PERITONITIS.
Acute diffuse inflammation of the peritoneum is seen in its most typical form after perforation of some portion of its gastrointestinal tract, and must be treated on the basis of its being a septic process. Even when a perforation does not exist the infective nature of the inflammation must be accepted.
As soon as a diagnosis has been made the abdomen should be opened with the least possible delay, as the result of innumerable statistics prove that the mortality rises with each hour of delay. Morphia should not be administered, because of the masking of the symptoms which invariably occurs, and results in procrastination of operative procedure till too late. Nothing must be given by the mouth when possible, and the rectum should be washed out by a copious warm enema. The bladder should be evacuated, and if foul-smelling matter has been vomited the stomach should be irrigated and a large hypodermic of normal saline administered. A general may be employed when the patients condition permits. Some surgeons prefer to operate under spinal anaesthesia, and the operation has been often performed under the local antesthesia produced by hypodermic injections of Stovaine or other local anaesthetic.
Where the exact diagnosis of the primary lesion is doubtful, the best plan is to make a median incision midway between the umbilicus and pubes, and to proceed at once with an exploration of the abdomen in order to discover the site of perforation, beginning in the right iliac fossa.
Should the appendix be found to be the septic focus, this is to be dealt with by the measures described under Appendicitis. Perforation of the stomach or intestine will require closure by the methods detailed in the articles dealing with these lesions, evisceration being when possible avoided. Should the intestines require to he drawn outside the abdominal cavity, they must be carefully protected by compresses soaked in hot saline solution. The utmost expedition compatible with efficiency should be aimed at in order to minimise shock, and all uninfected regions of the peritoneum should be protected from infection by gauze tampons.
The toilet of the peritoneum is carried out in various ways according to the fancy and experience of the operator. The practice of scrupulous mopping out of all traces of exudation and scrubbing off lymph and flushing the entire abdominal cavity with weak antiseptics or sterile saline solution with the view of afterwards sealing up the abdominal wound is steadily giving way to the more rational method of rapidly removing exudation by gentle friction with gauze and the establishment of efficient drainage.
This latter routine has unquestionably reduced the mortality enor mously when combined with the postural method of drainage introduced by Fowler, and rectal saline alimentation as carried out by Murphy. In localised peritonitis the introduction of a wide rubber tube when this can be introduced directly and kept in situ at the septic focus, as in appendicitis, answers all the requirements of efficient drainage, especially when com bined with gauze or " cigarette " drains. But in most cases of diffused septic peritonitis the best procedure is to place the patient in bed imme diately after operation supported by pillows in the Fowler position i.e., in a half-sitting posture—so that all fluid gravitates into the pelvis, from which it can effectually escape through a large drainage-tube passed down into Douglas's pouch. In pelvic peritonitis the peritoneal cavity may be drained through the vagina.
Murphy's method of continuous prododysis should be employed; this has reduced the mortality to about one-eighth of its former rate. A reservoir or fountain syringe capable of holding about 3 pints to which is attached a rubber tube with a long rectal nozzle is all that is required. The nozzle on being inserted within the sphincter is left in situ for a few clays, and the reservoir is elevated from 6 to 12 inches above the level of its extremity in the rectum and the fluid is permitted to trickle into the rectum at the rate of about 3o oz. in the hour. By putting this charge into the fountain every 2 hours it flows into the rectum within 6o minutes, which gives the bowel a rest of over i hour between the fillings and secures the administration of 18 pints or 36o oz. fluid in the 24 hours, all of which may be absorbed. The liquid should be at a temperature beyond the normal body heat to allow for cooling as it flows through the tube. Paterson's irrigator is provided with an electric heater, which secures a temperature of F. in the Saline solution as it enters the bowel. Murphy's fluid consists of 90 grs. each Chloride of Calcium and Chloride of Sodium to the 3o oz. water; ordinary normal saline So grs. Chloride of Sodium to each pint of water is generally employed. This continuous rectal infusion with saline flushes the skin and kidney, and promotes elimination of the toxins, at the same time secures restoration of the blood-pressure and retardation of the absorption of toxic products by the peritoneal surface. Beef tea may be added to the saline after the expiration of 24 hours in many cases with advantage.