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may be prevented by bandaging firmly and evenly up to the level of the ensiform cartilage, thus limiting muscular movement.
Temperature and Pulse Variations. These should be carefully noted every few hours until convalescence has well set in. They are not in themselves complications, but rather symptoms of complications. Their treatment is that of the complication of which they are the symptoms.
Thirst.—This may be considerable, but in cases where saline injections are used it is usually not of great importance. The mouth should be swabbed out with a mixture of glycerine and honey, or the patient may be allowed to suck a slice of lemon and cracked ice bound up in a muslin ,bag. Ice, by itself, is commonly used, the patient sucking it, but I have found the patient does much better if ice in this way is not allowed. Some allow hot water to be sipped, but this is also better omitted.
Flatulence. This may be due to simple causes or it may be caused by (a) intestinal paresis; (b) intestinal obstruction; (c) peritonitis. If it be due to simple causes, it may be treated by small doses of cajuput, peppermint, and the like, or by passing the long rectal tube well up into the sigmoid, leaving it in situ for some time. A stomach tube may be passed into the stomach which very often gives relief. If due to the more serious causes, enumerated above, the treatment is that of the condition of which it is one of the symptoms.
Intestinal Paresis.—Though not going into the question of the diagnosis of intestinal paresis, I may say that it is a condition accompanied by constipation, flatulence, temperature and pulse variations, and vomiting. In the treatment of such condition the main object is to procure free action of the bowels. The vomiting usually is so severe that it is not possible to secure this result by the aid of aperients alone. Copious enemata, simple or turpentine, may be used. If these fail it is necessary to stop the vomiting and to this end we have several means at our disposal. We may use one or we may be forced to try the group. Bismuth and hydrocyanic acid diluted may be used, but very often fail; morphine used hypodermatically is frequently successful; cerium oxalate and codeia also may be of service; and sometimes washing out the stomach may produce the desired effect. But the most potent remedy is the hydrochlorate of cocaine used in one eighth grain doses in two drams of water every two hours until the vomiting ceases. The pulse should be carefully watched during the administration of the cocaine and if any untoward signs arise it should be stopped. A hypodermic of strychnine may, however, counteract such adverse signs. The vomiting having ceased, a smart purge should be given, followed in a few hours by a copious enema. The bowels once open should be kept acting freely. In intestinal paresis it is, as a rule, not possible to feed by the mouth and it is then necessary to resort to rectal feeding. Mouth feeding, however, may be started as soon as the bowels are acting freely.
Intestinal Obstruction.—This may be due to (a) fecal accumulation; (b) onset of acute peritonitis; (c) causes active in the intestinal wall itself; (d) causes active outside of the intestinal tube. Intestinal obstruction is usually accompanied by signs and symptoms of shock, by pain, by vomiting, and by constipation. Sometimes, however, the lower bowel empties itself and gives rise to false hopes as to the prognosis. If due to fecal accumulations the onset is usually slow and signs of shock may not appear. The treatment is similar to that of intestinal paresis which, in itself, may be practically looked upon as a class of intestinal obstruction. If, however, the obstruction is due to strangulation, be the cause thereof what it may, the onset is sudden and the shock great. The only treatment is to reopen the abdomen which operation must not be too long deferred. It may be necessary to treat the shock before operating. It is wise not to relieve the pain by means of morphine and the like, as symptoms are likely to be masked. The abdomen having been reopened, a search for the cause should be instituted and the obstruction relieved, if possible. It may be necessary to leave the source of trouble alone for the time being and to open the distended bowel above the seat of obstruction. Even if the obstruction be relieved, one should not be satisfied until the bowel is emptied of its fetid contents and, to do this, it may be necessary to open up the lumen of the gut and leave a tube in situ until the acute symptoms have subsided. In urgent cases it may be advisable to operate, especially where fecal vomiting is present, without the aid of a general anesthetic. Such patients are suffering from severe depression and it is found that cocaine used as a local anesthetic is sufficient to meet the requirements of the case.
Sepsis.—Though not going into the bacteriology of the question, I may say that it is very important to have any pus that may be found examined microscopically. It is also important to have the blood examined for leukocytosis. Speaking of sepsis in a general way, one may say that it gives rise to temperature and pulse changes, to pain, and to constitutional symptoms. The temperature is usually high and may have gone up suddenly and may have been accompanied by a rigor, but in the extreme cases it is subnormal. In the beginning the pulse is increased in rate, full and bounding, but subsequently it becomes weak, thready, and running; the pain may be great and is due to pressure; the
constitutional symptoms are those due to the absorption of toxic material, plus those due to the febrile state which, of course, in itself, is due to the absorption of the toxins. Speaking also of treatment in a general way it is mainly symptomatic. A brisk purge may be given in the initial stages, but later the treatment must be of a more supporting character. Quinine is held by some men to have an effect on pus formation itself, by lessening, or even preventing, its formation. Personally, I do not think that we can expect much from the use of the drug outside of its thermic effect in large doses, and of its tonic effect in small doses. In high febrile conditions quinine is often of great service in depressing the temperature.
The use of serums is, at present, a debatable point, but undoubtedly upon further investigation they will prove to be of great service where the special microorganism, which gives rise to the trouble, can be detected by the microscope. Recently, in the treatment of severe toxemia from peritonitis or other severe inflammations a new mode has arisen—namely, large quantities of normal saline solution are injected intravenously, causing, directly, an increased diuresis and diarrhea, and, indirectly, an increased elimination of toxins. Practically, we may here classify sepsis as to its situation: (a) superficial or wound; (b) deeplocalised peritonitis, general peritonitis; (c) general-sapremia, pyemia, septicemia. In the separate treatment of each of the above divisions or subdivisions I will take it for granted that the wound has been exposed and examined.
Superficial or Wound Sepsis.-If there be any signs of irritation, or inflammation around any of the stitch holes, the offending stitch or stitches must be removed to relieve tension. If pus has formed, the wound should be opened to the extent of the suppuration and pus evacuated. The wound should then be cleansed, packed, and dressed regularly.
Deep Sepsis.-Under this heading may be put the two classes of peritonitis found as complications in abdominal work-namely, localised and general peritonitis. The question of peritonitis is too large a one for me to discuss fully here; let it suffice to say that peritonitis is always due to microörganisms, be their origin what it may.
Localised Peritonitis.--This is usually but not necessarily followed by suppuration. It gives rise to the constitutional symptoms of sepsis; vomiting may or may not be present; constipation is usually present. The pain is deep seated and the abdominal muscles over the site of the inflammation are held tense and board like. After suppuration has occurred, the pus may point toward the surface, or it may open into any of the hollow viscera; or, again, it may discharge into the general peritoneal cavity. The treatment in the early stages may be begun with a purge, but later on it should be constitutional and of a : supporting character. In some cases it may not be advisable to give a purge, and then the lower bowel should be washed out by an enema. The local lesion should be carefully watched, using at the same time fomentations to relieve the pain. When suppuration has occurred, however, operation is called for. An incision should be made over the tumor and the abscess opened. A gentle search for the cause may be instituted and when found it should be removed, but care should be taken not to break down any of the adhesions shutting off the general peritoneal cavity. The cavity of the abscess should be gently washed out with some mild lotion and free drainage arranged for. It is advisable to wait for 24 or 48 hours before commencing more vigorous irrigation. The case then demands regular dressing.
General Peritonitis.—This is accompanied by severe constitutional symptoms, vomiting, constipation, flatulence, distension, severe pain and exquisite tenderness. The temperature at first is usually raised, but towards the end in severe cases it is usually depressed or subnormal. The pulse rate rapidly increases, at first full and bounding but latterly it becomes weak, thready, and running. A falling temperature and an increasing pulse rate is an especially bad omen. Respirations are quick and shallow, being of a thoracic type. This condition having arisen the only treatment that is likely to be of any avail is the early reopening of the abdomen and thoroughly washing it out with normal saline solution. In doing this it may be necessary to expose each and every coil of intestine in order to get at all the pockets of inflammation. The temperature of the lotion should range from 59 to 62 C. Ample provision for drainage should be made before completing the operation. In some cases it may be wise to empty the distended bowel through a trocar puncture which may subsequently be closed by sutures. Where operative measures are not deemed advisable an attempt should be made to obtain a free action of the bowels, and the use of such stimulants as brandy and strychnine should be resorted to freely to support the strength of the patient. Antistreptococcic serum and intravenous injection of normal saline solution may also be given a trial.
Sapremia.—This, together with its train of severe constitutional symptoms, is due to the absorption of large quantities of toxins from a focus of suppuration occurring under pressure. The treatment consists of the general constitutional treatment as above depicted, and of local treatment which must be essentially radical in its nature and similar in character to that of deep abscess.
Pyemia.-By the term pyemia is meant the formation of multiple abscesses secondary to some focus of local infection. Each abscess gives rise to the signs and symptoms of sepsis. The constitutional symptoms are usually severe. The temperature is of an intermittent type and accompanied by rigors. The general constitutional treatment is as above laid out. The local treatment consists of dealing promptly with each and every focus of inflammation as above described under the treatment of deep abscess.
Septicemia.—This is due to the development of microörganisms in the blood and it is accompanied by very severe constitutional symptoms. It is fortunately of rare occurrence in abdominal surgery, but, when it does arise, it is of grave import. The wound should be opened, purified, and provision made for free drainage. Stimulants should be freely resorted to. Antistreptococcic serum in doses of 10 to 15 c.c., twice or thrice daily, may be used. The intravenous injection of normal saline solution may also be given a trial.
Pulmonary Complications.-In any elevated condition or sudden rise of the temperature the chest should be carefully examined and if there be any lesion there noted, it should receive prompt treatment. The condition which may be found, and its treatment, belong rather to the field of medicine, and, therefore, I shall not deal with them here.
Pulmonary Embolism.—This is due to the impaction of a thrombus, detached in or near the site of the operation, in one of the large pulmonary vessels. The result varies according to the size of the embolus and the situation of the impaction. If small, it may give rise to pain and urgent dyspnea which, however, passes off under cardiac stimulation. Generally, the onset of the trouble is so sudden, and the dyspnea is so great, that death ensues before help can be procured. Prophylaxis is the one important thing. The patient should be kept as quiet as possible, avoiding all unnecessary movement, until any thrombus which may be present is well on to the condition of organisation. The bowels should be kept regular and all straining at stool forbidden. Any bronchitic trouble should receive attention in order to prevent any violent effort in coughing.
Phlebitis and Thrombosis.-If these conditions arise the part affected should be purified, wrapped in a sterilised dressing, and kept at absolute rest. If they occur in an extremity, the limb should be slightly elevated. If there be much pain an evaporating lotion or fomentation may be used. The treatment should be continued until organisation is complete.