The closing of the abdominal cavity should be done as simply as possible and with the least practicable amount of suture material, to avoid the expulsion of the sutures from the infected wound (whenever possible tobacco-sack suture of the peritoneum). We close the skin and fascia' with figure-of-eight sutures which are tied on the skin.
The after-treatment has to avoid two clangers: ih•us and weakness of the heart. The net: is usually a dynamic one and it caused by the paralysis of the peristalsis from the suppuration and its toxins. By entirely closing the abdomen we place it again under its normal pres sure and osmosis. The muscular contraction, together with the pres sure from the diaphragm and the abdominal respiration, not only help in forcing the pus through drainage tubes, but they also place the peri toneum as much as possible under its normal conditions of function and blood-supply so that it can resume its fight.
Warm applications by means of thermophores or, because these cannot be borne on account of their weight, poultices or bags of chamomile, aid in re-establishing the function of the intestine. Rectal injections of glycerine and faradization of the abdominal wall are of service.
Of the greatest importance in these cases is the position of the patient in bed; to promote the discharge of pus the patient should be turned in the direction of the drainage tubes; Murphy advises a half-sitting pos ture whenever we have drained immediately above the symphysis or through the vagina. Smaller children are best placed in the right ventral position.
Should the paralysis be caused by agglutination of the loops of intestine, then the prognosis will be considerably worse; frequent washing with salt solution through the drainage tubes and oil infusions may give some relief, but they do not enter far enough; even eounter-drainage on the opposite side of the abdomen has not given us any favorable results.
As a last resort we may do a colostomy and pull out the first dis tended loop of intestine which is met on reopening the wound, open this, let out its contents and then form an artificial antis. The author, however, has never been able to convince himself that this operation, which has been lauded by others as a life-saving one, does much good.
The condition of the cardiac function is of the very greatest impor tance. The inflammatory reaction in the abdominal cavity (consider able differences of temperature between the rectum and axilla) dilates the abdominal blood-vessels tremendously and the child bleeds to death, so to say, into its own abdominal blood-vessels. The exudation and the formation of pus demand further large amounts of liquid, and this causes a dangerous sinking of the blood-pressure and interference with cardiac action. Infusions of salines with adrenalin give temporary relief, hut the amount of liquid in the blood diminishes more and more because the ingestion of liquid through the stomach and intestine is hindered.
Murphy has seen good results front the continuous rectal drop-irrigation of physiologic salt solution, but this is not feasible in children on account of their restlessness, and we therefore employ small hourly or half hourly enemas of salt solution (inicroclysinata); they must be just small enough to be retained (about 100 to 200 cc.) and must be given as often as absorption in the rectum allows (half-hourly). As soon as vomiting ceases, the liquid should nal tu.ally be ingested by mouth. With this treatment we have succeeded in the last few years in saving SO per cent. of our eases of general peritanitiS.
Though we may claim some of the credit for this conservative mode of treatment, which is well adapted to the physiological conditions of the child, we will find that the principal reason without doubt in the early operating which is now finally and universally adopted is the strong and healthy heart of the child.
We must not wait in operating for peritonitis until all internal treat ment has been proven in vain, until the heart has suffered from the intoxication and the sinking blood-pressure indicates imminent collapse, or until the diminishing leucocytosis (about method and value of blood examination see Appendicitis) tells us that the body is succumbing: then the additional shock from the operation will only hasten the inevitable.