Another question of importance is that of enterostomy. In some of these cases the acute bowel obstruction is the most predominating and distressing late feature, and an enterostomy may be attempted, even though it be known it will serve but a temporary purpose, in order to relieve distress. There never can be more than sentimental objection to it, in such cases, with the possibility of something more than mere temporary relief. It can be effected under local cocaine anesthesia, by attaching to the parietal peritoneum the first loop of distended small intestine that presents, and, after firmly fixing it in place, making a small opening, and then preferably inserting a glass or other tube for better drainage purposes.
These constitute the precautions to be followed and the advice to be given in cases of septic or surgical peritonitis. How successful they may be, or how satisfactory the termination of the case, cannot be foretold by statistics nor by reports of cases in the hands of others. Success will depend in large measure upon the early or late period at which the case is thus treated, and upon the general surgical discretion and experience of the operator. It is probable that disappointment will result more often than success. Nevertheless every life thus saved is one snatched from a certainly fatal termination without it, and if successful but once in ten times one life has thereby been saved that may be worth saving, without saving the other nine. While I would advise to make the attempt in any case which offers a reasonable prospect of success, caution should be used against doing it without a full understanding with those concerned that it is an effort in the right direction, concerning which no promise can be made; death results not from the operation so much as in spite of it.
Summarizing, briefly, the best methods of treating a diffuse septic peritonitis we may agree with Le Conte,[53] that they consist of the following measures: The least possible handling of peritoneal contents, the elimination of time-consuming procedures, most perfect drainage of the pelvis by a special suprapubic opening, as well as free drainage through the operative incision, the semi-sitting posture of the patient after its conclusion, the prevention of peristaltic movements by withholding all fluids by the mouth, and perhaps by small amounts of opium, and the absorption of large quantities of water through the rectum, by which there may be produced a reversal of the current in the lymphatics of the peritoneum, making it a secreting rather than an absorbing surface and increasing urinary secretion. It is inexpedient to waste time sponging peritoneal surfaces or wiping away lymph, for danger of septic absorption is increased rather than diminished. Patients with diffuse septic peritonitis bear brief operations fairly well, but prolonged ones badly; therefore a minimum amount of work should be done.
[53] Annals of Surgery, February, 1906.
One of the most valuable procedures in carrying out the above advice is Murphy’s method of slowly introducing large quantities of water into the rectum. The rectal tube used for the purpose ends with a sort of nozzle containing three or four openings, and the reservoir containing the solution is elevated but a few inches above the level of the bed, the intent being that it shall simply trickle into the bowel no faster than absorption can occur. In this way from a pint to a quart may be absorbed each hour, the pressure being continuous, and the flow so regulated that no accumulation of fluid takes place in the bowel. Murphy claims that by this method the lymph current in the peritoneal lymphatics is so reversed that the peritoneum is bathed with free discharge and that this should be afforded escape by suitable drainage methods, coupled with Fowler’s (the sitting) posture.
TUBERCULOUS PERITONITIS.
Acute or chronic tuberculosis of the peritoneum assumes usually, first, the miliary form, after which, in the slow cases, infiltration and great thickening occur to such an extent as to alter the appearance, texture, and behavior of the peritoneum itself. It is rarely a primary condition, but is usually secondary to some other tuberculous focus, which may be one or more of the mesenteric nodes, these being involved in consequence of infection from the alimentary canal; or the peritoneum may be easily infected either from the genito-urinary tract or directly from the intestine. In children, the most common path of infection is through the mesenteric nodes; in females, through the Fallopian tubes, and in males, either through the intestine or the kidneys or ureters. The peritoneum, under these circumstances, behaves very much as does the pleura, in the presence of acute or chronic tuberculous lesions which extend to and involve it. Thus it may become so thickened, and even “leathery,” as to have lost all its original characteristics, and to appear more like a dense, firm membrane than in its original semblance.
Peritoneal tuberculosis appears in three different types: A fibrinoplastic type, characterized especially by adhesions; an ulcerative and sometimes absolutely suppurative form, marked always by the presence of pus and pyoid; and an ascitic type, characterized by leakage of increasing amounts of serum and the development of well-marked ascites.
The first, or fibrinoplastic, is a localized lesion, and leads to the formation of dense adhesions, as, for instance, between a Fallopian tube and the pelvic walls or the other viscera. As the disease spreads all the tissues become matted together in a mass which renders them almost indistinguishable, frequently much resembling malignant disease. In some instances it may be possible to remove the entire affected area. At other times it is best to let it alone.
The ulcerative form is characterized by more general symptoms of conspicuous febrile type. It produces rapid loss of strength and weight, frequently attended with evidences of intestinal ulceration and with abdominal tenderness and pain. A certain proportion of these cases justify exploration, though but few of them will be found favorably disposed for radical surgical measures.