Reaction of the peritoneum as it affects the surgical pathology of peritonitis

Abstract The physiological surgeon's practice of adding more days of delay to the already too late patient is a most disastrous way of teaching the general profession earlier work. Any attempt to teach the general profession that there is a time to operate and a time to wait, can never meet with good results in a condition whose signs and symptoms are not proportionate to the underlying pathological lesion. The classification of the peritonitic patient into operative and non-operative hours is moving all acute perforative lesions to a later operative hour. The quiescent stage of the physiological surgeon is not a subsidence of a diffuse or general peritonitis, but is the subsidence of a very local condition. The physiological surgeon's determination as to the extent of the peritonitis following a ruptured appendix is based upon a false hypothesis, in that general tenderness and distention do not mean general peritonitis. We have a great number of times operated on the physiological surgeon's patient who had been put on the waiting list on account of a supposed diffuse peritonitis and have proved to all present that the patient never had a peritonitis. The peritonitis is not the only source of toxemia or infection which is to be considered following the perforation of any abdominal organ. A peritonitis following a perforated appendix has its protective elements as well as its toxemic and the peritonitic endothehal membrane has its powers of absorption of toxins reduced to a minimum. The peritonitis is physiological as well as pathological and were it not for the fact that the peritonitis superimposes other sources of toxemia upon itself, such as distal abscesses, bowel obstruction, etc., it would often win the fight. The Fowler position does not establish the most dependent point for drainage, as we have attempted to illustrate in figures which accompany this article. The Fowler position ignores the feeble and toxic heart of the peritonitic patient who should be placed in the position of flexion and rest. There is not a free circulation of fluids in the peritonitic abdomen which is divided into many compartments by the plastic peritonitis which prevents gravity of such infected fluids to the pelvis of the patient in the Fowler position. The lymphatics are not the true absorbents of the peritoneum, but the blood vessels are and there is little, if any, difference in the fertility of the absorbents of the upper and lower abdominal regions, which is one of our reasons for not endorsing the Fowler position. Gravity is of little importance in the peritonitic abdomen which is demonstrated by finding the pus in that particular location of the abdominal cavity where the appendix is located and not in the pelvis as one would expect from placing the patient in the Fowler position. Tubal drainage is inferior drainage as compared with gauze and drainage of the peritonitic abdomen cannot be dismissed as drainage per se, but the mechanical function of the coffer-dam of gauze as a drain is most important and absolutely necessary. The drainage must be conducted so as to drain the mucous membrane of the obstructed bowel, the absorption of toxins from which is often the cause of the final and fatal dose of infection; therefore the obstructed bowel must be released from its fixed point and often punctured in one or more places and in some cases producing a therapeutic fistula. All kinds of drainage are by necessity local after the first few hours following the operation, but gauze has many more times the area of surface drain than that of any other kind of drainage. Gauze drainage must be inserted as a continuous and solid wall, two or more columns of gauze are never inserted, as such flying buttresses of gauze predispose to postoperative bowel obstruction. We never insert a drain to a clean zone of the abdominal cavity anticipating on account of its dependent point that it may later become pus laden. Postoperative complications very rarely follow thorough primary work; postoperative bowel obstruction, distal abscesses, harmful adhesions, metastatic conditions, etc. are the penalties of incomplete primary work. The peritonitic patient from a ruptured appendix rarely dies from the peritonitis per se, but bowel obstruction is probably the cause of the final and fatal dose of toxemia. The surgical pathology of peritonitis will have to be rewritten in that the teaching thus far has been directed toward the peritonitis per se, ignoring all complications. The peritonitic peritoneum little absorbs infected fluids. The treatment of appendicitis of perforative origin is drainage. The principle on which intra-abdominal drainage is established is the release of intra-abdominal tension. Excessive intraabdominal tension injures the protective influence of the epithelium of the peritoneum and thus increases peritoneal absorption. In fact, all the surgical steps in the treatment of the peritonitic abdomen are based on the broadest principles of drainage, such as breaking of all adhesions, exposure of abscessed cavities, release of partial and complete bowel obstruction plus the removal of all gangrenous structures including the removal of the primary source of infection which is the very foundation of drainage.