Surgical treatment of peritonitis includes a recognition of the cause, and, if possible, its removal. Richardson has grouped in the following suggestive manner the indications for operative intervention in the early stages, when cases are not without hope:

On the other hand, in cases of fully developed peritonitis, where the surgeon may still consider the possibility of intervention, but where prognosis is far less favorable, the conditions include:

In such cases the decision rests largely upon the degree of collapse. To operate upon a moribund patient is hopeless and brings discredit upon surgery. Before operating upon any serious case of this kind the circumstances should be fully explained to those concerned, and they should be impressed with the fact that should the patient die he dies not in consequence of the operation but in spite of it.

The operation itself will in a large measure depend upon what can be learned of the etiology of the disease and the diffuseness of the resulting infection. To reach a localized focus the incision may be made at any point which will best afford access; but in dealing with a generalized process the middle line, and an extensive incision, will ordinarily afford the best opportunity for doing whatever is necessary.

The preliminary incision may be made short, as for exploratory purposes. Unless a loop of distended bowel be at once blown into the opening there will be prompt escape of fluid, whose character will reveal much of what has gone wrong within. If reasonably clear the operator is fortunate. If it be purulent he has to combat a most serious condition; if it be offensive, it is probably due to contamination from a septic abscess or from intestinal gases, while if the fluid be nondescript and contain floating particles of fecal matter there is an intestinal or gastric perforation. So soon as one comes upon fixation or adhesion of viscera he will find lymph, in condition of greater or less organization. Inside the masses thus bound together he will probably find the greatest centre of pernicious activity.

The more one sees of these intra-abdominal conditions the more respect he, as a surgeon, feels for the omentum. Only recently have surgeons learned to appreciate the kindly activities of this duplicature of the peritoneum, with its slight or heavy load of contained fat. It manifests a tendency which may be almost regarded as a sagacity or instinct for shifting itself toward a local focus of infection, and there throwing out lymph by which it becomes attached and helps to form a protective barrier that often is most effective. Were it not for this tendency many cases of acute appendicitis, for instance, which now recover would be lost during the early days of the attack, in consequence of a quickly disseminated infection. Thus a gangrenous appendix, or hernia, or gall-bladder, is frequently so wrapped up in a protective layer of omentum that the operator has first to detach this, or go through it, before he comes upon the actual site of the trouble. Some such disposition of the omentum, then, may be easily discovered during the earliest moments of his exploration, and if later he conclude to remove a portion of it, because of actual or impending gangrene, he nevertheless sacrifices it with a feeling of regret because of the good it has already done.

The further treatment of these cases is essentially a matter of what can be done to remove the exciting cause. Questions of gravest import, and often difficult of immediate decision, will present in nearly every case; as, for instance, whether to resect a portion of intestine, to remove a gall-bladder, to hunt for an appendix when embarrassed with the difficulty of the effort and necessity for widely separating intestinal coils, or of the treatment of distended bowel, which it may perhaps be impossible to restore to place, of extensive and complete flushing of the abdominal cavity, or of mere local cleanliness. And after these questions have been decided, and action taken, there comes still the question of drainage, with the wisdom of or necessity for counteropening, as in the loin or in the cul-de-sac, and the character of drain to be used. As to what should be attempted in general there will rarely be much room for doubt. As to how best to accomplish it should be decided according to the training, the experience, and the opportunities of the operator, and the nature of the environment. When the entire peritoneal cavity is invaded, and flooded with more or less infectious material the more thoroughly it can be washed out the better. At the same time to do this with any degree of even apparent thoroughness requires practical evisceration of the patient, and an amount of time spent and shock produced by handling the viscera, which are exceedingly depressing and may of themselves be more than can be borne. The meteorism, which is so conspicuous a feature of most of these cases, means the distention of the bowel to such a degree that when once the intestines lie upon the surface of the body they can usually be restored with the greatest difficulty; and this would raise the question of the desirability of either one or more punctures, through which gas should be allowed to escape, or a sufficiently wide opening, with the introduction of a Monk tube, and the complete emptying both of gas and putrefying fecal matter. The latter is certainly in theory the much more desirable measure, if the patient’s condition will only justify it. Probably after pelvic drainage the Fowler semi-sitting posture in bed would be desirable, while after high drainage the Trendelenburg position, with the pelvis higher than the thorax, would be preferable.

If free abdominal irrigation is to be practised a large quantity of warm sterile saline solution should be used, to which may be added perhaps a small proportion of acetozone or of mercury bichloride. The silver salts also make equally effective and less irritating fluid, the nitrate being used in the proportion of 1 to 10,000, or the citrate or lactate in proportion of 1 to 500 or 1 to 1000. These metallic salts will coagulate the albuminoid fluids and give to the peritoneum an opaque appearance, which, however, need cause no alarm.