The general indication having been met, the next question is one of local cleanliness and resort to irrigation. If the protection above described has been sufficient there will be a minimum of local cleansing required. This may be effected with hydrogen dioxide, or with or without other antiseptics, according to the choice of the operator. Obviously every focus of disease should be as thoroughly cleansed both of clotted blood and debris or pus. When this can be accomplished by gentle wiping or swabbing it may be sufficient. When this is not possible irrigation and drainage should be provided.
Irrigation of the abdominal cavity has been widely practised, and has advantages as well as disadvantages which have caused it to be differently regarded by different operators. While little hesitation need be felt about washing out a well-localized cavity, it is felt by many that to use a quantity of water within the complicated peritoneal cavity is to more widely distribute that which would best be not disturbed. On the other hand, it is maintained by some that infectious material so diluted and scattered is more easily capable of disposition by natural processes. The general trend of opinion is that a localized condition is best treated by local measures, and that general abdominal irrigation should be limited to cases of generalized infection. The temptation to use antiseptic solutions is very strong. Yet one must remember that any solution, of which a portion must remain, used in such a cavity and having sufficient strength to kill bacteria, will prove at least profoundly and perhaps fatally toxic to the individuals, because the peritoneum is a membrane of tremendous potential capabilities in the matter of absorption, and those chemicals which are toxic to germs are also harmful to the human tissues. Strong, then, as the temptation may be to use antiseptics under these circumstances, solutions used for the purpose should be made extremely weak if we are to do more good than harm. Warm sterile water or saline solution is then the generally accepted irrigating fluid, while a few use such antiseptics as acetozone in the strength of 1 to 10,000, or others of the more harmless drugs. In cases of tuberculous peritonitis exception may be taken to this and a solution used which is sufficiently strong to have some perceptible immediate effect.
When general abdominal irrigation is practised quarts and even gallons of fluid should be used, sufficient to accomplish the desired purpose. Various tubes have been devised for the purpose of conducting the fluid into the deeper recesses, and yet these, while convenient, are not essential. Practice varies somewhat as to whether to leave a considerable amount of saline solution within the abdominal cavity or try to free it of all fluid. The former practice is desirable, in theory at least, for if readily absorbed it will help in relieving shock and keeping the kidneys active. In general it may, however, be said that unless an isotonic saline solution is employed it is advisable to remove all that can conveniently be withdrawn before closing the belly.
The next important question is one of drainage, and here, again, men differ widely in their opinions. A distinctly purulent focus is doubtless always best drained. The question is argued rather with regard to the matter of possible spread of infection or in cases of general doubt. Drainage is always a confession either of fear or of impossibility of ideal removal of the primary difficulty. It certainly is less practised than in years gone by, but will always find a certain field of usefulness. Thus after some deep, extensive pelvic operations, where the separation of adhesions almost ensures a certain amount of leakage of blood, one should insert a glass or metal drain for a few hours, or a day or two, and through it aspirate at intervals such amounts as may accumulate in the cavity thus emptied. Nearly all cases of abdominal traumatism require drainage, best applied posteriorly, and practically all instances of acute pancreatitis, whether purulent or otherwise, will also require it, posteriorly as well as anteriorly. All old abscess cavities also demand drainage, no matter where located. No case of septic peritonitis, general or local, can be safely closed without similar provision. Drainage through the cul-de-sac is the best method of all, when available.
Drainage methods include the use of hard tubes made of glass, aluminum, or celluloid, perforated with numerous openings through which fluid may escape into their interior. These are used mainly for drainage of the pelvis through an abdominal wound. Soft-rubber tubes of varying sizes may be used in many ways, either by themselves or when split longitudinally, and made loosely to enfold a strip of gauze, or when lightly wrapped with gauze and covered with perforated oiled silk. Except when it is desired to drain a gall-bladder or some similar circumscribed cavity, which can be closed around the tube, such tube should have numerous large openings cut in it. Cigarette drains consist of small rolls of gauze wrapped with oiled silk, then fenestrated and secured with a piece of catgut tied around it to prevent it unwrapping.
Ordinary absorbent gauze or prepared gauze may be used by itself to any desired extent, but when so used it is usually well to make the amount sufficient to effect the purpose. Thus a drain at least one inch in diameter or even exceeding that size will be much more effective than two or three small strips. In using this it is well to protect the wound margins with strips of oiled silk, between which the gauze is deeply passed, as in this way its adhesion to the wound edges is prevented, such adhesion being undesirable both because it helps to prevent the escape of fluid and causes pain when the gauze is removed. In this way it is well to combine the double purpose of drainage, and pressure to check oozing, by packing in sufficient gauze to accomplish both. These gauze drains, when well soaked with discharge, are easily removed. Otherwise they frequently adhere and cause much discomfort during the act of removal. In such a case it is an advantage to wet them from the outside, perhaps three or four hours before withdrawing them. Even with such a gauze drain there is always the danger of causing fecal fistula if it be left too long in situ. It is, therefore, always undesirable to leave a drain, even of this apparently innocent character, longer than absolutely necessary.
In not a few cases through-and-through drainage—i. e., by a counteropening—will be of great value, this especially in many cases of peri-appendicular abscess, where pus has collected behind the cecum. So-called posterior drainage of the abdomen is also advisable in cases of acute pancreatitis or deep retroperitoneal phlegmon. Here the opening is made from the back, by an incision two or three inches in length, just outside the upper part of the quadratics lumborum and near the costovertebral angle. In stout individuals a distance of two or three inches, or even more, must be traversed. After the more superficial incisions this opening may be effected by blunt dissection, and is best done with conjoined manipulation, one hand working on the exterior and the other in the interior of the abdominal cavity. Occasional necessity for such posterior drainage shows the wisdom of the practice of sterilizing the back as well as the front of the body as part of the preparation for operation.
Drainage having been effected by one of the above methods, the best of good judgment will be called for in determining how long it should be continued. First of all, no drain which fails to effect the purposes intended should be allowed to remain, and any drain around rather than through which material is discharged may be regarded as useless and a mere deleterious foreign body. Gauze which is supposed to drain by osmosis often fails, and in some of these drains it may be well to insert a few strands of silkworm-gut in order that material which is to become moistened may not collapse and adhere, thus destroying its own capillarity. A pelvic drain in a non-septic or but slightly septic case, inserted for removing escaping blood or collecting serum, may be removed in from twelve to sixty hours, according to the amount of discharge, which when collected with a syringe should be carefully estimated. Any cavity which is not filled at a rate faster than 2 or 3 Cm. in an hour may be regarded as capable of disposing of all the fluid which may collect within it, and every tube which is no longer needed is an irritating foreign body, whose lower end may press upon intestine, and even produce ulceration if allowed to make pressure too long. Appendicular abscesses usually require to drain from two to three or four days; gall-bladders and hepatic abscesses for a much longer time. In nearly all instances it may be expected that within from forty-eight to sixty hours after the establishment of drainage a natural passage will be formed, by exudate appearing first around the drain, and remaining after its removal, which should serve drainage purposes as would a canal. Sometimes the outer end of such a canal tends to close too quickly, and then with accumulation in the deeper part there may come retention, with later spontaneous escape, or possibly rupture into the abdominal depths, which may be serious. In nearly every instance, however, a large drain may be substituted within a short time by a smaller one and final removal be thus accomplished. Any localized cavity whose discharges are offensive or putrefactive should be cleansed each day, either with hydrogen peroxide or by gentle irrigation, or with a reasonably strong antiseptic solution—iodine, silver nitrate, etc. While no such cavity will close until all such material has escaped, it nevertheless is well to keep the external opening wide open, in order to hasten the whole process. This may be accomplished by gauze packing or the insertion of a short tube.
Cavities which persist, with apparently permanent fistulas, require more radical treatment, which will consist at least of a thorough curetting and considerable enlargement of the fistulous opening, in order to permit of this. Such a cavity, then, may be comfortably packed with gauze for a few days.
The use of massive tampons and the introduction of large-sized pieces of gauze into the abdominal cavity have been generally discontinued, largely through the writings of Morris, who stigmatized such practice as “committing taxidermy upon patients.”