One or two of my correspondents have emphasized it, and I find a note of warning in the excellent lectures (5) above referred to. Every case of peritonitis at first is local. When it is not limited by adhesions, these writers prefer to call it "diffuse," the term "general" or "universal" being reserved for cases in which the entire peritoneum is involved. They claim, also, that no accurate opinion can be formed at the time of operation, as to whether a case is diffuse or general. If it be true that the method which omits flushing and handling and sponging gives the best results, as it seems to do, what are the reasons therefor? Let us examine the processes by which nature combats the infection. They are: 1. A serous exudate. 2. A fibrinous exudate. 5. Anatomical and physiological rest. (1) The serous exudate serves to dilute the toxins of the infections, and, perhaps, has a tendency to neutralize them with antitoxins. We may assist in this dilution by flushing, but there is a better way. Water introduced slowly by rectum will accomplish the purpose without traumatic effect upon the peritoneum. It also favors elimination. Murphy (6) says eighteen pints of salt solution may be introduced into the rectum in 24 hours, and retained, if introduced slowly under low pressure (one foot elevation). This I consider a most important element in treatment. (2) We all know something of the benefit to be derived from a fibrinous exudate. It tends to wall off the infection and change a diffuse into a circumscribed inflammation. It helps to protect the endothelial coat from the destructive effect of toxins. A blistered peritoneum is a distinct menace to the life of the patient, for the reason that it allows absorption to take place directly into the blood stream. Dudgeon and Sargeant (5) observed that the staphylococcus albus was the first organism to appear in peritonitis and the last one to disappear. It was always associated, when present, with a fibrinous deposit. They believe it has an influence upon the formation of the fibrin, as well as with the attraction of leucocytes into the field. The leucocytes produce a turbid appearance in the fluid present, and the surgeon has been trying all along to remove this creamy substance, which really is nature's bodyguard, fighting the infection. The point is, let the fibrinous exudate alone. How differently from the recommendation made to the French Surgical Congress by Demons (7) a few years ago, viz., to scrape the entire surface of the intestine. (3) Hyperleucocytosis, generally, is an expression of the natural resisting power of the individual, as compared to the amount and character of the toxemia present. It is favored by such measures as conserve the patient's energy, and the fact that leucocytes are present in the exudate in large numbers is no indication for flushing. Pus goes in the line of least resistance. You can not remove it from the peritoneal cavity without breaking up the fibrinous deposit, uprooting the endotheleal cells and producing multiple atria of infection. Give it an outlet and leave the rest to nature. (4) Robinson (8) and other observers have demonstrated that the place of greatest absorption is the diaphragmatic pleura; also that absorption takes place primarily through the lymphatics, chiefly in the direction of the thorax. Muscatello, in his experiments upon dogs, showed that the upright position retarded but did not prevent absorption by this route, and, furthermore, there was no evidence of absorption by any other channels. The abdominal organs, after five and one-half hours, contained none of the reagent used in the experiment. This explains the efficacy of the Fowler position, after operation. Absorption is delayed and time is gained for the patient, and time is an important element in the fight. (5) Nature enforces rest by inflicting the patient with pain. The normal peritoneum is practically without pain sensation. When it is inflamed, the pain is terrible. As a result, the diaphragm and other muscles are fixed; the parts are placed under enforced rest. Robinson (8) says the diaphragm acts as a force pump, sucking up the fluids from the peritoneum during respiration, and forcing them onward through the lymphatics. If this be true, rest is greatly to be desired. It also tends to limit the spread of infection throughout the peritoneal cavity, for it must be remembered that diffuse inflammation is not of necessity general. To sum up, I believe the indications for treatment are: 1. Early operation-and it must be remembered that this implies an early diagnosis. Do not wait for shock, which is a symptom of overwhelming infection. Learn to recognize the early symptoms as stated by Murphy (9): "Pain, nausea and vomiting, localized tenderness, circumscribed flatness on piano percussion, elevation of temperature and hyperleaucocytosis, in the order named." I repeat it, operate early. 2. Method--simple incision with simple drainage, placed in pelvis and such other fossae as seem to require drainage. Perforations should be closed, and appendix removed if it be the offender, provided these things can be done without too much handling of the viscera. 3. Fowler position to retard lymphatic absorption. 4. Normal salt solution by rectum, one and one-half pints every two to four hours for 24 to 48 hours. 5. Antistreptococcie serum, in hope to combat the effect of toxins absorbed. REFERENCES. 2. 1. Senn: Jour. Amer. Med. Ass'n. Sept. 5, 1897. Holmes: Illinois Med. Jour., 1904, vi, 499-515. Levings: Clin. Review, Chi. 1904-5, xxi, 161-170. 4. Ballance: Lancet, Lond., 1904, ii, 1195-1200. 3. 5. Dudgeon and Sargeant: Lancet, Lond., Vol. 1, 1905, 617 625. 6. Murphy: Prac. Med. Series, 1903, Nov., 282. 7. Demons: Trans. French Surg. Cong., 1890. 8. Robinson: The Peritoneum, Part 1, 288. 9. Murphy: Jour. Amer. Med. Ass'n., 1903, Apr. 11. MALIGNANT PERITONITIS. BY ETTA CHARLES, M. D., OF SUMMITVILLE, IND. Malignant peritonitis during the puerperium, unaccompanied by sepsis of the genital tract introduced from without, is not mentioned by many of our authors on obstetrics. Dr. Edgar, in his work on practical obstetrics, describes this condition so well I give it in his own language: "Bacteria of comparatively low virulence bring about benign peritonitis or perimetritis; and under precisely the same circumstances highly virulent germs cause a general peritonitis. According to the general teaching, the latter affection follows most commonly upon an endometritis set up by highly infectious germs. Lenhartz, however, has shown the great relative frequency with which severe parametritis can bring about malignant peritonitis. But this affection is not due necessarily to lymphatic extension, since it may result from direct inoculation of the peritoneum by the contents of a ruptured uterus or a preexisting abscess. It has been commonly taught that malignant peritonitis is usually a complication or feature of severe general sepsis, both being the natural consequence of highly virulent streptococci, but many case-histories seem to show that the general condition in malignant peritonitis is not septic infection of the blood, but profound toxemia caused by the rapid multiplication of germs over the entire peritoneal surface. In other words, malignant peritonitis may often represent a purely local infection, limited only by the great extent of the peritoneum. Malignant peritonitis is undoubtedly due to the high virulence of bacteria which spread over the peritoneal surface without any attempt at the formation of isolating adhesions. It does not appear that the germs are necessarily of unusual virulence before gaining the peritoneum, but may find conditions there which favor their rapid multiplication. Case-histories show that a woman may be fatally septic and yet have only a localized peritonitis; while, as already stated, complete purulent peritonitis may not be accompanied by general sepsis. There is much evidence to show that lymphogenic malignant peritonitis is a phase of puerperal morbidity which is of its own kind, bearing no definite relationship to perimetritis, endometritis or septic infection of the blood. It is pre-eminently a streptococcus disease. The symptoms are those of general peritonitis from other causes. The most striking symptom is the extreme degree of meteorism, which results from intestinal paresis, and which produces compression of the thorax and dyspnea. The prodigous amount of toxins produced and absorbed tends to overwhelm the heart, and the pulse rate rapidly mounts to the neighborhood of 150. Ahlfeld regards malignant peritonitis as essentially a disease of the very early puerperium, most frequently of the first day. The chill is often wanting, and the rapid supervention of great agony referred to the bowels. Vomiting, restlessness and anxiety suggest that the patient has swallowed an irritant poison. Or the puerperium may begin favorably, then parametritis develops and eventually peritonitis. All authors speak of the euphoria and mental clearness which are sometimes presented by women who are nearly pulseless. They no longer feel pain nor distress. The symptomatology of this condition. agrees with that of acute peritonitis from other causes. The diagnosis should be self-evident and the prognosis all but hopeless.' I was called at 3:00 p. m., January 6, 1905, to see this patient. She explained she was not suffering much, but wished me to see if she was going to be sick, that I might not leave town. Examination during uterine contraction showed dilatation beginning. I left, with instructions to be called when pains demanded it. Was called at 8:00 p. m. This was her second confinement. She had a daughter ten and one-half years old. The desire for another child had been so great, and the coming so anxiously awaited, that everything was in perfect readiness for it. After I left in the afternoon the patient took a bath, put on fresh, clean clothes, and the bed was put in readiness with all clean bedding. The clothes to be used had been especially prepared and put away. I had on a new gown and this covered with a large, freshly laundered |