w lAAAGEE TEST TAI 1.0 I.I 1.25 S. a "/^^i '/ Photograpl Science! Corporatii jimwiiiw— i«iiiiiiiiiiii«i*miiwmMmmniiii', lAAAGE EVALUATION TEST TARGET (MT-3) 1.0 I.I 1.25 ^m m «« iitt 1122 S m '""^ 2.0 12 I 40 1.8 1.4 1.6 Photographic Sciences Corporation 23 WEST MAIN STREET WEBSTER, N.Y. 14580 (716) 872-4503 CIHM/ICMH Microfiche Series. n Canadian Instituto for Historical IVIicroreprocluctiont /ICMH fiche CIHM/ICMH Collection de microfiches. ;al Microreproductions / Institut Canadian da microraproductions hiatoriquas Technical and Bibliographic Notes/Notes The Institute has attempted to obtain the best original copy available for filming. Features of this copy which may be bibliographically unique, which may alter any of the images in the reproduction, or which may significantly change the usual method of filming, are checked below. Coloured covers/ Couverture de couleur Covers damaged/ Couverture endommag^e Covers restored and/or laminated/ Couverture restaur6e et/ou pelliculde D Cover title missing/ Le titre de couverture manque I I Coloured maps/ D Cartes g6ographiques en couleur Coloured ink (i.e. other than blue or black)/ Encre de couleur (i.e. autre que bleue ou noire) □ Coloured plates and/or illustrations/ Planches et/ou illustrations en couleur D Bound with other material/ Re\\6 avec d'autres documents D Tight binding may cause shadows or distortion along interior margin/ La reliure serr6e peut causer de I'ombre ou de la distortion le long de la marge intdrieure D Blank leaves added during restoration may appear within the text. Whenever possible, these have been omitted from filming/ II se peut que certaines pages blanches ajoutdes lors d'une restauration apparaissent dans le texte, mais, lorsque cela 6tait possible, ces pages n'ont pas 6t6 film^es. D Additional comments:/ Commentaires suppl^mentaires; This item is filmed at the reduction ratio checked below/ Ce document est film* au taux de reduction indiqu6 ci-dessc 10X 14X 18X 2 E 12X 16X 20X ■■ >graphic Notes/Notes techniques et bibliographiques le best ires of this lique, ie y change )d below. / jl6e or black)/ leue ou noire) ns/ uleur 5 or distortion ombre ou de la 6rieure ation may r possible, these inches ajoutdes 9nt dans le texte, ces pages n'ont L'Institut a microfilm* le meilleur exemplaire qu'il iui a 6X6 possible de se procurer. Les details de cet exemplaire qui sont peut-dtre uniques du point de vue bibliographique. qui peuvent modifier une image reproduite, ou qui peuvent exiger une modification dans la m6thode normale de filmage sont indiquds ci-dessous. □ Coloured pages/ Pages de couleur □ Pages damaged/ Pages endommag6es □ Pages restored and/or laminated/ Pages restaurdes et/ou pelliculdes □ Pages discoloured, stained or foxed/ Pages d6color6es, tachet^es ou piqu^es □ Pages detached/ Pages d6tach6es I — I Showthrough/ Transparence □ Quality of print varies/ Quality in6gale de I'impression Includes supplementary material/ 1 I Comprend du materiel supplementaire □ Only edition available/ Seule Edition disponible D Pages wholly or partially obscured by errata slips, tissues, etc., have been refilmed to ensure the best possible image/ Les pages totalement ou partieilement obscurcies par un feuillet d'errata, une pelure, etc., ont 6t6 film6es d nouveau de faqon d obtenir la meilleure image possible. tio checked below/ notion indiqu6 ci-dessous. 18X 22X 26X 30X ^ ' 9nx 24X 28X 32X I I The copy filmed here hes been reproduced thanks to the generosity of: Library of Congress Photoduplication Service The images appearing here are the best quality possible considering the condition and legibility of the original copy and in keeping with the filming contract specifications. Original copies in printed paper covers are filmed beginning with the front cover and ending on the last page with a printed or illustrated impres- sion, or the back cover when appropriate. All other original copies are filmed beginning on the first page with a printed or illustrated impres- sion, and ending on the last page with a printed or illustrated impression. The last recorded frame on each microfiche shall contain the symbol —^ (meaning "CON- TINUED"), or the symbol V (meaning "END"), whichever applies. Maps, plates, charts, etc.. may be filmed at different reduction ratios. Those too large to be entirely included in one exposure are filmed beginning in the upper left hand corner, left to right and top to bottom, as many frames as required. The following diagrams illustrate the method: 1 1 2 3 1 2 4 5 9d thanks L'exemplaire film6 fut reproduit grAca A la ginirositA da: Library of Congress Photoduplication Service ijuality igibility tha Las images suivantes ont 6t6 reproduites avec la plus grand soin, compte tanu de la condition at da la nattat6 da i'axamplaira film6. at an conformity avec las conditions du contrat de filmage. re filmed ig on I impres- 9. All g on the pres- printed Les exemplaires originaux dont la couverture en papier est imprim6e sont film6s en commenpant par le premier plat at en terminant soit par la dernidre page qui comporte une empreinte d'impression ou d'illustration, soit par le second plat, selon le cas. Tous les autres exemplaires originaux sont film6s en commengant par la premiere page qui comporte une empreinte d'impression ou d'illustration et en terminant par la dernidre page qui comporte une teiie emp^'einte. che 'CON- •IMD"). Un des symboles suivants apparaitra sur la dernidre image de cheque microfiche, selon le cas: le symbole — ► signifie "A SUIVRE", le symbole V signifie "FIN ". iat le to be ned left to ( as tethe Les cartes, planches, tableaux, etc., peuvent dtre film6s d des taux de r(6duction diffdrents. Lorsque le document est trop grand pour dtre reproduit en un seul cliche il est film6 d partir de Tangle sup6rieur gauche, de gauche A droite, et de haut en bas, en prenant le nombre d'imagas nicessaire. Les diagrammes suivants illustrent la m6thode. 1 2 3 4 5 6 riita ^r ; I s> n (Itcpiinfcil Iriiin Tiiv: I'liii \i)i:i I'iiia Mi.nicAr. .loi'HNAt., I'Vlmiiiiy '.'li, 1S!18.J ^ „£ ^ THE GREAT OMENTUM. With More Especial Reference to the Part Played by It in Inflammations of the Abdominal Viscera.' Uy .1. (i. ADA.MI, M.A., M.D., riori'>siii- 111' PnllioloKy M<(iill ^nlVlT^lly, Mniilitiil. Whkn ao imuih has been written ii|)on othor organs, it is remarkable how little attention has been paid to the ^reat omentum. There i.s a .scanty literature upon patholof^ioal conditions of tlie organ — if organ it may be termed— mainly upon cn'sts and tumors of the .same. This, with a few papers upon its development, and still fewer upon sundry points in its histology and upon its surgery, and until the last few months ])rac- tically none upon its physiology, represents all that has been written during the century. Evidently, according to the Index MciliciLi, during the last ten years, when medical scril)bling has been at its height, not two papers per annum have been published, of which the main subject has been some one or other condition of this viscus. And yet this is the ominous organ of the augurs, every aspect of which, studied by then), wa.s found full of fate. The older priestly- com|)arative anatomist is long past and gone, and now no modern comparative anatomist so poor as to do the omentum reverence. Thus, if, following the time-honored custom, one wishes to lead gently up to his sulyect — to introduce it ' Hi'ing the main hiidy of a paper road before the Toronto Palliological So- ciety, December 21), 18ii7. Bi'3fii:!iii&fKi' ^^-'"'^-^ '^' in ;i iTsi'i'cirul iiiiiiiuor— by rolbrrin^' to tlit'oliHtM'vations uiid coiiclusioiH III' lluwo who have .troiio hornT, lio liiulH liiiii.solf cuiil'roiitcMl liy tlio tact that here, in coiiiu'ctioii witli tl\o >,'rcat oiiioiituiii. tlicrc i:^ littlu to Ijc said iiiilcss iiL! travels l)aek tlirouiili tiuM'entiirios. 'rhcroisno vohimiiious iiteraturo, no array of luodorii contiiieiital iuithoritios, wiiose names, in len^tli and dillicidty of pronunciation, are in inverse proportion ti> the facts and theories tliey brin^r forward. There are. it is true, isohite.i observations upon tlio oinentuin, of recent (latf— observations of irreaf value by Uanvier, Durham and otliers; luit for any attempt at In-oad >;eneralization upon the functions of tiie same we have to wander bai k to the seventecntli century, and boyonl>oerale, I.iltrc's oililion, I'aria, 1M9, \>.Mi. N^' , It is irue tliiit Littro and Adatus and tlie niodi'iii CDinniontulors re;,'ard the work in whidi this |)assa^«( occnrrt as almost certainly nut hy Hippocrates. lUit within the last few weeks, Spaet, in his study of a re- niarkalile manuscript {Anonyvntx Lmidincnsis, one of the rich horde recently unearthed in Kgypt hy the Hritish Museum authoriti<'s), points out that Hippocrates clearly indul^'ed in theoretical speculation, and that the com- mentators have been wronjj in taking from him all the so-called philosophical writings. Hence it is not im- possil>le that the treatise is by the physician of Cos. Whoever he the author, it \> curious that he should have spoken of this llux into the omentum a' most with the same Ijreath with his discussion upon dropsy. Indeed, he appears to imply that this llu.x is dropsical. The wise old Malpighi, commenting upon t' • passage, (jarrios the connection to its natural i onclusion md maKo, the definite suggestion that from the omeiifidi the tlux may pass into the abdominal cavity and i)e a cause of dropsy. It is remarkable that, so far as I can read, no authority since has taken up the relationship between this vascularity (and delicacy) of the great omentum and the development of ascites. There is only the suggestion of a German country practitioner, one Lundgraf,'' who in 1870 called attention to this pos- sible function. He gave the notes of a case of ascites associated with cardiac disease and of many months' duration, which had ])roved absolutely intractable to 14 tappings. Being called one day to the ease, he found the abdominal distension so great and the respiratory difiiculty so alarming that death appeared imminent unless the fluid were removed. He had no trocar with him and was ccrnpelled to perform paracentesis by means of a lancet and a i)iece of tubing. As a ' llf.utiches Archiv fiir kliiiische iletlicln. result tliere developed at the iiioir^ioii a liernia of the {ii-eat onientuiu of tlie ?i/e of a walnut, Th^ protrud- iiifi tissue, true to Hippocrates' apliorism. .slouulieil oil', am! there was no further untoward result; but within a few days the ascites came to an end, and, after one further tapjiinLr. never recurred. Land^naf makes the obvious, though it may not lie absolutely logical, suggestion tiiat the threat omentum is largely responsible for the exudation of ascitic lluid. At the last moment I find that a confrere here in 'r(jronto. Dr. .1. V. W. Huss. has arrived at a sinnlar conclusion and in his very full ar- ticle upon the omentinn,'' he quotes I/iwson Tait as holding like opinions. l>ut if nip])ocrates may iia.ve come near to indicating one important function of the viscus. that, namely, of regulating to a greater or less extent the amount of tluid passing into (and out of) the peritoneal cavity, those who followed him held other views. We owe to Aristotle the connnonly accepted o[)inion that it is formed of light membranes, and so placed, covering the intestines, as '"to preserve the innate heat of the body."" Cialen accepted and exjianded this view, lie gives the case of a gladiator who, having lost his omentum through an abdominal wound, recovered fronx the in- jury, tnit thereafter feU c- Id in his abdomen ! '' So far a.s I can find from inquiry, this Aristotelian view re- mains the most commonly accepted at the })resent day. With the renascence of medicine the obscurity of the omentum made it the text for nunu^-ous most wild dis- cussions. In his " Kxercitatio de Omento," ]\Ialpighi collects some of the leiuling theories. Thus, for exam- ple, Fabricius ab Aqua])endente (well known in con- nection with the di.scovery of the circulation) held that it was the seat of those winds wdiich so torture hypo- ■• Aiii-iicaii Jij'dihil iij' ()h.i/iiiii:-\ xxviii, IStK), No. li. <■' (iiilcn : lU' iisu ]ii»rtiiiiii. I'ruliciiiiis' oditiiin. T. i, lili. 4, 15(i7, p. VIU. rliondi'inos. T.auroiitius:. liiuiliiims. and otlicrs tninsid- ered that it collected tlic luimor.s goiiiir to the intes^tine or the excroinentitiou.s matters iVoiu tlie spleen, while Cordirus tanulit tiiat it was a second sloniach or loud - store I'roni wlncli the stomach received auain the food : whence, by him, man wa3 declared to ruminate like unto hriite heasts. ]\lal|)i;4hi himself was cautio\is of attaching' any func- tion to the viscus. He was even doulitful whether to accept the vulvar o|iinion as to its heat-preserving ])roperties. He was es|)ecially interested in its rela- tionship to the storaL'c of fat. and has not a little to say eoncernin i';\ses. Coiled and lyin^' over the trans- verse colon to the left, - I'a.ssin^f up over the liver, without adhesions, Passing uj) under tlie liver, 1 ease. Studying the organ in man, we are at a disadvan- tage, for most of the human subjects of the pathologist and anatomist have been bed-ridden for some little time, or may have sufVered from disease of the abdom- inal cavity. With long continuance in the supine posi- tion, it is more tiian pro!)able that this Uoating mem- brane becomes liable to assume relationships which would rarely be found in those suddenly killed. My observations tally with McLeod's suggestion that when the omentum is coiled up, the subject, in most cases, has been upon his back for some little time." On the other hand, when the omentum seems partic- ularly voluminous, completely covering over the whole anterior aspect of the lower abdomen, I have found that there may again be deception. Thus, only on Sun- day last, at an autopsy U[)on an individual presenting cerebral disturbance with no abdominal lesion, the edge of the membrane i)assed well beyond the pelvic brim into the pelvis; but here the stomach was large and full, the transverse colon crossed a good inch below the umbilicus, and as a conse(iuence the increased size of the omentum was only apparent. (i ranting all this, we must, however, grant also that there are variations -great variations. It can be most '■• Iiurliam ixiiiils mil that in rubliils and niiiiicapigs in which peritonitis hut \wvn iniliicfd, tlic'iiieiiluin hi'.oines milwl and Icildod tip, and lie notes tlial lie observed a similar (oudiiioii in a y.miii.' child. Wliile Mieli nilliuK up does im nir ill ass.uiation witli aeiile peritonitis, my notes .show that it is far from iM-inn a <'oiistaiil condition, (luirliatii, J). 9, J'l'inin) of I'iiIIihImi!/, iv, IS'.iT, p. :).'>•">.) ■31 voluiiiinous; it is also stated to have been found coni- ])letely absent. Personally I havenotconie across tbis last condition. In the above-mentioned 1 50 autopsies, there were two subjects, botli old men, in which the omentum bad a shrunken appearance and was only an inch and a half across, 'vliile in a third case, a plithisical patient of 2() years, it was representeil by three tags of delicate reticulated membrane, one ()X<) cm. (2.25 x 2. -Jo inches), arising from the postero-inferior aspect of the middle region of the transverse colon, one 7 x (i cm., from the antero-inferior asfjcct of the same region, while a third, 6x14 cm., passed up from the left extremity of tlio transverse colon to beneath the left lobe of the liver, in the lower animals it is much more regular in size and position, and there can be no (juestion of its being a disappearing organ. 1 ndecd, the contra,st l)etween the condition in man ami brute might also seem to give sup- port to liie protective-apron theory and to the further theory that the assumption of clothes by man is at last beginning to tell upon the internal organs— to lead to the transmission of atrophy of the internal apron in con- bcijuence of disuse I But were the " apron " theory valid, we should expect to find an inverse relationsliip between the develop- ment of the heat-retaining panniculus adi})osus and the development of the omentum. This we fail to find. When there is a thin abdominal wall, tnere, as a rule, the omentum is thin and with little fat. The apron theory nmst be put aside.' What, tlien, can we say concerning it and its function or functions? It seems to me that there is one feature about the great omentum which is the all-important ; Thai is, in its usuiil presentation, lint it is i)ossil)le tliat wlien.tliioiigli <.o1il, tlie vesnels of tl>c abdominal imrietea l)eoonie contracted and tlie s,,ian(hnic vessels distended and congested, tlie great omental vessels share in this con- gestion, and that, tin, warmed and congested memhrai.e is interposed between the cooled parieles i '.I'e inlCNtines. tValurf histol..:riciilly anrl i.liysiolo.iiiciill.V- iiiul tliiit is tho niiiin clKiractin-islic of its stnicturc It is tnio tlnit it is ii iiieinlirane. or. mort' cumvlly. n iloiiiik' mciu- l,raiu' foMcl iipnii itself, tlic two layers forniinir tl-.c anterior ami posterior serous investments of the stoniaeli, l.as^in.ii (lownwanls to form the anterior portion of tlie omentum, ami then douhliu^' ui)on themselves to form the ]H.r.terior aiu l.orkwood.) are nothin.ir l)Ut endothelial and couneori/.ation of delicate vessels separated hy as slijiht a cell-laver as possil.le from the peritoneal^ cavity. As nui^ht he expected, with the branchin-,' of the main vessels, the finest and most delicate vessels are largelv collected toward the periphery and along the free lii.rder of the omentum. Here it is, therefore, that the most prompt reaction is liahle to occin-. It is from this point, then, that we must start if we are to appreciate the part played hy the omentum in the econ..mv. 1 liave already hinted that it is from the al.undant network of oMiNAi, W.\ M.S.— .\s might be expected, there were several (8) instances of generalized adhesions, either plastic and acute, or fibroid and chronic, in cases of recent or old generalized peritonitis, ■■• riie imlliol.ini.iil iliaKn..>es i,( llic^c nise.* aiv to lie tmiiiil in dnail in tiic iiii- niiitl ropnils (i|- till' Hu-i,ilal fnr llic yiMrs ISIM and WX>. I i 11 I I and se\eral of localized adhe.sioii.s alonj,' th(> sites of oiioration-wouiids. Many of tlieso will be referred to later; (! were either in tlie middle line below the uni- biliciis or in the riuht inuuinal reuion (for appendicitis), where the ailhe.sion was in the ri^dit Hank following incision into a pericecal abscess. In the 2 cases there were old adliesions of the edge of the viscus along the pubic crest anteriorly. i>oth of these were cases of generalized tubenulosis, and in both, although there were subserous tubercles of the ileum in the pubic (or sui)rapubic) region, there were no adhesions of the under aspect to tlic intestines. There were 4 instances of old adhesions in tiie left llanU. 2 in the right tlank over the ascending colon, and 2 to tlie i)arietal ])eri- toneuni. covering the under surface of the ribs on the right side. All these, in the absence of operation- wounds or delinite local disturliance, may have been indications of a previous general peritonitis. There were ;'> examples of incarceration in an umbilical hernia, in one of wliicli there had been ''reduction en bloc," and in 1 case there was attaclimeut to a second- ary cancerous nodule at the navel, in 1 case, also, a large portion of the right border ])assed into the right inguinal canal, and was adherent over the te.stis. In a remarkable case of neglected gangrenous ai)[iendicitis, with suppurative thrombosis of the mesenteric vessels and retrojieritont.'al abscess, a large tag of the right border jtassed down between the intestinal coils to the hind wall of tlie alxloinen, where it was adherent to the right of the root of the mesentery, near the duo- denum. ri)on separating the recent adhesions, abun- dant pus welled out from a retroperitoneal abscess. Evidentlv this tag had prevented general peritonitis. In another case the right border passed down into the pelvis and was adherent to the pelvic wall, forming the roof of a localized pelvic abscess. Here, again, the ■ 12 Uenorali/iiti.^n ..f a supimrativc i.rocc.s was arrestcl l.v this n.oai.s. I shall speak ..f the uallinti vn oi i-en- tvi.hliti.' ahs.TSSus in connection with the aitpeiulix. ■ Of env.al interest are the locali/e.l a.lhesions dis- covere's button was applied without success, showed the right border ot the omentum adliorent by plastic; exudations over the seat ,,1 junction : and in another unsuccessful Murphy but- ton case, where some four in.'hes of the ileum close to the valve had been removed by Dr. .lames l^ell for sub- mucous sarcoma, there were similar adhesions. (In both these cases the intestines had become necrosed and perforated at the mesenteric attachment.) Another case, from .. man, aged 24, presented a condition which I can onlv regard as an old healed intussusception. Ihe upper half of the ileum was somewhat distended (11..") cm. in diameter as compared with 8 cm. below), the obstruction being due to the presence of an annular constriction admitting a cone 6.3 cm. in circumference. The mucosa over this ring showed no cicatrix, but ex- ternally there were evidences of old inrtammation in the shape of small longitudinal bands running from above the constriction to below it, while a delicate band of the right border of the omentum was adherent to th(> intes- tinal wall in the immediate neighborhood. l;i /; ;^1 Vl COHD- ,\|,,,|,^,„x.— In I ca.scs. ill! aciitr. plastic a. llK'.-i"ns wer.j t'ouiiil lui'iuin.u portions oC tli.' ivtaiuii^i walls iiround tlie al)scess in pLM'i'oraliv(3 npiieniicitis. In i>no <'as() already reconlod l.y Dr. C F. Martin, IIhtc was.ild peritvplditis witliont marked distiu'l-ancc ..I'thr appcn- ;reat nunilier from which to <,dean information, hut are the reverse. My set of cases is devoid of examples of nH)st of the conditions of omental disease to winch attention has hecn called by previous writers. There \ ere no examples of penetrating' wounds of the abdoi'.ien i)lu^'tred by the membrane to which Mcl.eod has moi-e especially drawn attention,'^ or of intestinal rents o' perforations obtaininii' primary closure bysimilar means, which dross was one of the Virst authorities to especially note." Mine are ordinary consecutive and unselected cases; bntassuch, the fact that the omentum may gain attachment to every viscus lying in the abdominal cavity, and does this very frequently, is brought into strong relief.'* It may pass upward and become attached to the stomach or liver, may journey to the right and form adhesions over the cecum and ascending colon in the neighborhood of the ai)pendix, or backward to act as a plaster over a retroi>eritoneal abscess, and, what is still more remark- able, its edge may wander down into the pelvis and be- come fastened to the rectum, the ovary, or even to the stump of the uterus after hysterectomy. The number of autopsies is not great; but notwithstanding, we tind this very large proportion of examples of oUl and recent abdominal inflammation, with the omentum forming adhesions in consequence. At first sight it looks almost as though the viscus were IS Kenneth McLeoil. H,ll„bimih Vv'/. Jmir., xxiii, 1877, p. 1. '•' Gross: "Svstcni of Surgery," 5tli editiiui, p. M-J. » I have left the spleen out of this enunieratlmi, l)ccaii»c, while 1 have an oc- casional note relative to omental adhesions of this organ, 1 recogni/.e that onr observations are far from complete, in consc(inence of the organ being pulled forward for bacteriological piir|Kises before its relationship in .utii could be pro|>- erly examined. Strictly speaking, every splenic adhcsioi.is an omental adhesion, because the organ is developed within the omentum. cmliiwi'd witli |M)\vcrs of ;i('ti\c liiroiiitilioii. and so soon an any locali/.iMl injnry ami inllaniniation nianil'estcil itsolf. loriliwitli sonic portion ol' its liotiliT, nior<; L'specially ul' its riy;lit IpordtT, t'ornicd a I'cclcr. niadt; its way to the all'cctcil area, and \\ itldn a liltli' tiino lic'cainc udliorcMit over it. tluis lii'lpinu' to ])rovont th« Hprfad of llif inllaniniation. It almost looks. I say. jnduin;,' from tiu; facts licic thus far rt'cordcd, as tliou^ih tin-' were the case. I'liit llici'c ;ire otiici' considci'ation.s to lie ln'ouirlit for- ward lieforc |passin;r jndument. .Mtliont^ii I have liccn alile to adduce so many ca-es ol' localized alidoniinai inllainnialion, followei. hy omental adin'sioiis. tiiero were numerous examples in our 1"><) cases in which no such adhesions had heen found, althoULdi similar lesions of various orjiaiis had iieen pri'sent. Naturally a taiile of these conditions woulil he much shorter, fur it could tinly include acute and recent t'ases of local in- fhimmation. in which the local lesion was proj;re.s.sinj,'. I'revion.s local disease without adhesions, followed l)y recovei'y. leaves little or no record. Aild to this that it is much mure ditlicult to wade through our somewhat voluminous post-mortem records and note every ease in which there has heen superlicial iidlammation of al>- duminal or^^aus. I have, however, noted in them two cases of cancer of the stomach, with perforation and ' j>erforative peritonitis; two cases of extensive cancer of the stonnich and cancerous peritonitis (without perfora- tion); two cases of very extensive tuhereulous |)eritoii- itis, all without si^iis of adhesion anywhere; a similar case of perforated tul)ereuU)Us ulceration of the small intestine and perforative peritonitis, and at least two cases of well-marked suhserous intestinal tuhereulosis, without noticeahle reactions of any kind in the omen- tum and neighhoring parts. In a case of enteric fever with perforative peritonitis, as is the general rule, there ■i V, WHS iu»t ii sii.'!! Ill' [iliistii' cxuilati'iii ov iiillu^inn any- wlicrr. Ill two casi'M of innuiiuil licinia tlif oniciitimi ii|i|K'anMl imlill'crciit ami iiiiairoctcil ; in chic tlicrc was wi'll-iiiiirUfil Idealized suliaeiitc peritonitis al'tt'i' iiieoni- |il<'ti' reduction of (lie hernia; i'l tin' otlieis t lie i;i'eat oiiii'ii- tuni did not uxti-nd liolow the uinliilicus, idtliouj.di tlion,' was |ilastic oxiidation around the oiieration-wound. A ease of chronic eholccystilis, Icadiiii,' to eiiipyoiiia of the fj;all-l)]a(hli.'r and |iorforative jicritonitis (auain a iMnrphy hutton case), showed neither old nor ro'ciit adhesions of the omentum. Doubtless 1 mi.Ldit niulti|ily examples. 1 have, however, ^dveii you eiioujih to show tliat tlie omentum does not hy any means neeo.ssarily send out proee.sses to eover over anti adhere to inllained abdoi! ' I areas, ft is not merely a f|uesti(in of the (pialily '., the inllammation that determines the adhe- sions. ITere are at least a few examples in wlii