Of the symptoms, the first in order which calls for treatment is usually the peritoneal pain. It is, as we have seen, commonly of a lancinating character, and is associated with hurried breathing and extreme frequency of the pulse. So soon as the pain is once fairly under control the violence of the onset begins to abate. It should be met, therefore, by the hypodermic injection of from one-sixth to one-third grain of morphia in solution. The anodyne action should be maintained by doses administered by the mouth in quantities and at intervals suited to the severity of the case. The most important object to be secured is freedom from spontaneous pain. It is, moreover, good practice to push the opiate until pain elicited by pressure is likewise controlled, provided it can be accomplished without producing narcosis. In susceptible patients and in localized inflammations the quantity required may not be very great, while in acute general peritonitis the tolerance of the drug exhibited by puerperal women is sometimes extraordinary. Thus, a patient of Alonzo Clark took the equivalent of 934 grains of opium in four days; a patient of Fordyce Barker 13,969 drops of Magendie's solution in eleven days; and one of my own, at the Maternity, the equivalent of over 1700 grains of opium in seven days.73 In this latter instance the patient was to all appearance moribund when the treatment was begun. Thus, the features were pinched, the face was drawn, the pupils were dilated, the finger-tips were blue and cold, the respirations were rapid, and the pulse was scarcely perceptible. In this condition the large doses of opium did not produce narcosis, but were followed by restoration of the circulation, by normal breathing, and by the disappearance of the symptoms of shock. Any attempt to relax the treatment was at once succeeded by a recurrence of the alarming symptoms. At the expiration of the disease the opium was discontinued abruptly without detriment to the patient.
73 The details of this case have been reported in the Am. Jour. of Obst., Oct., 1880, p. 864, by Dr. F. M. Welles, who conducted the administration of the opium.
In contrast to cases of acute peritonitis an extreme susceptibility to opium is often observed in the pyæmic variety. Here opiates seem to me rarely to do good. They do not hinder the migrations of the round bacteria, there is rarely pain to relieve, and I have sometimes thought that their administration was simply the addition of a second poison to the one which already was overwhelming the nervous system.
In pelvic peritonitis, in the course of forty-eight hours plastic exudation is thrown out and the pain to a great extent subsides. From this time very moderate doses of opium, as a rule, are needed to make the patient comfortable.
In France leeches applied to the abdomen are much used as a means of relieving peritoneal sensitiveness. That they do this is beyond question. Their disuse in this country is due probably more to popular prejudice than to their inefficacy.
In the beginning of an attack a turpentine stupe to the abdomen is a source of comfort to many women, while the sharp counter-irritation exercises possibly a favorable influence upon the course of the disease. At a later period I commonly employ flannels wrung out in water and covered with oil-silk to prevent speedy evaporation. It is an old experience that in the beginning of a puerperal fever the provocation of loose stools by purgatives is frequently followed by a fall in the temperature and a great improvement in the patient's condition. The result, however, is far from uniform, as in other cases these artificial diarrhoeas have a tendency to aggravate the peritoneal symptoms. Owing to this uncertainty in their action, purgative remedies should be administered with caution, not from any theory as to their eliminative powers, but because of the ascertained existence of fecal accumulation. In pelvic inflammations castor oil in two- or three-tablespoonful doses, or five to ten grains of calomel rubbed up with twenty grains of bicarbonate of sodium, as recommended by Barker, may be given when thus indicated. After the bowels have once been freed, however, the purgative should not be repeated. In cases of intense local inflammation and in general peritonitis enemata should alone be employed for the removal of constipation.
Every increase of body-heat is associated with rapid tissue-waste, with enfeebled heart-action and with exhaustion of the nerve-centres. Since the modern recognition of the deleterious effects of high temperatures per se, antipyretic remedies in place of the old-time cardiac sedatives have come to play the leading rôle in the treatment of fevers.
Of internal antipyretic agents quinia enjoys a deservedly high repute. In the remitting forms of fever it may be administered in five-grain doses at intervals of four to six hours. Given thus in medium doses, it moderates the fever, diminishes the sweating, and in most patients lessens gastric and intestinal disturbances. In continued fevers it should, on the contrary, be given in a single dose large enough to procure a distinct remission. By making a break in the febrile symptoms, if only of a few hours' duration, a retardation of the destructive processes is accomplished. At the first administration twenty to thirty grains may be given. In favorable cases the temperature falls in the course of a few hours below 101°. When the high temperature is only temporarily held in check, at the end of twenty-four hours, if all symptoms of cinchonism have disappeared, the same dose should be repeated. If the doses mentioned, given in the manner prescribed, produce no perceptible effect upon the fever, their continuance may be regarded as unnecessary.
C. Braun and Richter speak favorably of the action of salicylate of sodium.74 It possesses antipyretic properties, though in a less degree than quinia. It is, however, rapidly absorbed, circulates through all the parenchymatous organs, and finally is discharged unchanged in the urine. It is said by Binz, in small doses, to hinder the action of the disease-producing ferments, while it leaves untouched the normal ferments of the organism. It is of special service where quinia is not well tolerated, or when given fifteen to twenty grains at a time every four to six hours as an adjuvant to large single doses of quinia. The remedy should be continued until all traces of febrile disturbance have disappeared.
74 Richter, "Ueber intrauterine Injectionen," etc., Zeitschr. für Geburtsk. und Gynaek., Bd. ii. Heft 1, p. 146.