Should a nurse trained in the technique of Murphy's method of procto not be available to superintend the operation, very good results may be obtained by rectal injections of 1 to i pint of normal saline every 2 hours, the injection being given slowly through a rubber catheter and funnel so as to avoid inducing reflex movement of the rectum.
When for any reason the rectal route is not permissible, the saline should be administered hypodermically or in urgent cases intravenously.
If vomiting continues after operation, the stomach should be washed out, and as paralysis of peristalsis leads to great distension of the bowel with gas it is often necessary to empty the colon by a series of doses of a saline purgative (I dr. sodium sulphate every hour) preceded by a full dose of Calomel. In these cases of distension the injection of Pituitrin (1 c.c.) is often of great value.
Some surgeons recommend the routine performance of appendicosionzy in diffuse septic peritonitis before suturing the abdominal wound. The appendix having been removed, all but the sphincter at its base, any quantity of saline solution can be injected through a syringe introduced into the stump so as to flush out the entire colon several times a day. This method is especially valuable in the case of children whose restlessness prevents the satisfactory adoption of Murphy's rectal infusion.
In some cases it will be necessary to incise a distended coil of bowel when there is much difficulty in returning the intestines within the abdom inal cavity, and it may be imperative to insert a glass T-tube with an attached rubber tube, which is to be secured in the abdominal wound in order to permit the accumulated flatus to escape slowly from the paralysed bowel, especially when the diffuse peritonitis is the result of intestinal obstruction.
After operation, pain and restlessness may be so severe as to call for Morphia hypodermically. When this drug is employed, it is a good routine to combine Strychnine with it, and some surgeons in the after treatment of peritonitis affirm that the action of strychnine is of itself quite as satisfactory as the results of a narcotic when the symptoms are those of severe restlessness.
As little fluid as possible should be administered by the mouth for the first day or two. The rectal infusion usually effectually relieves thirst, but
when this remains intense small quantities of ice or hot water may he permitted.
In cases where the desperate condition of the patient does not permit of immediate operation saline should be injected hypodermically by the veins or by Murphy's rectal method, and after an attempt at rallying or reaction has occurred the abdomen can be opened with a better prospect or recovery.
Deaver, whilst acknowledging that the only hope of saving a patient suffering from perforation of the stomach, duodenum or intestine or from rupture of the gall-bladder, liver and spleen lies in immediate operation, believes that the peritonitis caused by cholecystitis and pancreatitis should not be immediately subjected to operation; he prefers, if the patient has been already ill for 48 or 5o hours, to wait for localisation of the signs.
Pneumococcal Peritonitis.--This form of acute inflammation of the peritoneum is commonly seen in childhood, and is often part of a general infection associated with pleuritic, pneumonia or pericarditis, the micro organisms reaching the abdomen through the blood-stream or by extension from the diaphragm. The treatment should consist in speedy laparotomy and the evacuation of the copious amount of fluid usually present, irriga tion of the cavity with hot saline and the introduction of a free drain down deep into the pouch of Douglas.
Post-operative Peritonitis.—The form of acute peritonitis which some times supervenes upon abdominal operations as ovariotomy, gastro enterostomy, &c., must also be treated as of septic origin, being as a rule either the result of leakage into the sac of intestinal contents or of accidental admission of septic organisms owing to imperfection in the technique of the operation.
The treatment will consist in the employment of rectal infusion by Murphy's method, and after alleviation of the symptoms of shock the abdominal wound should be opened up, irrigation of the sac with hot saline solution and the introduction of a drainage tube deeply into the pouch of Douglas should be effected, and such other procedures as the local condi tions associated with the primary operation demand in order to prevent further leakage and soiling of the peritoneum.