Arnie Localised Peritonitis.—When this is obviously of septic nature the best rule is to act upon the same principles as in the diffuse form of the disease. The urgency of operative interference is less exacting than in the diffuse form, and when the local conditions warrant delay, the wisest course will be to closely watch the progress of the case, leaving to nature the limit ;idol] of the infective process by adhesions which shut off the septic focus from the general peritoneal sac. Afterwards operative procedures for the evacuation of pus and the establishment of efficient drainage will he indicated by the nature of the local conditions present, as detailed under Appendicitis, Gonorrhcea, Gastric Ulcer, Gall-Bladder, &c.
Subphrenic Abscess .—This form of localised acute peritonitis may be due to duodenal or gastric ulceration, appendix trouble, pancreatic, renal, pleural, pulmonary, hepatic or gall-bladder suppuration, Fallopian tube or pelvic abscess, &c.
The treatment is modified by the site of the abscess, but the principle of early incision and the evacuation of pus and the establishment of efficient drainage is to be applied in all cases. The diagnosis should when possible he assisted by the X rays, and before attempting incision an aspirator or very long hypodermic needle should be inserted under the influence of a general anaesthetic, the surgeon being prepared to proceed with the evacuation of the pus as soon as the presence of this is detected by the needle. The needle may be entered at any spot where pus is most likely to be found; the best routine, however, is to penetrate the ninth or tenth intercostal space in the mid-axillary line, traversing the pleural cavity as the needle is thrust home till pus is reached. To prevent infection of the pleural sac, when the pus must be evacuated and the abscess cavity drained through the transthoracic route, some surgeons resect a portion of a rib, and pack the wound with gauze for 3o hours to insure adherence of the parietal and diaphragmatic pleura as in operating for hepatic abscess. As a rule, however, the urgency of the case demands completion of the operation at a single séance, which must be accomplished by carefully stitching the diaphragm to the intercostal muscles. When the case has been one which has lasted several days the chances are that the pleural cavity has been already obliterated by adhesions, and the subsequent procedure is much simplified. Each case must, however, he dealt with according to the local conditions found to be present. Often a
subcostal incision meets the difficulty, and in the extra-peritoneal variety of abscess the suhhepatic and kidney pouch can he reached and drained without opening the peritoneal sac.
Subphrenic abscess on the left side is usually due to posterior gastric ulcer, and the peritonitis soon invades the lesser sac of the peritoneum; if the pleura is not involved, the best routine is to open the abdomen in the middle line in the epigastric region. When the pleura is already the seat of an empyema, it may be possible to remove a portion of the ninth rib and drain the subphrenic abscess through this opening. Abscesses of splenic, duodenal and pancreatic origins are to be treated upon similar lines.
Chronic Diffused when of the suppurative type must be treated by laparotomv and drainage as in the acute variety. Adhesive or Proliferative chronic peritonitis, whether diffuse or localised, is best left alone unless the pain caused by adhesions becomes unbearable, or when the functions of the stomach and bowel become seriously interfered with, in which cases it will be necessary to open the abdomen and break down the adhesions, or to perform an anastomosis operation in order to remedy the resulting obstruction. Occasionally good results have been obtained by injections of Fihrolvsin, and this agent may be tried before laparotomy is undertaken, when the symptoms are not urgent in the localised adhesive peritonitis which so frequently occurs as a sequel to abdominal operations.
In those cases of chronic peritonitis arising from long-standing inflam mation spreading from the capsule of the liver and spleen, and in the type of affection occasionally seen in arteriosclerosis, Bright's disease, gout and other chronic totemic conditions the main indication afforded for treatment will be found in the removal of the accompanying ascites. Counter-irritation by flying blisters or Iodine may be tried when the amount of fluid is not great. Purgatives, diuretics, diaphoretics and alteratives like Mercury and Iodides are useless except when the ascites is part of a general dropsy; these agents cannot be counted upon for the removal of fibrino-serous or true inflammatory fluid. Paracentesis should be performed at suitable intervals as in the ascites of cirrhosis and mitral lesions.
The treatment of the chronic peritonitis caused by tubercle is considered in the article following.