Temperature is an uncertain factor. It sometimes rises high at first, and then falls, while if it fall too low the prognosis is serious. The pulse also shows very irregular variations, usually rising, however, as the disease becomes more severe, and being often almost uncountable at the end. A combination of rising pulse and falling temperature is of serious import.
In addition to the vomiting, which is a pronounced early feature of the disease, we have, as bowel obstruction comes on, an added fecal character to the vomitus, which sometimes is most characteristic of complete obstruction. This obstruction is due in part to toxic paralysis of the muscular coat of the bowels, and in part to the result of adhesions or fixations by which bowel motility is completely prevented. Thus in many instances of peritonitis following acute appendicitis there are loops of intestine glued together by exudate in such a way as to practically occlude or disable them.
The depression, shock, and final collapse of the disease are characteristic, as is also the facial appearance, the cheeks becoming discolored and the orbits hollowed out, so that the eyes early sink back. Other expressions of diminished blood pressure are not lacking—coldness of the extremities; cold, clammy perspiration; lividity of the skin, and the like.
While this is a picture of the most common expressions of acute septic or surgical peritonitis, it is occasionally found that conditions equally serious arise without such marked symptoms, and that the patients become rapidly worse, finally dying, who neither vomit continuously nor show extreme meteorism nor abdominal rigidity. Such cases are thereby stamped as those of more extreme toxicity, where systemic reaction is paralyzed almost from the outset, and are accordingly the more hopeless on that account.
Ordinarily it is not difficult to recognize the onset and the course of peritonitis in surgical cases. The condition may be confounded with one of septic intoxication from some focus which has not involved the peritoneum; otherwise differentiation is rarely difficult. The occurrence of such a condition does not necessarily indicate faulty technique on the part of an operator, as the condition is too often present when the surgeon begins his work. On the other hand, it too often follows faulty technique and constitutes the strongest argument for vigilance both in preparation, performance, and after-treatment.
Treatment.
—But little will be said here about non-operative treatment, although first it should be emphasized that treatment in the past was too often of the non-operative type. Many cases of peritonitis could be saved by operation were it performed while the infection is still localized, but this is at a period when they too rarely reach the surgeon’s hands, he being called in as such when the inefficacy of drug treatment has been already demonstrated. Without denying that the surgeon is not blameless in all these respects, blame should, nevertheless, be placed where it properly belongs, at the door of the man who fails to recognize and carry out plain surgical principles.
The opium treatment for peritonitis, with which the name of Clark will always be associated, was introduced at a time when many things were considered as peritonitis which were not necessarily such. It was furthermore an advance on previous methods and gave better results. That, however, is no excuse for adhering to it when better means are at hand. On the other hand it must not be denied that much can be done medicinally to give comfort and meet certain indications. In spite of the many disadvantages attaching to the use of opiates it seems unnatural to let patients suffer as they would without them. It is justifiable, then, to use them in cases which are hopeless, or in those which refuse operation; but given indiscriminately and early they often mask symptoms which, if properly appreciated, would lead to early diagnosis, and, it is to be hoped, early operative relief. Views also differ regarding catharsis. It is a great disadvantage to permit the intestines to retain fecal matter for days and add a consequent copremia to the other features of the disease. On the other hand, intestinal activity tends to disseminate infection, and is, consequently, most undesirable. If at the outset the intestinal canal could be emptied and then left at rest it would best meet the somewhat contrary indications.
Ordinarily, however, it is of small advantage to keep bombarding the stomach with repeated doses of laxatives which are more often rejected than retained, and which have little effect.
One of the most distressing features is vomiting, and here it is well to follow Berg’s suggestion and test the vomitus with litmus paper. If it be found alkaline small doses of morphine should be given, each with a drop or two of aromatic sulphuric acid, in a little chopped ice. If it be found acid small doses of milk of magnesia are advised or some such preparation, with minute doses of morphine, frequently repeated. The greatest relief in these cases, where the upper bowel is emptying itself into the stomach, will be obtained from lavage. In the same way tympanites and meteorism are best treated by passing a rectal tube high, leaving it in place, and utilizing it for lavage of the bowel, using warm water with a little sodium salicylate. Not the least distressing feature of such a case is the reflex hiccough which is produced by diaphragmatic spasm, since the phrenic nerve distributes sensitive fibers as well to the peritoneum. For this there is no really effective remedy. Small doses of Siberian musk, with or without morphine, beneath the skin will sometimes quickly relieve it. Depression and lowered blood pressure are best treated by adrenalin and digitalis, rather than by strychnine, which stimulates peristalsis. Fever, when high, should be treated by cold sponging rather than by antipyretics. The kidneys should be kept active, if necessary by hypodermoclysis, and the skin equally so by hot-air baths, as through both of these emunctories much elimination may be effected. The question of catharsis comes up again in considering what can be done to improve elimination of ptomains by watery stools, but these are hard to secure; it is, after all, questionable whether their effectiveness in this regard has not been greatly over-rated. Richardson, for instance, is inclined to believe that cases reported as cured by free catharsis would, in all probability, have recovered without it, it being doubtful whether the really infectious element be present.