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ies is very slight indeed, while, when a condition of peritoneal rest is once obtained, the vast majority of cases of even extensive and severe peritonitis show a rapid localization of the inflammatory process, which either subsides entirely or ends in the formation of a localized abscess. Practically this condition of peritoneal rest is obtained by prohibiting all foods and cathartics by mouth, while at the same time the thirst is allayed by the use of normal salt enemata, and the pain and restlessness by the use of morphine. Although this method of treatment has gained its chief renown in connection with the treatment of certain stages of appendicitis, as advocated by Ochsner, the fact must not be lost sight of that its results are equally brilliant in all cases of acute intra peritoneal infection, except possibly the frank perforations of the stomach or intestines. Not only have we used this plan of treatment in all cases not immediately operated, but we have used it as a routine post operative treatment in all cases, whether operated early or late, continuing the same for from forty-eight to seventy-two hours after the operation, or until sufficient time has elapsed for the walling off of drainage tracts and the closure of any fresh areas of infection which might have resulted from the operative manipulations. In this respect there is no essential difference between the post operative treatment as used in early diffuse peritonitis by Murphy and the Ochsner treatment when applied to post operative cases. The essential thing is that the peritoneal surfaces are allowed to remain at rest.
In addition to the prohibition of food and cathartics by mouth and the use of enemata of normal salt solution, we have kept all patients in the Fowler position and have used every precaution to keep the patient quiet in bed. We have never hesitated to use morphine in sufficient quantity to allay the pain or restlessness.
Under this same heading may be mentioned the avoidance of the spread of the infection during the operative work itself. We have attempted to accomplish this as follows: Firstly, by protecting all unsoiled surfaces with gauze pads during the operation. Secondly, by limiting the operating manipulations to the simplest possible procedures, always trying to leave the
natural barriers, such as limiting adhesions and granulating surfaces as far as possible undisturbed; and thirdly, we have uniformly refrained from operating during the acute period of the inflammatory process, when we believed that the pathological conditions were such that operative interferences could not be undertaken without more or less danger of spreading the infection. Manipulations conducted in an infected area during the acute stage of an inflammatory process, often accomplish little except the spread of virulent bacteria and their toxins at a time when the body is least able to take care of such additional burdens. However, after the subsidence of the acute process, conditions become vastly changed, for by this time not only are the technical operative difficulties much less, as a rule, but the individual is now largely immune to the less virulent organisms persisting in the infected area, so that there is very little danger of spreading the infection at this later period.
Fourth-The reduction of the absorption of toxins from the area of infection.
The more alarming clinical manifestations of all infections. are due largely to the absorption of the bacterial toxins into the general circulation, and just in so far as this absorption can be lessened do we improve the condition of the patient and lessen the dangers of the infection. In practice this can be accomplished in two ways: Firstly, by the reversal of the direction of the flow of the lymph streams so that the toxins are carried not from the site of the infection into the central blood stream, but away from it. This is the chief result accomplished by drainage, and the beneficial effects of efficient drainage, when this can be obtained, are known to all. Secondly, we can lessen the toxaemia by the production of a stasis in the lymph stream so that the toxins are no longer carried from the area of infection into the general circulation but remain confined within the area of infection. To accomplish this latter object, the one great therapeutic measure at our command is rest. There can be no doubt that in the recent area of radical surgery, with its far too frequent attempts to drain under most unfavorable
conditions, we have very often lost sight of the fact that the inflammatory processes themselves will very effectually confine the toxins, provided we do not constantly pump these poisons by mechanical means beyond the confines of the inflammatory barriers. For practical purposes we may liken an inflammatory area to a sponge filled with highly toxic material which nature is trying to encapsulate by a zone of infiltration. If the sponge is kept absolutely quiet, the toxic fluids remain in it, but if the inflammatory tissue is subjected to numerous little squeezes, twists and pulls, the highly toxic material is forced into the general circulation. No one, who has not tried to limit the absorption of toxins by treating inflammatory areas as though they were sponges filled with deadly poisons, and, therefore, avoided squeezing them, can have a correct idea of what an important factor this is. In our experience, the improvement in the pulse and temperature, and the general condition of the patient has been just as rapid after the institution of the simple rest treatment as after any operative procedure, and in not a single case has anything occurred to shake our confidence in peritoneal rest as a means of limiting the further spread of the infection and of reducing the absorption of toxins. Only two cases in the writer's total experiences have shown any exacerbation of peritoneal symptoms after beginning the treatment, and in each case the exacerbation followed gross errors in handling the patient.
The importance of being able, in the great majority of intra peritoneal infection, to limit the further spread of the infection, and at the same time reduce the absorption of toxins to a safe minimum by simply enforcing peritoneal rest can scarcely be overestimated, for not only does it enable one to almost eliminate the danger of post operative general peritonitis even in cases operated for intra peritoneal infections, but it enables us to choose the most favorable time for operation. I have already called attention to the fact that once a condition of peritoneal rest is obtained, cases of even extensive peritonitis show a rapid localization of the inflammatory processes which either subsides entirely or ends in the formation of a localized abscess, and if we study the inflammatory processes occurring
within the peritoneum from a purely pathological viewpoint, we find that they undergo a perfectly definite sequence of changes in which we find three stages of the disease corresponding in clinical experience to periods showing wide difference in operative mortality. During the first stages we find that if the peritoneal lesions exist at all, they are, as yet, not associated with marked alterations of the peritoneum itself, the lesions at this early period being of such a type as to require, if any, only temporary drainage. After the peritoneal infection has existed for more than about thirty-six hours, the peritoneal lesion becomes of such a character as to make the removal of the source of infection no longer in itself curative. No matter what the extent of the peritoneal involment may be, the peritoneal lesion is at this time essentially a diffuse inflammatory process, and the pathological conditions are of such a nature as to make drainage at best difficult and often impossible to accomplish efficiently, so that the lesion of this period is but doubtfully benefited by operation. This may be called the intermediate or diffuse stage of the peritoneal infection. On the other hand, if the peritoneum be kept at rest during the stage of the diffuse inflammation, we find that in the milder cases the peritonitis has largely disappeared by the eighth or ninth days, and at this time the more severe pus cases no longer present a diffuse undrainable lesion, but in its stead a well defind abscess cavity, the drainage of which, no matter how great the quantity of pus may be, is a simple but satisfactory procedure.
There can be no doubt of the advisability of operative interference previous to the time of the full development of the peritoneal infection, nor is there any doubt of the satisfactory results and low mortality of operative work in the stage of localized abscess formation. Operative interference in the intermediate stage has always been accompanied by a high mortality. This has been proven true in the hands of the most skillful operators, and the mortality of the occasional operator who interferes at this time is often little short of appalling. The clinical results of Ochsner and many others now overwhelmingly show that by limiting the further spread
of the infection and reducing of the absorption of toxins to a safe minimum, the vast majority of cases seen during the stage of diffuse intra peritoneal infection can be carried over for operation at a later and more favorable period, when the bacteria and their toxins may be successfully removed by drainage.
Fifth-The preservation of the patient's natural powers of
Some of the chief means employed to aid nature in her fight have already been mentioned. In order that their powers of resistance should be at their best, we have made every effort to keep the patients under the best possible hygienic conditions as regards good nursing, plenty of fresh air, and the avoidance of all things which might exhaust the vitality of the patient.
Sixth-The removal of toxic material from the stomach. Many of the alarming symptoms in severe cases of peritonitis are undoubtedly due to the absorption of highly poisonous material from the stomach and duodenum. This has long been recognized as a clinical fact, and the recent experimental investigations of Roger, Maury and others give us additional insight into the peculiarly toxic properties of the stomach contents under certain conditions. Patients whose stomachs are full of toxic material usually have a characteristic facial expression and present the general picture of one on the verge of collapse, all of which is promptly changed for the better by gastric lavage. We have washed the stomach whenever there have been severe nausea or vomiting or when the general condition seemed to indicate a stomach full of toxic material.
ANALYSIS OF CASES.
In studying the results obtained by the plan of treatment, as outlined above, I have included only those cases in which there was no question about the presence within the peritoneal cavity of an active infection, and in thus limiting the cases to those having a pathological diagnosis of an active infection, I have excluded 165 out of a total of 275 cases of appendicitis, and in like manner I have excluded 128 out of a total of 189