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toms many surgeons maintain that an operation should be performed at once, because the mildness of the symptoms is no assurance that even in an hour or two gangrene or perforation will not occur. Early operation is comparatively safe; operation after perforation, gangrene, or septic peritonitis arises must be done, but it is not unusually futile. Murphy, Deaver, and others operate at once in every case. Keen, Senn, White, Grieg Smith, and others strongly oppose this plan. Other surgeons, in a first attack, if the symptoms are mild, wait and temporize, apply a hot-water bag over the right iliac fossa to favor plastic exudation, and give opium in full doses. Some begin treatment by the administration of salines, apply an ice-bag over McBurney's point, and after a free movement of the bowels give opium and keep the patient on liquid diet. If the symptoms become worse, they recommend operation. The author does not believe that it is proper to always operate. Such a rule makes decision easy, but not of necessity right. In a case with severe symptoms operate at once, but in an ordinary mild case watch the patient for a few hours. McBurney says, if six hours after the beginning of the attack the patient is no worse, there is no pressing danger, and if in twelve hours symptoms are not intensified, they will soon begin to abate; but if in the twelve hours the case has become worse, operation is necessary. It is well, if possible, to operate in an interval in preference to operating in an attack. McBurney says, if in twenty-four hours from the onset of an attack the severity of the symptoms lessens, it is usually possible to wait for an interval; but if during the second twenty-four hours the abatement in symptoms has not gone on and there is doubt as to the condition, operate at once. It is not safe to delay operation in a pus case, hoping that the pus may become well limited. It may become limited, but it may instead pass up toward the liver or down into the pelvis, and delay is fraught with peril. The interval operation can be performed about three weeks after the attack, or later. If there has been but one acute attack, there may never be another, and operation need not be done unless tenderness persists or there are colicky pain and tenderness after exercise. But if a man has had two attacks, he is certain to have others, and an interval operation must be performed (see Operation for Appendicitis).

1 N. Y. Polyclinic, Jan. 15, 1897.

THE PERITONEUM.

Peritonitis. In rare instances peritonitis is said to be primary, following a cold; but most surgeons doubt this. Plastic peritonitis is due to an aseptic cause (traumatism or chemical irritation); it remains limited, and is really a process of repair rather than of inflammation. The symp toms of plastic peritonitis are local pain, tenderness, and rigidity. Fever exists, due to the absorption of fibrin-ferment and the products of tissue-change; adhesions form, which may be either temporary or permanent. Recovery is the rule. The treatment comprises saline purgatives followed by rest, a liquid diet, and local heat (hot-water bag or fomentations).

Diffuse septic peritonitis is apt to destroy life even before the peritoneum presents any marked change. Death ensues from the absorption of toxic alkaloids. Septic peritonitis may arise during puerperality, through lymphatic infection; it may be due to infection from without by an operation or an accident; to perforation of an ulcer; to gangrene of a portion of the intestine; to rupture of an abscess into the peritoneal cavity; or to migration of micro-organisms through a damaged wall of the bowel. It is made manifest by a chill, shock, or rapid collapse; very rapid pulse, which is at first wiry and later gaseous; a temperature which may be at times febrile, but which is apt to be subnormal or which soon becomes so; dry tongue, delirium, and persistent vomiting. Rigidity may exist, and also intestinal obstruction; often, but not invariably, there is distention. In puerperal peritonitis or septic peritonitis from operation there is often no pain; in perforative peritonitis there is acute pain. Patients usually die within five or six days. Treatment is rarely successful. Stimulants are strongly pushed. The patient is fed upon liquids (koumiss especially). The abdomen is opened in the middle and also upon one or both sides. Any perforation is closed. In some cases a suprapubic incision is also made, in other cases an opening is made in the loin. In a woman Douglas's sac is opened through the vagina. The peritoneal cavity is wiped out with gauze pads or is flushed out with gallons of hot normal salt solution. Special attention is given to cleansing Douglas's pouch and the space between the liver and diaphragm. The wounds are left open, and drainage is maintained by strips of iodoform gauze.

In fibrinoplastic peritonitis the septic organisms are

fewer or less virulent, the products of germ-action are limited and surrounded by adhesions, and circumscribed suppurative peritonitis is apt to arise.

Suppurative peritonitis differs clinically from septic peritonitis in the fact that it is more apt to be circumscribed and less apt to be fatal. The causes of both are identical. In septic peritonitis death occurs from absorption of toxins before obvious pathological changes occur in the peritoneum; in suppurative peritonitis the microbes are fewer, are less virulent, or vital resistance is more decided, and suppuration follows marked changes in the peritoneum. In suppurative peritonitis the pyogenic bacteria are always present, and there exists in the peritoneum a wound or damaged area to constitute a point of least resistance.

Symptoms. Chilliness or a rigor is common, followed by fever, the temperature rising to 102° or 104°; pain is intense, and is accentuated by motion and pressure; the attitude of the patient is assumed to relieve pain (he lies upon his back, with the shoulders raised and the thighs drawn up); there are vomiting, obstinate constipation, and distention and rigidity of the abdominal walls. The pulse is rapid; is at first wiry, but may become gaseous. The constipation may be due either to tympanitic distention or to the shock of a perforation inhibiting intestinal peristalsis. Vomiting is frequent. In perforation gas often passes into the peritoneal cavity and obscures the liver-dulness; in tympanites without perforation the liver is pushed up and its dulness usually remains, but on a higher level. Pus unconfined by adhesions will gravitate to the most dependent part of the peritoneal cavity. Circumscribed suppurative peritonitis presents the signs of a deep abscess (swelling, dulness on percussion, local rigidity, irregular temperature, sweats, and possibly edema of the belly-wall). In some cases of suppurative peritonitis there is no tympanitic distention or rigidity; in some cases there is no fever, and a subnormal temperature may even exist. The high-tension pulse of peritonitis is due to the tympanitic distention emptying the bowel-walls of blood, and thus increasing the amount of fluid in the other vessels of the body.

Treatment. In the beginning of ordinary peritonitis without perforation give a saline cathartic, which will empty the peritoneal cavity of fluid, will favor the elimination of microbes, and will combat inflammation. The old-time remedy was opium, but Tait proved its inefficiency, and showed that it masked the symptoms and often created a false sense of

security in the very midst of imminent dangers. The usual method of administering salines is to give 3j of Rochelle salt and 3 of Epsom salt every hour until a free movement occurs. This treatment will often cut short a beginning peritonitis, and will frequently prevent a peritonitis after an abdominal operation. Give an enema of turpentine at the same time as the saline. If this treatment fails, open the belly, explore for the causative condition, remedy it, flush, and drain. In perforative peritonitis do not give cathartics: they will only increase the extravasation and prevent its limitation by lymph. As soon as the patient has reacted from the shock of the perforation perform a laparotomy, suture the perforation, flush out the belly, and drain. A circumscribed abscess is to be opened and the primary lesion sought for and, if found, removed. Do not tear the lymph-barriers in an attempt to find the primary lesion; rather let it go undiscovered. Pack iodoform gauze against the intestines to reinforce the barrier of lymph, and insert a tube. In some cases make incision for drainage in the opposite side of the belly, above the pubes or through the right kidney pouch. It is frequently advisable to leave the wounds open and drain with iodoform gauze. Every patient with peritonitis requires stimulants and frequent feeding with liquid food.

Tubercular peritonitis is seen by the surgeon as a primary local tuberculosis, though it occurs also as an associate of phthisis and as a part of a general tuberculosis. Abdominal section with or without drainage cures not a few cases. Why it cures is doubtful. Abbe thinks that the fluid acts as a culture-medium for bacilli. When the fluid is removed the tissues regain their powers of resistance, and the inflammation which follows the operation, plus the vital resistance of the tissues, causes fibroid transformation of the peritoneal tubercles; but aspiration will not cure, while incision will.

Subphrenic Abscess.—A subphrenic abscess is a collection of pus beneath the diaphragm. The pus, as a rule, occupies a part of the lesser peritoneal cavity; in rare instances it is extraperitoneal (when it is of renal origin); in some cases it is contained in the area between the diaphragm, cardiac end of the stomach, and liver or spleen. It is an unusual thing for such an abscess to break into the general cavity of the peritoneum, but it may break into the pleural sac (Maydl).

Causes.-Perforation of a gastric ulcer, perforation of the gall-bladder or gall-ducts, ulceration of the duodenum, disease of the liver, spleen, pancreas, intestine, appendix, or kidney, hydatid disease, internal injury, metastasis, external injury,

caries of rib, or disease of the pleura may be responsible for a subphrenic abscess (Maydl).

Symptoms.-There are the constitutional symptoms of suppuration and a swelling in the subdiaphragmatic region, these symptoms ensuing upon one of the causative conditions before mentioned. In many cases the abscesscavity contains gas as well as fluid. Empyema and subphrenic abscess resemble each other. In empyema the upper limit of the fluid is concave; in subphrenic abscess it is convex. In empyema the flow of pus through an aspirating-needle will be most marked during inspiration; in abscess, during expiration-the same is true of the rush of gas. In empyema the needle does not oscillate; in abscess it does.1 The fact that an abscess contains gas is shown by the existence of a tympanitic percussion-note over a part of the cavity and an alteration in the area of tympany with an alteration in the position of the patient. An abscess of the liver does not contain gas and alters decidedly the outlines of the organ.

Treatment. Incision and drainage. The incision in some cases may be made through the abdominal wall (epigastric region, iliac region, hypochondrium, or loin). In other cases the chest-wall is incised, a rib is resected, the pleura is opened, and the diaphragm is incised.

THE LIVER AND GALL-BLADDER.

Wounds of the Liver.-A wound of the liver causes violent hemorrhage which is usually rapidly fatal. Such a wound is apt to divide bile-ducts and allow of the escape of bile into the peritoneal cavity. Bile if sterile will do little harm, but if it contains organisms will produce a diffuse peritonitis. Patients do not always die from a serious traumatism of the liver. Some recover because operation has been performed. Some few recover without operation. This last fact is proved by reports of autopsies in which scars were found in the liverparenchyma (Nussbaum). The fatality which usually ensues on a liver injury may be due to hemorrhage or peritonitis. If a surgeon is called to a patient suffering from wound of the liver, he must open the abdomen to arrest hemorrhage. In a penetrating wound, the wound in the abdominal wall must be enlarged. If the left lobe of the liver is wounded, or if the question as to which lobe is wounded is uncertain, the incision should be median. If the right lobe 1 Wharton and Curtis, Practice of Surgery.

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