form spoken of as _miliary carcinosis_ or _miliary

sarcomatosis_, for a tuberculous collection. While surgeons are occasionally deceived, one will usually find much in the history of the case, and in the results of local examination, which may save making this error, if it be so regarded; but, in effect, the opening and the evacuation will give relief, even though this character of the disease makes it less amenable to help from any such source.

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