Operation personally performed on nineteen cases of purulent peritonitis, ranging in age from 2 to 71 years. Six of these cases are still alive. One of them has a small intestinal fistula. Favorable age for operation is between 18 and 31. Korte (Centralb. f. Chir., Aug. 13, '92).
In septic peritonitis the incision should be made in the middle line, or elsewhere, if perforation is suspected, but in every case it should be large enough to allow the ready insertion of the surgeon's hand into the peritoneal cavity. All exudation should be removed from the peritoneum by sponging, irriga tion with hot (110° F.) sterile solutions, or by turning the patient into the prone or semiprone position and allowing it to drain out, When the intestines are distended, it is often advisable to make small incisions into them, or to puncture with a needle. Incisions are afterward sewn up. Free drainage should be estab lished. Usually capillary drainage is the more satisfactory. Plain sterilized gauze should be covered with one or two layers of iodoform gauze, so as to avoid the occurrence of iodoform poisoning. Drain age should be dispensed with as soon as possible, and should be left off gradually. Before closing the external wound it may be advisable to inject a strong solu tion of a saline cathartic into the lumen of the intestine through the walls. Senn (Brit. Med. Jour., Sept. 4, '97).
In operation of acute general perito nitis, when only the lower segment has as yet been invaded, the presenting bowels are mopped with sponges in clamps, dripping wet with hot salt solution (1 'A drachms to a quart), and dried again before other coils are drawn into the field of inspection. As soon as parts are found not much inflamed, a sterilized gauze tamponade, properly folded, is pushed among the bowels far away from the field of work. This has a tape sewed to it, to which a clamp is fixed and left outside the wound. One or two such tamponades may be thrust upward and across the abdomen before the pel vis is cleansed. This being thoroughly mopped out, a light packing of mild iodoform gauze is to be placed in the pelvis, and a short way among intestinal coils elsewhere. The abdominal wound should never be closed in any septic case. In the grave cases, a long, median in cision, or two lateral ones, will always be needed. The lumbar-drainage in
cision will not be necessary when the median cut is used. Drainage with ample gauze packing is to be used. When infection has been wide-spread, irrigation should be used, the interin testinal spaces being flushed systemat ically with hot salt water, as hot as the operator's hand can bear (which will be over 105°, usually). If the intestines are distended with gas and fluid faeces, it is well to let them come out of the abdomen, receive them in hot towels in charge of an assistant, and prick one or two prominent places with a knife to evacuate gas and excreta, which is washed away with a constant hot stream. Through one opening there should then be injected a syringeful of saturated solution of Epsom salts and the puncture closed. In regurgita tion, lavage of the stomach should be done before and after operation, and re peated as soon as regurgitation is re newed. Rectal tube to relieve distension by gas is of inestimable value. An ice coil, or light, broad ice-bags after a gen eral peritonitis retards the inflammatory action and bacterial growth either before or after operation. Strychnine, Vto grain every 2 hours, is sometimes neces sary, and in cases of severe pain when the patient is well out of ether, mor phine, hypodermically. Abbe (Med. News, May 29, '97).
In order to establish free drainage of the intestinal canal in grave forms of peritonitis complicated with paralysis it might be advisable to make one or more openings in the distended intestine, care being taken by packing that the dis charges from these openings be prevented from coming into contact with the peri toneum or the external wound. Three cases of acute septic peritonitis, in which this treatment was followed by good re sults. In two of these, inflammatory mischief had been set up by appendicitis. If in any case of acute peritonitis treated by laparotomy the distension and pa ralysis of the bowel be not complete, it might be found beneficial to leave some distended intestine in the external ab dominal wound, and to suture it there, so that at any subsequent time if the bowels be not moved, or if the symptoms of septic absorption continue, artificial openings may be made. Can Arsdale (Annals of Surg., Jan., '99).