Plan for the gradual introduction of saline solution into the peritoneal cavity after severe operations: before closing the wound a No. IS catheter is in serted at the lower angle and carried down into Douglas's pouch. The wound is sutured in the usual manner, and the catheter is cut off and its end secured with a wire suture and attached to a glass irrigator. After the dress ings have been applied a continuous flow of saline solution is begun and main tained for twenty-four hours at the rate of one cubic centimetre a minute. This is effected by compressing the supply tube with a clamp fitted with a milli metre-screw. About 3 pints of fluid are introduced in twenty-four hours. Eichel Arebiv f. klin. Chirurgic, B. 5S, II. I, 1900).
Three quarts of saline solution were in jected into the peritoneal cavity in two days in a case of rupture of the liver, with profuse haemorrhage, in which fully two quarts of blood had been lost. Eichel (Archiv f. klin. Chin, B. 58, H. 1, 1900).
Vomiting can usually be controlled by ice and small quantities of soda water or iced champagne; if, however, it persists, all nutriment should be given by means of rectal enemata. In distressing tympanites the long rectal tube and injections containing turpen tine may prove of value.
Antistreptococcic serum has been tried with apparently good results, but the evidence so far adduced is not suf ficient to warrant any conclusion as to its merits.
Case of general suppurative peritonitis in which, after multiple incisions and drainage by multiple packings of gauze and by a large drainage-tube passed into the vagina, the infection yielded only after injections of the antistreptococcic serum.
Antistreptococcic serum appeared to act as follows: Temperature and pulse rate were uniformly lowered after each administration; elimination of waste, infectious products was favored; pus production was checked. Grandin (Mcd. Rec., Apr. 3, '97).
The surgical treatment of acute gen eral peritonitis carried out with proper technique and thoroughness has given the most brilliant results. The incision will depend upon the location of the cause of the peritonitis. Where the cause cannot be determined, the incision should be in the middle line. In other cases the position of the incision depends upon the location of the cause. The in cision should always be large enough to admit the hand of the operator and, if necessary, for purposes of drainage, sev eral incisions may be made. Vaginal incision is nearly always necessary in these cases when the cause of the peri tonitis is due to disease of the uterus, tubes, or ovaries. The incision having been made and the exciting cause found, it should be removed if practicable. The vermiform appendix should always be removed in appendiceal cases when it is possible to do so. The pus or serous fluid should be allowed to escape, and the intestines be delivered and supported in clean towels rung out of sterile hot salt solution. They should be gently
examined coil by coil and thoroughly cleansed by irrigation or sponging with hot salt solution. If the intestines are much distended and filled with fluid faeces, they should be incised in some convenient place and the gas and faeces allowed to escape, after which the in cisions must be closed with Lembert sutures. Every part of the abdominal cavity must then be thoroughly cleansed by irrigation or mopping. The intes tines are then returned and drainage established by gauze, the ends of the drains being so placed above, below, and between the coils of intestines as to drain every portion of the peritoneum. The incision or incisions are then approxi mated by silk-worm-gut sutures, taking care not to close tightly in the position of the drains. Many operators advise leaving as large a quantity of salt solu tion in the abdomen as possible before closing the wound. It seems to prevent or minimize shock and to promote ab sorption. It also seems to act as a cir culatory stimulant. It is often advisable, in these cases, before the patient comes out of ether, to give high rectal enemas of hot salt solution. The quantity should be about 1 quart and the temperature from 105° F. to 110° F. During the first twenty-four hours the patient should be freely stimulated with whisky, and strychnine employed hypodermically. Rectal alimentation may begin early and be gradually replaced by mouth-feeding as soon as the condition of the wound warrants it. As soon as the stomach will permit of it, calomel should be given in divided doses, followed by small doses of salts and enemas until the bowels are freely opened and all distension disap pears.
One hundred and nineteen cases of laparotomy in general peritonitis col lected, the origin of which was deter mined in all but IS. of which 9 were successfully treated by laparotomy and 9 died. The majority of the remaining 101 cases belonged to the category of perforation-peritonitis. Of these, 36 were cases of general peritonitis following perforation of the vermiform appendix; 12 were cases of typhoid perforation, and these yielded 5 successes; 12 were due to perforation from gangrene and other causes implicating the bowels; of the gangrenous not 1 recovered, and of the S others only three were cured by the operation. Of traumatic cases, 3 of punctured wounds and 1 of gunshot wound recovered; but, of contusions, only 3 out of 8 cases recovered from laparotomy. The measure, however, saved 5 out of 13 cases of puerperal peri tonitis. Lastly, a group of cases of peri tonitis from various other causes gave 3 deaths and 6 recoveries. Total result is 119 cases of general peritonitis treated by laparotomy: 51 recoveries and 6S deaths. Krecke (Munch. med. Woch., Nos. 33 and 34, '91).