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evil omen. Prognosis is based on the conditions which influence the success or failure of the operation. The preoperative clinical manifestation of each patient should be known to the surgeon in order to avoid mistakes and regret as well as for the patient's welfare.
ANATOMIC AND PHYSIOLOGIC REST TREATMENT OF PERITONITIS; OR REST AND STARVATION TREATMENT OF
The most successful treatment of peritonitis or peritoneum in preoperative abdominal section I shall term the anatomic and physiologic rest treatment, rest and starvation treatment. I learned the main views from Mr. Lawson Tait, while his pupil in 1891, and I have employed the method more or less in a modified form for fifteen years. The method of treatment is applicable to all forms of peritonitis; however, its most brilliant results is in acute pelvic peritonitis, subsequent to abortions and acute salpingitis with peritonitis. The anatomic and physiologic rest treatment in appendicitis is more uncertain because appendicitis is the most dangerous and treacherous of abdominal disease. It is dangerous because it kills and it is treacherous because its capricious course cannot be prognosed. The essential prognostic story of appendicitis is has the appendicular perforation occurred in the area of the enteron (the dangerous, the absorptive, the nonexudative area of the peritoneum) or has the perforation occurred in the area of the colon (the nondangerous area of peritonitis-the nonabsorptive, the exudative area). The "rest and starvation" treatment of peritonitis, that is, the anatomic and physiologic rest treatment consists of, (1), anatomic rest, that is, maximum quietude of voluntary muscles. The patient lies as motionless as possible in bed and does not rise for defecation and urination; (2), physiologic rest, that is, minimum function of viscera. Food is prohibited per os. A minimum quantity of fluid per os is allowed which will not excite the gastric peristalsis or emesis and will aid to slake the raging thirst. Ample fluid may be introduced per rectum to supply the demand of the tractus vascularis and to slake thirst. The object of minimum visceral function (physiologic rest) is to protect the peritoneum from the distribution of sepsis through intestinal and other active peristalsis. Visceral rest, quietude, corrals, circumscribes sepsis by imprisonment, sterilization and digestion of bacteria (through peritoneal exudates and the body guard of leukocytes). The method of treatment of peritonitis by "anatomic and physiologic rest" was especially advocated by Sir Samuel Wilkes, the distinguished English physician, in 1865 (living, 1906), continued by the celebrated American, Alonzo Clark (1807-1887) by the "opium splint," and established forever in 1888 by one of the greatest surgical geniuses of his age-Lawson Tait (1845-1902). Opium checks visceral peristalsis by allowing minimum organ function and the peritoneum ample time to prepare exudative barriers to obstruct and circumscribe progressive bacterial invasion. The anatomic and physiologic
rest treatment circumscribes the bacterial infection by exudative barriers, localizes it, so that no operation or a local operation may relieve. In the presentation of preoperative treatment I shall consider analytically each thoracic and abdominal visceral tract. Though we cannot treat the visceral tracts as separate mechanisms, for the patient must be treated as an individual, yet a careful consideration of the functional capacity of each visceral tract will safeguard both patient and surgeon. The functional capacity of each visceral tract demonstrates the vital power of the patient. The analysis of the patient's anatomy and physiology constitutes the diagnosis and the prognosis-the probable fate of the patient-depends on the diagnosis. The visceral tracts will practically be considered in the order of their physiologic significance. I.—TRACTUS URINARIUS.
The tractus urinarius plays the major rôle of influence in abdominal section not only in immediate mortality but in subsequent nephritis. At the Mary Thompson Hospital, where I have performed abdominal sections for the past eleven years, I estimate that over fifty per cent of fatal nonemergency subjects are due to postoperative nephritis (perhaps mainly exacerbated nephritis from anesthesia, surgical procedure, infection). Perhaps the tractus urinarius is as important in abdominal section as all other influences combined. During the three days of usual preoperative treatment the functional capacity of the kidneys-quantity and quality-will be demonstrated by each day's measurements and observation. The tractus urinarius is of maximum importance in body sewerage. Sudden overwhelming with toxic matters, or the excessive burdens of anesthesia or infection may jeopardize life.
First, the daily quantity of urine for three days should be measured. For a woman of one hundred and fifty pounds, three pints should be voided. Changes in daily quantity of urine should excite suspicion. The visceral drainage modifies the quantity and color. Second, the urinary constituents must be studied daily.
The chief urinary constituents demanding practical study are: (a), albumin; (b), sugar; (c), casts (granular, hyaline); (d), urea; (e), various urinary salts (urine for microscopic specimen should be secured by the catheter, especially from women).
The presence of albumin in the urine is not an absolute contraindication in abdominal section. If the albumin be present in considerable and persistent quantities it is an evil omen and proper to wait a period and treat the patient. The quantity of albumin is an untrustworthy, unreliable test to indicate the renal structure or functional capacity. It is the most common morbid urinal constituent. Though it may indicate merely pathologic physiology of the kidney-not pathologic anatomy
it is an evil omen. In general the clinical significance of albuminuria is pathologic conditions of the kidney and particularly of an inflammatory or degenerative character.
Glycosuria, or the presence of sugar in the urine, of a pronounced and persistent form is diabetes mellitis and may be viewed as a symptom of grave defects of the brain, liver and pancreas. It may be tem⚫porary or constitute simply pathologic physiology. A pronounced and persistent form relatively contraindicates peritonotomy. It is progressively fatal in adolescence, in middle life less severe and fatal, in senescence it is amenable to treatment. It can be produced experimentally in animals.
URINARY CASTS (GRANULAR, HYALINE, EPITHELIAL, BLOOD, PUS, FAT, BACTERIAL).
Granular casts usually consists of metamorphosed epithelium, pus or blood. The granular cast varies in dimensions, form, color and character of granule. Clinically the granular cast is, generally, indicative of grave pathologic conditions of the kidney of a chronic or degenerative character. It is true that the granular cast does not announce the degree of structural change or functional incapacity of the kidney. However, the conscientious and scientific surgeon dare not disregard it. I consider the presence of numerous granular casts such a vital contraindicating element in renal incapacity that I refuse to perform the abdominal section. For ten years this has also been the advice to me by competent pathologists. Also the records of the fatal cases of postoperative nephritis demonstrate that numerous granular casts were the main characteristic. Hyaline casts I do not view in general as a vital phenomena in preoperative peritonotomy.
BILE IN THE URINE.
Practically the bile in the urine should be eliminated previous to the section. Clinically bile appears in the urine chiefly from obstruction of the biliary ducts. Icterus is usually present.
BLOOD IN THE URINE (HEMATURIA).
Blood in the urine is a pathologic condition of the tractus urinarius. Blood may originate from any segment of the tract, the source of which the cystoscope and ureteral catheter aid to locate. Clinically it signifies calculus, neoplasm, infection, hemorrhage from renal papillæ, inflammatory processes-nephritis. An attempt should be made to locate the source of the blood.
Pus may be derived from any segment of the tractus urinarius, the source of which the cystoscope and ureteral catheter aid to locate. Pus is the most common of all pathologic urinary sediments. Pus is such an important pathologic element in the urine that its source should be discovered if possible before the abdominal section.
It is important to estimate the urea in preoperative states. The normal urine contains about two per cent of urea, or about ten grains per ounce. Less than one-half urea is a contraindication to abdominal section and the preoperative treatment should be prolonged.
The presence of excessive quantities of urinary salts is not a contraindication to abdominal section. The usual three days of preoperative treatment of visceral drainage will perhaps sufficiently correct-by increasing the quantity and clarifying the urine. Dilution of the urine separates and dissolves the salt granules which become so distant from each other in their mechanical suspension that clarification ensues. In the preoperative treatment of the tractus urinarius I administer during the usual three days eight ounces of one-half to one-fourth normal salt solution every two hours for six times daily. (In parenchymatous nephritis-known by the presence of granular casts-sodium chloride is not administered as it excessively stimulates the renal epithelium). The patient may and should also drink other fluids during the preparation. This method of visceral drainage treatment tests the renal functional capacity, increases the quantity, clarifies the urine, dissolves the salts, and increases the attenuation of the mechanical suspension. It eliminates the waste-laden material, flushes the tubuli uriniferi and aids the body sewerage. The "visceral drainage” treatment places the tractus urinarius at a maximum normal function. It is consequently, prepared to withstand, resist anesthesia, trauma of operation and infection. The urine should be examined every day during the usual three preoperative days. During the three usual days of preoperative treatment the patient receives the complete "visceral drainage" treatment, namely, one alkaline and one-third sodium chloride tablet on the tongue every two hours, followed by eight ounces (a glassful) of fluid six times daily. The sodium chloride stimulates particularly the renal epithelium. In preoperative treatment the tractus urinarius and its contents or products should be considered separately. Since the tractus urinarius is the most important factor in abdominal sectionsince it has the most potent influence of all the visceral tracts—its anatomy, physiology and pathology must be distinctly in the mind of the operator for every individual case, as well as the physical, chemical, and microscopic characteristics of the urine.
II. TRACTUS VASCULARIS AND ITS CONTENTS-BLOOD. The tractus vascularis not only requires preoperative treatment, but also its contents-the blood.
The volume of the tractus vascularis should be placed at a normal maximum by the "visceral drainage" treatment. It requires about four pints of fluid daily administered at regular intervals to maintain normal
maximum volume of blood, which, streaming through the vascular tract, sustains its function, namely, sensation, peristalsis, absorption, secretion. Normal blood volume is required by the vascular tract in order that its peristalsis (heart and arterial contraction) may force the blood into peripheral organs and tissue. The common function of viscera (sensation, peristalsis, absorption, and secretion) depends on the presence of the blood-in quantity and quality. The result of the diminutive blood quantity and consequent diminutive pulse is observed with facility in diminished quantity of secretion of urine and glandular secretion in general shares similarly with the renal glands. A certain degree of blood pressure is required for normal glandular secretion (urine, perspiration, intestinal secretion) for normal bodily elimination. A proper preoperative examination of the tractus vascularis may reveal valuable knowledge-atheroma, arteriosclerosis, syphilis, aneurysm, and hence aid operative decisions. Blood pressure is secured by administering sufficient fluids to distend the tractus vascularis in order that it will perform its peristalsis contraction vigorously-eight cunces of one-half to one-fourth normal salt solution every two hours for eight times daily is generally amply sufficient. The circulation of the blood is one of the most perfect mechanisms in nature. It may be remembered also that the circulation in conjunction with respiration is an automaton; each is dependent on the other for vital stimulation. In man the respiratory and circulatory centers are separated. Hence careful preoperative supervision may enhance the success of peritonotomy.
THE BLOOD-CONTENTS OF THE TRACTUS VASCULARIS.
Modern surgical science not only requires an ample volume or quantity of blood for appropriate preoperative treatment in abdominal section, but also that the quality of the blood shall approximate the normal as intimately as possible. The quality and quantity of hemoglobin contained in a patient's blood is a practical test of vital resistance. Patients with less than fifty per cent of hemoglobin resist the opposing factors of surgical procedures defectively-anesthesia, trauma, infection become prominent menacing factors. If the deficient hemoglobin be accompanied by malignancy (carcinoma, sarcoma, pernicious anemia) the patient resists operation defectively. I have operated successfully with hemoglobin of thirty per cent. With hemoglobin less than fortyfive per cent it is the practice of Doctor Lucy Waite and myself in the Mary Thompson Hospital to place the patient in bed-anatomic restand resort to forced feeding. The patient is given a certain quantity of wholesome food for the three regular meals (limited), cereals, albumen, milk, cream, vegetables. Also midway between meals, as at 10 A. M., 3 P. M., and 9 P. M., the patient receives eggnog (composed of one raw egg, four ounces of milk, four ounces of cream, one to two drams of spiritus frumenti) or other nourishing fluid. The method of