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THE AFTER-TREATMENT OF 
 OPERATIONS 
 
WORKS BY THE SAME AUTHOR 
 
 DISEASES OF THE COLON. 
 
 / 
 
 DISEASES OF THE RECTUM AND 
 
 ANUS. 
 
 THE SIGMOIDOSCOPE. 
 
THE AFTER-TREATMENT 
 OF OPERATIONS 
 
 a noanual for practitioners anb Ibouec 
 Surocons 
 
 BY 
 
 P. LOCKHART-MUMMERY, F.R.C.S. Eng. 
 
 B.A., M.B., B.C. Cantab. 
 
 Senior Surgeon, St. Mark's Hospital /or Cancer, Fistula, and other Diseases of the 
 
 Rectu-m ; The Queen's H ospiial for Children, London; 
 
 and Honorary Stirgeon to King Edward Vllih's Hospital for Officers; 
 
 Special Consulting Surgeon to City of London Military Hospital and Fulhajn 
 
 Military Hospital; 
 
 Jacksonian Prizeman, and Late Hunterian Professor, Royal College of Surgeons 
 
 FOURTH EDITION 
 
 NEW YORK 
 WILLIAM WOOD & COMPANY 
 
 MDCCCCXVI 
 
Printed in England 
 
 
PREFACE TO THE FOURTH EDITION 
 
 The continued popularity of this book and the call for a 
 fourth edition are very gratifying, and show that it has, 
 at any rate, proved of real value to those readers for 
 whom it was designed. In the present edition much new 
 matter has been added, and the whole book, as far as is 
 possible, brought completely up to date. In particular the 
 chapter on Surgical Shock has been entirely rewritten in 
 the light of more recent work on this subject. Although 
 the treatment of Gunshot Wounds is, perhaps, not strictly 
 within the scope of this book, there are so many medical 
 men at present acting as surgeons in charge of military 
 hospitals of one kind or another, that the author 
 thinks a chapter on this subject will be a useful addition, 
 more especially as he has received requests from old 
 readers to include such a chapter in the present edition. 
 
 A very natural criticism that has been made by some 
 reviewers of previous editions is, that while the after- 
 treatment of some operations is very fully described, that 
 of others is only scantily treated. The author wishes to 
 point out that this is necessarily so in a work of this size, 
 as without greatly enlarging the book it would be impos- 
 sible to describe the after-treatment of all the operations 
 in any detail. Operations like gastrostomy, operations 
 
vl Preface to the Fourth Edition 
 
 on the brain, and, in general, those which are only per- 
 formed by expert surgeons, do not require the same 
 detailed consideration here, since the after-treatment 
 of these cases usually is, and always should be, under 
 the direct supervision of the operating surgeon, who, 
 one may assume, does not require instruction on the 
 subject. The after-treatment of the more common and 
 less serious operations is, as far as possible, described 
 fully, as these are the cases in which the after-treatment 
 is most likely to be left to the general practitioner or 
 house surgeon. 
 
 P. LOCKHART-MUMMERY. 
 
 9, Hyde Park Place, W. 
 
 April, 1916. 
 
PREFACE TO THE FIRST EDITION 
 
 The after-treatment of operation cases is a subject of 
 such importance that it is not a little surprising to find 
 how little has hitherto been written about it. What has 
 been written is to be found, for the most part, in a some- 
 what fragmentary form in the larger text-books, and is 
 not convenient for reference. 
 
 I have attempted in the present manual to put the 
 subject in a useful and practical form for ready reference 
 by those who, having to treat such cases, wish to know 
 what complications may be expected, and how they are 
 to be met when present. 
 
 The after-treatment of operation cases adopted by 
 different surgeons varies very considerably. But as no 
 good purpose would be served by a recital of all the 
 different methods, I have given in each case that line of 
 treatment which seems to be the most practical, and have 
 avoided entering into any discussion upon the relative 
 merits of the different forms of treatment sometimes 
 adopted. 
 
 In the chapter on shock, a short description of the more 
 recent physiology of this condition has been included, in 
 the hope that it may assist the reader in the treatment of 
 this most important complication. 
 
viii Preface to the First Edition 
 
 Considerable space has been devoted to the after-treat- 
 ment of abdominal cases, as it is here, perhaps more than 
 anywhere else, of importance. 
 
 I have to offer my best thanks to Mr. Herbert Ailing- 
 ham for kindly looking through the manuscript, and to 
 those others of my friends Mrho have assisted me. 
 
 P. LOCKHART-MUMMERY. 
 
 September, 1903. 
 
CONTENTS 
 
 CHAPTER P/VGE 
 
 I. INTRODUCTORY . . . . i 
 
 II. TREATMENT OF THE WOUND - - ' ^5 
 
 III. TREATMENT OF GUNSHOT WOUNDS - "43 
 
 IV. HAEMORRHAGE AFTER OPERATIONS - " 5^ 
 ^^y. SURGICAL SHOCK - - - "74 
 
 VI. POST-AN.«STHETIC COMPLICATIONS - - Q7 
 
 VII. THROMBOSIS FOLLOWING OPERATIONS - - Io6 
 
 VIII. POSTOPERATIVE RASHES AND DRUG-POISONING Il6 
 IX. OPERATIONS ON THE MOUTH, NOSE, AND 
 
 PHARYNX - - - - - 131 
 
 X. OPERATIONS ON THE HEAD - - - 14I 
 
 XI. OPERATIONS ON THE NECK - - "149 
 
 XII. OPERATIONS ON THE THORAX - - - 158 
 
 XIII. OPERATIONS ON THE ABDOMEN GENERAL 
 
 TREATMENT AND COMPLICATIONS - - 1 69 
 
 XIV. OPERATIONS ON THE ABDOMEN {contitiued) - 1 97 
 
 X.V. OPERATIONS ON THE GENITO-URINARY TRACT- 215 
 
 XVI. OPERATIONS ON THE RECTUM, AND COLOTOMY 228 
 
 XVII. OPERATIONS ON THE JOINTS - - - 239 
 
 XVIII. THE AFTER-TREATMENT OF AMPUTATIONS, AND 
 
 SOME SPECIAL OPERATIONS - - - 250 
 
 APPENDIX - - - - - 264 
 
 INDEX 
 
 273 
 
 IX 
 
THE AFTER-TREATMENT 
 OF OPERATIONS 
 
 CHAPTER I 
 
 INTRODUCTORY 
 
 The after-treatment of operation cases is one of the most 
 interesting studies in surgery, and at the same time one 
 of the most important. Nothing will better repay care- 
 ful and intelligent observation by those having such cases 
 under their care. Whether an operation is successful or 
 otherwise depends, of course, to a large extent upon the 
 manner in which the operation is carried out and upon 
 the skill of the operator, but it also depends to no small 
 extent upon the care and attention which is paid to the 
 after-treatment. The operation is the most showy and 
 impressive part of the treatment of the disease or con- 
 dition, and, in consequence, it has become too common 
 to think that the operation is everything, and that the 
 after-treatment is merely a matter of course. This is, 
 however, not the case. Many operations depend for their 
 success on the way in which the treatment afterwards is 
 carried out, and many an almost hopeless case has been 
 saved by skilful after-treatment. 
 
2 The After-Treatment of Operations 
 
 To no branch of medicine or surgery does the old 
 maxim ' Prevention is better than cure ' apply more 
 aptly than it does here. The best results will always be 
 obtained by anticipating complications, and taking steps 
 to prevent their occurrence, rather than by treating them 
 after they are well established. Our line of treatment 
 should be to put the patient under the most favourable 
 circumstances for rapid recovery, and by bearing in 
 mind the complications that are liable to occur, to 
 anticipate them, and so treat the patient that they are 
 avoided. A surgeon may perhaps get great credit for 
 saving a patient by brilliant treatment when he is^ in 
 extremis, but the best surgeon will, nevertheless, be he 
 whose patient has never got into this condition. Artificial 
 conditions should be avoided as far as possible, and 
 when a patient has a natural desire for any particular 
 thing, it should be gratified, unless there is some reason- 
 able objection to doing so. Nature is, after all, the best 
 judge of what is good for a patient or what is not good, 
 and, as a rule, the patient will not wish for those things 
 which are dangerous in his condition. There should be 
 a definite reason for e^ery course of treatment, and rule- 
 of-thumb methods must especially be avoided. No two 
 cases are exactly alike, even after an almost identical 
 operation, and exactly the same treatment need not 
 necessarily be adopted. When, after an operation, 
 complications occur, the treatment should be prompt 
 and thorough. Meddlesome interference, however, must 
 be avoided, and as long as the patient is doing wxll he 
 should be left alone. The after-treatment of operations 
 may be said to be the study of details, and the two most 
 useful adjuncts to success are careful observation and 
 common-sense. There is a saying of the great physician 
 Sydenham which is well worth bearing in mind : ' More 
 
Introductory 3 
 
 importance is to be attached to the desires and feelings 
 of the patient, provided that they are not excessive, than 
 to the doubtful and fallacious rules of medical art.' 
 
 The Importance of Posture in the After-Treatment 
 of Operation Cases. 
 
 It seems to have become an accepted dictum with 
 many people that, after operations of a certain degree 
 of severity, the proper position to nurse the patient in 
 is the dorsal recumbent one. This seems to have been 
 assumed on somewhat insufficient grounds. As regards 
 the comfort of the patient, this position is not a success. 
 It is not a natural position. Few people sleep on their 
 
 'ILliiLLd ' ^f'ni.'ifi I iiiiM I nMiiiiif,' mj_)j_ /i'(ii(ii(i/('/i/^ 
 
 Fig. I. — Dorsal Recumbent Position. 
 
 backs, and when those who are unaccustomed to it are 
 obliged to do so they are often unable to sleep well. It 
 is a very common experience to hear patients who are 
 under treatment for fractures or some other complaint 
 necessitating the dorsal position complain that their 
 backs hurt them more than the injury, and who say that 
 they would be quite comfortable if they were allowed to 
 turn on to their side. Often their only complaint is the 
 discomfort of the position. 
 
 The recumbent position on the back is not anatomi- 
 cally sound. The skin covering the sacrum and lower 
 lumbar region is very badly supported for withstanding 
 
 I — 2 
 
4 The After-Treatment of Operations 
 
 continuous pressure. The sacrum is very superficial, 
 and in the majority of individuals there is but little fat 
 and muscle between it and the skin. The same may 
 also be said of the other bony points on the back. The 
 angle of the spine of the scapula is just beneath the skin, 
 and but slightly covered. The spines of the vertebrae 
 also are immediately beneath the skin, and the latter is 
 unduly subjected to pressure, owing to the prominent 
 position of the spines. There are many other objections 
 to the position. Women who are kept long in this 
 position are very liable to develop cystitis from the 
 presence of residual urine in the bladder, as most women 
 are unable to empty their bladders completely when 
 lying on their backs. This fact should be remembered, 
 as it is a very common cause of cystitis in women after 
 operations. It may be prevented by passing a catheter 
 occasionally, but a much better way is to allow the 
 patient to turn on to her side in order to micturate, or, if 
 possible, to sit up for the purpose. 
 
 The Prone Position (Fig. 2). — This is often very 
 much better than the dorsal position, and is particularly 
 suitable when it is desired to drain a wound opening 
 upon the anterior surface of the body, as in some cases 
 of appendix abscess, psoas abscess, etc., or, again, when 
 the dorsal position has resulted in the formation of bed- 
 sore, or it is feared will do so. In this position the 
 patient lies on the face with a pillow under the chest, 
 and another is placed to rest the side of the head upon. 
 Patients soon become accustomed to this position, and 
 often find it more comfortable when unable to move than 
 the dorsal one. The front of the body is well provided 
 against pressure, and bed-sores are practically never 
 seen. (The knees are the only places where sores are at 
 all likely to occur.) The tendency to distension of the 
 
Introductory 
 
 abdomen, which is common in the dorsal position, and 
 especially when the patient is on a fluid diet, is much less, 
 and the cystitis just mentioned in connection with the 
 dorsal position in women does not occur, as the bladder 
 is able to empty itself easily by gravity. 
 
 The late Mr. AUingham also pointed out the value of 
 this position after injury to the main femoral vessels. 
 Under such circumstances the integrity of the limb 
 
 Fig. 2. — Prone Position, 
 
 depends upon the rapid development of a collateral cir- 
 culation, and it is therefore of the greatest importance 
 that the collateral vessels should be relieved from all 
 pressure. As many of these collateral vessels are in the 
 gluteal region and back of the thigh, the dorsal position is 
 very unsuitable to this end, and the prone position should 
 be adopted. Mr. AUingham had a case where it was 
 necessary to resect a portion of both the main femoral 
 vessels in removing a tumour of the femur, and in which 
 the prone position was adopted ; the collateral circulation 
 was soon established, and the limb recovered perfectly. 
 
 Semi-recumbent Position (Fig. 3). — Here the patient 
 is propped up into a half-sitting posture with pillows and 
 a bed-rest ; a bolster is also placed under the thighs to 
 prevent the patient from slipping down in the bed. Care 
 must be taken to see that there is not undue pressure 
 
6 The After-Treatment of Operations 
 
 on the lower part of the sacrum, otherwise bed-sore is apt 
 to occur at this spot ; this may be prevented by flexing the 
 knees over a bolster or junk, and allowing the weight to 
 
 Fig. 3. — Semi-recumbent Position. 
 
 be taken on the under-surfaces of the thighs. The 
 bolster should be a stiff one (a good size is 3 feet long 
 by 9 inches diameter), and should be attached to the 
 head of the bed at either end with straps. A good sub- 
 stitute can be made by wrapping a blanket round a 
 broomstick and tying the ends of the latter to the head 
 of the bed. 
 
 This is the position in which all elderly people should 
 be nursed whenever possible. The recumbent position 
 is particularly unsuitable for such patients, as, although 
 their lungs may have been previously healthy, they are 
 very liable to develop a moist bronchitis or hypostatic 
 congestion of the lungs if kept lying down for any length 
 of time, and this is particularly the case when the opera- 
 tion interferes with the thoracic or diaphragmatic move- 
 ments, as after removal of the breast or operations on 
 
Introductory 
 
 7 
 
 the stomach, etc. This position is the best after most 
 operations on the stomach, after operations on the thorax, 
 and many others which will be mentioned later. It is 
 also preferable to the recumbent position in many cases 
 of weak or failing circulation, when this weakness or 
 failure is in any way dependent upon deficient aeration 
 of the blood in the lungs. This is probably to be ac- 
 counted for by the greater freedom of the chest move- 
 ments allowed by the position. This is also the position 
 in which all patients should be nursed, if possible, who 
 are suffering from peritonitis or in whom this complica. 
 tion is feared. It allows tke products of inflammation 
 within the abdominal cavity to gravitate into the pelvis, 
 where they will do least harm and can be most easily 
 and safely dealt with. This is now often called ' the 
 Fowler ' position. 
 
 Fig. 4. — Lateral Position. 
 
 The Lateral Position (Fig. 4). — This is the natural 
 resting position of most people, and it is the most com- 
 fortable position for many patients when circumstances 
 will allow of its being permitted. The patient lies on the 
 side with the under-knee well flexed and the upper one 
 slightly so ; the trunk should also be a little flexed. 
 Many patients are rendered more comfortable if a pillow 
 or bolster is put to support the back. 
 
 Position after Laparotomy. — It has been, and to a 
 
8 The After-Treatment of Operations 
 
 large extent still is, customary to consider that the best 
 position for patients after abdominal section — at any rate 
 for the first few days — is lying on their backs ; this is, 
 however, unnecessary and inadvisable except in special 
 cases. Comfort and sleep are here of the greatest impor- 
 tance, and if the patient can be got quietly to sleep during 
 the first twenty-four hours after the operation, much will 
 have been gained. As it is advisable in these cases to 
 avoid the use of opiates as much as possible, it becomes 
 all the more important to secure the patient's comfort. 
 Patients after laparotomy are, as a rule, much easier if 
 allowed to turn on to the side ; they should be moved on 
 to that side on which they are accustomed to sleep, and 
 carefully assisted into the position which they find most 
 comfortable, and in many cases they will drop off to sleep 
 in a few minutes. No harm to the wound need be 
 apprehended, and the position on the side with the knees 
 well drawn up, by relaxing the recti muscles, often gets 
 rid of the pain which sometimes follows the operation. 
 This pain is no doubt often due to spasm of the abdominal 
 muscles resulting from the traumatism, and relaxing these 
 muscles by slightly flexing the trunk is often quite enough 
 to stop the pain. When the abdominal wound is to one 
 side and has not been closed, as in colotomy and appendix 
 abscess, it is best not to allow the patient to turn on to 
 the wounded side, as this might result in prolapse of the 
 intestine ; he may, however, be turned on to the opposite 
 side with safety. 
 
 After abdominal section in children it is particularly 
 important that no unnecessary restraint should be insisted 
 upon. No child, unless it is very ill indeed, will remain 
 for long in the recumbent position without constant 
 watching or the use of some retentive apparatus ; and 
 constraint soon renders children restless and irritable. 
 
Introductory 9 
 
 and prevents them sleeping. If allowed to move about 
 as they choose they seldom come to any harm, and, as a 
 rule, keep much quieter than if subjected to restraint. 
 In young children it is best to fix the dressing with 
 broad pieces of strapping encircling the body ; this pre- 
 vents the movement of the child from disturbing the 
 dressings, and at the same time supports the stitches. 
 When it Is necessary to keep a child on its back for any 
 length of time, a preferable method to the use of shoulder 
 straps is to apply extension strapping to the child's legs 
 and to sling both legs up to a cross-bar, as in the treat- 
 ment of fractured femur by Bryant's method. This is a 
 much more effectual method than the use of shoulder 
 straps, and children do not object to it so much ; it also 
 enables the child to be kept clean very easily. 
 
 As little restraint as possible should be put upon a 
 child's movements after an operation, and the younger 
 the child the more important this becomes. 
 
 Lastly, it should always be remembered in connection 
 with the position of a patient after an operation, that the 
 position of greatest comfort is also that of greatest rest, 
 and therefore the best. 
 
 Illustrative Case. — A child, aged six months, was admitted to 
 the hospital for acute intussusception. Abdominal section was 
 performed, and a large ileo-csecal intussusception found which 
 involved nearly the whole of the large intestine ; the bowel was 
 black and oedematous, but still shiny. This was reduced and the 
 abdomen closed with fisii-gut sutures. The operation took about 
 twenty-five minutes. Two broad pieces of strapping were fixed 
 round the child's body over the first layer of dressings, so as to 
 take the strain off the stitches. Previous to the operation the child 
 had been entirely breast-fed. After the operation the child was 
 not weaned, but was taken out of the cot by its mother and put to 
 the breast every three or four hours. The first feed was given six 
 hours after the operation. The child's movements were not 
 restrained in any way, and it was fed exactly as if no operation had 
 
10 The After-Treatment of Operations 
 
 been performed. In spite of its youth and the damaged condition of 
 the bowel it made an uninterrupted recovery, and left the hospital on 
 the sixteenth day. 
 
 Sleeplessness after Operations. 
 
 This may be due to a variety of causes, and must be 
 treated accordingly. When due to pain, morphia must 
 usually be given so as to secure a good night's rest, 
 The commonest cause is undoubtedly discomfort, and 
 everything should be done to make the patient as com- 
 fortable as is possible under the circumstances. If the 
 patient complains that the bandages are too tight, these 
 may be loosened a little ; if he finds his position uncom- 
 fortable, he should be moved into a new one, and especially 
 into that position in which he is accustomed to sleep ; if 
 he is thirsty, he should be allowed a drink of water, milk, 
 or lemonade, etc. An ounce of whisky or brandy given 
 in hot water will often act as a most effectual sleeping- 
 draught, and can be very seldom contra-indicated. A 
 very useful sleeping-draught for use after operations is 
 the following : 
 
 ^ Liq. morphinje tartratis ... ntxxv. 
 Aquam pimentae - - - - ad gi. 
 
 If morphia is not advisable chloral may be given, or 
 any of the numerous drugs which are now in use for 
 insomnia ; of these trional is one of the best, and should 
 be given in 20-grain doses ; it is often rendered more 
 effective if administered with a little whisky and hot 
 water. Paraldehyde is a very effective drug, but owing 
 to its unpleasant property of making the patient's breath 
 smell it often cannot be used ; it should be administered 
 in peppermint water with some syrup to disguise the ta-ste: 
 
 ^ Paraldehyde - . > . 3i.ss. 
 
 Tinct. aurantii . _ _ . gij, 
 
 Aqus menth. pip. - . - - gi.ss. 
 
Introductory 1 1 
 
 It is always better to avoid the use of sleeping-draughts 
 if possible, and they should never be made use of as a 
 routine practice. 
 
 Pain after Operations. 
 
 A certain amount of pain after an operation is common, 
 and may be due to a variety of different causes, such as 
 tightly tied sutures, tight packing with gauze, powerful • 
 antiseptics in contact with exposed nerve-endings, etc. 
 In an ideal operation on a healthy subject there should 
 be no pain afterwards, and after many operations, where 
 healthy tissues have been cleanly cut, there is no pain. 
 Unfortunately, a certain amount of pain is the rule after 
 most operations, and it ought to be our object to prevent, 
 or at least ameliorate, this as far as possible. There is 
 probably nothing which will make patients more grateful 
 or bring the surgeon more credit than the relief of pain 
 after an operation ; and if patients find that they can 
 undergo operations without suffering pain, much will 
 have been done in making operations less dreaded by the 
 general public than they are at present. 
 
 Pain is due to the stimulation of nerve-tissue, and more 
 especially of nerve-endings, and in a clean-cut wound this 
 stimulation ceases when the cutting is finished ; any pain 
 that occurs after that is either the result of movement in 
 the part wounded or of tension, and in some cases of 
 stimulation of the nerve elements by irritants. Move- 
 ment taking place in the wound can be guarded against 
 by proper splinting, etc., except in the neighbourhood of 
 the thorax, where it is more or less inevitable. Tension 
 may occur in several ways : it may be from too tight 
 splints or bandages, or tight sutures ; in many cases it is 
 due to congestion and swelling of the tissues of the 
 
12 The After-Treatment of Operations 
 
 wound. Pain from this cause is particularly well marked 
 in acute inflammation. Thus, during the formation of an 
 acute abscess, the tension in the abscess causes pressure 
 upon the nerve-endings, and pain is the result, the 
 severity of the latter being proportionate to the elasticity 
 and nerve-supply of the part affected. Thus, when acute 
 inflammation attacks the tightly bound down skin of the 
 nose (as when boils occur at the margin of the nostril), 
 or the pulp of the finger (as is the case in whitlow in this 
 neighbourhood), the pain is out of all proportion to the 
 severity of the inflammation. A certain amount of 
 inflammation is set up locally after any traumatism, and 
 it is the congestion resulting from this that gives rise to 
 the pain in most cases. 
 
 In order, therefore, to prevent pain after operations, 
 we should try to relieve this local congestion. The most 
 effectual way of doing this is by elevation of the part. 
 The pain which often follows amputations is often much 
 reheved by well elevating the stump. Any bandages or 
 clothes which, by pressing upon the veins on the proximal 
 side of the wound may tend to keep up this congestion, 
 should be loosened. By keeping in mind this cause of 
 pain, much may often be done by the simplest means to 
 relieve the pain following operations. 
 
 Another cause of pain after operations is spasm of the 
 muscles in the neighbourhood of the wound. This spasm 
 sometimes causes intense pain, and prevents the patient 
 going to sleep. Pain from this cause can often be pre- 
 vented, if the affected muscles are in the limbs, by flexing 
 the joints or altering the position of the limb so as to 
 relax the affected muscles. Spasm is much more likely 
 to occur in a tense than in a relaxed muscle, Gentle 
 smooth rubbing of the muscles, if it can be carried out, 
 will immediately and effectually stop this spasm. 
 
Introductory 1 3 
 
 The value of heat for relieving pain, applied either in 
 the form of fomentations or stupes, is well known, and it 
 may sometimes be made use of in these cases. Unfortu- 
 nately, it is seldom possible to make use of fomentations 
 or stupes for the relief of pain after operations, as the 
 wound is covered up with dressings which it is not 
 advisable to remove. Cold applied by means of an 
 ice-bag may sometimes be used ; after operations upon 
 joints, such as the knee, it is often efficacious in relieving 
 the pain. A heavy ice-bag should not be allowed to rest 
 upon the wound, as its weight will cause more pain than 
 the cold will relieve. The bag must be suspended from 
 a cradle or some other arrangement made to take the 
 weight off the wound. 
 
 There are certain operations after which pain is gener- 
 ally severe for a time. Operations involving interference 
 with bones seem to be peculiarly liable to be followed by 
 severe pain, and especially such operations as excision of 
 joints. Well-fitting splints which are not too tight and 
 elevation of the limb will do much to relieve the pain in 
 these cases, but morphia is often necessary as well. The 
 pain can often be relieved in such cases by giving aspirin 
 in 10 grain doses every six or eight hours, beginning 
 with 5 grains directly after the operation. The pain 
 after operations on the stomach or intestines is best 
 relieved by small doses of morphia or laudanum given 
 by the mouth. 
 
 Drugs should not be given indiscriminately for the 
 relief of pain, but should only be made use of when other 
 means fail, or in conjunction with them. Opium in some 
 form, and especially its derivative morphia, is the most 
 valuable drug we possess for this purpose, but there are 
 several other drugs which are sometimes of value. 
 Phenacetin in 15 to 20 grain doses will often relieve pain 
 
14 The After-Treatment of Operations 
 
 if not very severe, and is a very safe drug to give, or 
 Trional may be used. Forty grains of chloralamide 
 placed on the back of the tongue is sometimes very 
 effectual in stopping restlessness and procuring sleep. 
 In all severe pain, however, morphia should be given in 
 doses from ^ to ^ grain hypodermically, unless contra- 
 indicated for some other reason. The dose of morphia 
 that has to be given varies very considerably, both as 
 regards the individual and as regards the severity of the 
 pain, and it is well to bear this in mind. In some cases 
 a small dose is quite as effectual as a much larger one 
 would be ; too small a dose, however, will in many 
 people produce restlessness and excitement. Morphia 
 must never be given continuously for more than a few 
 days, as there is great danger of setting up the morphia 
 habit. A week is probably the outside that it is safe to 
 continue using the drug, without either intermitting the 
 dose or reducing it. The pain after operations usually 
 ceases after twenty-four or thirty-six hours at most ; but 
 when it does not do so, and it is necessary to continue 
 the administration of morphia for its relief, the best plan 
 after the first two or three days is to either reduce the 
 dose by a half or to give an injection of plain water 
 instead of, and at the time for, the usual morphia injec- 
 tion. The moral effect of this renders it often quite as 
 effectual as the morphia would be, and this does not apply 
 only to neurotic individuals ; the most strong-minded 
 people will often be quite satisfied by an injection of 
 sterilized water if they imagine that it is morphia and it 
 is given at the usual time. The results of the continuous 
 use of morphia are so bad and so common that the 
 greatest care must be taken to prevent the habit being 
 established, and such an innocent deception is therefore 
 perfectly justifiable. 
 
Introductory 15 
 
 Smoking" and Drug Habits. 
 
 Patients often ask how soon they may be allowed to 
 smoke after an operation, and many patients are very 
 anxious to be allowed their pipe or cigarette. 
 
 Unless there is some obvious contra-indication, such 
 as is the case after operations upon the throat or 
 pharynx, it is advisable to allow them to smoke in 
 moderation as soon as they express a desire to do so. 
 
 Smoking often makes a patient more contented, and 
 so adds to his general comfort and well-being. 
 
 It is never wise to entirely stop the use of tobacco in 
 the case of a patient who is an habitual heavy smoker. 
 Under such circumstances the sudden abstinence in the 
 use of tobacco is very liable to cause insomnia and 
 indigestion, besides often making the patient miserable 
 and discontented. 
 
 The same also applies to other drugs. Thus a patient 
 who is accustomed to take large quantities of alcohol 
 daily should not be entirely forbidden his accustomed 
 stimulant, but should be allowed alcohol in moderation. 
 
 And in the case of a morphia maniac it is never wise 
 to stop the use of the drug or even to reduce the dose; 
 the patient should be allowed his ordinary daily dose of 
 morphia at the time at which he is accustomed to have 
 it. These patients are always bad subjects for opera- 
 tions, but it not infrequently happens that it is necessary 
 to operate upon them, and the risks of the operation are 
 much increased if, at the same time, the drug is stopped. 
 
 It must always be remembered when dealing with a 
 patient who is the slave of any drug, whether it be 
 tobacco, alcohol, or morphia, that from long habit his 
 normal condition of both mental and bodily equilibrium 
 is that in which he is more or less under the influence of 
 
i6 The After-Treat ment of Operations 
 
 his particular drug ; and that to suddenly make him an 
 abstainer is to change him into an abnormal state. 
 
 I am sure that the only satisfactory way of obtaining 
 good results from operations performed upon such 
 patients is by assuming that their normal condition is 
 when under the influence of their particular drug, and to 
 treat them accordingly. 
 
 Thirst. 
 
 Thirst is a very common complaint of patients after an 
 operation. This thirst is no doubt partly due to an 
 actual loss of fluid from the body. There is generally 
 free perspiration either during or immediately after an 
 operation ; the salivary glands also secrete freely, and 
 there may have been fluid in the shape of blood or 
 serum lost from the wound, so that the total fluids lost 
 from the circulation during a long operation may be con- 
 siderable. Also after operations of any degree of severity 
 there seems to be a tendency for the secretion of mucus 
 from the mucous membranes to be inhibited for a time. 
 This results in the mucous membrane of the mouth being 
 dry, and makes the patient feel thirsty. 
 
 The practice of only allowing patients after an opera- 
 tion to have sips of hot water is to be deprecated. It is 
 neither sound in theory nor practice. The body is in need 
 of fluid, and nothing is to be gained by withholding it. 
 Unless there is some very definite contra -indication, 
 which is but seldom the case, the patient should be 
 allowed to slake his thirst with water or any other suit- 
 able fluid, the only restriction being that a large quantity 
 is not swallowed at one time (the quantity should not 
 be more than i pint at a time). The contention raised 
 against the practice of allowing fluids in proper quantities 
 is that it causes sickness. As a matter of fact, it does 
 
Introductory 17 
 
 not often do so, and when it does the fluid is beneficial in 
 washing out the stomach, and the patient is much more 
 comfortable afterwards ; while, on the other hand, sips 
 of hot water are just as liable to cause vomiting, and 
 neither satisfy the patient's thirst nor wash out his 
 stomach if he is sick. Hot tea is often very comforting, 
 and can do no harm ; a good plan is to give a cup of 
 weak tea with a sliee of lemon and a little sugar in it. 
 Thirst should be looked upon as the natural call of the 
 body for more fluid, which may be administered either 
 by the mouth or rectum, according to circumstances. It 
 is difficult to see how, apart from its causing sickness, 
 water can do harm under any circumstances,. It needs 
 no digestion, and does not cause peristalsis. 
 
 When thirst is troublesome, and there is some reason 
 which renders it inadvisable to give fluid by the mouth 
 in any quantity, large warm-water enemata should be 
 given. Many surgeons make a practice of giving a 
 warm saline injection per rectum immediately after 
 any long operation ; this is an excellent plan. The 
 practice of filling the abdominal cavity with warm saline 
 solution before closing the wound is a most effectual 
 way of preventing the thirst which so commonly follows 
 abdominal operations ; and this method is still used by 
 some surgeons, though the majority consider it injurious 
 to the peritoneum, and therefore prefer the administration 
 of water by the rectum or subcutaneously. 
 
 Flatulence. 
 
 This is often a troublesome complication after opera- 
 tions, and causes the patient considerable discomfort. The 
 following is an excellent prescription for the relief of this 
 condition : 
 
 ^ Sal volatile, gi. 
 
 Sodium bicarbonate (a pinch). 
 In a wineglassful of water. 
 
 2 
 
1 8 The After-Treatment of Operations 
 
 This generally gives immediate relief. A few drops of 
 peppermint on a lump of sugar or soda-mint tabloids are 
 also very useful. The best way, however, of relieving 
 flatulence is to open the bowels by administering an 
 aperient or to give a turpentine enema : 
 
 ]^ Turpentine .... gss. 
 
 Gruel ..... gxv. 
 
 The author has for some years used hypodermic injec- 
 tions*of the infundibular portion of the pituitary gland for 
 this purpose, with excellent results. One cubic centi- 
 metre of a standard preparation of this drug should be 
 injected about five minutes before the administration of 
 an enema. As a rule, a free evacuation of wind will occur 
 almost immediately. The author has found this drug 
 quite invaluable in bad cases of abdominal distension. 
 Eserine is another drug which has been similarly used. 
 
 Bed-Sore. 
 
 This troublesome complication will occasionally arise 
 in spite of the greatest precautions. It is, however, 
 usually a preventable complication, and should not occur 
 when proper trained nursing is obtainable. The question 
 of the relation of the position of the patient after the 
 operation to the formation of bed-sores has already been 
 spoken of (p. 4). Soiling of the bedclothes, due to 
 lack of proper care after the patient has micturated or 
 the catheter has been passed, rucking up of the patient's 
 nightdress or of the bedclothes, are all frequent and easily 
 preventable causes of bed-sore. By far the most potent 
 cause of bed-sore is a moist condition of the skin where 
 it is subjected to pressure, and the greatest care should 
 always be taken to keep the skin as dry as possible. 
 After a bed-sore has formed, the part must be relieved 
 
Introductory 19 
 
 from all pressure, either by turning the patient into 
 another position or by the use of ring air-cushions, etc. 
 The sore itself must be kept dry, and must not be treated 
 with strong or irritating antiseptics; boracic powder or 
 Fuller's earth are the best applications to use, but they 
 should not be allowed to form crusts over the sore. If 
 much sloughing takes place, the patient must be turned 
 over upon the face or side and the sore dressed frequently 
 and kept as clean as possible. Dry dressings are much 
 preferable to wet ones, unless it is desirable to hasten the 
 separation of the slough, when the following dressing will 
 be found useful : 
 
 ^ Unguenti sambuci viridis - • • partes ii. 
 
 Unguenti elemi - - • - ,, xvi. 
 
 Copaib£e --••»,, Hi.* 
 
 This dressing should not be allowed to come into contact 
 with the healthy skin round the sore. 
 
 Painting the sore over with Friar's balsam will some- 
 times hasten the healing process. If there is much 
 destruction of tissue, Thiersch grafting should be em- 
 ployed to hasten healing and prevent scarring. The 
 sore should first of all be got quite clean, .and then all the 
 granulation tissue should be scraped away and the grafts 
 laid on the underlying fibrous tissue ; the dressing should 
 not be removed for at least a week. Thiersch grafting, 
 if properly done, often gives most excellent results in 
 these cases, and considerably hastens the healing process. 
 
 The worst cases of bed-sore are those which occur in 
 pysemic cases and cases associated with some spinal 
 lesion ; in many of these cases a bed-sore will form in 
 spite of the utmost care. 
 
 The separation of the slough is often a very slow 
 process in the bad cases, and it is sometimes advisable to 
 * St. George's Hospital Pharmacopoeia. 
 
20 The After-Treat men t of Operations 
 
 hasten it by occasionally cutting through the toughest 
 bands of fibrous tissue with a pair of scissors, care, of 
 course, being taken not to cut into healthy tissue. 
 Hydrogen peroxide is a most valuable disinfectant and 
 antiseptic to use in these sloughing cases ; it should be 
 painted or sprayed on frequently. Sanitas on lint is also 
 a good dressing. 
 
 Post-Operative Insanity or Mania. 
 
 This is a condition which is but seldom met with. 
 It does not seem to bear any definite relation to the 
 operation— that is to say, as regards cause and effect. 
 The symptoms usually first show themselves during con- 
 valescence. The onset of insanity or mania is probably 
 to be attributed to the mental anxiety and morbid brood- 
 ing over the operation by a mind which is naturally 
 unstable rather than to any direct effect of the operation 
 itself. Sometimes a patient who is the subject of re-- 
 curring attacks of insanity may get an attack after an 
 operation ; m this case the operation acts merely as an 
 exciting cause. The condition is more often seen in 
 women than men. It is said that a suicidal tendency is 
 a common and well-marked feature of most cases. 
 
 Professor Clifford Allbutt describes the condition as 
 one of neurasthenia rather than of insanity, and says that 
 a certain degree of it more commonly follows operations 
 than is generally supposed. He does not, however, point 
 out why this should be the case ; and it is possible that in 
 some of these cases a patient of a particularly morbid 
 turn of mind has thought herself to be suflfering from 
 some affection, and has so far deceived her medical 
 attendant that he has advised operative interference, 
 which, having been duly carried out, has subsequently 
 been ascribed as the cause of her mental condition. 
 
Introductory 2 1 
 
 Many of the earlier cases of acute and fatal post- 
 operative insanity which have been reported, or have 
 found their way into the literature on the subject, were 
 in all probability cases of acute sepsis or cerebral abscess 
 resulting from the operation, and were therefore not in 
 reality insanity at all. In one case of supposed post- 
 operative mania which came under the observation of the 
 writer, it was discovered at the post-mortem examination 
 that there was a large abscess in the brain. 
 
 Under the name post - operative psychoses, several 
 forms of mental derangement have been described which 
 only affect the intellectual functions ; the symptoms are 
 mainly a melancholic type of insanity commonly accom- 
 panied by delusions. 
 
 This type of insanity seems to be most common after 
 operations upon the sexual organs, such as ovariotomy, 
 hysterectomy, removal of the breast, castration, etc, 
 and after operations such as colotomy, gastrostomy, 
 etc., the results of which constantly remind the patient 
 of his, or her, diseased condition. It has been pointed out 
 that operations upon persons of a highly-strung and 
 nervous temperament may occasionally be followed by a 
 complete nervous breakdown and general neurasthenia, 
 which may persist for a considerable time, and thus 
 greatly delay recovery. Dr. Burr quotes a case where 
 a young man of highly nervous temperament, but whose 
 previous health had been good, was attacked by appendi- 
 citis and operated upon. After the operation he made, 
 from a surgical point of view, a good recovery ; but he 
 remained prostrate in bed, unable to do anything from 
 complete nervous breakdown, and it was some months 
 before he was well again. 
 
 Before operating upon all such patients the greatest 
 care should be taken to prepare them properly for the 
 
2 2 The After-Treatment of Operations 
 
 operation. An attempt should be made to get them into 
 a better mental condition by careful attention to the 
 general nutrition and hygiene, and they should be given, 
 as far as possible, a complete rest in both body and mind, 
 so as to get them into a normal mental condition before 
 performing the operation. There can be no doubt that 
 in the careful preparation of the patient beforehand lies 
 the chief safeguard against post -operative mental con- 
 ditions. 
 
 In examining the recorded cases where mania has 
 followed an operation, it is noticeable that in a large 
 number of the cases the wound was septic. This 
 suggests that the mania might have been due to septic 
 poisoning rather than to any mental change in the 
 patient produced directly by the operation, and that 
 such cases should really be looked upon as delirium, 
 similar to that which may occur in the course of any 
 acute infection. 
 
 A well-marked group of cases are those where delirium 
 tremens follows an operation upon an alcoholic subject. 
 I think that in these cases the partial starvation or 
 alteration in diet necessitated by the operation is more 
 often the cause of the delirium than the actual operation 
 itself. When an alcoholic patient has to be operated 
 upon, the best way of preventing the occurrence of 
 delirium is to first accustom the patient to a reduced 
 and altered diet, and to the change in conditions which 
 the operation necessitates. 
 
 Dr. Savage has recorded a large number of cases 
 which seem to show that the anaesthetic alone may be 
 the cause of mental disturbance in some cases. The 
 use of iodoform in the wound has also been considered 
 as the cause by some writers. 
 
 As regards the important subject of prognosis^ the late 
 
Introducto 
 
 vy 23 
 
 Mr. Clinton Dent, who collected a large number of cases, 
 came to the following conclusions : 
 
 The prognosis is most grave when acute mania occurs 
 shortly after a serious operation, although the purely 
 surgical aspect of the case may be favourable. The 
 more chronic the mania the better is the prognosis so 
 far as life is concerned. 
 
 In ordinary insanity the prognosis is favourable if the 
 patient gains weight and strength. 
 
 Illustrative Case. — Sarah C, married, aged forty -eight, was 
 admitted to St. George's Hospital. She had had eight children, of 
 whom six were alive and well, and the youngest six years old. 
 She had always lived in the country, was of healthy appearance, of 
 slightly reserved manner. Absolutely no history, even remote, of 
 hereditary disease, and no trace of insanity in her family. 
 
 Four years previously she had noticed a small swelling in the 
 abdomen on the left side ; this increased rapidly up to a certain 
 point, and then appeared to remain stationary. 
 
 Ovariotomy was performed. The tumour consisted of one large 
 cyst and several smaller cysts. Ether was given. The progress of 
 the case subsequently for the first six days was satisfactory enough; 
 she was cheerful, anxious to get well, and slept and ate normally. 
 On the sixth day her physical condition was satisfactory, but her 
 expression had entirely altered. She still recognised her husband 
 and those who were immediately concerned with her care, but her 
 mind was full of delusions, varying in their nature, but all, to her, 
 of an alarming character. She was very restless in bed. On the 
 eighth day she was in a condition of acute mania. She recognised 
 no one, attempted to injure those about her, and was very violent. 
 The hair became coarse and rough. There was a little superficial 
 suppuration in the wound, where she had torn the edges apart in 
 her struggles, but in all other respects, so far as the immediate 
 operation was concerned, everything was perfectly satisfactory. 
 During the next eight-and forty hours the mania continued with 
 undiminished intensity. Her physical condition became weaker, 
 and the greatest difficulty was experienced in getting her to take 
 any food. She died exhausted on the eleventh day. No iodoform 
 was used, nor carbolic acid ; no peritonitis was found, nor, indeed, 
 anything in the abdomen worthy of note, at the post-mortem 
 examination. 
 
24 The After-Treatment of Operations 
 
 Illustrative Case. — E. H., an unmarried woman, aged thirty-one, 
 had been suffering for some months from rectal haemorrhage, and 
 on examination this was found to be due to cancer of the bowel- 
 She was of rather a nervous and excitable temperament, and was 
 just about to be married at the time of this distressing discovery- 
 She was not informed of the nature of the trouble, but was told 
 that an operation was necessary. The operation was agreed to, 
 and I removed the rectum and growth, and was able to bring down 
 the sigmoid and restore the normal anal opening. The result was 
 extremely satisfactory, and the wound healed by first intention 
 without any rise of temperature. She was able to return home in 
 three weeks, and in a short time regained the normal use of her 
 bowels. The result from a surgical point of view was excellent, 
 and the patient appeared contented and most reasonable. But 
 about four months later she began to show signs of severe melan- 
 cholia, and in spite of the fact that she suffered no inconvenience 
 as the result of the operation, beyond the necessity of occasionally 
 using an enema, she developed suicidal tendencies, and became so 
 unmanageable that she had to be confined in an asylum. Her 
 mental symptoms gradually improved after this, and she made a 
 complete recovery. A year and a half after the operation she was 
 quite well, and six months later she got married. 
 
 REFERENCES. 
 
 Picque and Briand: Archives de Neurologic, March, 1903. 
 
 ' Unusual Forms of Nervous Prostration following Operations ' : 
 
 Lancet, May 17, 1902, p. 1415. 
 ' Paralyses and Psychoses following Prolonged Anaesthesia ' : 
 
 Lancet, June 3, 1899, p. 1508. 
 Article by Dr. C. Burr, Philadelphia Medical Journal, April 19, 1902. 
 ' Insanity following Surgical Operations ' : C. T. Dent, Journal 0/ 
 
 Mental Science, April, 1889. 
 
CHAPTER II 
 TREATMENT OF THE WOUND 
 
 In these days the vast majority of wounds are aseptic and 
 run an aseptic course, and it is not necessary or even 
 advisable to change the dressings often. From one cause 
 and another, however, suppuration will sometimes take 
 place, and it is therefore a matter of considerable im- 
 portance to detect the presence of suppuration when it 
 does occur at the earliest possible date, so that it may 
 be promptly dealt with ; and not to discover, perhaps at 
 the end of a week, on removing the dressings, that the 
 wound has all broken down and the dressings are soaked 
 with discharge. The temperature chart, if properly inter- 
 preted, is a most valuable guide to the condition of the 
 wound, and a chart of the temperature should always be 
 kept after any operation. 
 
 It is important to remember that a rise of temperature 
 during the first thirty-six or even forty-eight hours is the 
 rule after an operation of any magnitude. On examining 
 a hundred consecutive cases after operation in the wards 
 of St. George's Hospital, in all of which the wound ran 
 a perfectly aseptic course, the writer found that a rise of 
 temperature occurred in 85 per cent, within the first forty- 
 eight hours. The following table will show the results 
 of this investigation : 
 
 25 
 
26 The After-Treatment of Operations 
 
 Table of the Temperatures during the first Forty- 
 eight Hours of ioo Consecutive Cases of Opera- 
 tion IN WHICH THE WoUND REMAINED ASEPTIC. 
 
 Per Cent. 
 There was a rise of temperature to or above 
 
 ioo° F. in . . . . . . . . • • 27 
 
 There was a rise to or above 99° F. in . . . . 46 
 
 There was a rise above normal, but below 99° F. in 12 
 The temperature remained normal or fell below it 
 
 in.. .. .. .. .. •• 15 
 
 lOf 
 
 y. 
 
 
 
 
 
 
 
 
 
 
 '*j 
 
 
 
 
 
 
 
 
 
 10 tf 
 
 ■s. 
 
 
 
 
 
 
 
 
 
 9S 
 
 3(f 
 
 J 
 
 ^ 
 
 
 
 ^ 
 
 
 
 
 ^~ 
 
 t 
 
 - 
 
 k 
 
 h/ 
 
 
 
 te- 
 
 - 
 
 fy-y' 
 
 \ 
 
 
 
 
 
 
 
 
 
 8? 
 
 
 
 
 
 
 
 
 
 
 C3 
 02° 
 101° 
 100" 
 99" 
 96° 
 9? 
 
 §i 
 
 
 
 
 
 
 
 
 
 
 
 
 J- 
 
 
 
 
 
 
 
 
 
 
 
 ^ 
 
 
 
 
 
 
 
 
 
 
 
 i.^ 
 
 0^ 
 
 ^ 
 
 
 
 K 
 
 Sn 
 
 
 
 
 
 ^- 
 
 - 
 
 -- 
 
 V 
 
 
 - 
 
 
 ■»• 
 
 ^ 
 
 ♦ 
 
 ^ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 •: 
 
 Fig. 5. — Radical 
 CURE OF Hernia 
 (Aseptic). 
 
 Fig. 6. — ^Amputation of 
 THE Thigh (Aseptic), 
 
 This shows the double rise. 
 
 It is further noticeable that in 
 children this rise of temperature is 
 often much more marked than in 
 adults ; the high temperature is often 
 a morning one, and is followed by an 
 evening drop. The rise in children 
 may be very high sometimes, and in 
 the above 100 cases one child had a 
 temperature of 104-5° (^ig- 9)' though 
 there was no cause discoverable beyond 
 the operation. After operations in- 
 volving interference with bone, it is 
 
 
 ^ 
 
 
 
 
 
 
 
 101° 
 
 0; 
 
 
 
 
 
 
 
 (J. 
 
 
 f 
 
 
 
 
 
 99 
 
 0: 
 
 J 
 
 \ 
 
 
 
 
 
 ^- 
 
 
 
 \j 
 
 P 
 
 <•< 
 
 A 
 
 97° 
 
 
 
 
 6 
 
 
 
 
 
 
 
 
 
 
 
 Fig. 7. — Ampu- 
 tation OF the 
 Breast (Asep- 
 tic). 
 
Treatment of the Wound 
 
 27 
 
 remarkable that the post -operative pyrexia is often 
 high ; the operation for the Hgature of piles also 
 
 KM 
 
 ^ 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 101° 
 
 0. 
 
 
 
 
 
 f 
 
 
 
 
 
 93° 
 
 98° 
 87° 
 
 / 
 
 
 
 
 
 
 i 
 
 -- 
 
 4- 
 
 '^ 
 
 gs 
 
 ^8 
 
 
 
 
 
 
 
 
 
 
 
 
 
 KM 
 
 C3 
 102° 
 101° 
 100° 
 99" 
 98° 
 S7 
 
 
 
 
 
 
 
 
 
 
 
 fi 
 
 
 
 
 
 
 
 
 
 
 0: 
 
 u 
 
 
 
 
 
 
 
 
 
 
 
 
 i 
 
 K 
 
 
 
 
 
 
 
 0: 
 
 
 I 
 
 \ 
 
 h 
 
 
 
 
 
 
 
 
 ^ 
 
 •^ 
 
 
 \ 
 
 4 
 
 
 
 
 / 
 
 - 
 
 -- 
 
 -\- 
 
 - 
 
 V 
 
 > 
 
 W 
 
 •- 
 
 « 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Fig. 8. — Operation 
 FOR Hare-Lip on 
 A Child Five 
 Months Old. 
 
 Fig. 9. — Laparotomy 
 FOR Intussusception 
 ON A Child aged Two 
 Years (Aseptic). 
 
 seems often to result in an exceptionally high tem- 
 perature (Fig. 10). It was found in the investigation 
 of the above 100 cases that a second slight rise in 
 the temperature not uncommonly fol- 
 lowed the first (see Fig. 6). 
 
 This rise of temperature is probably 
 due to reaction, and is what the text- 
 books describe as aseptic fever. There 
 is generally a preliminary drop to a 
 subnormal temperature immediately 
 after the operation, followed by re- 
 action and a rise to about 99° or 100° 
 (Fig. 5), In some cases, and especially 
 in children and young adults, the rise 
 is considerably higher ; this would 
 naturally be expected, as young 
 patients always react much more 
 
 
 
 
 
 
 
 
 
 
 \^ 
 
 
 
 
 
 
 
 
 ■^ 
 
 
 
 
 
 
 
 
 
 
 H 
 
 
 
 
 
 
 
 
 J 
 
 1 
 
 
 
 
 
 99' 
 
 
 f 
 
 
 I 
 
 ^ 
 
 
 
 ^ 
 
 - 
 
 - 
 
 
 - 
 
 ^ 
 
 =&■ 
 
 
 
 
 
 
 
 
 
 ^ 
 
 
 
 
 
 
 
 
 Fig. 10. — Opera- 
 tion FOR Piles 
 BY Ligature 
 (Aseptic). 
 
28 The After-Treatment of Operations 
 
 violently than older ones. Again, in the case of patients 
 who are in exceptionally good general health at the time 
 of the operation, the reaction and consequent tempera- 
 ture is often high. The rise of temperature usually takes 
 place on the first night after the operation, sometimes on 
 the second. This rise of temperature is a good sign, as 
 it shows reaction, and is very much better than a drop to 
 a subnormal temperature which persists. This post- 
 operative temperature or aseptic fever should therefore 
 
 
 
 
 
 
 
 
 
 ■_ 
 
 
 
 > 
 
 
 O. 
 
 
 
 
 
 
 
 
 
 fi 
 
 'j 
 
 100° 
 
 1 
 
 
 
 
 
 
 
 ' f 
 
 
 I 
 
 ^ 
 
 
 Q 
 
 
 
 
 
 
 ■ 
 
 / 
 
 ^ 
 
 I 
 
 <v 
 
 
 H' 
 
 - 
 
 t . 
 
 r 
 
 ^ 
 
 rfr- 
 
 i 
 
 -- 
 
 — ^- 
 
 
 \ 
 
 f 
 
 v 
 
 
 "il 
 
 
 
 
 86^ 
 
 :• 
 
 
 
 \t\ 
 
 
 
 ; 
 
 
 
 
 Fig. II. — Operation on the 
 Knee-Joint (Septic). 
 
 Fig. 12. — Operation for 
 Radical Cure of Hernia 
 (Septic).* 
 
 be expected, and must not be confused with a tempera- 
 ture due to sepsis ; it usually falls again at once, and the 
 subsequent temperature is normal. After very severe 
 operations involving much shock, this post-operative 
 temperature, as one would expect, is often delayed until 
 the shock has passed off. 
 
 The above was written in 1903, before the use of 
 rubber gloves and masks became the usual practice, and 
 some modification of these views is now necessary. It 
 has been decided, however, to let the passage stand, as it is 
 
 * There was pus in the wound on the fourth day. 
 
Treatment of the Wound 29 
 
 essentially correct, although by the use of the present 
 surgical technique the reactionary temperature is often 
 abolished, and no alteration of temperature occurs. In 
 other words, the high reactionary temperature then seen 
 in the healing process of wounds which healed by first 
 intention was sometimes due to the reaction against 
 micro-organisms introduced into the wound, but which 
 the tissues dealt with successfully. Blood-clot in a 
 wound will, however, often give rise to a sharp reaction- 
 ary temperature, quite apart from septic infection. 
 
 When the wound is septic, this preliminary rise in 
 temperature is not followed by a drop, but persists, often to 
 become intermittent later on (Fig. 11); or the preliminary 
 rise is absent, being replaced by a slightly subnormal 
 temperature for the first two or three days, and is then fol- 
 lowed by a rise to 102° (Fig. 12) or higher. In most cases 
 when the wound has become septic the temperature rises 
 on the evening of the second or third day, and sometimes 
 as late as the fifth or sixth day after the operation. So that 
 a rise of temperature during the first forty-eight hours, 
 unless accompanied by other local or general signs of 
 sepsis or unless it remain up, need not be looked upon as 
 evidence of sepsis, but, on the other hand, as a favourable 
 sign ; persistence of this temperature, however, especially 
 in the morning, or a rise occurring after the second day 
 following the operation, is to be looked upon as evidence 
 of sepsis, and should be followed at once by an examina- 
 tion of the wound. Unfortunately, in a certain number 
 of cases the chart shows a perfectly normal temperature, 
 except, perhaps, for the reactionary rise ; and yet when the 
 wound is examined some days after the operation, it is 
 found to have broken down and contain pus. These are 
 mostly cases where blood-clot has been left in the wound, 
 and some comparatively non-pathogenic organism, such 
 
30 The After-Treatment of Operations 
 
 as Staphylococcus pyogenes alius or citreus or the Bacillus 
 epidermidis, has obtained access to it and converted it 
 into pus. When a wound that has apparently healed 
 breaks down ten days or a fortnight after the operation, 
 it is generally due to infected catgut used for buried 
 sutures, sepsis commencing at the time when the sutures 
 begin to dissolve. 
 
 In such cases there is usually but little local inflamma- 
 tion in the wound, but a cavity is found containing pus 
 which originally contained blood-clot. The condition 
 does not, as a rule, cause any temperature or pain, 
 though the patient may sometimes complain of dis- 
 comfort at the site of the wound. Fortunately, this 
 condition is not of very serious import, and such wounds 
 heal very rapidly after the removal of the pus, providing 
 that care be taken to prevent the wound becoming 
 subsequently infected by some more virulent organism. 
 Pain referred to the site of the wound, if it continues, is 
 often a sign of inflammation and sepsis. After the first 
 twenty-four hours an aseptic wound, unless it be in 
 some special situation, is, as a rule, painless. 
 
 At the present time, with the best technique, infection 
 of surgical wounds, unless infection is present at the time 
 of operation, should be a very rare occurrence. Many 
 surgeons have reduced their proportion of cases in which 
 infection of the wound takes place to fractions of i per 
 cent. ; and any surgeon who finds infection occurring in 
 even i per cent, of his cases should seriously revise his 
 methods. The latest figures published from the Mayo 
 clinic are 117 cases of infection in 6,825 cases, or o'oiy 
 per cent, (Surgery, Gynecol., and ObsteL, May, 1914). 
 
Treatment of the Wound 31 
 
 Aseptic Wounds. 
 
 I. Where the Dressings have not been soaked 
 THROUGH BY OoziNG. — Unless the dressings have become 
 loose or soiled, the wound need not be dressed until the 
 time has come for the removal of the stitches. The 
 time at which the stitches should be removed varies 
 considerably in different cases. In moderately small 
 wounds they should, as a rule, be removed about the 
 sixth or seventh day after the operation. In wounds on 
 the face or neck they may be removed earlier, as healing 
 in this situation is rapid, and it is particularly desirable 
 to avoid scarring ; they should be removed about the 
 second or third day. In the case of large wounds, or 
 wounds the edges of which are subject to tension, the 
 stitches should be left for ten days or a fortnight. It is 
 also advisable to leave the stitches somewhat longer 
 when the skin round the wound is not well nourished, as 
 is often the case in wounds for the removal of varicose 
 veins of the leg. 
 
 Some surgeons habitually dress all wounds on the 
 second or third day after the operation. This, however, 
 seems unnecessary and inadvisable in the majority of 
 cases. Usually a certain amount of blood oozes from 
 the wound immediately after the dressings are applied. 
 This soaks into the dressings, and, hardening, sticks 
 them to the wound and surrounding skin, thus forming 
 a sort of splint to the wound, which acts very beneficially 
 in keeping it and the surrounding skin at rest. Of 
 course, when this oozing has come to the edge of the 
 dressings, and has come in contact with the air, it should 
 at once be changed, as otherwise it may act as a tract for 
 the entrance of septic organisms. 
 
 A pair of scissors and forceps which have been 
 
32 The After-Treatment of Operations 
 
 sterilized by boiling should be at hand in a tray contain- 
 ing carbolic lotion. The bandages should then be cut 
 through with a different pair of scissors, and removed, 
 together with the cotton-wool, so that the wound 
 remains covered only with the gauze. A warm towel 
 which has been previously sterilized, either by boiling or 
 immersion for some time in carbolic lotion, should then 
 be placed round the gauze covering the wound. The 
 surgeon should then clean his hands in the ordinary way, 
 by first scrubbing them with soap and water, and then 
 immersing them for a minute or two in some antiseptic 
 solution, preferably an alcoholic solution of biniodide of 
 mercury (i in i,ooo). The gauze should next be removed 
 from the wound. If it is much stuck, it is best to soak 
 it well with some lotion before removing it. As soon as 
 the gauze is removed the wound should be covered with 
 a swab or a piece of gauze, and the skin round swabbed 
 over with lotion to clean it. If the wound appears to be 
 healed, which will probably be the case, the stitches 
 should be removet^. 
 
 The skin is now often prepared before operation by 
 using iodine, which is painted over the wound area ; and 
 in this case, when the dressings are changed or the stitches 
 are to be removed, the wound should be again painted 
 over with the iodine solution. When iodine solution is 
 used, the skin round the wound should not be made wet 
 with a watery lotion, as this interferes with the action of 
 the alcoholic iodine solution. 
 
 Removal of Stitches. — This is best done with a pair of 
 blunt-pointed scissors which cut well at the points. All 
 the stitches should be divided first before any of them are 
 removed. The scissors should be used on the flat, one 
 blade being inserted below the stitch, and then the latter 
 cut as close as possible to the skin surface. The forceps 
 
Treatment of the Wound 33 
 
 should be used to steady or lift the stitch if necessary. 
 After all the stitches have been cut they may be removed 
 by pulling on one end with the forceps. If the stitches 
 are not cut through close to the skin an elbow or kink 
 will probably be left in the stitch which will cause pain 
 when it is drawn out through the stitch- tract. This 
 applies especially to stiff sutures, such as fish-gut. If 
 the stitches are removed in this way, very little pain will 
 be caused, and with a nervous patient this is a point of 
 some importance. When the stitches have become 
 buried in the skin, as is often the case in abdominal 
 wounds, especially in fat people, the cut ends of the 
 suture, which can always be seen, should be pulled on 
 with forceps until the knot comes into view ; then the 
 points of the scissors (held on the flat) must be passed 
 down behind the knot, and the suture divided and with- 
 drawn. It is often advisable not to remove all the 
 stitches at one time, but to leave a few till a later date. 
 If after removal of the stitches the wound is found to be 
 dry and does not gape, it may be sealed up by placing 
 over it a piece of dry gauze cut to the required shape, 
 and painting over the whole with flexible collodion. A 
 large pad of cotton-wool is then placed over it and the 
 bandage applied, or the latter may be dispensed with 
 altogether if the wound is a small one. Should there be 
 any gaping or other reason rendering it undesirable to 
 seal the wound, it may either be redressed as before with 
 wet gauze, or powdered over with boracic acid powder 
 or dermatol, etc., and covered with dry gauze and cotton- 
 wool. When there is much gaping of the wound after 
 removal of the stitches, the edges should be drawn 
 together with strapping. The so-called American or 
 Mead's strapping should be used for this purpose, and the 
 
 part crossing the wound should be cut very narrow. A 
 
 3 
 
34 The After-Treatment of Operations 
 
 good plan of cutting the strapping is shown in the illus- 
 tration (Fig. 13). Two pieces, AB and CD, are cut of the 
 shape shown ; the part C is fixed to the skin on one side 
 of the wound, and the part B on the other. The part A 
 is then passed through the gap in CD, and D and A are 
 pulled upon in opposite directions until the gap is closed 
 and the edges of the wound well approximated ; they are 
 then stuck down. 
 
 Fig. 13. 
 
 2. Where the Dressings have been soaked 
 THROUGH. — When blood from the wound has soaked 
 through the dressings and stained the bandages, the 
 wound should at once be dressed. This should be done 
 in the same way and with even more care than in the 
 case of a wound which is not dressed until the stitches 
 are removed. Even if only a little blood has soaked 
 through at one part of the dressings it is better to change 
 them, as otherwise the blood which has soaked into the 
 dressings may act as a tract for the entrance of organisms 
 to the wound. 
 
 3. Where Drainage has been provided for by a 
 Tube or Gauze Plugging at the Operation. — As a 
 rule, it is better to remove the tube at the end of twenty- 
 four or forty-eight hours. This will, however, depend 
 a good deal on the reasons for which the tube was used. 
 It is not desirable to leave a tube in an aseptic wound 
 
Treatment of the Wound 35 
 
 longer than is absolutely necessary, as a very unsightly 
 scar with inverted edges is apt to result, and the healing 
 of the wound is delayed. Also there is seldom any 
 necessity for the use of a tube after the first twenty-four 
 hours. A very good plan is to pass a stitch through the 
 skin on each side of the tube and to leave the ends 
 untied. The stitch can then be tied up after the tube has 
 been removed. Great care should be taken in dressing 
 these wounds, as there is of necessity an open tract into 
 the depths of the wound, and healing is at a stage when 
 infection can readily take place. Special care should be 
 taken to clean up the skin round the wound with anti- 
 septic lotion and swabs. This should be done from the 
 wound, and not towards it. Thus a swab which has 
 been used for cleaning the outlying areas of the skin 
 must not subsequently be placed in contact with the 
 wound. The dressing should be carried out in the same 
 way as before, except that the wound should not be 
 sealed up with collodion, and it is best not to apply 
 any of the antiseptic powders, as they are often not 
 sterile. 
 
 In many operations, notably in abdominal section for 
 localized peritonitis and operations for necrosis or abscess 
 of bone, it used to be a common practice for the cavity 
 to be left plugged with gauze, the end of the gauze being 
 left protruding from the wound so as to act as a drain. 
 When a large cavity in the abdomen has been plugged in 
 this way, it is often rather difficult to remove the plug 
 without causing the patient a considerable amount of 
 pain. The best plan is to leave the plug in for five or six 
 days or even longer until it has become loosened ; it will 
 then, as a rule, be found to come away quite easily. 
 While the gauze is being removed it should be wetted 
 from time to time with some suitable antiseptic lotion, 
 
36 The After-Treatment of Operations 
 
 or with peroxide of hydrogen, 5 volumes per cent., as it 
 is much more easily removed when it is wet than in a 
 half-dried condition. It should be drawn upon first from 
 one side and then from the other, and considerable 
 patience is often necessary in order to avoid hurting the 
 patient. In cases of acute necrosis of bone, etc^ when 
 a cavity in the bone has been packed with gauze, it is not 
 advisable to wait until the gauze has become loose, and 
 the packing should be removed in twenty-four or forty- 
 eight hours ; as this is frequently a very painful proceed- 
 ing, an anaesthetic should be administered. Nitrous 
 oxide is quite sufficient for this purpose, and under its 
 influence the gauze can be quickly removed, and the 
 cavity, if necessary, repacked. This practice of plugging 
 wounds with gauze is now practically obsolete, cavities 
 being simply drained with tubes or left open. 
 
 4. When the Wound has become Septic — When 
 from the condition of the patient's temperature or from 
 some other indication it is suspected that the wound has 
 become septic, it should at once be dressed, the same 
 care being exercised as if dealing with an aseptic wound. 
 It is sometimes thought that it is not necessary to take 
 the same aseptic precautions in dressing a septic wound 
 as with one which is aseptic. This is quite erroneous. 
 Sepsis may result from many different kinds of organisms 
 of varying pathogenicity and virulence, and if the wound 
 is carelessly dressed fresh organisms may get in, which 
 will find a congenial soil in the already septic wound, 
 and a much more serious type of sepsis may be the 
 result. 
 
 The wound having been exposed and found to be 
 inflamed and septic, a sufficient number of stitches 
 should be cut through to allow a free exit to the pus and 
 to relieve all the tension on the tissues. This is a very 
 
Treatment of the Wound 37 
 
 important point, as if the pus is subjected to tension in 
 any part of the wound it will be much more liable to find 
 its way into the lymphatics and veins, or to push its way 
 along the planes of cellular tissue, than will be the case 
 if it is given a free exit through the skin. All pus should 
 be removed from the wound, and the wound itself dried 
 out with swabs or sponges. Opinion differs a good deal 
 as to whether during the acute stage of the inflammation 
 the wound should be irrigated with some antiseptic lotion 
 or not. The chief objection to the irrigation of the 
 wound with strong antiseptic solutions is that the anti- 
 septic irritates the already inflamed and injured tissues, 
 and is liable to break down the delicate lymph barrier 
 which has probably formed between the pus and the 
 lymphatics, so allowing organisms which before were 
 only local to gain an entrance to the general circulation ; 
 while, on the other hand, washing out the wound with an 
 antiseptic will not destroy all the organisms in the tissues 
 surrounding the wound, and therefore cannot arrest the 
 septic process. It is to the tissues themselves that we 
 have to look for an arrest of the condition, and care 
 should therefore be taken to avoid injuring them. There 
 cannot, however, be any objection to gently irrigating 
 the wound with normal salt solution or with some weak 
 antiseptic, so as to wash away as much as possible of the 
 pus and infective material present in the wound. Saline 
 solution previously sterilized is undoubtedly the best fluid 
 for this purpose, though a weak solution of carbolic or 
 biniodide may be used if this is not at hand. 
 
 In cases of very severe sepsis, where the tissues show 
 little reactive power and there is evidence of general 
 infection, such as the enlargement of the neighbouring 
 lymphatic glands, lymphangitis, or the presence of severe 
 general symptoms, an attempt may sometimes be made 
 
38 The After-Treatment of Operations 
 
 to destroy as far as possible the organisms present at the 
 source of infection, with the hope of so preventing any 
 further absorption of their toxic products. To carry this 
 out the wound should be freely opened up, and well 
 swabbed out with some powerful antiseptic^ such as 
 I in 20 carbolic acid or i in 500 biniodide. Unfortu- 
 nately, almost all the present antiseptics in use coagulate 
 albumen, and when used in this way a thin coagulum is 
 formed over the surface of the tissues, so that the action 
 of the antiseptic is limited, as a rule, to the superficial 
 parts of the wound. This method of dealing with septic 
 wounds is not a safe one to use when the wound has an 
 extensive surface, especially in children or old people, as 
 under such circumstances it may be followed by symptoms 
 of poisoning by the drug used. Drainage-tubes should 
 be inserted into all the pockets of the wound, and steps 
 taken to keep the wound open by packing it lightly with 
 gauze. If there is much local inflammation, hot fomenta- 
 tions may be made use of with advantage. For this 
 purpose the ordinary boracic fomentation is very unsuit- 
 able, as it only remains hot for a very short time, and has 
 very slight absorbent properties, not to speak of the fact 
 that its antiseptic power is practically nil. Most of the 
 ordinary septic organisms can be grown upon it with 
 ease. A very good fomentation can be made by using a 
 thick layer of gauze wrung out in a towel after it has 
 been well soaked in a hot solution of i in 100 carbolic 
 acid ; the carbolic, besides insuring the asepticity of the 
 fomentation, acts as a local anaesthetic and reduces the 
 pain. 
 
 Gauze is one of the most absorbent dressings we 
 possess, and it is very important to use a dressing that 
 will quickly soak up all the discharge from the wound. 
 Gauze is, unfortunately, rather expensive, but plain un- 
 
Treatment of the Wound .39 
 
 medicated gauze can be used ; this is much less expensive 
 than the cyanide or alembroth varieties, and is equally 
 useful for this purpose. A very good fomentation may 
 also be made by using ordinary absorbent cotton-wool 
 instead of the gauze ; it has the advantage of remaining 
 hot for a very long time. Whatever is used for the 
 fomentation should be put on as hot as possible, and 
 changed as soon as it has cooled down to the body 
 temperature. This will usually mean changing the 
 fomentation every fifteen or twenty minutes. Fomenta- 
 tions may be made to keep hot for longer than this if they 
 are made very thick, and a thick layer of cotton-wool is 
 placed outside them. 
 
 A fomentation to be effective must be hot, and must be 
 capable of soaking up all the discharge from the wound. 
 This latter factor is very important, as the discharge 
 from an acutely septic wound not only swarms with 
 organisms, but contains toxic material formed by these 
 organisms. This toxic material acts as a poison to the 
 tissue cells, tending to paralyze or destroy them, and so 
 prevent their dealing effectually with the organisms. 
 
 As soon as the acute inflammation in the wound has 
 to some extent subsided, the fomentations may be left off 
 and the wound dressed with damp gauze — i.e., gauze 
 with a layer of oil-silk or jaconet over it. Damp gauze 
 has the advantage of being more absorbent than dry 
 gauze. The wound should at first be dressed at least 
 twice a day, and as long as there is any discharge the 
 wound ought to be dressed often enough to insure its 
 being kept free from the accumulation of pus, etc., in it. 
 At this stage the edges of the wound may with advantage 
 be drawn together with strapping, as already described. 
 When all inflammation has subsided, dry dressings may 
 with advantage be substituted for the damp ones. 
 
40 The After-Treatment of Operations 
 
 In the case of septic wounds on the extremities, good 
 results often follow the use of the water-bath if the wound 
 is in a suitable position. The water in the bath should 
 be kept as far as possible at an even temperature, and 
 should be kept constantly flowing through so as to keep 
 the water clean. Most limb-baths are now made with a 
 tap at the bottom end, to which an indiarubber tube can 
 be attached passing to a bucket beneath the bed. 
 Another tube connected with a suitable receiver should 
 be arranged to allow water to flow into the bath. 
 
 General Treatment of Sepsis. — In all cases where sepsis 
 occurs in the wound a free purge should be administered 
 at the earliest opportunity. Calomel (5 grains), followed 
 in four hours by a dose of salts, is one of the best purges 
 for this purpose, and will do a great deal to cut short 
 sepsis and bring down the temperature. A purge 
 administered immediately there is the slightest sign of 
 sepsis will occasionally prevent the wound breaking 
 down, and when it does not succeed in this, will at any 
 rate do a great deal to relieve the symptoms. The way 
 in which a purge acts in diminishing the effects of sepsis 
 in a wound has not been satisfactorily explained. That 
 it does so cannot be doubted. Purgation now takes the 
 place of the blood-letting which was so popular in the 
 treatment of all acute inflammatory conditions a hundred 
 years ago, and no doubt it acts in much the same way — 
 i.e., by depletion. The most probable explanation of the 
 value of purgation in the treatment of sepsis is that, by 
 removing a large quantity of the fluid constituents of the 
 blood, it renders the tissues of the body drier and less 
 cedematous ; obviously a wound which is not sodden or 
 oedematous will react to sepsis much more favourably 
 than one that is. 
 
 With regard to drugs, no drugs except those used as 
 
Treatment of the Wound 41 
 
 aperients are of much value. Quinine is supposed to be 
 efficacious in some cases, and especially in those where 
 there are signs of general septic infection. To be of 
 service it should be given in large doses, 5 grains three 
 times a day. 
 
 5. Cases v^^here Symptoms of Septicemia occur. — 
 These cases are now, fortunately, rare. They still occur 
 occasionally, however, and, when they do, require prompt 
 and energetic treatment. The chief points in the treat- 
 ment of these cases are : 
 
 (i) Disinfection of the wound as effectually as possible 
 and the prevention of tension in it by free drainage. 
 
 (2) Keeping up the patient's strength by judicious 
 feeding. These patients need to be fed every two or 
 three hours. 
 
 (3) Keeping the bowels acting freely. 
 
 (4) Alcohol in the form of brandy or whisky should be 
 given freely — 5 or 8 ounces daily. 
 
 (5) The administration of quinine or quinine and iron 
 is often useful. 
 
 Serum and Vaccine Treatment of Sepsis. 
 
 The treatment of severe cases of sepsis by anti- 
 streptococcic or antistaphylococcic serums, and also the 
 more recent method of using vaccines prepared from the 
 pus of the wound, while admirable in theory and occa- 
 sionally successful, often, unfortunately, fail to produce 
 the beneficial results which it is reasonable to expect. 
 While the success which has attended these methods of 
 treatment does not as yet justify us in using them in 
 place of the older and well-established methods, they 
 may with advantage be used in conjunction with the 
 latter. Before usiUj^ any serum a bacteriological examina- 
 
42 The After-Treatment of Operations 
 
 tion of the pus should be made, to ascertain what is the 
 nature of the organism or organisms present, so that a 
 suitable anti-serum may be selected. 
 
 The injection of the serum, when successful, has a 
 marked effect in reducing the temperature, and, as a rule, 
 there is a drop of several degrees within a short period 
 after the injection. It is absolutely necessary that the 
 serum should be quite fresh, and serum that has been 
 prepared for more than two weeks is useless. 
 
 The usual site for injection is the loin or abdominal 
 w^all. The serum should be injected quite slowly and 
 about 10 c.c. or more used at a time — the exact dose 
 does not seem to matter ; the injection should be repeated 
 every twenty-four hours or oftener, if it is doing good. 
 The serum should always be obtained from some reliable 
 source, such as the Lister Institute. 
 
 When there is doubt as to the exact nature of the 
 infection, a so-called polyvalent serum may be used. 
 This is prepared from several different strains of strepto- 
 cocci, and consequently the chance of its proving correct 
 is greater. Very little can be expected from a single 
 injection, and if the serum is to be of any real use it must 
 be injected freely and repeated. 
 
 In treating a patient by vaccines, his opsonic index is 
 first ascertained, and then a vaccine used which has been 
 prepared from a pure culture of the organism found in 
 the pus from the wound, the object being to raise the 
 patient's natural resistance to the infection. 
 
 This method of treatment is difficult and complicated. 
 It can only be satisfactorily carried out by a skilled 
 bacteriologist. It must be confessed that this method of 
 treating septic infection has been very disappointing. 
 
CHAPTER III 
 
 THE TREATMENT OF GUNSHOT WOUNDS 
 
 This subject is such a wide one that no attempt will be 
 made to deal with it m all its aspects, as this would be 
 quite impossible in the present volume. The following 
 remarks are the result of experience gained by the author 
 in attendance upon the wounded at King Edward VII. 's 
 Hospital for Officers and other military hospitals in the 
 metropolis. Before arriving at these hospitals the 
 patients have already been under treatment for periods 
 varying from a few days to a few weeks at hospitals in 
 France or elsewhere. No attempt will therefore be made 
 to describe here the treatment of wounds as seen on the 
 field, or immediately after an action, but only cases 
 as they present themselves when they come into the base 
 hospitals and into hospitals in England. By this time 
 most of the wounds have passed what we may call the 
 first stage, and at least a week has usually elapsed since 
 the original injury. The methods of dealing with wounds 
 which are described here are those which the author has 
 found most satisfactory, and he does not suggest that 
 they are the only means that can be adopted to obtain 
 good results ; but in practice the results obtained by 
 these methods have proved very satisfactory, and he 
 hopes that they may be found a useful guide to those 
 
 43 
 
44 The After-Treatment of Operations 
 
 surgeons who find themselves called upon to undertake 
 the care of wounded men, and who have not had much 
 previous experience of such cases. 
 
 Clean Bullet Wounds. — These in the present war 
 are unfortunately very few, but, nevertheless, form a 
 certain proportion of the total. When the bullet has 
 passed through soft parts without having met with much 
 resistance, the entrance wound is quite small, and has 
 generally healed by the time the patient has reached 
 his destination. The exit wound is usually about the 
 size of a sixpence, and is covered with a dark brown 
 scab. In most instances the wounds have been treated 
 by painting them with iodine and covering them up with 
 aseptic dressings. The best plan is to continue this 
 treatment, and not to disturb the wounds in any way. 
 The exit wound should be allowed to heal under a scab 
 if it will do so, and should the scab separate an anti- 
 septic dressing should be applied, or the wound dressed 
 with some aseptic ointment, such as one of those men- 
 tioned later. On no account should any attempt he made to 
 probe the wounds, even if they contain foreign bodies. 
 
 The Removal of Bullets or Pieces of Shell. — -If 
 there is reason to suppose that the bullet has lodged, or that 
 a piece of shell is embedded somewhere in the tissues, this 
 should not be probed for, but at the earliest opportunity 
 the patient should be examined with the X-rays. If then 
 a foreign body is found to be present, the next question 
 will be as to whether it should be removed or not. There 
 should be no rule in this matter. A foreign body, 
 such as a bullet or portion of shell, is not necessarily 
 harmful when retained in the tissues. Its removal is 
 only called for if it is causing symptoms — if, for instance, 
 it is pressing upon the nerves, interfering with the action 
 of a muscle or joint, or if it is causing pain. This does 
 
The Treatment of Gunshot Wounds 45 
 
 not, however, apply to foreign bodies within the brain, 
 which are a different matter, and for the treatment of 
 which the reader is referred to other authorities. Much 
 harm may be done by the removal of foreign bodies 
 which are not causing trouble or inconvenience. The 
 patient may safely be assured that no harm will result 
 from the bullet being left inside him. In the case of 
 septic wounds there is more reason for removing the 
 foreign body, as it often means that the sinus will refuse 
 to close, although there have been plenty of instances in 
 this war where pieces of shell, etc., in septic wounds 
 have been left and have ceased to give any trouble at all. 
 It is obvious that in many cases the removal of pieces of 
 shell or bullets is quite impossible owing to their situa- 
 tion. For instance, the writer saw one case in which a 
 bullet had lodged in the anterior part of the body of the 
 fourth cervical vertebra, slightly injuring the posterior 
 wall of the pharynx. It is clear that the removal of 
 such a foreign body would be a most dangerous pro-' 
 cedure. No attempt was made to remove it, and the 
 patient made a perfect recovery, and suffers no incon- 
 venience from the presence of the bullet. 
 
 In another case a shrapnel bullet had passed through 
 the sacrum and fractured the anterior surface of the 
 promontory, where with a finger in the rectum one could 
 feel it bulging against the mucous membrane on the 
 posterior wall of the rectum. This foreign body was 
 also impossible of safe removal. 
 
 Should it be decided, owing to the persistence of pain 
 or interference with a joint, that a bullet must be re- 
 moved, this should not be attempted until the bullet has 
 been carefully localized by means of Sir Mackenzie David- 
 son's or some other reliable X-ray method. To attempt 
 to remove foreign bodies on the strength of X-ray photo- 
 
46 The After-Treatment of Operations 
 
 graphs without proper localization is to ask for trouble. 
 Such efforts will almost certainly result in the patient's 
 being damaged by a large wound and the foreign body 
 being left behind, owing to the surgeon's inability'to find it. 
 With proper localization, and especially with the aid of 
 Sir Mackenzie Davidson's telephone probe, the surgeon 
 should generally have little difficulty in removing a 
 foreign body through a small incision. As a rule no 
 attempt should be made to remove pieces of bullet, etc., 
 from the chest or abdominal cavity. 
 
 Septic Bullet Wounds. — The first question that will 
 arise in dealing with such wounds is whether the drainage 
 is adequate or not. If the patient's temperature is raised 
 at night, and especially if in addition there are local signs 
 of cellulitis and redness of the skin in the neighbourhood 
 of the wound, the drainage is almost certainly in- 
 adequate, and proper drainage must at once be pro- 
 vided. For this purpose it will usually be necessary to 
 administer an anaesthetic and to enlarge the wound or 
 wounds, and to pass the largest bore drainage-tubes that 
 can be conveniently used, provided with plenty of side- 
 holes into every part of the wound, being particularly 
 careful to see that the most dependent part of the wound 
 is properly drained. After this the wound should be 
 irrigated constantly with normal saline or hypertonic 
 solutions, and should also be fomented frequently. For 
 this purpose the ordinary hospital fomentation is quite 
 useless. It generally consists of two or three layers of 
 boracic lint, which are usually cold before the bandages 
 have been applied. It must always be remembered that 
 the object of fomentations is not to apply a warm dressing, 
 but to apply sufficient heat to produce marked hypersemia 
 of all the tissues in the neighbourhood of the wound, 
 and that no fomentation which does not cause marked 
 
The Treatment of Gunshot Wounds 47 
 
 reddening of all the tissues is of any use. The best 
 fomentation is ^ pound of cotton-wool thoroughly boiled 
 in a towel and then rung out as dry as possible. This 
 fomentation will keep hot for at least half an hour, and 
 should be changed as often as possible, care being taken 
 not to burn the patient, but to go as near it as possible. 
 Almost immediate relief of pain and considerable im- 
 provement in the wound will follow this treatment. As 
 a rule, within about forty-eight hours the discharge will 
 have begun to diminish and the temperature will have 
 come down. The tubes may then be partially removed 
 or shortened, the patient being carefully watched to see 
 if any rise in temperature, or increase in discharge, follows 
 their removal. Irrigation of the wound should not be 
 overdone, The author is of opinion that little is to be 
 gained by irrigation of the wound after the first day or 
 so, unless it is with the object of washing out some 
 pocket in which pus tends to accumulate. The presence 
 of such a pocket, however, is in itself evidence of inade- 
 quate drainage, and further drainage ought to be provided 
 in order that accumulation of pus may not occur. 
 
 In all these septic wounds the dressings should be 
 changed frequently, at least twice in the twenty-four 
 hours, and if possible oftener, the object being to keep 
 the wound as free as possible from pus, or contact with 
 pus. Antiseptics, especially strong ones, are of very 
 little use at this stage, and only tend to damage the 
 tissues and delay healing. Sterilized water, or salt solu- 
 tion, or very weak carbolic, are the best solutions. After 
 the wound has taken on a healthy appearance fomenta- 
 tions should be stopped, and a wet, absorbent dressing 
 applied. By this is meant a dressing which is put on 
 wet and covered with a large sheet of oil-silk or jaconet. 
 Wet dressings have the advantage of being more absor- 
 
48 The After-Treatment of Operations 
 
 bent and of not sticking to the wound. Consequently 
 they do not cause pain when they are being changed, or 
 destroy the growing edge of the wound. If the Avound 
 is dirty, as is usually the case, and the surface of it is 
 covered with sloughs and bits of dead tissue, a very 
 good dressing is peroxide of hydrogen, 5 or 10 volumes 
 per cent. The best way of applying this is to soak small 
 pieces of gauze in the peroxide and pack these into the 
 wound very lightly. The wound should not be so packed, 
 however, that the packing projects above the surface of 
 the skin, or, when the bandages are applied, there will be 
 pressure on the wound which will tend to cause pain. A 
 piece of gauze rung out of the same peroxide should be 
 applied over the packing, and over this a piece of rubber 
 sheeting, in order to keep it wet. This dressing should 
 also be changed two or three times a day. After a few 
 days the wound should take on a healthy appearance, 
 with bright red granulations covering all the surface. 
 When the deep parts of the wound are healed, and there 
 is left only an area covered with healthy granulations, 
 an ointment dressing may with advantage be substituted 
 for the wet dressing, and more rapid healing will occur. 
 It is obvious that ointment dressings must not be applied 
 while there is any discharge from deep sinuses or holes. 
 The following ointment has been found to give excellent 
 results in wounds at this stage : 
 
 "^ Castor- oil = - . . 78 per cent. 
 
 Alcohol - . - - 10 ,, ,, 
 
 Scarlet-red - - - - 4 ,, ,, 
 
 Amido-azotoluol - - - 8 ,, ,, 
 
 Sterilized vaseline, or equal parts of castor-oil and 
 sterilized olive-oil, may also be used. The red ointment 
 should only be applied in very small quantities, as it 
 tends to spread and make a mess. It has, however, the 
 
The Treatment of Gunshot Wounds 49 
 
 property of healing up epithelium at an extraordinary- 
 pace. Another good dressing that may be applied at this 
 stage, if the wound is slow in healing, is Friar's Balsam. 
 
 Septic Bullet Wounds involving Fracture of the Bones. — 
 These are some of the most difficult cases to deal with, 
 and only a very general outline of the treatment can be 
 indicated here. If a compound fracture of one of the 
 long bones has taken place, the patient must be put in 
 some splint which will keep the limb in as good a posi- 
 tion as possible, and which will allow of the wound 
 being dressed frequently and adequately. It is often a 
 most difficult matter to arrange suitable splints, more 
 particularly where large portions of the bone are missing. 
 Little is to be gained by removing broken fragments 
 unless these are obviously necrosed, as they may be of 
 use in helping to fill up the gap in the bone, many of 
 them retaining sufficient vitality to act as foci of bone- 
 formation. 
 
 The remarks already made on free drainage apply 
 with even greater force to these injuries involving bone. 
 It is extraordinary how even the most desperate-looking 
 injuries, accompanied by sepsis, will recover with quite 
 excellent results if properly treated, and will leave good 
 and useful limbs. 
 
 Secondary Amputations. — These should seldom be 
 called for, and are always a confession of failure on the 
 part of the surgeon. The reason why a patient recovers 
 after the amputation of a septic limb is that the drainage 
 of an amputation stump is good, and that consequently 
 suppuration of the stump is not so serious as that of the 
 previous wound in the limb. In other words, the surgeon 
 amputates the limb because he is unable otherwise to 
 establish free drainage of the wound. It is always wise 
 to bear this in mind, and the moral is that thorough 
 
 4 
 
50 The After-Treatment of Operations 
 
 drainage and frequent dressings should save most limbs. 
 The only conditions which necessitate amputation are 
 ulceration of the bloodvessels and gangrene, or a com- 
 pletely disorganized limb. 
 
 Injuries of Joints. — Septic injuries of the joints are 
 even more serious than septic compound fractures, by 
 which, however, they are nearly always accompanied. 
 Experience has shown that even in the case of septic com- 
 pound fractures associated with suppuration of a joint 
 excellent results can be obtained, and amputation is not 
 necessary. A more or less stiff limb is, however, likely 
 to result, and this should be borne in mind during the 
 healing process, so that the limb, should it become 
 fixed, may be in the best position for subsequent utility. 
 In the case of a badly septic joint accompanied by much 
 bone injury, good results may sometimes be obtained by 
 tenotomy of the flexor muscles, In nearly all cases where 
 limbs are affected much may be done by means of mas- 
 sage and exercises, after the wounds are healed, to obtain 
 restoration of function. As a rule, restoration of function 
 takes place much more rapidly in the upper limbs than 
 in the lower. This is due to the fact that no weight has 
 to be transmitted in the case of the arms. 
 
 Persistent Sinus. — If it is found that there is a sinus 
 in one of the wounds, which continues to discharge pus, 
 the inference is that there is some foreign body at the 
 bottom of it. This may be a portion of necrosed bone, a 
 piece of clothing carried in on the bullet, a piece of shell, 
 etc. The author has seen one case in which a large plug 
 of wood was driven into the wound. It is obvious that 
 many of these foreign bodies will not show in X-ray 
 photographs. The proper treatment is to open up the 
 sinus, thoroughly scrape it out, and remove any foreign 
 body that is present. Healing will then recommence. 
 
CHAPTER IV 
 
 HEMORRHAGE AFTER OPERATIONS 
 
 The occurrence of haemorrhage from the wound after an 
 operation is one of the most troublesome complications 
 that can arise. There are several reasons for this 
 besides the mere fact of its seriousness. There is 
 nothing which is so calculated to alarm a patient, or to 
 make him lose confidence in his medical adviser as 
 haemorrhage from the wound, even though it may be 
 quite trifling in amount. Blood seems to have a par- 
 ticularly frightening effect upon most people, medical 
 men excepted ; and haemorrhage after an operation, 
 coming on as it usually does quite suddenly and 
 unexpectedly, often has the effect of reducing the 
 patient to a condition of panic, though the amount of 
 blood lost may not be serious. It is also a trying 
 complication to the surgeon. He has, as a rule, to meet 
 it unexpectedly and at a moment's notice. Moreover, 
 no two cases are exactly alike. In some the bleeding is 
 easily stopped, and again in others the greatest difficulty 
 may be experienced. Frequently the proper instruments 
 are not at hand and reliable assistance is unobtainable. 
 
 In the following description, haemorrhage will be 
 divided into recurrent and secondary. The treatment of 
 primary haemorrhage does not come within the scope of 
 this work. By recurrent haemorrhage, or intermediary 
 
 51 
 
52 The After-Treatment of Operations 
 
 haemorrhage, as it is sometimes called, is meant a recur- 
 rence of the primary bleeding from imperfect arrest. It 
 usually occurs within twenty-four hours of the operation. 
 
 Recurrent Haemorrhagre. 
 
 This may result from various causes. The haemor- 
 rhage may have been entirely stopped before sewing up 
 the wound, but owing to the patient's circulation being 
 feeble and the blood-pressure low at the end of the opera- 
 tion, from shock or some other cause, no bleeding takes 
 place from some of the smaller vessels that have been 
 cut. When, however, the patient comes round from the 
 anaesthetic, and the shock has passed off, the pressure in 
 the vessels increases with the improved circulation, and 
 haemorrhage occurs. Again, some vessel or vessels 
 have become occluded by clot, and so long as the patient 
 remains quiet this is sufficient to prevent bleeding. On 
 coming round from the anaesthetic, the patient moves 
 about, and bleeding results from the displacement of the 
 clot. These are very common events, and account for 
 most of the cases where haemorrhage occurs about four 
 or five hours after the operation. A less common cause, 
 but one which may, nevertheless, give rise to serious 
 trouble, is the partial division at the operation of some 
 small artery. The bleeding may be so trifling that it is 
 not noticed, or it is thought that it will stop when the 
 bandages are applied. When an artery, however small, 
 is only partially divided, the contraction of the muscular 
 coats and sheath tends to keep the wound open, so that a 
 vessel thus divided will go on bleeding almost indefinitely. 
 An artery bleeding into a confined space acts like an 
 hydraulic press, and the pressure thus exerted upon the 
 interior of the wound may be very considerable. When 
 bleeding is taking place in this way into a wound, a very 
 large haematoma may form, and the skin round the 
 
Hemorrhage after Operations 53 
 
 wound be stripped up for a considerable distance. Also, 
 owing to the small size of the vessel which is bleeding, 
 the haemorrhage takes place slowly, and often does not 
 give any external evidence of its presence for some hours 
 after the operation. 
 
 The following case illustrates this form of recurrent 
 haemorrhage : 
 
 A man of about forty-five years of age had his right testicle 
 removed for tubercular disease. All bleeding was stopped at the 
 operation, and the wound was sewn up. At 12.30 p.m., and 
 about eight hours after the operation, the patient noticed that the 
 dressings were wet, and on examination the nurse discovered that 
 there was a quantity of blood on them and in the bed. The house- 
 surgeon was sent for, and on his removing the dressings it was 
 found that an enormous haematoma had formed under the wound 
 and had stripped up the skin over the abdominal wall half-way 
 to the umbilicus. It was at first thought that the ligature on the 
 cord had given way. An anassthetic was administered and the 
 wound opened up ; it was then found that the bleeding was taking 
 place from a small subcutaneous artery not much larger than a pin 
 in diameter. The vessel was partially divided, and had no doubt 
 been wounded by the needle in sewing up the wound. The vessel 
 was clipped and ligatured, and the wound sewn up again after 
 clearing out the clot. In this case, in spite of the slowness with 
 which the bleeding must have taken place, and the comparatively 
 small amount of blood lost, the patient was suffering from very 
 pronounced symptoms of collapse. 
 
 Other causes of recurrent haemorrhage are softening or 
 slipping of a Ugature, and failure to secure the distal end 
 of a divided artery ; in the latter case, bleeding will take 
 place as soon as the collateral circulation is established. 
 
 Treatment of Recurrent Hcsmorrhage. — The best treat- 
 ment, when it can be carried out, is to at once reopen the 
 wound and, ligature or secure the bleeding vessel. In 
 some cases pressure alone may prove sufficient, but, as 
 already pointed out, this cannot be relied upon. 
 
54 The After-Treatment of Operations 
 
 An anaesthetic should, as a rule, be administered, as it 
 is next to impossible to make certain how much may 
 have to be done before the bleeding is stopped ; also, the 
 various steps of opening the wound and securing the 
 vessel that is bleeding can then be carried out with much 
 greater deliberation, and there will, in consequence, be 
 less danger of the wound becoming infected. 
 
 If the haemorrhage is found to have stopped by the 
 time the surgeon reaches the patient, or if it should stop 
 after the administration of the anaesthetic, the wound 
 should nevertheless be opened if the previous bleeding 
 has been at all severe, as it will probably recur again, 
 and the risk of this is greater than that of opening the 
 wound. Moreover, the presence in the wound of a large 
 mass of blood-clot will very materially delay healing, and 
 is much better removed. 
 
 In cases where the bleeding is venous instead of 
 arterial, pressure should be carefully applied over the 
 bleeding point, and the limb or part well raised on 
 pillows, etc. Care should be taken to see that there are 
 no bandages or straps of splints, etc., constricting the 
 parts above the wound, as this is the commonest cause 
 of such venous bleeding, all that is required in many 
 cases being the removal of the constricting bands and 
 the elevation of the part. 
 
 Recurrent Hsemorrhag"e from the Wound as the 
 Result of Some Constitutional Condition of 
 the Patient. 
 
 The treatment of recurrent haemorrhage by opening 
 the wound and securing the bleeding vessel previously 
 mentioned, though the best procedure in most cases, is 
 not always applicable. There are some cases where a 
 
Hsimorrhage after Operations 55 
 
 general oozing of blood occurs from the wound. This 
 oozing may continue uninterruptedly, or it may stop, and 
 after an interval of hours or days start afresh. The 
 bleeding is usually not copious, but the quantity lost is 
 often considerable, and the patient soon gets into a most 
 dangerous condition. 
 
 In some cases of this nature the bleeding does not 
 come on for some days after the operation. The cause 
 is probably always constitutional, and is due to some 
 blood change which interferes with the proper clotting of 
 the blood. What the exact nature of these blood changes 
 is has not yet been determined. One of the best explana- 
 tions seems to be that it is due to an absence or deficiency 
 of the calcium salts. The constitutional conditions 
 in which this type of haemorrhage is most commonly 
 met with are haemophilia, jaundice, and leucocythemia. 
 There are, however, cases which do not apparently come 
 under the head of any of these three diseases, in which 
 bleeding of this nature occurs, and it seems probable that 
 there are other conditions, as yet unrecognised, in which 
 similar blood changes take place. 
 
 The best way of treating these cases is by the adminis- 
 tration of calcium lactate in large doses. This drug 
 is of most value in preventing haemorrhage, but unfortu- 
 nately it is only seldom that we are able to foresee such 
 haemorrhage. 
 
 If calcium chloride is administered in large doses as 
 soon as the haemorrhage occurs, it is usually effectual in 
 stopping the bleeding in a short time, though, since it 
 acts by correcting a constitutional deficiency of the blood, 
 it cannot be expected to act rapidly. 
 
 It should be given in doses of from 13 to 20 grains or 
 more three times a day either by the mouth or rectum. 
 
 The administration of very large doses of this dru^- 
 
56 The After-Treatment of Operations 
 
 would appear on theoretical grounds to be dangerous, 
 though the author knows of no cases where it has proved 
 so. Large doses administered to animals cause intra- 
 vascular clotting, and one would expect to find thrombosis 
 as a possible consequence of the too free administration 
 of the drug. 
 
 The local application of adrenalin is also sometimes 
 effectual in these cases. 
 
 Jaundice. — When patients are suffering from jaundice 
 at the time of the operation, as is often the case in opera- 
 tions for occlusion of the common bile-duct, they are very 
 liable to bleed in this way. The bleeding takes place 
 from all parts of the wound and even from the stitch- 
 holes. Pressure alone is seldom of much use in stopping 
 the haemorrhage. Styptics may be tried, preferably supra- 
 renal extract or Ruspini's styptic. These styptics are 
 best applied by soaking narrow pieces of lint in them, 
 and then packing the lint into the wound and applying 
 pressure over it. Mr. Mayo-Robson has drawn atten- 
 tion to the value of calcium chloride in large doses in 
 the treatment of these cases ; he advises the drug to 
 be given by the rectum in 60-grain doses three times a 
 day, until all signs of oozing from the wound have 
 ceased. 
 
 HEMOPHILIA. — These are most serious cases^ and often, 
 in spite of all treatment, result fatally. Ruspini's styptic or 
 suprarenal extract should be applied locally and be aided 
 by pressure. These drugs can be given internally at the 
 same time. Ruspini's styptic can be given in doses of 
 ID minims hourly in about i ounce of water. 
 
 Calcium lactate in 10 to 20 grain doses, given internally> 
 is also sometimes efficacious ; it should be given as soon 
 as possible after a diagnosis of haemophilia has been 
 made, and repeated, as it takes some time to act. 
 
Hasmorrhage after Operations ^y 
 
 Weil has recently stated that fresh human or animal 
 serum, when added in a dose of 3 drops to 3 c.c. of the 
 blood of a hgemophilic subject, will favour coagulation to 
 a marked degree in the inherited form, and absolutely in 
 the accidental form of the disease. In the adult, from 
 10 to 20 c.c. of fresh serum is sufficient for a venous, and 
 from 20 to 30 c.c. for a subcutaneous, injection. In 
 children half these doses should be used. The best 
 serum next to that of man is that of the horse or rabbit. 
 If these are unobtainable, Weil advises using anti- 
 diphtheritic serum, which is readily obtainable. 
 
 Direct transfusion of blood from a healthy person has 
 been used successfully in cases of haemophilia. This re- 
 quires the performance of a temporary arterial anasto- 
 mosis between the bloodvessels of the patient and the 
 person who is willing to give the blood. This is a delicate 
 operation requiring considerable care. There is no serious 
 risk to the donor of the blood, but a certain amount of 
 temporary weakness necessarily results. The amount of 
 blood transfused should be about 2 pints. 
 
 Leucocythemia. — This is another disease in which 
 bleeding of this nature often occurs. The treatment is 
 the same as in the previous instances. 
 
 Secondary Haemorrhag'e. 
 
 By this term is usually meant haemorrhage starting at 
 any time from one day to three weeks after the operation. 
 The cause is either failure in the healing of one of the 
 vessels in the wound or ulceration into a bloodvessel ; it 
 usually results from septic arteritis, and consequently does 
 not occur in aseptic wounds. Another factor of importance 
 is disease of the arterial wall ; thus extensive atheroma of 
 the arterial walls may be the cause of secondary haemor- 
 rhage in the aged. The treatment is the same as in the 
 
58 The After-Treatment of Operations 
 
 case of recurrent hemorrhage ; that is to say, opening 
 up the wound and securing the artery, except that it is 
 even more important to do this immediately any signs of 
 bleeding show themselves. The bleeding is usually 
 slight at first, but later may be furious, and it is therefore 
 particularly important to deal with it in the early stage 
 before this has occurred. Pressure should be applied 
 over the main vessel on the proximal side of the bleeding 
 point if this is possible, and then an attempt made to 
 secure the bleeding vessel. In cases where the wound 
 is in a sloughy condition this is often a very difficult 
 matter, and the vessel cannot be secured by a ligature. 
 Under these circumstances a good plan is to underpin it 
 (acupressure). This may be done by passing a stitch 
 deeply through the tissues so as to include the vessel, 
 and then tying the stitch ; or another way is to pass a 
 hare-lip pin beneath the vessel, and compress the artery 
 by figure-of-eight turns made with silk round the ends of 
 the pin and over the artery, or a clip can be put on to the 
 bleeding point and left in situ. These methods failing, 
 recourse may be had to the actual cautery. One of the 
 great objections to the latter is the liability to fresh 
 haemorrhage when the sloughs separate. 
 
 Secondary Hemorrhage from Bullet or Shell 
 .Wounds. — Secondary haemorrhage in wounds produced by 
 shell or bullets is often a most serious accident, and may 
 call for the very greatest skill and promptitude in order to 
 save the patient's life. Much will depend upon the nature 
 of the wound, and no definite rules can be laid down for the 
 treatment of such cases, as the conditions cannot always 
 be foreseen, and very often the surgeon will have to 
 depend upon his own ingenuity and resource in order to 
 stop the bleeding. Some of the worst cases are those in 
 which there is a septic wound in the neighbourhood of 
 
Hsmorrhage after Operatioils 59 
 
 one of the main arterial trunks. All patients with such 
 wounds should be kept very quiet until healing has 
 reached a stage at which secondary haemorrhage is no 
 longer to be feared. Unfortunately, secondary haemor- 
 rhage will sometimes occur no matter how carefully the 
 patient is treated. The bleeding generally occurs at any 
 time from a week onwards, and is due to some ulcer 
 eating its way through the coats of the artery. Usually 
 the haemorrhage begins slowly by a slight leak, and this 
 is the stage at which the surgeon should, if possible, 
 interfere. Presently, as the hole in the vessel enlarges, 
 the bleeding will become furious. The proper treatment 
 is immediately to give the patient a hypodermic of 
 morphia and to administer an anaesthetic. If the bleeding 
 vessel can easily be reached through the wound, the 
 surgeon should expose it and ligature the main vessel 
 above and below the bleeding-point. Before attempting 
 this, however, the main vessel on the central side should, 
 if possible, be controlled by an assistant, in order to save 
 any furious bleeding during the operation. It will often 
 happen that it is not possible or advisable to reach the 
 vessel through the wound, in which case the main artery 
 as near as possible above the wound must be cut down 
 upon and ligatured. When the vessel concerned is the 
 femoral artery or vein, or the axillary artery in the arm, 
 there will be considerable danger of subsequent gangrene 
 of the limb, more particularly in the case of the femoral 
 artery, In order to prevent this, so far as is possible, the 
 limb should be kept warm and should be elevated. In 
 the case of the leg a very good plan is to nurse the 
 patient lying on his face, so as to take the pressure off the 
 vessels at the back of the thigh through which the 
 collateral circulation will, in the main, have to be estab- 
 lished. If signs of gangrene occur, amputation offers 
 
6o The After-Treatment of Operations 
 
 the only means of saving the patient's life. In some 
 cases ligature of the vessel will not be possible, especially 
 where the wound is somewhere in the trunk. Firm 
 plugging must then be resorted to, together with measures 
 to keep down the patient's blood-pressure. The following 
 cases which occurred recently will illustrate the difficulties 
 that may be experienced. 
 
 1. An officer who had been wounded at the Battle of 
 the Marne was brought back to one of the hospitals in 
 London with a bullet wound of the left loin. The 
 bullet had smashed the wing of the ilium and penetrated^ 
 together with fragments of the bone, behind the peri- 
 toneum through the lumbar muscles to the opposite side 
 of the spine. The fragment had been driven forwards, 
 and had opened the sigmoid flexure. The patient had a 
 f cecal fistula through a compound septic fracture of the 
 ilium, and, soon after his admission, leakage of arterial 
 blood through the wound. The bleeding appeared to be 
 coming from one of the lumbar arteries. In order to 
 deal with this condition the patient was put under an 
 anaesthetic, and the abdomen opened on the left side. 
 The hole in the sigmoid was found, excised, and sewn up. 
 The posterior wound was then investigated and plugged 
 as far back as the spine in order to control the haemor- 
 rhage, which had become severe. Two days later a 
 tremendous haemorrhage occurred suddenly in spite of 
 the plugging, and very nearly proved fatal. Fortunately, 
 it was again controlled by plugging, and the patient made 
 a good recovery. 
 
 2. An officer was wounded at Ypres by a bullet which 
 entered through the left cheek, passed behind the last 
 molar tooth in the upper jaw, and through the centre of 
 the soft palate, and emerged through the right tonsil in 
 the line of the carotid vessels on the right side of the 
 
Haemorrhage after Operations 6i 
 
 neck. He was admitted to the hospital in London eight 
 days after injury. Both wounds were almost healed, 
 and his only complaint was of a sore throat, There was 
 a septic-looking wound in the soft palate and a haematoma 
 on the right side of the neck, but no pulsation. He had 
 a good pulse in the right temporal artery. He appeared 
 to have quite recovered from the wound. While he was 
 asleep, however, on the twelfth day a large vessel, prob- 
 ably the internal carotid artery, gave way into the 
 mouth behind the soft palate. He woke up with tre- 
 mendous haemorrhage, which continued until he fainted, 
 when it fortunately stopped. The author, under whose 
 care he was, was immediately sent for. He found the 
 patient almost dead, but the haemorrhage had stopped. 
 It was decided that it was not wise to risk a recurrence 
 of the haemorrhage when the pulse began to recover. 
 Accordingly, in spite of the danger of shock, the patient 
 was put under an anaesthetic at two o'clock in the 
 morning, and the common carotid was tied just below the 
 bifurcation. The patient was then kept lightly under 
 morphia for the next forty-eight hours. He made a 
 perfect recovery. 
 
 Internal Hsemorphag'e. 
 
 The evidence of this will usually be the onset of 
 symptoms of syncope and collapse, which are otherwise 
 difficult to account for, accompanied by signs indicating 
 the presence of free fluid in the abdomen or chest. It is 
 of interest to notice that a high temperature may accom- 
 pany internal hagmorrhage. This temperature is probably 
 due to the absorption of some of the constituents of the 
 blood. It is advisable to bear this in mind- -as otherwise 
 
62 The After-Treatment of Operations 
 
 the symptoms may be ascribed to sepsis, and the true 
 nature of the case not detected till too late. 
 
 The proper treatment is to at once open up the wound, 
 expose the bleeding point, and secure it. This in the 
 case of haemorrhage into the abdominal cavity often 
 means an operation of equal or even greater gravity than 
 the original one. The proper treatment of internal 
 haemorrhage under such circumstances, therefore, may 
 be a matter of the greatest difficulty, or even impossible. 
 The facilities for operating may not be at hand, or the 
 condition of the patient may be such that reopening ths 
 abdomen is out of the question. When the source of the 
 haemorrhage cannot be dealt with directly, the patient 
 should be kept as quiet as possible, ice should be applied 
 over the probable source of bleeding, and morphia should 
 be administered subcutaneously to reduce the blood- 
 pressure and to keep the patient quiet. Stimulants are 
 best avoided, as, by raising the blood-pressure, they tend 
 to increase the haemorrhage. 
 
 The Treatment of Hsemorrhagre after Special 
 Operations. 
 
 HEMORRHAGE AFTER THE REMOVAL OF ToNSILS OR 
 
 Adenoids. — The following causes of severe haemorrhage 
 after the removal of tonsils or adenoids are given by 
 Cordes :* 
 
 1. Haemophilia. 
 
 2. Cardiac disease or arterio -sclerosis (in adults). 
 
 3. Anomalies in the course of the internal carotid. 
 
 4. A preparatory application of cocaine. 
 
 5. Small shreds of vegetations remaining partly at- 
 
 • W. Milligan, Med, Ami., 1901. 
 
Hasmorrhage after Operations 63 
 
 tached to the pharynx ; the haemorrhage ceases when they 
 are removed. 
 
 6. Occasionally severe haemorrhage results in females 
 if the operation be performed at the time of the menstrual 
 period. 
 
 Hemorrhage after Removal of Tonsils. — The patient 
 should be made to sit up and breathe with the mouth 
 well open, preferably in a draught of cold air, as, for 
 instance, in front of an open window. The upright 
 position tends to empty the vessels and the cold to make 
 them contract. Ice or iced water may be given to drink, 
 or iced water applied to the side of the face. This is all 
 that is necessary in slight cases of haemorrhage, and 
 serious haemorrhage is very uncojnnion. 
 
 If, however, the bleeding is severe, and will not yield 
 to such simple measures, the following may be tried : 
 When the bleeding is from the tonsil, a piece of lint or a 
 small Turkey sponge previously soaked in turpentine oi 
 some other styptic (perchloride of iron should not be 
 used) is twisted round the end of a clip or pair of tongue 
 forceps and pressed against the bleeding surface, counter 
 pressure being at the same time made over the position 
 of the tonsil outside. Pressure should be maintained for 
 some minutes until all bleeding has ceased. If no styptic 
 is available, the lint or sponge must be wrung out of hot 
 water (any heat under a temperature of 100° F. will tend 
 to increase the bleeding rather than to stop it). 
 
 If an artery is spurting, or the bleeding refuses to 
 stop with the above measures, a gag should be placed in 
 the mouth, and an attempt made in a good light to clip 
 the bleeding point. If this is successful, the clip may be 
 left on for a few minutes or the vessel twisted. 
 
 Hemorrhage from the Naso -pharynx after the Removal of 
 Adenoids. — The bleeding, though often severe at first, 
 
64 The After-Treatment of Operations 
 
 stops, as a rule, after a minute or so. If it should not 
 stop, pressure should be applied to the bleeding surface 
 by passing a small Turkey sponge up behind the soft 
 palate and pressing it against the posterior pharyngeal 
 wall with the finger ; or the sponge can be wrung out of 
 spirits of turpentine, or any other suitable styptic, and 
 applied in the same manner. The sponge can be held 
 in place either by the finger or a clip. Another plan is 
 to wrap a strip of lint round the end of a Gottstein's ring- 
 knife (which will be at hand), and press on the bleeding 
 point with it. When it is not possible to control the 
 bleeding by any of the above measures, and it seems 
 probable that the bleeding is due to the accidental 
 wounding of an abnormally-situated internal carotid or 
 other vessel, it may sometimes be necessary to ligature 
 the common carotid artery. This is, however, a very 
 doubtful expedient, as, if the blood is coming from the 
 internal carotid, it is unlikely that the haemorrhage will 
 cease even after ligature of that vessel, owing to the 
 free communication from the opposite side. It should 
 certainly not be ligatured unless it is found that compress- 
 ing the vessel in the neck controls the bleeding. 
 
 Bleeding from the Nose after Operations for the 
 Removal of Polypi or one of the Turbinate Bones. 
 — Syringing the nose out with iced or hot water will 
 usually suffice, or a strip of lint soaked in adrenalin or 
 some other styptic may be placed in the nose for a few 
 minutes. In cases of severe haemorrhage, the following 
 plan, which is advised by Mr. Shield,* may be tried : A 
 small, soft Turkey sponge of suitable size is wrung out 
 of spirits of turpentine, and passed up behind the soft 
 palate ; it is then seized by forceps passed through the 
 nose from in front, and the latter are pulled upon so as 
 * ' Lectures on Nasal Obstruction,' 
 
Hasmorrhage after Operations 65 
 
 to draw the sponge against the posterior nares. 
 will stop any bleeding from the back of the 
 nares, and in the case of bleeding further 
 forward, strips of lint can be pushed into 
 the nostril from which the blood is coming 
 while the sponge is in position, the sponge 
 preventing the lint from going into the 
 naso- pharynx. When the haemorrhage 
 has in this way been controlled, the forceps 
 and sponge can be cautiously removed, 
 leaving the plug in place. Other methods 
 are to plug the nose in the ordinary way 
 for epistaxis, or to insert an inflatable india- 
 rubber tampon (Fig. 14). If a plug is 
 inserted, it should be removed in twenty- 
 four hours. 
 
 HEMORRHAGE AFTER ToOTH-EXTRAC- 
 
 TiON. — This is seldom of any consequence, 
 and when it is, usually results from haemo- 
 philia, or some other constitutional con- 
 dition in the patient. The tooth-socket 
 should be plugged with cotton-wool from 
 the bottom, the wool having been first 
 soaked in some suitable styptic ; then a 
 pad of folded lint should be placed on the 
 top of the plug. This pad should be of 
 sufificient thickness to prevent the teeth 
 meeting, so that when the jaw is closed 
 and tied up tight with a jaw-bandage, pj^ 
 pressure is maintained upon the plug. 
 
 A good plan in some cases is to put a stitch th 
 
 This 
 
 * The tampon is smeared with vaseline, passed into the nose, 
 and inflated, - 
 
66 The After-Treatment of Operations 
 
 the gum on each side of the socket and tie it tightly, so 
 as to close the cavity. This plan is a very useful one, 
 especially when there is not a tooth on each side of the 
 empty socket. The most troublesome cases of haemor- 
 rhage after dental operations are those resulting from a 
 wound of the posterior palatine artery. This accident 
 may happen from the forceps slipping, or from the 
 improper use of an elevator on an upper molar. Pressure 
 may be tried, or an attempt made to clip the vessel. 
 This is, however, seldom successful, as the vessel usually 
 lies in a groove in the hard palate. The bleeding can 
 be stopped by pushing a small wooden plug up the 
 posterior palatine canal The position of the posterior 
 palatine canal is about a quarter of an inch to the inner 
 side of the last molar tooth. An incision must be made 
 in this situation through the mucous membrane and the 
 plug inserted. It should be removed at the end of 
 twenty-four hours. 
 
 HEMORRHAGE AFTER REMOVAL OF THE ToNGUE. If the 
 
 wound has been kept aseptic after the operation, this but 
 rarely occurs. When haemorrhage does occur, however, 
 it is usually very dangerous. If the whole tongue has 
 been removed, it is best to leave a silk thread through the 
 stump, and to secure this outside the mouth with a piece 
 of strapping. In case of bleeding taking place, the stump 
 can then be easily pulled forward and the bleeding point 
 clipped. If no such thread has been placed through the 
 stump, the latter must be caught hold of with a clip or 
 vulsellum forceps and pulled well forwards, so as to 
 expose the bleeding point. Two or three clips should be 
 kept handy in cases where there is any possibility of 
 haemorrhage. If secondary haemorrhage does occur, it 
 will probably take place from a week to ten days after 
 the operation. 
 
Hasmorrhage after Operations 6y 
 
 Bleeding from the Intercostal Artery after 
 Operation for Empyema, etc. — The bleeding point 
 should be picked up, if possible, with a clip, and 
 ligatured, the wound, if necessary, being enlarged to 
 expose the vessel. Or the centre of a square piece of 
 lint may be pushed into the wound, and the cavity so 
 formed packed with cotton-wool ; then, by pulling on the 
 lint, the bleeding can be controlled. 
 
 Bleeding from the Fr^nal Artery after Cir- 
 cumcision, ETC. — The artery should be picked up with 
 a clip, if possible, and ligatured. If this is difficult, 
 a stitch may be inserted beneath the vessel and tied 
 over it. Or a pin can be passed through beneath the 
 vessel and a figure of eight made over it with silk. A 
 strip of lint soaked in lotio plumbi will often stop the 
 slight haemorrhage that is sometimes seen after circum- 
 cision, and makes an excellent dressing. 
 
 Bleeding from the Perineum after Lithotomy, 
 ETC — Any bleeding points that can be seen must be 
 picked up and ligatured, or the clip left on. This failing, 
 a tube with a petticoat tied round it should be inserted 
 into the wound, and gauze or wool packed round the 
 tube. Two strings are then attached to the end of the 
 tube, and fastened to a band round the patient's waist. 
 If there is no necessity for draining the bladder through 
 the wound, the latter may be simply plugged in the 
 ordinary way, and pressure made on the perineum by a 
 perineal bandage. This bandage is an excellent method 
 of applying pressure to the perineum. It is put on as 
 follows : A piece of 4-inch bandage is tied round the 
 waist, and the ends cut off. The roll of bandage is then 
 passed under this behind, and carried forwards across 
 the perineum, beneath the waist-bandage in front, and 
 back again. The two free ends of the bandage are then 
 pulled upon, and tied together in the centre of the 
 
68 The After-Treatment of Operations 
 
 perineum. In this way considerable pressure can be 
 exerted on any desired point. 
 
 HEMORRHAGE AFTER OPERATIONS ON THE BlADDER. 
 
 This is very seldom met with, but may occur after opera- 
 tions for the relief of enlarged prostate or for the removal 
 of growths, especially papillomata (villous tumour). It 
 may also follow lithotrity, but should not do so if the 
 operation has been properly performed. Again, it may 
 result from the too rapid evacuation of an overdistended 
 bladder, especially in old men. The great difficulty in 
 dealing with the bleeding in these cases depends upon 
 the fact that the bladder is usually filled with blood-clot, 
 and nothing can be done until this has all been removed. 
 As large a catheter as possible should be passed, and a 
 stream of warm water forcibly injected with a large bore 
 syringe. At first only a very small quantity of fluid 
 should be injected, and then allowed to flow back again ; 
 as the clot comes away more and more fluid may be 
 injected each time. This must be persisted with until 
 all the clot has been washed out of the bladder, as evi- 
 denced by the absence of clots in the water coming back 
 from it. Some styptic solution should then be injected 
 into the bladder : for this purpose a strong solution of 
 hazeline or Ruspini's styptic is recommended ; but other 
 styptics, such as suprarenal extract, turpentine, etc., may 
 be used instead. Styptics having a caustic action, such 
 as liq. ferri perchlor., etc., must not be used, as they set 
 up cystitis. 
 
 Of course, if there is an opening into the bladder? 
 either through the perineum or above the pubes, the clot 
 can be washed out much more easily through it. And 
 when there is such an opening, if the haemorrhage will 
 not yield to i-typtics and hot lotion, the bladder may be 
 packed with strips of hnt after passing a tube or tubes 
 
Haemorrhage after Operations 69 
 
 down to the openings of the ureters. The lint should be 
 in long strips, and the ends left outside the wound. In 
 cases of severe haemorrhage from the prostate or trigone 
 the bleeding can be temporarily controlled by passing 
 one finger into the rectum and compressing the prostate 
 and trigone against the back of the pubes, or by com- 
 pressing the bladder bimanually by one hand above the 
 pubes and a finger in the rectum. 
 
 HAEMORRHAGE FROM THE Rectum. — This is, fortunately, 
 a rare occurrence with the present improved methods of 
 operating; it still, however, occasionally follows operations 
 for piles, etc. It is a very troublesome complication, not 
 only on account of the difficulty of stopping it, but because 
 a large amount of blood may be lost into the bowel before 
 there is any external evidence of its presence. The 
 haemorrhage usually takes place after the bowels have 
 acted for the first time following the operation, and is, as 
 a rule, due to the slipping or premature separation of a 
 ligature. The bleeding is free, and is accompanied by a 
 considerable amount of collapse. The bleeding may, 
 however, occur where no ligature has been used. In a 
 case which the author saw recently, a haemorrhage which 
 might have been fatal and which necessitated plugging 
 the rectum occurred three weeks after the operation and 
 a week after all the ligatures had separated. 
 
 It is well to remember that the amount of blood lost 
 externally is no indication of the total haemorrhage, as 
 the rectum and sigmoid may be filled with clot. An 
 anaesthetic should be administered and the sphincter 
 dilated, then, after emptying the bowel of clot with the 
 finger and by syringing with hot water an attempt 
 may be made to clip the bleeding-point and religature 
 it. To facilitate this manoeuvre the wall of the rectum 
 above the bleeding-point should be caught with a pair 
 
7<^ The After-Treatment of Operations 
 
 of pile forceps or an ordinary clip, and drawn down so 
 as to give good access to the bleeding spot. Even then 
 it is often by no means an easy matter to control the 
 haemorrhage, as the rectum tends to lie in folds, and the 
 bleeding often comes from a surface rather than a point. 
 If, as is not infrequently the case, it is found to be 
 impossible to control the haemorrhage in this way, the 
 rectum must be plugged. 
 
 This is best done as follows : A piece of sterilized 
 indiarubber drainage-tube about 3^ inches long and 
 ■^ inch in diameter is taken, and round one half of this 
 
 a strip of dry gauze or 
 wool is wrapped, so as to 
 increase its diameter by 
 about three times. The 
 surface of the gauze is 
 then well greased with 
 sterilized vaseline, and 
 the tube is inserted into 
 the rectum, with the big 
 end upwards. The por- 
 tion of the tube which 
 projects out of the anus 
 should then be pulled upon so as to bring the dilated 
 part down against the bleeding surface. A large safety- 
 pin should next be passed through the end of the tube 
 about i inch away from the anus, and a long strip of 
 gauze, which has been previously greased with vaseline, 
 wrapped round and round the tube between the anus and 
 the safety-pin. Any required amount of pressure can 
 thus be exerted upon the bleeding-point, as the gauze 
 wrapped round outside pulls down the tube and retains 
 it in place (see diagram. Fig. 15). Another method of 
 plugging the rectum which is useful in cases where an 
 
 
 Fig. i= 
 
Hemorrhage after Operations 71 
 
 anaesthetic cannot be given is to cut a finger-stall out 
 of an indiarubber operating-glove, and, having greased it 
 inside and out and having inserted one's finger into it, 
 pass it gently into the rectum. Then withdraw the 
 finger and plug the inside of the finger-stall with gauze, 
 using a large safety-pin as before to prevent the plug 
 clipping up too far into the bowel. 
 
 It is seldom necessary to leave the plug in for more 
 than forty-eight hours. After its removal a small piece 
 of drainage tube may be left in the bowel to give warning 
 should any further bleeding occur. 
 
 In cases of secondary haemorrhage — i.e., when bleeding 
 occurs a week or more after the operation, and is due to 
 sloughing — no attempt should be made to catch the 
 bleeding-point with clips, but plugging should be resorted 
 to at once. In women, haemorrhage from the rectum 
 can be temporarily controlled by passing a finger into 
 the vagina and compressing the rectal wall against the 
 sacrum. 
 
 Bleeding after Incision into Inflamed Tissues. — 
 It is not at all uncommon for rather free htemorrhage to 
 occur after incisions have been made into inflamed tissues, 
 such as for the relief of tension in cellulitis, etc. The 
 ends of any small vessels that may have been divided do 
 not contract, but are held open, and, in consequence, 
 bleeding from them continues for some time. A certain 
 amount of bleeding in these cases is advantageous, as it 
 relieves the local congestion. If it continues for long, 
 however, something may have to be done to stop it. 
 It is generally useless to attempt to pick up the bleeding- 
 points, as the tissues are often so rotten that they give 
 way at once-. Elevation of the part and the application 
 of a really hot fomentation and pressure will almost 
 always suffice to stop the bleeding. Should it not do 
 
72 The After-Treatment of Operations 
 
 so, the incisions must be packed with strips of gauze or 
 lint, and firm pressure applied with cotton-wool and 
 bandages. 
 
 When severe haemorrhage occurs from a wounded 
 vessel situated in rotten or gangrenous tissues, and the 
 vessel cannot be picked up with a clip owing to the 
 tissues tearing away, the best way to secure the vessel 
 is to pass a hare-lip pin or needle through the tissues 
 beneath it, and then compress the vessel by a figure of 
 eight made with silk round the ends of the pin — i.e., 
 secure the vessel by acupressure. This is also the best 
 way of arresting haemorrhage from an artery in the 
 base of an ulcer or ulcerating surface. The tissues should 
 be under-pinned on the proximal side of the bleeding- 
 point. 
 
 HAEMORRHAGE FROM THE StUMP AFTER AmPUTATIOXS. 
 
 — Recurrent haemorrhage after an amputation will usually 
 stop if firm pressure is applied and the part elevated. 
 Should it not do so, the wound must be reopened, and 
 any bleeding-points clipped and hgatared. 
 
 Secondary haemorrhage after an amputation is, fortu- 
 nately, a very rare occurrence now, though it used to be 
 common. Ligature of the main vessel above has been 
 advised, but most authorities agree that it is better to 
 re-amputate higher up. 
 
 Constitutional Treatment of Patients suffering 
 from Haemorrhage. 
 
 Immediate Treatment. — This is mainly the treat- 
 ment of shock, which is gone into in the next chapter. 
 
 The patient should be freely stimulated if all the bleed- 
 ing-points have been properly secured. Liquor is strych- 
 ninae may be given hypodermically in doses of from 5 to 
 
Haemorrhage after Operations "]% 
 
 lo minims. Brandy or whisky may be given ; this is best 
 done by giving repeated doses of from |^ to i ounce by 
 the rectum — or mouth if there is no danger of vomiting — 
 or alcohol can be given hypodermically in small doses 
 (lo to 20 minims). 
 
 Remote Treatment. — Patients who have suffered 
 from severe haemorrhage are usually very anaemic, and 
 in old or weakly patients this condition may persist for 
 some time. In children and young adults the blood- 
 forming capacity is good, and they soon make up any 
 deficiency. In order to assist the tissues in forming new 
 blood, iron in some form or another should be given until 
 all signs of anaemia have disappeared. Port wine is an 
 excellent remedy in these cases, and 3 to 6 ounces should 
 be given per diem unless otherwise contra-indicated. 
 Patients who are suffering from anaemia due to loss of 
 blood must not be allowed to get up and about too soon ; 
 they must be made to go very gradually at first, as there 
 is great danger of thrombosis if they are allowed to get 
 up too quickly. Massage to the lower limbs, if carried 
 out for a day or so previous to their getting up, will do 
 much to prevent this danger. 
 
CHAPTER V 
 
 SURGICAL SHOCK 
 
 Surgical shock is a condition of exhaustion of all the 
 vital faculties, which is liable to occur after any severe 
 injury or surgical operation. Before the discovery of 
 modern aseptic surgery by Lister, the two great dangers 
 of surgical operations were sepsis and shock. Thanks 
 to his discovery, the danger of sepsis has now been 
 almost eliminated ; but it was not until comparatively 
 recently that any attempt was made to study, from a 
 scientific point of view, the shock following operations, 
 or to iind out how it could be best combated. The first 
 real scientific researches into this subject were made by 
 G. W. Crile in America. The publication of the results 
 of his researches in 1897 ^^^'^ the foundation of our 
 modern conception of what is really meant by surgical 
 shock. Since that date research on this subject has been 
 almost continuous. In 1905 the author of this book 
 published the Hunterian Lectures delivered at the Royal 
 College of Surgeons, on the ' Physiology and Surgical 
 Treatment of Shock and Collapse.' The most recent 
 research work on the subject is a book just published, by 
 G. W. Crile and W. E. Lower, entitled ' Anoci-Associa- 
 tion,' in which a large amount of very valuable experi- 
 mental work is recorded, and it may now be said that the 
 physiology of surgical shock is no longer a closed book, but 
 
 74 
 
Surgical Shock 75 
 
 that the main factors in the causation of this curious con- 
 dition are well known and understood. The greatest credit 
 is due to Dr. Crile for the careful and thorough manner in 
 which his experimental work has been carried out, for no 
 stone has been left unturned and no corner uninvestigated. 
 
 It is obviously impossible to give a complete description 
 of the physiology of shock in the present volume. The 
 reader is, however, referred to the works mentioned at 
 the end of this chapter for further information on this 
 interesting subject. 
 
 The symptoms of surgical shock must be familiar to 
 everyone who has worked in the hospital wards of a large 
 hospital. The most typical picture that one can take is 
 perhaps that of a man who has undergone a serious and 
 severe operation which has resulted in shock. Previous 
 to the operation the patient presented the ordinary ap- 
 pearance of a healthy human being (apart from the 
 condition for which the operation was performed), with 
 a good colour, normal pulse, and muscles which re- 
 sponded promptly to his call. If we examine this same 
 patient after the operation, when he is in a condition of 
 shock, we find that the skin is p ale^ covere d with sweat, 
 and feels col d to the ej cajpLnijogJiand ; the pulse is rapid 
 and so slight as to be hardly perceptible except in the 
 larger arteries ; the temp erature is subnormal , and the 
 respiratio ns rapid and shallow ; the eyes have a glazed and 
 anxious app earanc e ; and although the patient is quite 
 conscious, he is incapable of doing anything for himself, 
 and is only just able to answer questions. There is 
 generally a certain amount of restlessness, and the face 
 expresses extreme exhaustion and a fear of impending 
 dissolution, while the skin appears to have shrunk over 
 the facial bones. The patient complains of thirst, and is 
 constantly asking for something to drink. He is hardly 
 
76 The After-Treatment of Operations 
 
 able to lift his head from the pillow, and his muscles are 
 in a condition of complete relaxation, as if he were utterly 
 exhausted after running a long race. Food cannot be 
 digested, and all the functions are more or less inhibited. 
 Thus, the mouth is dry owing to a lack of salivary secre- 
 tion, there is very little urine passed, and digestion has 
 ceased owing to the lack of digestive juices ; the most 
 marked feature of this condition, however, is the great 
 lowering of the blood-pressure. The blood-pressure of a 
 normal man is 120 to 130 millimetres of mercury, as mea- 
 sured by a sphygmometer. In the condition of shock we 
 have been describing the pressure will be found to have 
 fallen to 60 millimetres of mercury, or even lower. The 
 blood has accumulated in the large vessels of the abdomen, 
 and if the patient were sat up he would, in most cases, im- 
 mediately collapse and become unconscious, owing to the 
 anaemia of the brain caused by the blood, under the force 
 of gravity, flowing out of it to the lower parts of the body. 
 This condition, which sometimes follows severe operation 
 or other injuries, is a most interesting physiological prob- 
 lem, and the factors producing this curious condition have 
 been very carefully investigated. The following is a brief 
 outline of the more important factors concerned in its 
 production. 
 
 Physiologry of Shock. 
 
 In a normal human being the pressure of the blood in 
 the vessels of the various parts of the body is maintained 
 at, or about, a constant pressure (roughly between 120 
 and 130 millimetres of mercury) by the contraction or 
 relaxation of the muscular walls of the arteries and 
 arterioles, while the circulation through the vessels is 
 maintained by the action of the heart. It is obvious that 
 if there were not some means of controlling the pressure 
 
Surgical Shock j'j 
 
 within the vessels, constant and disastrous changes would 
 occur in the distribution of the blood as the result of 
 changes of position, owing to the force of gravity. Thus, 
 in the erect position the blood would tend to flow to the 
 feet and away from the brain, and so produce uncon- 
 sciousness by anaemia of the brain-cells. In a healthy 
 person the pressure of the blood is maintained by means of 
 certain centres in the brain called the vasomotor centres. 
 These centres not only keep the pressure within the larger 
 vessels at a more or less constant figure, but also control 
 the amount of blood in any one part of the body at a time, 
 and by so doing adapt the supply of blood to the require- 
 ments of the particular organ which is most in need of 
 an increased supply of blood at any one time. If these 
 centres in the brain cease to act, the blood immediately 
 accumulates in the splanchnic area, and a great fall in 
 general blood-pressure occurs. • Thus, experimentally, if 
 the vasomotor centres in the brain are cocainized, a great 
 fall in general blood-pressure results, and the animal 
 passes into a condition similar to that of surgical shock. 
 A similar condition results from damage to the vasomotor 
 centres, or from section of the spinal cord. E xperimental 
 investigation has__proved_tha t the cond ition of surgical^ 
 shock is the_r£5ult__o f exha ustion of the great centr es in 
 the central n ervous syste m, which control the vital Junc:: 
 tions of the 'body, more pa rt i cularly~t hose centres~w hich_ 
 directly control the maintenanc e of a normal circulation 
 throughout the bo^7~siicB~asthe vasomotor and the 
 respiratory cenfres, although all ttie cenTresTnTthe brain^ 
 arejnore[o r less affectedT 
 
 The whole of the surface of the body and some of the 
 deeper parts are supplied with nerve-endings, or ' noci- 
 ceptors,' whose function it is to send messages to the brain 
 when they are stimulated. Stimuli are of two kinds — 
 
78 The After-Treatment of Operations 
 
 those of ordinary sensation, which might be described as 
 messages conveying information to the brain-centres, and 
 useful in assisting the ordinary functions of the body; 
 and, secondly, stimuli of pain, conveying messages to the 
 brain when damage is being done to that particular part 
 of the body, and, if we may say so, asking for assistance. 
 The immediate result of painful stimuli is motor activity, 
 in order to get away from, or remove, the cause of the 
 pain. If the person or animal is under an anaesthetic, 
 this motor activity cannot be manifested in movement of 
 muscles ; but there is, nevertheless, expenditure of energy 
 within the brain. This can be seen experimentally by 
 direct increase in the blood-pressure, increased frequency 
 of the pulse, and increased frequency of the respiration 
 as the result of painful stimuli. 
 
 Dr. Crile has recently gone much further, and has been 
 able to show that actual microscopic changes occur in the 
 cells of the cortex of the brain as a result of stimuli reach- 
 ing the centres from the nerve-endings in the skin. He 
 has been able to show that if stimuli of a painful character 
 from the nerve-endings on the skin pass up the afferent 
 nerves in sufficient quantity and severity, demonstrable 
 lesions occur in the cells of the brain, suprarenals, and 
 the liver. There are certain organs in the body, among 
 which are the brain, the thyroid, the suprarenals, the 
 liver, and the muscles, whose function is that of convert- 
 ing latent into kinetic energy in response to adaptive 
 stimulation. In response to environmental stimuli of 
 any sort, these organs convert latent energy into motion, 
 or into heat. As the result of long-continued painful 
 stimuh, certain changes can be demonstrated to take 
 place in the cells of these organs. Thus, if shock of a 
 severe character is experimentally produced in a normal, 
 anaesthetized dog, changes in the cells of the brain cortex 
 
Surgical Shock 79 
 
 and cerebellum are found to take place as a result. 
 These changes are — (i) chromatolysis ; (2) alteration in 
 the nucleus-plasma relation ; (3) rupture of the nuclear 
 and cell membranes ; (4) in extreme cases, disintegration 
 of the cell itself. These changes in the cortical cells 
 occur as the result of long-continued painful stimuli, 
 such as would be caused by a severe and protracted 
 operation or a severe traumatism ; but it has also been 
 demonstrated that such emotions as fear and anger, if 
 prolonged and intense, will likewise produce similar 
 changes in the brain-cells which are indistinguishable 
 from those produced by shock. Severe local infections, 
 such as peritonitis, will also cause similar changes. 
 
 As a result of clinical experience we know, of course, 
 the extremely important part played by fear and terror 
 in the production of shock when associated with trauma. 
 It seems certain that the centres in the brain, the 
 muscles, the liver, suprarenals, and probably many other 
 of the internal secretory glands, act together as a system 
 to preserve the integrity of the body as a whole. This 
 system has been termed by Crile the 'kinetic system,' 
 its object being to protect the body against harmful 
 affects from outside agents. The whole of this system 
 suffers together in conditions such as shock, and shows 
 demonstrable changes in its cells. 
 
 In recent years a good many theories of shock have 
 been propounded with a view to showing that the pheno- 
 mena of shock are due to changes in the contents of the 
 blood, or to the noxious products of metabolism cir- 
 culating in the blood-stream. It is obvious that the 
 correctness or otherwise of any such theory is easily put 
 to the proof by experiment, and for many years the 
 author has wanted to perform such an experiment with 
 a view to testing once and for all the correctness of 
 
8o The After-Treatment of Operations 
 
 such theories. Such experiments are, however, difficult 
 to perform in this country, and he has never been able to 
 carry out the experiment. Recently Dr. Crile has per- 
 formed this experiment with complete success. The 
 experiment consists in crossing the circulation of two 
 dogs. It is obvious that if the circulation of two animals 
 can be united in such a way that the blood circulates 
 through both of them, and if one of these animals is put 
 into a condition of shock, then, provided that the cause 
 of shock is due to any change in the gaseous or other 
 contents of the blood, both animals — the shocked animal 
 and the other animal — will suffer alike ; but if shock is 
 due to damage or exhaustion of nerve - centres by re- 
 peated stimuli, as Dr. Crile and the present writer believe, 
 then the non-shocked animal will be quite unaffected. 
 
 Dr. Crile performed this experiment by anastomosing 
 the proximal end of one carotid artery of Dog A with 
 the distal end of the corresponding carotid artery of 
 Dog B, and one jugular vein of Dog A with the corre- 
 sponding vein of Dog B. The dogs were as nearly as 
 possible alike, and were both under an equal amount of 
 anaesthesia. Dog A was subjected to traumatism 
 sufficient to produce shock. Both animals were then 
 killed, and their brains examined. It was found that 
 the typical changes in the cells of the brain cortex were 
 present in Dog A, while they were completely absent 
 in Dog B. The result of this experiment proves that 
 gaseous or other changes in the blood cannot be the 
 primary cause of shock, and it therefore disposes of the 
 acapnia theory of Yendall Henderson. 
 
 It is obvious that if an operation is to be performed in 
 such a way that no shock shall result, tw'o factors are 
 necessary: (i) All stimuli of a painful character must be 
 prevented so far as possible from reaching the brain from 
 
Surgical Shock 8i 
 
 the area of operation ; and (2) the patient must be pro- 
 tected from the harmful effects of fear, terror, etc., which 
 might be caused by the performance of the operation or 
 its anticipation. Further, if these two conditions can be 
 fulfilled there should be no shock resulting from an 
 operation, unless there has been severe haemorrhage. 
 
 Different parts of the body have different shock-pro- 
 ducing properties when operated upon, and it is important 
 that these should be known, so that special care may be 
 taken when operating upon such parts. 
 
 The Relation between the Region operated upon and the 
 Shock produced. — It appears that operations upon the 
 abdominal contents and visceral peritoneum, and opera- 
 tions upon the male generative organs, produce the most 
 profound shock as a general rule. In the abdomen the 
 severity of the shock produced is in proportion to the 
 distance of the part operated upon from the pelvis, the 
 shock being most severe after operations in the neighbour- 
 hood of the stomach, pylorus, and duodenum. 
 
 In the extremities the amount of shock caused by 
 operation is in direct proportion to the nerve-supply of 
 the part — that is, to the area of skin and muscle injured 
 and the relative number of nerve-endings in that area. 
 Thus, a crush of the paw of a dog will cause more pro- 
 nounced shock than amputation of the limb high up. 
 Crile states that in animals subjected to extensive 
 removal of integument, shock was induced with a 
 rapidity proportional to the area exposed, and its depth 
 corresponded to the duration of the exposure. 
 
 Recent experimental work carried out by Dr. Symes 
 and the present writer has proved that injury or inter- 
 ference with the parietal peritoneum or mesentery will 
 produce shock, while similar manipulation of the visceral 
 peritoneum has no effect. 
 
 6 
 
82 The After-Treatment of Operations 
 Collapse. 
 
 Collapse is a very similar condition to shock, but with 
 certain marked differences. Collapse, unlike shock, 
 occurs suddenly, and is accompanied by a great and 
 sudden fall in blood-pressure, often with resulting anaemia 
 of the brain and unconsciousness. It is due to a sudden 
 paralysis of the kinetic system, or, in other words, of the 
 centres of the brain and cord controlling the maintenance 
 of the blood-pressure. It differs from shock in that it may 
 be successfully treated by means of stimulants. Since, 
 however, the important cause of the trouble is the sudden 
 fall in blood-pressure, the obvious indication is to 
 support the blood-pressure, and the brain and heart, by 
 putting the patient into a recumbent position, or with 
 the head down, to drive the blood out of the limbs and 
 abdomen by pressure, while at the same time stimulants 
 are administered or the bloodvessels transfused in order 
 to combat the lowered pressure in the vessels. 
 
 The condition following severe haemorrhage differs 
 from both shock and collapse in that the centres in the 
 brain are not at first affected, the falling blood-pressure 
 being due to an actual loss of fluid. If, however, the 
 haemorrhage has been severe and the lowered pressure 
 has persisted for some time without relief, a condition of 
 true shock may supervene. The obvious treatment for 
 severe haemorrhage is transfusion, preferably with blood 
 from another subject, but failing this, with a physiological 
 salt solution. 
 
 The Treatment of Shock. 
 
 It will be obvious from the foregoing description of 
 the physiology of shock that it is possible to prevent 
 shock from occurring as the result of an operation, and 
 
Surgical Shock 83 
 
 that the best way of protecting one's patient from this con- 
 dition is to so perform the operation that shock-producing 
 factors will be absent. In fact, post-operative shock is 
 now, or soon will be, as much a reflection on the surgical 
 technique of the surgeon performing the operation as is 
 sepsis in the wound ; that is to say, that when an opera- 
 tion can be performed under circumstances carefully 
 chosen and selected by the surgeon beforehand, and with 
 the necessary proper assistance and preparation, surgical 
 shock should not result from any operation, provided the 
 surgeon is sufficiently skilled in the technique of oper- 
 ating. 
 
 Methods of preventing- Shock. 
 
 The ideal method of preventing shock is so to anaes- 
 thetize the patient that no afferent impulses of a painful 
 or harmful character can reach the brain-centres. It has 
 been shown that in order to secure such conditions all the 
 nerves passing from the area of operation must be tem- 
 porarily blocked by a local anaesthetic, so that no impulses 
 can pass from the operative field, and at the same time 
 the higher brain-centres must be further protected from 
 outside impulses by a preliminary narcotic and suitable 
 general anaesthetic to the point of unconsciousness, This 
 method of performing shockless operations has been very 
 carefully worked out by Dr. Crile and others, and is now 
 interesting many surgeons. This method has proved that 
 in most operations it is possible by means of the correct 
 technique to be absolutely certain that no shock will 
 follow the operation, and no doubt in time and with 
 increased knowledge it will be possible to apply this 
 method to all operations. The exact technique of the 
 method cannot be described here for want of space, but 
 it will be found in Dr. Crile's textbook. 
 
84 The After-Treatment of Operations 
 
 There are certain factors in an operation which are 
 particularly liable to produce shock, and by taking care 
 to avoid these, much may be done to prevent its occur- 
 rence. Thus, tearing and crushing tissues causes much 
 more shock than cutting with a sharp knife. The rough 
 use of retractors, dragging or pulling on the intestine, 
 and, in fact, roughness of any kind, should be avoided. 
 Again, certain areas require particularly careful handling, 
 as, owing to the distribution of the nerves in these areas, 
 shock is especially liable to result from interference with 
 them. Such areas are the upper region of the abdomen 
 and diaphragm, the extremities of the limbs, the neigh- 
 bourhood of the anus, and the parts round the mouth and 
 larynx. 
 
 One must also realize that emotions such as fear and 
 terror have a powerful effect in producing shock, and in 
 accelerating it when combined with an operation, so that 
 patients who are highly nervous about themselves and 
 dread an operation are much more liable to suffer from 
 shock. For these reasons, the patient must be protected 
 by every possible means against such influences. Care- 
 ful preparatory treatment, avoiding all details in the prep- 
 aration which may tend to frighten the patient, and the 
 administration of a preliminary narcotic, such as morphia, 
 and atropine or scopolamine, are valuable agents. The 
 author's practice is to administer from | to ^ of mor- 
 phia combined with -^-^ of atropine hypodermically 
 about an hour before the operation. An important 
 point also, which is often neglected, is to see that 
 when the patient enters the operating-room no 
 time is wasted in getting him immediately under the 
 anaesthetic. To keep a patient waiting even two 
 minutes while the anassthetist is getting ready is of 
 much more consequence than many people suppose. 
 
Surgical Shock 85 
 
 Complete quiet during the period of induction of anaes- 
 thesia is also an important factor. 
 
 Pain and discomfort after the operation are potent 
 causes of shock, so that a patient who was not suffering 
 from shock when he left the operating-table may be found 
 deeply affected by shock some hours later if careful 
 means have not been taken to prevent painful impulses. 
 Everything should be done to relieve pain, and when 
 shock is feared a narcotic, such as morphia or heroin, 
 should be administered at regular intervals in sufficient 
 quantities to keep the patient free from pain and discom- 
 fort. The rapid increase in the pulse and respiration is a 
 sign calling for the administration of a narcotic. 
 
 Treatment of Shock. 
 
 When a patient is seen who is already suffering from 
 shock, the first thing to do is to remove the cause of this 
 condition, if still operative — that is to say, if the patient is 
 in pain, morphia or heroin should be administered hypo- 
 dermically in sufficient doses to shut off immediately all 
 painful impulses and produce rest and quiet. This 
 should be done before any other treatment is given. 
 
 Warmth. — The patient should be kept warm with 
 blankets and hot bottles, but care must be taken not to 
 overdo this ; the patient should never be kept in a con- 
 dition of profuse perspiration, as this will tend to greatly 
 increase the shock. Although it is important to maintain 
 the body temperature, at the same time much heat will 
 cause dilation of the superficial vessels, and when this 
 occurs it means a still greater loss of blood to the 
 essential circulation. 
 
 Position. — The position of the patient is of great 
 importance in treating shock. The best position to place 
 the patient in, is with the foot of the bed so raised that 
 
86 The After-Treatment of Operations 
 
 the abdomen is on a higher level than the thorax and 
 head. This tends to prevent the blood from accumulating 
 in the abdomen and lower limbs, and helps the blood to 
 flow from the great veins into the heart. The foot of 
 the bed should be raised on blocks a foot or more in 
 height, and the patient should not have a pillow under 
 the head. 
 
 Bandagins: the abdomen, rapidly and effectuall}' raises 
 the general blood-pressure, and may be tried if there is 
 no serious centra-indication to its use ; since it tends to 
 embarrass the respiration care should be taken to see 
 that the thorax is free to move, and is not pressed upon 
 by heavy bedclothes, etc. Bandaging the extremities is 
 also effectual in raising the blood-pressure, and is a 
 useful way of treating shock in suitable cases. The 
 limbs should be tirmly bandaged all the way up "snth 
 some elastic bandage, such as flannel or domet. The 
 bandages must be put on carefully so that there are no 
 creases, and must not be left on for long, or they vi-ill do 
 harm by cutting off the blood-supply to the limbs. 
 
 Stimulants. — These are worse than useless in the 
 treatment of shock. ]\Iany cases of shock can easily be 
 rendered much more serious by stimulation. It must be 
 remembered that the cause of the condition is exhaustion 
 of the great nerve-centres, and that stimulation increases 
 this exhaustion and does not give the centres time to 
 recover. Again, if the heart be stimulated while the 
 blood-pressure is still so low that the great venous trunks 
 passing to the right auricle contain only a small amount 
 of blood with which to supply it, the heart will only 
 exhaust itself by beating more forcibly mthout being 
 able to raise the blood-pressure or improve the circula- 
 tion, except momentarily. And to stimulate the heart 
 to increased action when it has nothing to work on will 
 
Surgical Shock 87 
 
 only have the effect of hastening the time when it must 
 fail. It is true that an injection of strychnine will 
 improve the pulse for a time, but it does so by forcing 
 the already exhausted nerve-centres into action, and this 
 will be followed by further exhaustion of these centres 
 as soon as the effect of the strychnine has passed off. 
 Again, it has been repeatedly proved by experiment, and 
 is a well -observed clinical fact, that stimulants ad- 
 ministered while the patient is in a condition of shock 
 are often not eliminated, but remain in the system, so 
 that when the shock passes off" the combined effect of 
 all the stimulants administered will be produced, with 
 perhaps a fatal result. This is particularly the case with 
 strychnine. 
 
 It has recently been proved by a series of experiments 
 upon animals that the administration of strychnine in 
 repeated doses to a normal animal will cause shock by 
 overstimulation of the vaso-motor centres and consequent 
 exhaustion. In all degrees of shock the administration 
 of strychnine caused the animals to sink into a deeper 
 degree of shock as soon as the first effects of the adminis- 
 tration had passed off. These facts seem to be well 
 supported by clinical observation, and it follows that 
 strychnine is not only useless, but absolutely harmful, in 
 the treatment of shock. In collapse, on the other hand, 
 strychnine may be of service, as the vaso-motor centres 
 are not exhausted. Even in the collapse following a 
 severe haemorrhage, strychnine though it may do good, 
 is not so useful as transfusion, which directly treats the 
 cause of the collapse. 
 
 Saline Infusion. — The obvious indication in treating 
 shock is to raise the blood-pressure as near as possible to 
 the normal level, and to keep it there until the vasomotor 
 centres have recovered sufficiently to maintain the pres- 
 
88 The After-Treatment of Operations 
 
 sure at or about the normal. The most certain and 
 rapid method we know of raising the blood-pressure is 
 that of saline infusion into the bloodvessels. Unfortu- 
 nately, it has been proved by experiment, and confirmed 
 by clinical observation, that the pressure can only be 
 maintained for a short time by this method ; and although 
 it will raise the pressure rapidly and quickly if the shock 
 is severe, continued intravenous or subcutaneous infusion 
 will merely result in the water-logging of the tissues, and 
 the pressure will slowly fall back. 
 
 The only form of transfusion which is permanently 
 effective is human blood from another patient. This method 
 is difficult and quite inapplicable in most cases. It doeo 
 not follow that infusion with physiological salt solution is 
 useless. It often enables us to tide over a crisis, and gives 
 the patient the chance of recovery that is alone necessary. 
 It is useless, however, to repeat it for any length of time, 
 and other methods must be found. 
 
 The fluid should not be allowed to flow in too quickly, 
 and it should be kept warm (at blood temperature). 
 There is generally a very marked improvement in the 
 pulse and general condition as soon as transfusion is 
 started ; this must, however, not be taken as an indication 
 that the transfusion can be stopped, but the fluid should be 
 allowed to flow in slowly until about 2 or 3 pints have 
 been injected, and then the patient should be watched 
 for a time to see if the blood-pressure is sustained. 
 
 Method of performing Transfusion. — The best apparatus 
 for the purpose is about 2 feet of rubber tubing, to one 
 end of which a glass funnel is attached, and to the other 
 a glass cannula ; the cannula should taper to a narrow 
 point, and should have a slight bend in it. The cannula 
 must be tied into the end of the tubing before com- 
 mencing the operation, A very good cannula can be 
 
Surgical Shock 
 
 89 
 
 made by using the needle of an exploring syringe ; it 
 has the advantage that it can be very rapidly introduced 
 into a vein without even a preliminary incision being 
 made in the skin, and, in addition, it can be introduced 
 into a much smaller vein than the glass cannula ; and this 
 is of importance, as in some patients the veins, even such 
 veins as the median basilic, are so small that it is almost 
 impossible to get an ordinary glass cannula into them. 
 
 Introducing the Cannula. — A bandage should first be 
 tied round the upper arm to make the veins prominent ; 
 then, any large vein being 
 chosen (this will usually 
 be the median basilic), an 
 incision is made over it 
 and the vein exposed. A 
 double loop of silk or cat- 
 gut is then passed beneath 
 the vein with an aneurism 
 needle, and the thread is 
 divided so that there is a 
 double ligature round the 
 vein. The lower of these 
 ligatures is then tied up 
 so as to shut off the vein 
 below ; the other is held up by the surgeon so that 
 the vein is steadied in the loop. Next, a longitudinal 
 incision is made into the vein with the point of the 
 knife, the cannula is slipped into it, and the upper 
 ligature tied over the point so as. to fix it in the vein. 
 Before introducing the cannula, the surgeon should 
 see that the whole of the rubber tubing and cannula 
 are full of fluid, and that there are no air-bubbles in the 
 apparatus. 
 
 If the needle of an exploring syringe is used instead of 
 
 Fig. 
 
 16. — Author's Apparatus 
 FOR Intravenous Infusion 
 WITH Adrenalin. 
 
90 The After-Treatment of Operations 
 
 the glass cannula, it can simply be stabbed through the 
 skin into the vein in a direction towards the heart. 
 
 The best solution to use for intravenous infusion is a 
 physiological solution such as the following : 
 
 R NaCl - . . . . o-g. 
 
 Potassii chloras .... o'03. 
 
 Calcii chloridum - . - . o'oi. 
 
 Aqua - . . . . 100-00. 
 
 Messrs. Burroughs Wellcome and Co. also supply 
 ' soloids,' which when dissolved in water make a physio- 
 logical solution (' Soloid ' Sal. Comp.). 
 
 When no such solution is obtainable, a fairly satis- 
 factory solution can be made by adding a teaspoonful of 
 common salt to i pint of water. The solution should 
 be boiled to sterilize it, and then cooled down to about 
 iio° F. The right temperature may be roughly esti- 
 mated in cases of emergency by the surgeon putting 
 his fingers into the solution ; he should be able to just 
 bear his fingers in it with comfort. In an emergency 
 also, when it is necessary to waste as little time as 
 possible, the fluid need not be sterilized, but common 
 tap-water may be used, to which sufticient boiling water 
 from the kettle has been added to raise it to the desired 
 temperature. In carrying out the transfusion, the fluid 
 should be allowed to flow in slowly, and if there are any 
 signs of dyspnoea at any time after the fluid has been 
 running in, the transfusion must be stopped until this has 
 passed off, when it can again be allowed to flow in. 
 Some time should be occupied in introducing the fluid, 
 and thirty minutes for the introduction of 3 pints is 
 about the average time necessary : 2 or 3 pints of fluid 
 should be allowed to flow in, and then the cannula may 
 be removed and the wound sewn up ; or the cannula may 
 be left in, and the rubber tube, after being clipped, can 
 
Surgical Shock 91 
 
 be wrapped round the arm so that it is all ready for use 
 again. All that is then necessary in order to retransfuse 
 is to unwrap the tube, refix the glass funnel, and remove 
 the clip. It might be supposed that there is a danger of 
 the blood clotting in the cannula and vein, and this clot 
 being swept into the circulation by the next lot of fluid 
 used for transfusion. This is, however, not the case, as 
 the cannula and vein remain full of water. As already 
 mentioned, the addition of adrenalin or hemesine to the 
 infusion fluid in suitable quantities greatly increases the 
 value of infusion. 
 
 It will be as well to mention here that rigors some- 
 times occur after transfusion of normal salt solution or 
 even of water. They usually come on about twenty 
 minutes or half an hour after the transfusion ; they are 
 not accompanied by any rise of temperature, and soon 
 pass off without doing any harm. What the cause of 
 them is it is very difficult to say ; that they are not due 
 to the accidental introduction of septic matter or other 
 poison into the circulation is certain, as beyond the rigors 
 no other bad effects follow, and they occur however care- 
 fully the solution and instruments are sterilized. They do 
 not apparently occur if physiological solutions are used. 
 
 Rigors more commonly follow transfusion in men than 
 in women, and do not occur except in a comparatively 
 small number of cases. Dyspnoea is said to follow trans- 
 fusion occasionally ; this occurs when the fluid is injected 
 too quickly into the circulation, and is due to sudden 
 dilution of the blood in the lungs. It does not take place 
 if the fluid is injected slowly so that it is able to mix with 
 the blood before passing into the lungs. If it should 
 occur, the injection must be stopped until it has passed 
 off, and then continued more slowly. 
 
 Rectal enemata of saline solution may be made use of 
 instead of transfusion, but are not so effectual. In cases 
 
92 The After-Treatment of Operations 
 
 of very severe shock where the circulation has ahnost 
 failed, the fluid is not absorbed fast enough to be of use, 
 as there is not enough circulation to carry it into the 
 great vessels. It is, however, a very useful method when 
 the degree of shock is not very severe, and we want to 
 prevent it from increasing. 
 
 The water used for the injection should be at a tempera- 
 ture of about 110° F. As much water as possible should 
 be allowed to flow into the bowel — as a rule not more than 
 I pint at a time can be retained ; but this depends to a 
 large extent on the care with which it is injected. By 
 allowing it to flow in quite slowly while the buttocks are 
 well raised on a bolster it is often possible to get a couple 
 of pints retained without any discomfort ; at least twenty 
 minutes should be occupied in introducing this quantity. 
 The best apparatus for injecting the water is a No. 8 
 soft rubber catheter, with a glass funnel attached to the 
 free end ; the eye end of the catheter should be passed 
 well up into the bowel, and then the fluid should be 
 poured slowly into the funnel. 
 
 Another method of performing infusion is by the sub- 
 cutaneous injection of normal salt solution. The injection 
 is usually made into the subcutaneous cellular tissue of 
 the breast. This method has, however, no advantages 
 over the intravenous or rectal methods, and on the other 
 hand, it has many disadvantages. 
 
 The Use of Drugs, — There are certain drugs which 
 have the property of causing contraction of the vessels in 
 the peripheral circulation, and of so raising the general 
 blood-pressure independently of the action of the vaso- 
 motor centres. It is obvious that such drugs are of the 
 greatest value in treating a condition such as shock, in 
 which it is necessary to maintain the circulation until 
 such time as the brain-centres have recovered. There 
 
Surgical Shock 93 
 
 are several drugs which have this property, but only three 
 need be mentioned here — namely, extract of the infundi- 
 bular portion of the pituitary gland (usually called 
 pituitary extract), adrenalin, and nicotine. All these drugs, 
 if administered intravenously, will raise the blood-pressure 
 to, or above, the normal level in the complete absence of 
 the central nervous system. Nicotine, however, owing to 
 its poisonous properties, is not a suitable drug for clinical 
 administration. The most powerful drug of the three is 
 adrenalin, which, if administered in small doses together 
 with saline infusion intravenously, will raise the blood- 
 pressure under any condition of shock. Unfortunately, 
 in practice this drug is not very suitable, owing to the 
 fact that it is rapidly oxidized in the tissues, and its 
 effects are therefore only transitory, and frequent admin- 
 istration is required. Moreover, it has to be given 
 intravenously, owing to the fact that subcutaneous injec- 
 tions have no effect upon the bloodvessels. Pituitary 
 extract, however, is a very valuable drug for clinical use 
 in the treatment of shock. Dr. Symes and the author 
 were able to prove by experimental work some five years 
 ago that pituitary extract would raise the blood-pressure 
 under any condition of shock, and would maintain it at 
 or about the normal level for a considerable time without 
 readministration, and, moreover, that it could be adminis- 
 tered subcutaneously provided there was sufficient 
 circulation to carry it into the general circulation. 
 
 It is obviously useless to administer pituitary extract 
 or any other drug hypodermically to a patient suffering 
 severely from shock. The circulation of the blood beneath 
 the skin has practically ceased in such circumstances, and 
 drugs so administered have no chance of reaching the 
 general circulation. It is therefore necessary to inject the 
 drug into one of the larger veins, such as the median basilicj 
 
94 The After-Treatment of Operations 
 
 or to administer it in association with an intravenous 
 infusion of saline solution if the blood-pressure has already 
 reached a very low level. The alternative practice in 
 such circumstances is first of all to infuse the patient 
 intravenously, and, after a pint of fluid has been run in, 
 to inject i c.c. of pituitary extract into the india-rubher 
 tube passing from the reservoir to the veins, thus insuring 
 that the drug is carried well into the circulation. This 
 drug may be readministered after four or five hours 
 subcutaneously, if the pressure has not dropped back to a 
 very low level. 
 
 Pituitary extract has now been used for a number of 
 years, and it has been found the most effective method of 
 treating shock. It can now be obtained in fairly stan- 
 dardized solutions from the leading chemical manufacturers. 
 One peculiarity about pituitary extract is that second and 
 third injections have far less effect than the first one. 
 The exact reason for this has never been explained, but 
 experimentally it is very marked. 
 
 It must always be remembered that if a patient is 
 rallying from a condition of shock our best method of 
 preventing a relapse is by keeping him absolutely quiet, 
 by administering nourishment in suitable quantities either 
 by the mouth or rectum, by assisting the respiration with 
 oxygen, and, above all, by protecting the central nervous 
 system with narcotics, such as morphia or heroin, at 
 suitable intervals. 
 
 Artificial Respiration. — This has often a remarkable 
 effect on patients suffering from shock. It does good by 
 drawing blood into the chest to supply the heart, and by 
 increasing the oxygenation of the blood. It may be done 
 gently in severe cases of shock, and may with advantage 
 be combined with the administration of oxygen. 
 
 When the patient remains in a condition of shock for 
 
Surgical Shock 95 
 
 many hours, it becomes most important to administer 
 nourishment in some form, as the condition is one that 
 gives rise to a great deal of tissue change, and the 
 patient has probably been without food for some time 
 previous to the operation. Some easily digested form of 
 food must therefore be administered in the hope that 
 some of it may be assimilated and help to keep up the 
 vitality of the patient. Nutrient enemata of albumin or 
 peptonized milk should be given every one or two hours, 
 or appropriate food may be given by the mouth if the 
 patient can swallow. 
 
 In conclusion, it must be borne in mind that the condi- 
 tion called shock which follows severe operations and 
 injuries is, in a large measure, a mechanical one, in 
 which the circulation is the main factor at fault, and that 
 therefore it is a condition which it is possible to treat 
 successfully in many cases, since by appropriate means 
 the mechanical disadvantages under which the circulation 
 is labouring can be overcome. One of the chief factors 
 in maintaining shock is the exhaustion of the nerve 
 centres in the cord and medulla, and although we cannot 
 directly influence these, in most cases their recovery is 
 only a matter of time, if meanwhile we can succeed in 
 maintaining the circulation. Our efforts, therefore, must 
 be exerted in maintaining the circulation in as efficient 
 a condition as possible until such time as the exhaustion 
 of the nerve centres has passed off. 
 
 We must not expect this to take place suddenly or 
 quickly in bad cases, and considerable patience and per- 
 severance will be called for. The most difficult cases to 
 deal with successfully are those where a profound condi- 
 tion of sepsis or toxaemia is present in addition to the 
 shock ; it is often extremely difficult or impossible to 
 distinguish the one condition from the other, and patients 
 
96 The After-Treatment of Operations 
 
 under such circumstances often react extremely badly, or 
 not at all, to treatment, and when they do react, relapse 
 again almost at once. 
 
 The best results will always be obtained by preventing 
 shock rather than by treating it. 
 
 REFERENCES. 
 
 ' Surgical Shock ' : G. W. Crile, New York, 
 
 ' Problems relating to Surgical Operations ' : Same author. 
 
 ' Blood-Pressure in Surgery ' : Same author. 
 
 ' Shock in Abdominal Operations ' : George Hawkins-Ambler. 
 
 'The Physiology and Treatment of Surgical Shock and Collapse' : 
 
 Lockhart Mummery, Lancet, vol. i. 1905, pp. 696, 776, 846. 
 ' Shock and Collapse ' : Clifford Allbutt's ' System of Medicine.' 
 ' GyuEecological Operations ' : Dr. Kelly, Baltimore. 
 'The Specific Gravity of the Blood in Shock ': Proceedings of thi 
 
 Physiological Society, July 20, 1907. 
 ' Some Points on the Experimental Production and Control of the 
 
 Vascular Atony of Surgical Shock ' : Lockhart Mummery and 
 
 W, Lrgge Symes. British Medical Journal, September 19, 1908. 
 ' Anoci-Association ' : G. W. Crile and W. E. Lower. 
 
CHAPTER VI 
 
 POST-ANESTHETIC COMPLICATIONS 
 
 Owing to the great improvements in the methods of 
 administering anaesthetics which have taken place re- 
 cently, the after-effects are now less important than 
 formerly, and we do not so often find the results of the 
 anaesthetic complicating the after-treatment of an opera- 
 tion case. It is especially in the old and weakly subjects 
 that these after-effects are most likely to cause trouble. 
 The after-effects are much diminished if the patient has 
 been properly prepared for the anaesthetic beforehand. 
 In some cases, however, and especially in emergency 
 operations, time will not permit of the patient bemg 
 properly prepared for an anaesthetic, and it is in these 
 cases that we most often see post-anaesthetic complica- 
 tions. Most of the after-effects result more in dis- 
 comfort to the patient than in any actual danger; 
 occasionally, however, the results of the anaesthetic, 
 either alone or by complicating some condition caused 
 by the operation, may .give rise to symptoms of the 
 gravest import. The nature of the anaesthetic used and 
 the method of administration are of considerable impor- 
 tance. Ether is undoubtedly more liable to cause 
 unpleasant after-results than chloroform, but its other 
 advantages sufficiently outweigh these to render it a 
 
 97 1 
 
9 8 The After-Treatment of Operations 
 
 preferable anaesthetic in the majority of cases. The 
 liability to, and the severity of, post-anaesthetic com- 
 plications are proportionate, to a large extent, to the 
 length of the administration. 
 
 Vomiting". 
 
 A certain amount of vomiting may be said to be the 
 rule after ether ; the vomited material is usually little 
 else than mucus, and vomiting generally passes off before 
 the patient regains consciousness. Occasionally, how- 
 ever, it is more severe, and may continue for many hours 
 or even days. When this is the case it is very distress- 
 ing to the patient, and may be dangerous, by lowering 
 his strength and preventing the proper assimilation of 
 nourishment. 
 
 Vomiting is more liable to occur if the patient is jolted 
 or moved carelessly soon after the anaesthetic ; care 
 should therefore be exercised in moving the patient back 
 to bed, both to avoid jolting and to keep him as flat as 
 possible. The cause of the vomiting has been attributed 
 to the presence of ether in the stomach. Hess of New 
 York, who has investigated this subject, comes to the 
 conclusion that the drug is excreted by the gastric 
 mucous membrane, and as it is usual for the stomach to 
 be empty during an operation, it remains there in a con- 
 centrated form mixed with mucus ; no doubt also a 
 considerable quantity of ether finds its way into the 
 stomach with the saliva which is swallowed. Hess 
 considers that the bad cases of post-anaesthetic vomiting 
 are due to a gastritis set up by the ether present in the 
 stomach, and suggests that the best way of preventing 
 this is by diluting the stomach contents. He advises 
 that the patient should be given a draught of water before 
 
Post-Angssthetic Complications 99 
 
 the commencement of the anaesthetic, so that any ether 
 that may find its way into the stomach will be rapidly 
 diluted. Whether the vomiting is due to any local con- 
 dition of the stomach or is of central nervous origin is 
 still somewhat doubtful ; that, at any rate, the vomiting 
 is not entirely due to local causes seems probable, as 
 vomiting follows the anaesthesia produced by rectal 
 etherization. And, again, some of the worst cases of 
 vomiting occur after chloroform. That ether does get 
 into the stomach during the administration of the anaes- 
 thetic there can be no doubt, and draughts of water after 
 the administration, whether retained or not, will assist in 
 either diluting or washing it away. 
 
 Although vomiting is more common after ether than 
 after chloroform, the worst cases of vomiting are seen 
 after the latter drug. The presence of blood in the 
 stomach (which has been swallowed during the anaes- 
 thesia) is a common cause of subsequent vomiting. In 
 children, vomiting after ether is very much less common 
 than with adults, in spite of the fact that, as a rule, 
 children are sick from very slight causes ; and it seems 
 that old people are also less liable to post-anaesthetic 
 vomiting. 
 
 The position of the patient after an anaesthetic is of 
 some importance in preventing sickness. The patient 
 should be turned on to the right side if possible, so as to 
 allow any fluid in the stomach to find its way easily into 
 the duodenum. In cases of very intractable vomiting, 
 propping the patient up into a sitting or half-sitting 
 position will often be efficacious in stopping the sickness. 
 When the vomiting consists in simple regurgitation of 
 fluids directly they are swallowed, this is all that is 
 usually necessary to stop it and enable the patient tq 
 retain nourishment. 
 
loo The After-Treatment of Operations 
 
 Another point of great importance with regard to the 
 posture after an anaesthetic may be referred to here — that 
 is, that after the patient has been put back to bed, and 
 before he has regained consciousness, the head must be 
 kept well to one side, as if he be allowed to lie on the 
 back with his head in the midline, should any sickness 
 occur there is a great danger of the vomited material 
 becoming sucked into the air-passages and obstructing 
 respiration. This may occur even though a nurse is 
 watching the patient, and several deaths have been re- 
 corded from this cause after the administration of ether. 
 
 When from the nature of the operation it is particu- 
 larly advisable that the patient should not vomit after 
 the operation is finished, or when it is known that the 
 particular patient is liable to exceptionally severe vomit- 
 ing after anaesthesia, an excellent plan is to wash out the 
 stomach with warm water before sending the patient 
 back to bed ; this is often effectual in completely pre- 
 venting vomiting. 
 
 As soon as the patient is conscious after the anaes- 
 thetic, if vomiting does not cease he may be given 
 some quite hot water to drink (about | pint may be 
 allowed) ; this will sometimes have the effect of making 
 the patient sick, but will do no harm, as it washes out 
 the stomach and gets rid of the ether. 
 
 Another plan is to give 15 to 20 grains of bicarbonate 
 of potash in | pint of hot water ; or 3 minims of tinc- 
 ture of iodine dissolved in ^ pint of cold water is some 
 times very effectual. Another way of giving iodine is 
 I minim of iodine in i drachm of water every two hours. 
 Strong hot coffee may be tried, or champagne is some- 
 times useful. 
 
 There are several drugs which enjoy a reputation for 
 preventing vomiting after anaesthesia ; thus hydrocyanic 
 
Post-Anaesthetic Complications loi 
 
 acid in small repeated doses is said to be of value. 
 Morphia is certainly sometimes of use, and may be given 
 either hypodermically or by the mouth. Sir F. Hewitt 
 says that when there is a neurotic element in the vomiting, 
 bromide of potassium may be given as an enema (20 grains 
 in 2 ounces of water) with good results. Sometimes 
 10 grains of bromide placed on the back of the tongue is 
 effectual. 
 
 Counter-irritants to the region of the stomach are some- 
 times effectual. The best of these is a flannel rung out of 
 boiling water and applied to the epigastrium ; it must be 
 applied as hot as possible and changed as soon as it has 
 become cool. Blisters have also been used with success. 
 
 Strong essence of peppermint is sometimes very 
 effectual ; it is best given as 5 or 10 drops on a lump 
 of sugar, the latter being sucked slowly, or it may be 
 given with a little water : it probably acts in the same 
 way as a counter-irritant. In cases of very severe and 
 intractable sickness the stomach should be washed out 
 with warm water by means of a soft rubber tube, until 
 the water comes back quite clean ; this removes any 
 decomposing or irritating material that may be present, 
 and it is the most effectual method we possess of stopping 
 vomiting. The repeated inhalation of oxygen has some- 
 times proved effectual in controlling vomiting in bad 
 cases. Patients who have suffered from severe vomiting 
 often complain of pain round the lower part of the chest, 
 especially on deep inspiration, for a day or two after- 
 wards ; this is due to the muscles having been strained 
 during the violent retching. This pain often gives rise 
 to a great deal of discomfort, and may even give rise to a 
 suspicion of pleurisy. It should be relieved by rubbing 
 the skin over the painful muscles with linamentum 
 saponis or by gentle massage. 
 
io2 The After-Treatment of Operations 
 Lungr Complications. 
 
 The liability to lung complications after anaesthetics is 
 probably greater than is usually supposed. These com- 
 plications are most commonly seen after ether, and but 
 rarely after chloroform. The most common of these 
 complications is bronchitis, which may go on to broncho- 
 pneumonia in bad cases. The so-called ether pneumonia, 
 which is of the lobar type, seems to be much more rare 
 than its name would imply. 
 
 The term ' ether pneumonia,' though commonly used, 
 is a bad one, and ' post-operative pneumonia ' would be 
 better. That ether is not responsible for all the cases 
 of pneunomia which occur soon after an operation is 
 shown by the fact that pneumonia also occurs after 
 chloroform and infiltration an?Esthesia. There is little 
 doubt that many of the cases quoted as ' ether pneumonia ' 
 are due to infarction of the lung. This is also borne out 
 by the fact that pneumonia more frequently occurs after 
 abdominal and pelvic operations, and it will be seen by 
 reference to the chapter on Thrombosis that these are 
 the operations after which infarction is most liable to 
 occur. 
 
 Crouch and Corner, who investigated this subject 
 recently at St. Thomas's Hospital, found in 2,400 
 administrations of ether, ten cases of subsequent lung 
 complications which were directly attributable to the 
 anaesthetic. Of these ten cases, three were broncho- 
 pneumonia (one of whom died), one developed pleurisy, 
 and the remainder bronchitis of varying degrees of 
 severity. It may be mentioned that in this series of 
 cases the anaesthetics were given, for the most part, by 
 inexperienced anaesthetists. The liability to these com- 
 plications appears to be greater after prolonged anaesthesia, 
 
Post-Anaesthetic Complications 103 
 
 and especially when the patient is subjected to changes 
 of temperature or draughts soon after the administra- 
 tion, as is the case when he has to be conveyed along 
 passages, etc., on the way from the operating-table to 
 the bed. It is, therefore, commoner in hospital than in 
 private practice. To prevent these complications great 
 care should be taken not to let the patient be subjected 
 to any draught or sudden change of temperature after an 
 anaesthetic, and if it is necessary to move a patient some 
 distance from the operating-room, the head and mouth 
 should be covered over with a thin blanket. The treat- 
 ment is, of course, that which is appropriate for the lung 
 condition present. Many cases of ' ether pneumonia' are 
 really lobar collapse m connection with inhibited action 
 of the diaphragm during and after abdominal operations. 
 
 Other Complications. 
 
 Among other complications that may be seen are the 
 following : 
 
 Renal Troubles. — Some observers state that albu- 
 minuria for a day or two is very common, and is more 
 often seen after chloroform than after ether. Two cases 
 have recently been reported in which uraemic coma 
 followed an anaesthetic. Disease of the kidneys was found 
 to be present in both cases at the post-mortem. Such 
 cases show the importance of examining the urine before 
 giving an anaesthetic. 
 
 Jaundice has been recorded as occurring after chloro- 
 form. 
 
 Insanity. — Several cases of this have been recorded. 
 It is specially liable to occur in patients the subjects of 
 recurring attacks of insanity, the anaesthetic acting as the 
 exciting cause in bringing on another attack. 
 
 Diabetic Coma has been known to be brought on by 
 the administration of an anaesthetic. Of course, this is 
 
104 The After-Treatment of Operations 
 
 best prevented by carefully dieting the patient before the 
 operation. 
 
 Paralysis. — Dr. Blumfeld mentions three varieties of 
 paralysis that may follow anaesthesia : (i) Those of 
 peripheral origin. These are due to the patient, while 
 his volition is in abeyance, being allowed to remain for 
 some time in a strained position, which has resulted in 
 some nerve or nerves being pressed upon. Deltoid and 
 ulnar paralysis are examples. (2) Those of central origin. 
 These are really apoplectic fits, resulting from the con- 
 gestion due to the anaesthetic. (3) Indeterminate. 
 
 Persistent Hiccough, — This may occur and prove 
 very difficult to stop. Tongue traction has sometimes 
 been successful. 
 
 H^MATEMESis. — -This complication is very rare, but is 
 sometimes seen after operations, and it is doubtful how 
 much of it is due to the anaesthetic and how much to the 
 operation itself. It seems to be commoner after operations 
 on the intestinal tract than after operations on other parts 
 of the body. A case is reported in the Lancet, August 22, 
 1902, where hsematemesis occurred four days after the 
 operation, and Mr. Mayo Robson cites several cases of 
 this complication, some of which were fatal. 
 
 HEMOPTYSIS. — This also is a rare complication, but is 
 occasionally seen. Of course, as a rule it is seen in 
 tubercular patients who have cavities in the lungs, and 
 the congestion resulting from the anaesthetic acts as the 
 exciting cause. Sometimes, however, no history of any 
 previous lung trouble is obtainable, and on examination 
 of the chest it is not posible to discover any signs of 
 mischief. It is, as one would naturally suppose, most 
 commonly seen after ether. 
 
 Delayed Chloroform Poisoning is a condition in 
 which the patient, usually a child, having apparently 
 
Post-AnsBSthetic Complications 105 
 
 recovered from the effects of the anaesthetic, begins to 
 vomit repeatedly. The onset is usually twelve to thirty- 
 six hours after operation ; the vomiting continues, acetone 
 appears in the urine, the temperature rises, and delirium, 
 restlessness, and coma supervene, terminating in death. 
 Milder forms of this complication, from which patients 
 have recovered, have also been described. The most 
 hopeful form of treatment is stated to be repeated wash- 
 ing out of the stomach with solutions of bicarbonate of 
 soda (5i. to the pint), a small quantity of the solution 
 being left behind in the stomach. Glucose should also 
 be given per rectum. 
 
 Diet. 
 As a rule, no food should be given by the mouth for 
 from four to six hours after the anaesthetic, as it will 
 probably only cause vomiting. The first food that is 
 given should be something that is easily assimilated, but 
 need not necessarily be fluid. Solids or semi-solids are 
 often more readily retained, and are more satisfying to 
 the patient. A cup of tea with some soft bread-and- 
 butter and a lightly-boiled eg^g may be given. Anything 
 in the way of a large meal should not be allowed, as it 
 will almost certainly cause sickness. When the adminis- 
 tration has been a long one, of course the interval that 
 must be allowed to elapse before food is given should be 
 longer. On the day following the operation the patient 
 may be allowed to go back to his ordinary diet if there is 
 no sickness and it is not otherwise contra-indicated by 
 the nature of the operation. 
 
 REFERENCES. 
 
 Anaesthetics ' : Sir F. Hewitt. 
 
 Vomiting after Anaesthetics ' : Dr. Biumfeld, Clinical Journal, 
 August, 1901. 
 
CHAPTER VII 
 
 THROMBOSIS FOLLOWING OPERATIONS 
 
 This is, fortunately, a rare complication. It may result 
 from two conditions : (i) After a prolonged or severe 
 operation upon an anaemic subject ; (2) as the result of 
 sepsis in the wound. The thrombosis differs considerably, 
 according to which of these conditions has caused it, 
 both as to its type and its liability to give rise to infarc- 
 tion. In the first case, the thrombus is due to stagna- 
 tion of the blood and infarction if it occurs, will do so 
 during the period of formation of the clot, and there is 
 very little tendency for it to do so later. In the second 
 case, the thrombus is a septic one, and the chief period of 
 danger is during the softening of the clot ; moreover, in 
 this case, if infarction occurs abscess will probably form 
 at the site of the infarct, and a condition similar to 
 pyaemia will be set up. It is well to bear these facts in 
 mind as it is of the utmost importance that the patient 
 should be kept absolutely quiet during the dangerous 
 period. There seems to be an exceptional liability to 
 bed-sores in some of these cases, and if the case is a septic 
 one necessitating prolonged immobility, it is best to turn 
 the patient on to his face, lifting him on a sheet so as 
 to disturb him as little as possible. The liability to the 
 formation of bed-sore is much less in this position, as has 
 already been pointed out. 
 
 106 
 
Thrombosis following Operations 107 
 
 Thrombosis most commonly occurs about a week or 
 ten days after the operation, though it may take place 
 very much earlier than this, and, as in the second of the 
 appended cases, it may occur as late as three weeks after- 
 wards. In a resume of forty-eight cases of crural 
 thrombosis following surgical operations collected by 
 Shenck, and reported in the New York Medical Journal, 
 September 6, 1902, it was found that out of a total 
 of 7,130 gynaecological operations there were forty- 
 eight cases of thrombosis of the veins of the lower 
 extremity. 
 
 In the more recent statistics from the Mayo clinic 
 for the year 1913 (Beckman, 'Complications following 
 Surgical Operations,' Journ. Surg., GyncBcoL, and Ohstetrics, 
 May, 1914) there were fourteen cases out of a total of 
 6^825 cases. These figures show a very marked improve- 
 ment, and are what one would expect as the result of the 
 improved technique and greater attention to after-treat- 
 ment that have been the chief features of surgical advance 
 in the last ten years. The fourteen cases in these last 
 statistics occurred in twelve different types of operations, 
 although all were abdominal operations. The conclusion 
 arrived at from these figures is that there is no special 
 liability for thrombosis to occur in septic cases as opposed 
 to clean ones. 
 
 Shenck also points out that this complication is much 
 more common after operations on the pelvis, than after 
 operations on any other part of the body, and that injury 
 to the large venous trunks by the too forcible use of 
 retractors is a possible cause in some cases. Ligature of 
 a vein close to the point at which it enters the main 
 venous trunk may cause thrombosis in that trunk by 
 extension of the clot, and this was thought to be the 
 cause in some of Shenck's cases. The most common 
 
io8 The After-Treatment of Operations 
 
 date for the onset of this compHcation was found in this 
 series of cases to be between the twelfth and sixteenth 
 days after the operation. It was found that the anaemia 
 and cachexia accompanying malignant disease was a 
 factor in many of the cases where thrombosis followed 
 operation for the relief of this condition. An infective 
 origin for the thrombosis was also traceable in many of 
 the cases. 
 
 In an investigation carried out by Wright and Knapp 
 into the cause of post-typhoid thrombosis, it was shown 
 that there was a decrease in the coagulation time of 
 the blood of typhoid patients during the later stages of 
 that disease (i.e., that the blood coagulates more rapidly 
 than normal), and that this increased coagulability is 
 accompanied by an increase in the amount of calcium 
 salts present in the blood. This increase in the calcium 
 salts is attributed to the fact that typhoid patients are fed 
 almost exclusively on a milk diet, which contains a high 
 percentage of these salts. If this view is correct, and it 
 seems a reasonable one, and is well backed by experi- 
 mental evidence, the thrombosis following typhoid is in 
 part due to a milk diet. And it is possible that some of 
 the cases of thrombosis that follow operations are due to 
 the same cause. Wright and Knapp suggest the use of 
 citric acid to precipitate the calcium salts as a prophy- 
 lactic agent. 
 
 It would seem that operations in the neighbourhood 
 of the pelvis are those most liable to be followed by 
 thrombosis, and that this is attributable to direct injury 
 or infection of the main venous channels or the ligature 
 of their immediate^ branches. Anaemic or cachetic con- 
 ditions undoubtedly predispose to the condition. 
 
 The onset of thrombosis is usually accompanied by 
 pain in the part or by itching. This pain is generally of 
 
Thrombosis following Operations 109 
 
 a dull, aching character. On examining the part there 
 is found to be tenderness over the site of the vein, or the 
 thrombosed vein, if superficial, may sometimes be felt 
 like a lead pencil beneath the skin. The greatest care 
 must, however, be taken in examining a patient in whom 
 thrombosis is suspected, as otherwise there is great 
 danger of dislodging the clot. The treatment should 
 consist in wrapping the affected parts in cotton-wool and 
 elevating the limb. Absolute rest in bed for at least five 
 weeks is usually necessary, and this time may have to be 
 considerably extended. Splints should not be used, but 
 the limb, if necessary, may be steadied by sand-bags. 
 
 Great care must be exercised in the nursing, especially 
 during the period when the clot is extending, and the 
 patient must be moved as little as possible and very care- 
 fully, otherwise there is great danger of a portion of the 
 clot becoming detached and giving rise to an infarct in 
 the lung ; the patient should also be warned as to the 
 danger of moving. For the same reason anything in the 
 nature of a purge must not be given, and if there is any 
 difficulty in getting the patient's bowels to act, enemas 
 should be used. 
 
 Roughly speaking, it may be said that in the non-septic 
 cases most of the danger of infarction is over in a fort- 
 night from the commencement of the thrombosis. In 
 the septic cases the time is longer, being roughly five or 
 six weeks. When there is marked anaemia, it is most 
 important to treat this condition by careful attention to 
 diet and the administration of iron in some form or 
 another. 
 
 When infarction does occur and is not immediately 
 fatal, the patient should be sat up and oxygen adminis- 
 tered to relieve the dyspnoea, which is very distressing ; 
 some stimulant is usually necessary, such as strychnine 
 
1 1 o The After-Treatment of Operations 
 
 or brandy. As soon as the dyspncea has to some extent 
 passed off, which in most cases is in about five or ten 
 minutes, the patient should be propped up with pillows 
 and kept as quiet as possible. Alkalies, and especially 
 ammonium carbonate, seem to be of some value in pre- 
 venting further extension of the clot, and may be given 
 in large doses by the mouth. In thrombosis of septic 
 origin, if the position of the clot will permit of it, the 
 vein on the proximal side of the clot may be cut down 
 and ligatured. When sudden death has occurred from 
 infarction and the medical attendant is at hand, it is 
 always worth while to try and restore the patient by 
 artificial respiration, etc., as the cause of death in most 
 cases is quite momentary. 
 
 Infarction is usually accompanied by a rise of tempera- 
 ture to ioi° or 102° F. ; the temperature falls again in 
 twenty-four hours, as a rule, though it may remain 
 slightly elevated for some days. In the septic cases 
 there is, of course, the ordinary septic temperature. A 
 careful examination of the chest on the day after infarc- 
 tion has taken place will sometimes reveal a patch of 
 consolidated lung corresponding to the area cut off by the 
 infarct. 
 
 Illustrative Cases of Thrombosis and Infarction 
 following Operations. 
 
 Case i (Fig. 17). Thrombosis following Operation for Appen- 
 dicitis. — A rather ansemic-looking girl was admitted with s3-mptoms 
 of acute appendicitis. At the operation, which was performed on 
 January 16, a large abscess containing much foul pus was opened 
 and drained. The case progressed favourably for the next few 
 days, and there was free discharge of pus from the wound. On the 
 22nd (six days after the operation) the patient complained in the 
 morning of some pain in the right leg, and it was discovered on 
 examination that the right femoral vein and most of the veins of the 
 calf were thrombosed. At 3 p.m. the same day the patient had a 
 
Thrombosis following Operations 1 1 1 
 
 sudden attack of dyspnoea, faintness, and cyanosis. She was very 
 bad for some few minutes, but was relieved by the inhalation of 
 oxygen and an injection of strychnine. She had to sit up. The 
 respirations were 50. 
 
 On the 23rd the patient was still dyspnoeic. Respirations 40. 
 
 This condition remained practically unchanged till the 26th. 
 Nothing at this time was found in the lungs. The condition now 
 improved, but on the night of the 28th there was another attack of 
 dyspnoea (i.e. , another infarct). There was at this time some oedema 
 of both legs, and both the femoral veins were thrombosed. The 
 legs were dressed with lead and opium lotion, and 20 grains of 
 ammonium carbonate was given three times daily by the mouth. 
 The wound was now almost healed, and the tubes had been 
 removed. On February 6 the patient complained of pain and stiff- 
 ness of the right shoulder, and it was noticed that the superficial 
 veins of the right side of the chest and all down the arm were 
 dilated. All the veins of this region that could be seen or felt were 
 found to be thrombosed, and it appeared certain that the right 
 innominate vein was thrombosed. 
 
 On the nth an eczematous rash appeared over the legs, chin, 
 and right hand. There were no further infarcts, and the patient 
 rapidly improved. The thromboses all cleared up in the course of 
 about ten days or a fortnight after this, and the patient left the 
 hospital quite well on March 6. 
 
 At first the patient was fed with albumin water, but after the ap- 
 pearance of the thrombosis a more nourishing fluid diet was allowed. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 V- : 
 
 : P'h " 
 
 
 
 
 :g 
 
 \^ 
 
 M iSTi 
 
 '• ' 1 *-'! 
 
 
 inrt 
 
 1 
 
 ■ W 
 
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 Fig. 17. 
 
 and iron in the form of cachets of pil. ferri (5 grains) was given 
 three times a day ; half a pint of stout was also given daily and 
 port wine. For the pain and distress when the infarction took place 
 
112 The After-Treatment of Operations 
 
 a hypodermic injection of morphia was administered. Large doses 
 of alkaHes, sodium bicarbonaie, and ammonium carDonate were 
 given throughout. 
 
 In what way alkalies act in the treatment of these cases 
 is very doubtful, but they seem to have a very beneficial 
 effect. 
 
 Case 2 (Fig. iS). Thrombosis following an Operation for 
 Appendicitis. — This was the case of a man, aged forty-five, who 
 was operated on for acute appendicitis, and had a large abscess in the 
 neighbourhood of the appendix drained. About twelve days after the 
 operation the patient had what was described as an acute cardiac 
 attack, accompanied by very severe dyspnoea. (This seems to have 
 undoubtedly been an infarct in the lung.) There was at the same 
 time cedema of the right leg, and the femoral vein was found to be 
 thrombosed. A week later there was another attack of a. similar 
 nature to the first one. After this attack some friction was noticed 
 
 03_ 
 
 «::::::::::; 
 
 
 
 .,•?; 
 
 ;:;•;;■: M jrr : 
 
 m \ \ \ \ \ \\^ 
 
 
 CO*®- 
 
 ; M; ; : ; ; i i ; 
 
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 \3«U-- 
 
 
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 V ^ \u ■7\ ^ ^ TAI 
 
 ^ ; 
 
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 Fig. 18. 
 
 on listening with the stethoscope over the lower part of the left side 
 of the chest. The thrombosis gradually cleared up, and the patient 
 was able to go away to the country two months after the operation. 
 
 The temperature charts of both these cases are appended, 
 and it will be noticed that there is a rise of temperature 
 coincident with the infarction of the lung. 
 
 Case 3 (Fig. 19). Thrombosis following an Operation for 
 Hernia. — A woman, aged forty-nine, was operated upon for the 
 radical cure of a hernia on the right side, on November 22. 
 
 On the third day after the operation there was a slight rise in the 
 temperature. This, however, dropped again, and remained normal 
 
Thrombosis following Operations i 1 3 
 
 till the 28th., when it again rose, and continued high. On De- 
 cember 2, as sepsis was suspected, the wound was dressed, though 
 the patient complained of no pain in the wound. The wound was 
 found to be quite healthy, and almost healed. On this day pain was 
 complained of in the calf of the left leg, and on examination it was 
 found that the iliac, femoral, and saphena veins were all thrombosed. 
 There was some cystitis present, for which she was treated by 
 washing out the bladder. 
 
 The same afternoon, while being moved in bed, she had an infarct 
 in the lung. There was sudden, very severe dyspncsa; the pulse 
 became irregular and uncountable, and she was in great distress. 
 Oxygen and stimulants were administered, and she gradually 
 rallied. On December 6 she had another pulmonary infarct, which 
 almost proved fatal. On December 27 she had another pulmonary 
 infarct of a severe nature, and another less severe attack on the 
 28th. At this time the patient was very ill indeed, and vomited 
 everything. There was much dyspnoea, and she was very cyanosed. 
 
 . •; ; 1 M M i ! ; ; i ; i ; ; : M : 'i : ?■ : • ; ^ • 
 
 ^ ' U \ \ \ ■ : I ' \ \ ;?jj! ;:;■,:;■;■ M M : 1 ; : 
 
 10; ■ *i •••■•■ • '... -B '^' 'A ■tf • -^ • '■ ■ • ■ • "ft ■« ■ ■■ 
 
 : i 3 M ; ; ; : J,3t/ ; tMl± ^ ^ ^ ^J^^^ '^ 
 
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 »' J_ -L _L _L J — i — L _L J-. _i_ J — L _L J- -i — \ — i — U-J — L,JL-LJ — Lj — \ — L__L 
 
 
 
 
 
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 Fig. 19. 
 
 The breathing gradually improved in the course of the next few 
 days. 
 
 On January 8 a large sloughing bed-sore formed over the sacrum, 
 and she was accordingly turned on to her face and subsequently 
 
114 The After-Treatment of Operations 
 
 nursed in this position. The bed-sore was very septic, and con- 
 tained much gangrenous tissue. From time to time there were 
 rigors, and her temperature remained high. 
 
 On February 3 her temperature went up very high, and she 
 became extremely ill. 
 
 On February 12 she had several rigors, and developed a bad 
 cough, though no signs could be discovered in the chest. 
 
 On February 28 she coughed up a quantity of pus on two 
 occasions. 
 
 After this the temperature gradually came back to the normal, 
 and by April 10 the cough had disappeared, and she soon afterwards 
 left the hospital for the seaside. 
 
 This case was one of septic thrombosis, though the 
 cause of infection is somewhat doubtful. It may have 
 been from the wound (which, however, did not break 
 down), or from the cystitis which was present. It shows 
 very well how much more dangerous these cases are than 
 those of simple thrombosis, and how the danger of infarct 
 extends for a much longer time. 
 
 There can be little doubt that the bed-sore and the 
 abscess in the lung were due to septic emboli. There 
 were no signs of the lung abscess for over two months 
 from the time of the formation of the thrombus ; this 
 shows the great importance of complete rest in bed for 
 a long time in these septic cases. Cases of pulmonary 
 embolism are often more serious, there being no indica- 
 tion of anything wrong before the sudden onset of 
 dyspnoea and death. These cases are veritable tragedies, 
 death often occurring in a few minutes without any 
 warning, though the patient was apparently doing well. 
 In most of these suddenly fatal cases an autopsy will 
 reveal the presence of a clot in the right pulmonary 
 artery and thrombosis of the femoral or pelvic veins. 
 
Thrombosis following Operations 1 1 5 
 
 REFERENCES. 
 
 ' Crural Thrombosis following Surgical Operations ': B. R. Shenck. 
 New York Medical Jow/nal, September 6, 1902. 
 
 ' Post-Typhoid Thrombosis ' : Drs. Wright and Knapp. Lancet, 
 December 6, 1902. 
 
 Dr. Wright and Dr. Paramore. Lancet, October 14, 1905. 
 
 ' Pulmonary Embolism and Thrombosis after Laparotomy ' : L. Bid- 
 well. Practitioner, February, 1909. 
 
 ' Complications following Surgical Operations ' : Beckman. Surgery, 
 Gynecology, and Obstetrics, May, 1914. 
 
CHAPTER VIII 
 
 POST-OPERATIVE RASHES AND DRUG-POISONING 
 
 Septic Rashes. 
 
 For a long time great confusion has existed in the 
 diagnosis of rashes following operations, and hitherto 
 many of them have been called scarlet fever. Some 
 text-books describe a form of scarlet fever called 'surgical 
 scarlatina,' which occurs in patients with open wounds ; 
 it seems most probable that this is really a septic condi- 
 tion. Though undoubtedly there are from time to time 
 cases where a genuine attack of scarlet fever follows an 
 operation, careful investigation seems to show that these 
 cases are rare, and that most of the cases described as 
 scarlet fever following injury or operation are in reality 
 septic in origin. 
 
 A septic rash generally makes its appearance at the 
 time that other septic manifestations usually appear — 
 that is to say, from one to four days after the operation 
 — though the time after the operation at which the rash 
 appears is often slightly shorter than in the case of 
 ordinary sepsis in the wound, as the nature of the 
 infection is more acute. The appearance of the rash is 
 generally accompanied by a marked rise in temperature 
 to 102° to 103° F., and is followed by other constitutional 
 
 116 
 
Post-Operative Rashes 117 
 
 symptoms, such as malaise, rapid pulse, restlessness, etc. 
 The rash itself is usually a scarlet erythema, which much 
 resembles the rash of scarlet fever. It usually appears 
 quite suddenly in the course of a few hours. Often the 
 rash is an almost uniform injection of the skin, at other 
 times it may be more punctate or blotchy in appearance. 
 Occasionally it is papular. The rash often fades on 
 pressure, but this depends to some extent upon the 
 intensity of the injection. The exact appearance of the 
 rash is by no means constant. Its distribution also 
 varies a good deal ; the most common type is a uniform 
 scarlet rash, which appears simultaneously all over the 
 body. In some cases, however, the rash is more limited 
 in its distribution, and may be confined to the buttocks 
 and flexor aspects of the thighs, or to the skin over the 
 joints of the extremities, around the ankles, knees, and 
 wrists. Most commonly the rash only lasts for a few 
 days, and then fades away ; occasionally it may persist 
 for a week or even longer. Desquamation often occurs, 
 and especially if the rash has been at all severe. Slight 
 albuminuria is sometimes present for a few days in the 
 more severe cases. 
 
 In the worst cases all the symptoms of septicaemia 
 develop, and the patient soon sinks into a typhoid state 
 and dies. In the milder cases the rash lasts for a few 
 days, accompanied by an elevated temperature, but often 
 by very few other constitutional symptoms, and then 
 clears up, and the patient makes a good recovery. 
 Almost any degree may be seen between these two types 
 of case. Septic rashes are much more often seen in 
 children than in adults. In children a very mild degree 
 of sepsis is often followed by a rash, and frequently the 
 rash is almost the only symptom present. It is quite 
 common to see a child, as the result of some septic 
 
ii8 The After-Treatment of Operations 
 
 infection, such as the opening of an abscess or the 
 presence of an infected wound, develop a scarlatiniform 
 rash and perhaps a temperature of 103° F., and in twenty- 
 four hours or forty-eight hours to see the whole of the 
 rash disappear and the temperature come down to 
 normal. 
 
 As regards the condition of the wound : there are often 
 no signs of sepsis in it at the time when the rash 
 first appears ; it may be a little puffy round the edges, 
 but often there is little more than this, and sometimes 
 there is nothing to be seen at all. Later on the wound 
 usually gets into a sloughy condition, or breaks down 
 and suppurates. 
 
 The argument often used against the diagnosis of the 
 rash as septic, that the wound does not show signs of 
 sepsis, or only shows them slightly, is quite fallacious. 
 It must be remembered that the appearance of a septic 
 rash after an operation is evidence of a general septic 
 infection in contradistincton to a local infection, and 
 that therefore the wound itself, Avhich is the site of 
 infection, does not always break down or show signs of 
 sepsis. 
 
 General septic infection only occurs in the cases where 
 the local resistance to septic organisms is absent or 
 insufficient ; and since pus in the wound is the result 
 of local resistance, one would not expect to see the wound 
 break down to any marked extent in these cases. And, 
 in fact, it may be stated as a rule that in those cases 
 where, after an operation, general infection of the blood 
 occurs as manifested by the appearance of a rash or other 
 constitutional symptoms, the wound shows little or no 
 evidence of sepsis. And the more severe the general 
 infection, and the more rapid its onset, the less likely is 
 the wound to show marked signs of sepsis. There is, 
 
Post-Operative Rashes 119 
 
 however, another class of case in which the wound first 
 breaks down and suppurates, and then later on, the local 
 resistance to the action of the septic organisms proving 
 insufficient to protect the body from general infection, 
 general infection takes place and a rash develops ; in this 
 class of case the rash will, of course, not appear for some 
 time after the operation. 
 
 The diagnosis is often a matter of very considerable 
 difficulty. The conditions under which the rash appears 
 — that is to say, within a few days after an operation — 
 should make one suspicious of sepsis, and cases should 
 not be called scarlatina and removed to a fever ward 
 without strong evidence in favour of scarlet fever and a 
 history of possible infection. If there is much doubt as 
 to whether the case is one of scarlet fever or sepsis, the 
 patient should be isolated as far as possible for a few days, 
 when the diagnosis will probably be cleared up. The 
 so-called strawberry appearance of the tongue which is 
 seen in scarlet fever is not seen in cases of sepsis, though 
 the tongue is furred. 
 
 The following are some of the points which may help 
 in distinguishing a septic from a scarlet fever rash : 
 
 1. The premonitory febrile symptoms are usually 
 absent, the rash being the first thing noticed in most cases. 
 
 2. The distribution of the rash is irregular ; it appears 
 often simultaneously all over the body, and not, as in 
 scarlet fever, on the neck and face first. 
 
 3. There are no throat symptoms, except in those cases 
 where the wound is in the throat. 
 
 4. The pyrexia is high and of the septic type, with 
 often marked intermissions. 
 
 Subsequent peeling is no proof of scarlet fever, as it 
 not infrequently occurs in the cases of undoubtedly septic 
 rash. 
 
I20 The After-Treatment of Operations 
 
 The following are good illustrative cases of septic rash 
 following operations : 
 
 A child was operated upon for curved tibiae ; the right tibia was 
 divided on November 15, and the left on the 22nd. On the 27th 
 the child developed a scarlet rash all over the body. The wound 
 in the right leg was found to be swollen, and it subsequently broke 
 down and suppurated. On December i the rash had cleared up, 
 and the patient was peeling freely all over the trunk and right leg. 
 This child was in a ward with twelve other children, none of whom 
 developed scarlet fever, so that there could be no doubt as to the 
 rash being septic. 
 
 A boy of sixteen had the tendons at the back of the ankle divided 
 for talipes. Two hours after the operation he had a shivering fit. 
 The next morning he was hot and flushed, and had a temperature 
 of 101° F. The chest and limbs were covered with a mottled, rose- 
 coloured rash, which disappeared on pressure. Forty-eight hours 
 after the operation the rash had commenced to fade away. The 
 temperature was 101° F. and the pulse 126. On the follov/ing day, 
 three days after the operation, the rash had disappeared. The 
 temperature was 100° F. On examining the wound, it was found that 
 the skin round it was red, swollen, and very tender, and the foot 
 and ankle were oedematous. On the seventh day after the opera- 
 tion all the symptoms had cleared up, and the patient made a good 
 recovery. 
 
 The following is a good example of a doubtful case, in 
 which the diagnosis was difficult : 
 
 A boy, aged six, had an exostosis removed from the lower end of 
 the femur. Thirty-six hours after the operation his temperature 
 went up to ioi"2° F, Forty-eight hours after the operation the tem- 
 perature had risen to 104° F. , and he was in a state of high fever, with 
 a flushed face, rapid pulse (156), and quick, shallow respiration. 
 The whole of the body and limbs were covered with a bright, 
 scarlet, punctiform rash, fading on pressure, and not elevated or 
 perceptible to the touch. The tongue was furred and the pharynx 
 was congested. The wound at this time was swollen round the 
 edges, but otherwise showed no signs of suppuration. On the 
 fourth day a bright erythematous patch was noticed on the back of 
 the left wrist-joint. On the fifth day the rash was the same as 
 
Post-Operative Rashes 121 
 
 before, but there was in addition extreme hyperaesthesia over the 
 whole body, and the patient complained of pain in the wound. On 
 the sixth day a trace of albumin was found for the first time in the 
 urine. On the eighth day both elbow-joints were painful and 
 swollen, and the patient complained of pain in the knees. At this 
 time the wound was very foul and sloughy, and contained some 
 very foetid pus. On the tenth day the rash had faded slightly, and 
 there was commencing desquamation on the chest and face. The 
 inguinal glands were enlarged, and there were pysemic abscesses in 
 several places. The patient died in the afternoon. 
 
 At the post-mortem the elbow-joints and knees were found to 
 contain pus, and there were other signs of pysemia. 
 
 Scarlet Fever following Operations. — There have 
 been a considerable number of cases reported from time 
 to time of scarlet fever following an operation. Many of 
 these cases are certainly not scarlet fever, but cases of 
 sepsis which have been mistaken for scarlet fever. It is 
 sometimes extremely difficult or even impossible to dis- 
 tinguish between a genuine attack of scarlet fever follow- 
 ing an operation and a septic rash. In some of the 
 cases, however, other persons who have been in attend- 
 ance on, or in contact with, the patient have subse- 
 quently developed scarlet fever, and thus the infective 
 nature of the rash has been conclusively proved. 
 
 Operations upon the nose and throat — such as for the 
 removal of adenoids, tonsils, etc., and operations for cleft 
 palate — seem to be those most commonly followed by an 
 attack of scarlet fever. Quite a large number of cases 
 seem to have followed the operation for adenoids. The 
 source of infection has not always been clear. In some 
 cases it has afterwards been found that the room or house 
 was infected, or that the patient had come into contact 
 with infected persons just prior to the operation, or even 
 that the operator was the source of infection, as in a case 
 quoted by Sir James Paget. 
 
122 The After-Treatment of Operations 
 
 The late Dr. Washbourne, in an article on this subject, 
 in which he quoted several cases, stated that he thought 
 the organism or infective virus of scarlet fever remained 
 dormant in the mouth, and that the traumatism caused 
 by the operation allowed of its entry and development. 
 This is a similar view to that of the late Sir James Paget, 
 who said that the operation, by lowering the patient's 
 resisting power, allowed of the development of an other- 
 wise dormant virus. 
 
 Another view which would seem a very probable one 
 in many cases is that the virus of scarlet fever finds an 
 entrance by the wound at the time of the operation in 
 the same way that septic infection occurs. This view 
 will account for the very short incubation period in these 
 cases of post-operative scarlatina, owing to the more 
 direct method of entry of the virus into the system. 
 That this view is the correct one — in some cases, at any 
 rate — is supported by the fact that occasionally the rash 
 starts in the neighbourhood of the wound, and then 
 spreads over the rest of the body. 
 
 The type of scarlet fever which follows operations seems 
 to vary somewhat from that seen under ordinary circum- 
 stances, the characters of the attack being apparently 
 modified by the conditions under which it occurs. Thus 
 the incubation period is often very short. In a series of 
 sixty-three cases collected by Edward C. StirHng the 
 commonest time for the appearance of the rash was two 
 days after the operation. The value of this series of 
 cases is, however, very doubtful, as there are a great 
 many cases included in the series, if not the majority, 
 that are really septic cases. An analysis of the un- 
 doubtedly scarlatina cases, however, shows that the time 
 at which the rash appears is often very short — two or 
 three days in many cases, and as short as twenty-four 
 
Post-Operative Rashes 123 
 
 hours in a few. Most of the other variations that have 
 been described seem to be the result of the inclusion of 
 septic cases among those of genuine scarlet fever, and 
 therefore but little value can be attached to them. 
 
 Rashes due to Enemata. — These are not at all un- 
 common, and it is most important that they should be 
 recognised, as otherwise they may be confused with septic 
 or scarlatinal rashes, and cause considerable confusion. 
 The practice of giving an enema just before an opera- 
 tion is now so usual that it is not uncommon to see a 
 rash follow an operation, and be mistaken for the onset 
 of septicaemia or scarlet fever, when it is really due to the 
 enema that was given before the operation. The rash 
 generally makes its appearance very shortly after the 
 injection, usually in from three to twenty-four hours. 
 The most common time seems to be about twelve hours. 
 The rash lasts from two to four days, and then gradually 
 fades away. 
 
 The distribution of the rash is very variable ; it may 
 be evenly distributed over almost the whole body, or it 
 may be confined to certain parts. The buttocks and 
 thighs — especially about the inner aspects — and over the 
 sacrum are perhaps the most common places for the 
 rash to appear, and it is here that it is usually best 
 marked and thickest. The rash often appears on the face, 
 and sometimes on the arms and upper part of the chest. 
 
 The type of the eruption also varies a good deal. 
 Dr. Monro describes three types of rash from enemata : 
 (i) The scarlatiniform ; (2) the measly ; and (3) the urti- 
 carious. More than one of these types may, however, be 
 present at once, or the rash may start as one type and 
 subsequently change to another. 
 
 There is usually no itching in the first two types, but 
 the urticarious form is, as a rule, accompanied by very 
 
124 The After-Treatment of Operations 
 
 severe itching. Very rarely desquamation follows the 
 rash. The rash most commonly seen is a bright 
 erythema, which fades on pressure. It is usually patchy, 
 and often much more distinct in some places than others. 
 The spots are sometimes raised, and the similarity to 
 measles may be close. As a rule, the rash is not accom- 
 panied by any pyrexia, but occasionally the temperature 
 is raised for a time. In some of the recorded cases the 
 onset of the rash has been accompanied by sickness and 
 vomiting. The diagnosis is often very difficult when the 
 rash first makes its appearance. The cause may, how- 
 ever, be suspected when a rash appears within twenty- 
 four hours of the administration of an enema, and is 
 not accompanied by pyrexia and other constitutional 
 symptoms. 
 
 The cause of enema rashes is somewhat doubtful. It 
 appears to occur only after large injections, and is not 
 seen after the use of suppositories or small enemata. 
 Soap enemata, and especially enemata made from hard 
 soap, seem to be the most common cause of the rash. 
 Soft soap, when used to make enemata, seems to be much 
 less liable to give rise to a rash. Turpentine enemata 
 also occasionally cause a rash. It has been supposed 
 that the cause of the rash is the absorption of faecal 
 matter by the intestinal wall as the result of solution by 
 the enema. It appears more probable, however, that the 
 material composing the enema is the responsible agent. 
 No treatment is, as a rule, called for. Subsequent 
 enemata may cause a reappearance of the rash, or they 
 may be quite unaccompanied by any further trouble. 
 When there is severe itching, as is often the case in the 
 ■articarious form of the rash, a weak lotion of carbolic 
 acid should be used to bathe the skin. This will generally 
 relieve the itching. 
 
Post-Operative Rashes 125 
 
 Illustrative Cases. — E. G., a woman, aged thirty, was operated on 
 for the removal of a lipoma on January 15. She had been given 
 an enema of hard soap and water (16 ounces) five hours before the 
 operation. Three hours after the operation she was seen to be very 
 flushed, and on examination it was found that she had a bright ery- 
 thematous rash on the face and limbs and a large part of the trunk. 
 There was no itching, and there were no symptoms except the rash. 
 The temperature was normal. The rash lasted for two days and 
 then faded away, having entirely disappeared by the 19th. 
 
 Miss M. was given an enema consisting of 2 pints of soap 
 and water at g a.m. on November 23. At 12.30 chloroform was 
 administered, but no operation was performed. At 7 p.m. the 
 same evening she complained of headache, and had a shivering fit. 
 The temperature was normal. During the evening she developed 
 a red rash on the neck and greater part of the trunk, which was 
 accompanied by itching. During the night the patient vomited. 
 On the following day there was a profuse red eruption all over the 
 body. The temperature in the morning was 99*4° F., and in the even- 
 ing it rose to 99 "8° F. The pulse was also rapid (102). On the 25th 
 the temperature was normal, and did not again rise, and the patient 
 felt quite well. The rash was still present, though fading. On the 
 26th the patient was quite well, and the rash had almost gone. 
 
 Salicylic Rash. — There is a peculiar rash sometimes 
 seen when saHcylic wool has been used as a dressing. 
 This rash only occurs on those parts of the skin with 
 which the wool has come into direct contact, and its 
 distribution, therefore, corresponds to the area of the 
 dressing, and thus renders its nature immediately 
 apparent. The rash usually consists of numbers of 
 small clear vesicles, which may have an inflamed base. 
 The rash is not accompanied by itching. It soon dis- 
 appears if the salicylic wool is changed for sal alembroth 
 or plain wool. 
 
 Herpes following Operations. — Several cases have 
 been recorded where an attack of herpes, accompanied 
 by a high temperature, has followed an operation or even 
 the passage of instruments into the bladder. In most of 
 
126 The After-Treatment of Operations 
 
 the cases the herpes made its appearance in crops of 
 vesicles on the neck and face, and around the mouth. 
 In many of the cases there appears to have been some 
 septic infection. 
 
 Ether Rash. — This rash often makes its appearance 
 during the administration of ether. It is a bright roseolous 
 rash, and best seen on the face and chest, though often 
 also present on the limbs. It usually disappears very 
 quickly. 
 
 Erysipelas. — This is now a very rare sequel to opera- 
 tions, but is still sometimes seen. 
 
 Drug"-Poisonmg". 
 
 Cases of poisoning from the excessive use of antiseptics 
 have been recorded from time to time, and the possibility 
 of such an occurrence should be borne in mind. These 
 cases often give rise to a great deal of difficulty in 
 diagnosis, as the symptoms are often put down at first to 
 some complication of the operation, and poisoning is not 
 suspected. Many of the cases follow the use of dressings 
 saturated with strong antiseptics and kept damp by 
 placing oil-silk or jaconet over them, such, for instance, 
 as may be used for preparing the skin previous to opera- 
 tion. Of course, the larger the area of skin so covered, 
 and the longer the time that the skin is subjected to the 
 action of the antiseptic, the more pronounced will be the 
 result. 
 
 Poisonous symptoms may follow the packing of large 
 cavities with antiseptic gauze or washing out large 
 cavities with strong antiseptic solutions, especially if 
 care is not taken to remove the antiseptic afterwards. 
 Poisonous symptoms are much more liable to follow the 
 use of antiseptics in children than in adults, and patients 
 whose kidneys are not working properly are more prone 
 
Drug-Poisoning 127 
 
 to develop symptoms from comparatively small quantities 
 of antiseptics than those whose renal organs are sound. 
 Again, some individuals seem much more susceptible to 
 certain drugs than others. 
 
 Iodine Solution.— This also causes blistering of the 
 skin, resulting in the epidermis peeling off over most of 
 the area to which the iodine has been applied. Iodine 
 should not be applied to the scrotum or to areas, such as 
 the axillae, where the skin is very loose. Where blistering 
 has occurred, the best dressing is sterilized stearate of 
 zinc powder or sterilized vaseline. 
 
 Iodoform Poisoning. — This may follow the packing of 
 a large cavity with iodoform gauze or the use of iodoform 
 emulsion in the treatment of tubercular joint affections. 
 The chief symptoms in the acute cases are a very high 
 temperature (104° to 107° F.), accompanied by cerebral 
 disturbance, either in the form of delirium, mania, or 
 coma. The pulse is rapid, and in the fatal cases the 
 patient soon passes into a condition of collapse, followed 
 by coma and death. In addition, the pupils are generally 
 contracted, and there may be haemorrhage from the 
 rectum. The symptoms usually come on within twenty- 
 four hours. In the chronic cases there is disturbance 
 of digestion, loss of appetite, insomnia, vertigo, with a 
 rapid pulse and a raised temperature. 
 
 As soon as the symptoms show themselves, any iodo- 
 form-gauze packing, if present, should be removed and 
 the cavity washed out with a solution of bkarbonate of 
 potash, which is said to act as an antidote. The same 
 drug may also be given by the mouth. 
 
 Illustrative Case. — F. W., aged fifty-two, was operated upon for a 
 large hydronephrosis of the right kidney. The kidney, or what was 
 left of it, was shelled out of its capsule as the intestines and other 
 viscera were firmly adherent to the latter. The walls of the cavity 
 
128 The After-Treatment of Operations 
 
 were stitched to the edges of the abdominal wound, and the cavity 
 itself was packed with iodoform gauze. A very large quantity of 
 the gauze had to be used. The operation was a very severe one, 
 but the patient rallied as well as could be expected, after being 
 transfused with normal saline and having an injection of strychnine. 
 Next day she was comfortable, and her condition was good. Her 
 urine was normal, containing no albumin, and being normal in 
 quantity as far as could be estimated. 
 
 At 11.30 p.m. her pupils were noticed to be contracted. Up to 
 this time she had had no morphia. Later in the evening an 
 injection of ^ grain of morphia was given to secure sleep and 
 allay the restlessness which was present. She slept all night, but 
 at 5 a.m. her temperature was found to be 105° F., and she was 
 drowsy and could not be aroused. The pulse was very rapid, and 
 there was some twitching of the muscles of the face. The pupils 
 were still more contracted than on the previous evening. At 7 a.m. 
 the temperature was 107° F. This was reduced by sponging to 
 102° F. She was very hot and perspiring freely. The pulse was 
 almost imperceptible, and very fast. There was marked twitching 
 of the fingers and facial muscles. She had some haemorrhage from 
 the rectum. The case was thought to be one of iodoform poisoning, 
 and the gauze was all removed from the wound, and the cavity 
 washed out with a solution of potassium bicarbonate (20 grains 
 to the ounce). She also had 20 grains by the mouth. The 
 temperature again went up to 104° F. , and remained up till death, 
 which took place a few hours later from heart failure. 
 
 Carbolic Acid Poisoning. — The symptoms usually 
 come on within a few hours of the application of the 
 dressing or compress ; the initial symptoms are commonly 
 drowsiness and pallor. The respirations are markedly 
 affected as a rule, there may be dyspnoea, or the breath- 
 ing may be laboured or stertorous — the chief symptoms 
 seem to be due to the action of the drug on the central 
 nervous system — sooner or later there is complete coma 
 with muscular relaxation : the pupils may be contracted 
 or normal. The urine is turned a dark olive-green colour, 
 and its specific gravity is increased. It is said that a 
 premonitory sign of poisoning is the disappearance of 
 
Drug-Poisoning 129 
 
 sulphates from the urine, the absence of all sulphates 
 being a sign of danger. The prognosis is favourable, the 
 symptoms usually passing off, after the cause has been 
 removed, in the course of a day or two. 
 
 Lysol, if used too strong, may also cause symptoms of 
 carbolic acid poisoning, and I have known it produce 
 these symptoms when used as an enema. 
 
 Illustrative Case. — The pa: lent was a child, aged Tour years. An 
 operation was going to be performed to get rid of the deformity 
 of genu valgum, and to prepare for this the skin of both legs was 
 thoroughly cleaned up and a compress of i in 40 carbolic acid 
 applied to most of the skin of the lower extremities. Six hours 
 later it was noticed that the child was rather sleepy, but nothing 
 was thought of it. Soon after this it was found that the child 
 was in a comatose condition. She could not be aroused, and the 
 muscles were relaxed. There was, however, slight response to 
 stimulation. The skin was cold and very pale. Respiration was 
 rather rapid — about 36. The pulse was iSo. The knee-jerks 
 were absent. The pupils were normal in size, and reacted to light. 
 Some urine which was drawn off was found to be of a greenish 
 colour and of a specific gravity of 1,022. 
 
 Carbolic acid poisoning was diagnosed, and the compresses 
 removed. Saline purgatives were administered and stimulants 
 given. Recovery took place slowly in the course of about two 
 days, but the urine remained green and the pulse rapid for a 
 day or so. 
 
 Perchloride and Biniodide of Mercury Poisoning. 
 — The symptoms are the ordinary ones of ptyalism. 
 There is generally marked gastro-intestinal disturbance, 
 especially diarrhoea ; vomiting may also be present. 
 Salivation is often a marked symptom. Suppression of 
 urine sometimes occurs, and is a very dangerous com- 
 plication. The pulse is feeble and quick. The symptoms 
 often vary very considerably in different cases, but if the 
 condition is thought of, there is seldom any great difficulty 
 in arriving at a correct diagnosis. The treatment should 
 
 9 
 
130 The After-Treatment of Operations 
 
 be directed to washing ihe drug out of the system by the 
 use of sahne purgatives and large draughts of fluids.' 
 
 Poisoning from Strychnine or Nux Vomica. — 
 This may occur if large repeated doses of strychnine 
 have been used to treat shock. As the patient recovers 
 from the shock the drug begins to act, and, having a 
 cumulative action, produces poisoning symptoms. 
 Apart from overdosage, hovs^ever, there are certain 
 individuals who are peculiarly susceptible to even small 
 doses of nux vomica. Such individuals get violent 
 purging and other alarming symptoms if this drug is 
 administered. I remember the case of a man who had 
 been operated upon for piles, in whom a single dose of a 
 tonic containing 5 minims of tincture of nux vomica 
 produced violent purging and severe constitutional 
 symptoms. A minute dose of strychnine given to this 
 patient on another occasion caused the same result. I 
 have also seen other similar cases. 
 
 It is, of course, not possible to prevent this, but when 
 a patient after an operation develops inexplicable 
 symptoms, one of which is purging, it is advisable to 
 inquire if strychnine in any form is being given. 
 
 The remedy is, of course, to stop the drug and give 
 morphia. 
 
 REFERENCES. 
 
 ' Observations on Certain Eruptions of the Skin which occur after 
 
 recent Operations or Injuries ' : Edward C. Stirling, St. George's 
 
 Hospital Reports, 1879. 
 ' Six Cases of Rash after Enemata ' : T. R. Monro, Glasgow Medical 
 
 Journal, 1899. 
 ' Scarlet Fever following Operations ' : Dr. Washbourne, Clinical 
 
 Journal, October 15, 1902. 
 'Sir James Paget's Lectures and Essays,' p. 349. 
 
CHAPTER IX 
 
 OPERATIONS ON THE MOUTH, NOSE, AND 
 PHARYNX 
 
 Removal of Adenoids. 
 
 Complications. — (i) Severe sepsis, followed occasionally 
 by septic pneumonia ; (2) severe septic throat due to 
 diphtheria or scarlet fever ; (3) septic rash ; (4) acute 
 otitis media. 
 
 Complications after an operation for the removal of 
 adenoids are but rarely seen, but when they occur they 
 are often grave ; this is all the more unfortunate, as the 
 operation is usually considered to be a very simple one. 
 In order to avoid these complications as far as possible, 
 it is particularly desirable that the patient should not be 
 operated upon unless the throat is in good condition at 
 the time, and the patient has not recently been exposed 
 to the bad effects of unhealthy surroundings, or is likely 
 to be exposed to them afterwards. With this object 
 in view it is an excellent plan to have any bad and 
 especially septic teeth removed before the operation, and 
 to let the patient have the throat sprayed with some 
 suitable antiseptic for a day or two previous to the 
 operation. The greatest care should always be taken to 
 see that the patient has not recently been subjected to 
 any risk of catching scarlet fever, diphtheria, or any 
 
 I3i 
 
132 The After-Treatment of Operations 
 
 other fever. After the operation is over the patient 
 should be kept in bed for twenty-four hours, and provided 
 with plenty of clean pocket-handkerchiefs on which to 
 blow his nose. It is advisable in private cases to warn 
 the parents that the child may vomit some blood occa- 
 sionally for the first twenty-four hours, as otherwise this 
 may give rise to the idea that the child is bleeding, and 
 cause considerable alarm. Care must be taken to see 
 that the patient is not put in a draught ; a stuffy room is, 
 however, to be particularly avoided. Some light food 
 may be given in about two hours after the operation. 
 No particular diet is necessary, but, as a rule, semi- 
 solids, such as custard, bread-and-milk (boiled), thick 
 soups, etc., are more easily swallowed than fluids. On 
 the day following the operation the throat should be 
 sprayed with some suitable antiseptic, such as one of the 
 following : ' 
 
 9 
 
 9 
 
 or, if the patient is old enough, he should be made to use 
 the same solution as a gargle; this helps to get rid of any 
 accumulated blood or mucus at the back of the throat, 
 and at the same time tends to keep the latter free from 
 infective material. The throat should be sprayed or 
 gargled before and after each meal for the first week after 
 the operation. Anything in the way of syringing or 
 spraying the naso-pharynx is generally better avoided, as 
 it increases the danger of middle-ear trouble. 
 
 Sodse sulph. - 
 
 Si.ss. 
 
 ^ 
 
 Sodae sulph. 
 
 3ii. 
 
 Hydr. iodidi rubri - 
 
 grs. ii. 
 
 
 Sodae bicarb. 
 
 grs. X. 
 
 Sodae iodidi - 
 
 grs. ii. 
 
 
 Glycerine of car- 
 
 
 Aquam destill. 
 
 ad Oi. 
 
 
 bolic acid 
 Aquam destill. - 
 
 111X1. 
 
 ad Oi. 
 
 Sodae sulph. - 
 
 3i- 
 
 
 
 
 Sanitas - 
 
 5iii. 
 
 ^ 
 
 Listerine 
 
 5iii. 
 
 Aquam destill. 
 
 ad Oi. 
 
 
 Aquam destill. 
 
 ad Oss, 
 
Mouth, Nose, and Pharynx 13J 
 
 If it is thought advisable to syringe the naso-pharynx, 
 care must be taken that the fluid is not injected 
 forcibly, and that a free exit is allowed for its escape. 
 Mr. Sheild advises that a syringe of about 5-ounce 
 capacity should be used, with a piece of rubber tubing of 
 small diameter attached to its end. The tubing should 
 be passed along the floor of the nose, and should fit the 
 nares quite loosely. He also recommends allowing the 
 patient to inhale the vapour of creosote, iodine, or carbolic 
 acid from one of the usual forms of apparatus, two or 
 three times a day, after an operation on the nose or 
 throat. 
 
 A saline purge should be administered on the day 
 following the operation, and repeated, if necessary. The 
 patient may be allowed to get up on the day after the 
 operation in uncomplicated cases, but should be confined 
 to one room, if possible, for two or three days. For the 
 first day or so, and sometimes for a week after the opera- 
 tion, the symptoms of nasal obstruction often persist, 
 owing to the swelling of the mucous membrane which 
 takes place. At the end of this time, however, it is of 
 great importance to make the child do regular respiratory 
 exercises, so that he may get accustomed to breathing 
 properly through the nose. The child should be made 
 to close the mouth and breathe entirely through the nose 
 for five or ten minutes at a time ; this should be done 
 two or three times a day, and the child encouraged to 
 breathe as much as possible through the nose at all 
 times. 
 
 In cases where it is difficult to get the patient to do 
 this properly, owing to lack of intelligence, etc., a good 
 plan is to fix a piece of oil-silk over the mouth by tapes 
 round the head, for an hour or so daily, so as to oblige 
 the child to breathe through the nose. These exercises 
 
134 The After-Treatment of Operations 
 
 must be continued until the child has got into the way of 
 carrying out normal respiration with the mouth shut. If 
 previous to the operation the child has got into the habit 
 of pronouncing words in a nasal manner, as is almost 
 always the case when there is pronounced obstruction, 
 he must be carefully taught to pronounce these words 
 properly, repeating them over and over again until the 
 proper sound is obtained. The importance of these 
 exercises of breathing and speaking must not be under- 
 estimated ; children who have suffered from adenoids for 
 any length of time have contracted the habit of breathing 
 through the mouth and speaking in an incorrect manner, 
 and it is not to be expected that the mere removal of the 
 growths will remedy all this unless care and patience are 
 exercised in breaking the child of the habit. And, more- 
 over, it is only by carefully teaching the child nasal 
 breathing and stopping habitual mouth breathing that 
 any guarantee against a recurrence of the adenoids can 
 be secured. 
 
 If the naso-pharynx becomes septic, accompanied by 
 foul-smelling breath, and perhaps a high temperature, 
 the naso-pharynx should be irrigated with a nasal douche 
 two or three times a day, warm water, or water to 
 which a little bicarbonate of soda has been added, being 
 used for the purpose ; the fluid must not be allowed to 
 flow in under pressure, but should flow gently in at 
 one nostril and out at the other, the patient being in- 
 structed to breathe through the mouth meanwhile. A 
 purge should, of course, be administered at once, and 
 small doses of quinine and iron are sometimes useful. 
 
 If symptoms of otitis media develop after the operation, 
 a blister or leeches should be at once applied behind the 
 affected ear, or hot fomentations repeatedly applied to 
 that side of the head. The naso-pharynx must also be 
 
Mouth, Nose, and Pharynx 135 
 
 irrigated. If suppuration occurs in the ear, the case 
 must be treated as an ordinary case of otitis media. 
 
 Children who have just undergone the operation for 
 adenoids seem especially liable to catch diphtheria or 
 scarlet fever if they are subjected to any infection, and 
 when they contract one of these diseases under such 
 circumstances it is a very serious matter. Care must, 
 therefore, be exercised to prevent as far as possible any 
 chance of the child contracting them. An attack of 
 influenza may supervene upon an operation for adenoids, 
 and when this occurs there may be considerable difficulty 
 in correctly diagnosing the symptoms, which may be very 
 alarming at first. 
 
 The appearance of a rash after an operation for the 
 removal of adenoids or tonsils seems to be commoner than 
 is generally supposed. In an analysis of sixty such cases 
 made by Dr. Wyatt Wingrave,* he found that a rash 
 appeared in about 2 per cent, of all cases of operation for 
 tonsils or adenoids. In only four out of the sixty cases 
 was the rash proved to be scarlet fever, in one case it 
 was diphtheritic, and in the remainder it appears to have 
 been septic in origin. In a large number of the cases 
 the rash was not accompanied by any other constitutional 
 symptoms of sepsis. The rash generally appears on the 
 second or third day, and lasts about four days. In four 
 out of the sixty cases the rash was followed by acute 
 inflammation of the cervical glands. 
 
 On the fourth or fifth day after the operation the 
 Eustachian tube should be irflated by means of Polit- 
 zer's bag, and this should be repeated daily for three or 
 four days, and for longer in cases where there is any 
 marked deafness associated with the adenoids. Or, if 
 the child is old and intelligent enough to understand, he 
 * Medical Press and Circular, January 27, 1904. 
 
136 The After-Treatment of Operations 
 
 may be shown how to inflate the Eustachian tubes for 
 himself by holding his nose and forcing the air into his 
 pharynx. Of course, if there is any sepsis after the 
 operation, the use of the Politzer's bag must be deferred. 
 In all bad cases of adenoids it is a good thing to insist on 
 the child doing daily respiratory exercises, with deep 
 breathing, for some months after the operation. 
 
 Removal of Tonsils. 
 
 The complications are practically the same as in the 
 case of adenoids, except that otitis media does not occur. 
 The after-treatment is also the same. As in the case of 
 adenoids, the throat should be sprayed for the first few 
 days after the operation at frequent intervals. Gargling 
 is usually impossible, as the throat is too sore. On this 
 account also swallowing is more painful, and while this 
 is the case the patient should be given such things as 
 jellies, custard, bread-and-milk, etc., as these are often 
 swallowed more easily' than fluids. A condition very 
 closely resembling ordinary follicular tonsillitis sometimes 
 occurs on the raw surface after the removal of the tonsils. 
 It should be treated as for that afl"ection by chlorate of 
 potash, gargles, etc. Chlorate of potash internally is 
 often very useful in these cases : 
 
 ^ Pot. chlor. - - - - - gr. V. 
 
 Aquam menth. pip. - - - - ad gi. 
 
 Sig. ; Three times a day. 
 
 or the following mouth-wash may be used, and some of 
 it swallowed : 
 
 1^ Pot. chlor. - - - - - gr. vii. 
 
 Tinct. ferri perchlor. ... - mx. 
 
 Glycerini - - - •. - 5i- 
 
 Aquam luenth. pip. - - . - - ad gi. 
 
Mouth, Nose, and Pharynx 137 
 
 There is one point of considerable importance in the 
 after-treatment of both adenoids and tonsils which must 
 be kept in mind : the patients are often in weak health, 
 and the enlargement of their tonsils, etc., is largely the 
 result of their constitutional condition, and therefore care 
 must be taken after the operation to improve their general 
 health. If possible, they should be sent away for a 
 change of air, preferably to the seaside, as soon as they 
 have recovered from the operation — i.e., in about a week 
 or ten days' time. 
 
 Tooth Extraction, etc. 
 
 It is not usually considered necessary to pay any atten- 
 tion to the wound after the extraction of teeth, except in 
 the event of haemorrhage proving troublesome. This 
 carelessness is not, however, justified ; sepsis not infre- 
 quently occurs, and there are many recorded cases where 
 the most serious results have followed from this cause. 
 Lately, considerable attention has been paid to oral sepsis 
 and its results, and it seems probable that it is answer- 
 able for many more diseases than had previously been 
 supposed. Some attempt, therefore, should be made, by 
 the constant use of mouth-washes, etc., to keep the mouth 
 clean for the first two or three days after teeth have 
 been extracted. One of the best preparations for this 
 purpose is phenate of soda (about i drachm to the pint). 
 This has the double advantage of keeping the mouth 
 clean and relieving the pain after extraction. A solution 
 of tincture of arnica, which is very popular, can also be 
 used, but is not so efficacious as phenate of soda. A 
 very excellent mouth-wash in all septic conditions of the 
 mouth, and one which can be used after extraction, is the 
 following : 
 
38 The After-Treatment of Operations 
 
 Alcohol 
 
 . 
 
 - 
 
 - 100 parts 
 
 Tinct. rhatany 
 
 - 
 
 . 
 
 - 40 ., 
 
 Acid, benzoic. 
 
 . 
 
 . 
 
 8 ,, 
 
 Saccharine - 
 
 . 
 
 . 
 
 4 .. 
 
 Olei menth. pip. 
 
 
 - 
 
 h part 
 
 Olei cinammomi 
 
 - 
 
 - 
 
 - h .. 
 
 Sig. : Fifty drops 
 
 to half a pint 
 
 of water. 
 
 Operations on the Tongue, etc. 
 
 Complications. — (i) Sloughing and haemorrhage ; 
 (2) septic pneumonia ; (3) oedema of the glottis ; (4) 
 cellulitis, etc. 
 
 A certain amount of sepsis often accompanies these 
 operations, and is quite unavoidable ; but much may be 
 done to reduce it. It is very important that before the 
 operation any decayed or septic teeth should be removed, 
 and the mouth and throat well washed out with some 
 suitable mouth-wash for several days prior to the 
 operation. The most effectual way of keeping the 
 mouth clean after operations upon the tongue is to make 
 the patient lie right over on his side, so that the fluid 
 cannot get into his throat, and then to gently irrigate the 
 oral cavity with warm boracic, or other suitable solution. 
 (Mr. Jacobson advises i in 60 or 80 carbolic to be used.) 
 If this is done with care, the mouth and stump of the 
 tongue can be very effectually cleansed without any 
 discomfort to the patient, and without causing coughing. 
 The irrigator should be provided with a glass nozzle, and 
 very little pressure should be used. A syringe may be 
 used instead, if desired. The mouth should be frequently 
 irrigated out in this way during the first few days after 
 the operation. After this the patient may rinse the 
 mouth out for himself in the ordinary way. The 
 alcoholic mouth-wash already mentioned (under ' Extrac- 
 tion ') is a very good one in these cases. Mr. Jacobson 
 
Mouth, Nose, and Pharynx 139 
 
 advises painting the stump over every two or three hours 
 with a solution of formalin. The patient should be nursed 
 in a sitting position, well propped up with pillows. 
 This position tends to prevent congestion of the lungs, 
 and also prevents the stump of the tongue falling back 
 and obstructing the air-passage, which, if it has been 
 freely cut away from the floor of the mouth, it is apt to 
 do in the prone position. 
 
 The patient should be fed after the operation by 
 means of a feeder with about 3 or 4 inches of india- 
 rubber tube attached to the nozzle. The end of the 
 tube is passed to the back of the throat, and the feeder 
 gently tilted up. For the first day or so the diet has to 
 be fluid only, but after that semi-solids can usually be 
 taken. A calomel or saline purge should usually be 
 given on the day following the operation. For haemor- 
 rhage after operations on the tongue, see p. 66. 
 
 Operations on the Nose. 
 
 All that has been said in connection with adenoids 
 also applies here. The treatment of haemorrhage after 
 operations on the nose has already been described in the 
 chapter on haemorrhage. A piece of gauze kept over 
 the nose, and damped occasionally with some volatile 
 antiseptic, is of assistance in preventing sepsis in some 
 cases, especially after removal of the turbinates. Per- 
 sistent sneezing is a curious complication that some- 
 times occurs after operations on the nose. This may 
 prove extremely troublesome. If it continues for any 
 length of time, the best way of treating it is to 
 paint the nasal cavity with a solution of cocaine, or 
 cocaine and suprarenal extract. It may also often be 
 stopped by simply syringing out the nose with warm 
 
140 The After-Treatment of Operations 
 
 water. As a rule, after operations on the nose, one or 
 both nostrils are left plugged. The plugs will either 
 consist of gauze or pieces of rubber sponge. The plugs 
 are generally removed in forty-eight hours, and after this 
 the patient is allowed to breathe through the nose. The 
 patient should be told on no account to attempt to blow 
 his nose during the first day or two. If crusts form in 
 the nostrils and obstruct the passage, they should be 
 carefully removed by soaking them till they are soft, and 
 then sponged away. 
 
CHAPTER X 
 OPERATIONS ON THE HEAD 
 
 Operations on the Brain : Trephining-, etc. 
 
 Complications, — (i) Hernia cerebri ; (2) oedema of the 
 brain. 
 
 After any operation on the brain, the patient must be 
 kept as quiet as possible, preferably in a darkened room, 
 and anything that may tend to excite the patient, such 
 as visits from friends, etc., prevented. The bowels should 
 be kept acting freely by the administration of calomel. 
 The use of alcohol in any form must be avoided. In 
 cases of trephining for haemorrhage on to the dura mater, 
 the patient need not be subjected to so much restraint, 
 and, as a rule, he may be allowed to sit up soon after the 
 operation ; in these cases it may be assumed that the 
 patient is well as soon as the wound has healed. In- 
 flammation, if it occurs after these operations, will 
 usually show itself by a high temperature and symptoms 
 of increased intercranial tension on or about the third day 
 after the operation. 
 
 After operations in which the dura has been opened, 
 drainage is generally provided for by means of flat pieces 
 of thin 'rubber. These drains can usually be removed 
 in twenty-four hours after operation, unless sepsis was 
 present in the first instance. 
 
 141 
 
142 The After-Treatment of Operations 
 
 If shock occurs after an operation on the brain, it is 
 best treated by small repeated doses of morphia rather 
 than by stimulants. 
 
 After any operation on the brain-tissue, it is most 
 important to insist on the patient abstaining from any 
 form of mental strain for some months after the operation. 
 At first reading should be forbidden, and later only 
 allowed in moderation. A complete change and rest for 
 some months is very important in most of these cases. 
 
 Hernia cerebri is caused by unrelieved tension in the 
 brain, and is generally the result of sepsis ; the cause of 
 the tension should therefore be investigated, and, if 
 possible, removed, when the hernia will probably dis- 
 appear. Not infrequently pus will be found in the 
 interior of the hernia, or a superficial abscess will be 
 found beneath it. The hernia itself consists mainly of 
 granulation tissue, and contains very little brain sub- 
 stance, so that there need be no hesitation in scraping it 
 away and applying pure carbolic acid to the stump. This 
 requires no anaesthetic, as the protrusion is insensitive. 
 The hernia may be treated by applying pressure over 
 a piece of sterilized tin-foil. 
 
 Hare-lip Operations. 
 
 Complications. — (i) Bronchitis and pneumonia ; 
 (2) diarrhoea ; (3) sepsis ; (4) dyspnoea and asphyxia. 
 
 A low form of sepsis sometimes occurs after these 
 operations, especially when it has been necessary to 
 interfere with the bone in any way. Care must be taken 
 to keep up the strength of the patient under these circum- 
 stances, and to keep the mouth as clean as possible. In 
 very young infants who have had a large cleft closed by 
 operation there is danger of sudden death from asphyxia 
 
operations on the Head 143 
 
 soon after the operation, and this should be borne in mind. 
 The nasal passage in young infants is often too small to 
 be used efficiently for respiration, and it easily becomes 
 blocked up with secretion ; the sudden great diminution 
 in the size of the oral cavity may result in sudden 
 dyspnoea some hours after the operation. Mr. Jacobson 
 cites three cases in which fatal dyspnoea occurred from 
 this cause. The nurse should be instructed to watch for 
 any difficulty in the breathing, and to depress the lower 
 lip of the infant from time to time so as to allow of a free 
 entry of air, or the lower lip may be held down by apply- 
 ing a piece of plaster unAil the child has had time to 
 become accustomed to the new conditions. 
 
 If hare-lip pins have been made use of, they should be 
 removed on the second day after the operation ; if fish-gut 
 or silver wire has been used for the supporting sutures, 
 one of them should be re- 
 moved on the third day and 
 the other left for a day or 
 so longer. The fine sutures 
 used for approximating the 
 edges of the wound should 
 not be removed for a week, 
 unless they are causing 
 stitch abscess, when they 
 must be removed at once. 
 While examining or re- 
 moving stitches, the cheeks 
 must be held together so as to prevent the wound being 
 subjected to any tension. After the stitches or pins are 
 removed, a piece of adhesive plaster, cut with a narrow 
 bridge to go over the upper lip, and expanded ends to 
 fit on to the cheeks, must be put on firmly so as to 
 bring the cheeks together and prevent any tension coming 
 on the wound (Fig. 20). 
 
 Fig. 20. 
 
144 The After-Treatment of Operations 
 
 Cleft Palate. 
 
 Complications. — (i) \^'hooping-cough ; (2) exanthe- 
 matous fevers ; (3) diarrhoea. 
 
 After the operation the child's hands should be secured 
 either by applying splints or by wristlets attached to 
 a broad piece of webbing fixed across the bed ; if the 
 child can be constantly watched by a competent at- 
 tendant, it is better to dispense with this restraint, 
 as it tends to make the child restless, and may lead to 
 crying. Nothing should be given by the mouth for three 
 or four hours after the operation, and for the first forty- 
 eight hours only barley-water and albumin-water or milk 
 allowed ; rectal feeding may be added if necessary after 
 this, and for the first week the diet should be confined to 
 soups, broth, egg and milk, etc., and then jellies, light 
 puddings, and food which does not need mastication for 
 a week more. If the child is old enough to understand 
 and do what it is told, the mouth should be syringed out 
 or sprayed with some mild antiseptic lotion several times 
 a day. If this procedure leads to any struggling, or the 
 child is too young to keep quiet during the process, it 
 must be discontinued. Everything possible in the way 
 of careful nursing must be done to prevent the child 
 from crying or being sick. If old enough to talk, the 
 child must be prevented from doing so. In three or 
 four days after the operation, if the weather is fine, the 
 patient should be got out into the open air for an hour 
 or two every day. It is best not to inspect the stitches 
 at all till the time arrives for their removal. As a rule, 
 some of the stitches may be removed at the end of a 
 week or ten days, and the remainder at the end of a 
 fortnight ; but unless the stitches are causing sloughing 
 or ulceration, it is well to leave them as long as possible. 
 It is usually about three weeks after the operation before 
 the wound is firmly united. 
 
Operations on the Head 145 
 
 If the operation has been successful and the gap in the 
 palate has been closed, the next thing that calls for 
 attention, and which is of the greatest importance, is to 
 teach the child to pronounce its words properly, and this 
 is of still greater importance if the child has already 
 learnt to talk and has got into the habit of pronouncing 
 words wrongly. A great deal of care and patience is 
 often necessary ; the patient should be made to sit on 
 a chair facing the teacher and pronounce words, and 
 especially those words which he has got into the habit 
 of pronouncing badly, after him, and at the same time 
 watch the way in which the teacher moves his lips and 
 tongue. The teacher should exaggerate these move- 
 ments, so as to make them more obvious. Words with 
 sibilants and labials in them should especially be taught 
 with great care, as these words are the ones most likely 
 to be pronounced badly as the result of the cleft-palate. 
 Nasal breathing exercises should also be carried out 
 daily to get the child used to breathing properly through 
 the nose when the mouth is shut (see under Adenoids). 
 After the Davies-Colley operation at least three weeks and 
 often more should be allowed to elapse before the stitches 
 in the mouth are removed ; those in the deep flap must 
 be left to come out in the best way they can. Sloughing 
 of the large flap need not be apprehended in this opera- 
 tion. 
 
 Artificial Appliances. 
 
 For the Relief of Cleft-Palate. — An obturator 
 should only be fitted in those cases where no operation 
 is possible, as, for instance, after repeated operations 
 have failed to close the gap, when there is not enough 
 tissue to close it, or when the hard palate has been suc- 
 cessfully operated upon, but owing to lack of tissue or 
 scar contraction it is not possible to close the gap in the 
 
146 The After-Treatment of Operations 
 
 soft palate. In such cases a properly fitting obturator 
 is necessary. There are two principles of fitting obtu- 
 rators — the Kingsley method, in which an ordinary 
 vulcanite or gold plate is fitted to the hard palate, and 
 to the back of this is attached a soft rubber vellum, 
 which fits into the gap in the soft palate and moves with 
 the palate muscles ; and the Seursen method, in which 
 there is a fixed vulcanite obturator taking the place of 
 the hard palate. In the Seursen method the fixed 
 obturator fits in between the pharyngeal muscles, and 
 passes backwards to within ^ inch of the posterior 
 pharyngeal wall ; when the patient swallows or phonates, 
 the muscles close round it and shut off the naso-pharynx 
 from the buccal cavity. It is fixed in place by a 
 dental plate fastened by bands round some of the upper 
 teeth. The Seursen method is particularly adapted to 
 cases where the gap in the soft palate is very wide. 
 Very good phonation can be obtained by means of 
 these instruments, but to obtain good results it is of 
 the utmost importance that the patient should be care- 
 fully taught to speak after the instrument has been 
 fitted. 
 
 After the Removal of the Upper Jaw. — The 
 instrument usually fitted in these cases consists of a gold 
 or vulcanite plate, to the upper surface of which is 
 attached a hollow obturator, made so as to fit into the 
 gap left by the removal of the jaw ; the plate takes its 
 purchase from the opposite teeth and the remains of the 
 hard palate. Artificial teeth are fixed to the plate, so as 
 to complete the upper set on the side on which the jaw 
 has been removed. These obturators are made of gold 
 or vulcanite, and should be very smooth, so as not to 
 cause any irritation ; the chief value of them is in pre- 
 venting the falling-in of the cheek, which is such a 
 
Artificial Appliances 147 
 
 Fig. 21. — KiNGSLEY Obturator for Cleft Palate ; made 
 OF Soft Rubber. 
 
 Fig. 22. — Seorsen Obturator for Cleft Palate : made 
 OF Vulcanite. 
 
 Fig. 23. — Obturator for Repair of the Hard Palate and 
 Alveolar Arch after Remoyal of the Left Upper Jaw. 
 
148 The After-Treatment of Operations 
 
 distressing after-result in many of these cases. By 
 restoring the roof of the mouth they also help phonation, 
 and prevent food from getting into the nasal cavities. 
 They should be fitted as soon as the wound has healed, 
 and before the parts have had time to contract and cause 
 deformity. 
 
CHAPTER XI 
 OPERATIONS ON THE NECK 
 
 Tracheotomy and Laryngrotomy. 
 
 Complications. — (i) Surgical emphysema ; (2) ulcera- 
 tion of the trachea ; (3) sloughing of the wound. 
 
 Surgical emphysema is either the result of a faulty 
 operation, or is due to the tube not being in the trachea. 
 If the tube is properly in the trachea and the air-way 
 free, emphysema cannot occur. When it occurs, the tube 
 must be removed and carefully reinserted, or a better 
 fitting one substituted. Ulceration of the trachea is due 
 either to the tube not fitting or to its being worn for too 
 long a time. A metal tube should not be left in for more 
 than a week without being changed ; at the end of that 
 time, if the tube cannot be dispensed with, a rubber one, 
 such as Morant Baker's, should be substituted. Many 
 tubes are made with too great a curve on them, and the 
 lower end in consequence presses on the anterior wall 
 of the trachea and causes ulceration. The necks of 
 different individual's differ very considerably, and it may 
 be necessary to try several different tubes before one can 
 be found to fit well. In young children especially it is 
 most necessary to get a properly fitting tube, as their 
 tissues will not stand pressure in the same way as adults, 
 and ulceration is very liable to occur from a badly-fitting 
 
 tube. 
 
 149 
 
150 The After-Treatment of Operations 
 
 Sloughing of the Avound may be diphtheritic or may 
 result from the tube pressing too tightly against the 
 wound. The tapes should be relaxed, and the wound 
 dressed frequently with ointment or gauze, a collar of 
 which should be kept beneath the tube. If the sloughing 
 tends to spread, the wound should be well painted with' 
 carbolic acid or nitrate of silver. 
 
 After the operation the patient must be put back to 
 bed, and made as warm as possible. Most surgeons 
 have a steam-tent put round the bed, so as to keep the 
 atmosphere warm and moist. The value of this is, how- 
 ever, somewhat doubtful, as the steam seldom gets any- 
 where near the tube, and usually expends itself in damp- 
 ing the tent. Fresh air is of the utmost importance, and 
 if the temperature of the air round the cot can be kept 
 up to about 60° F. and the child kept free from draughts 
 without the use of the tent, it is much better not to use 
 one. Whether a steam-tent is used or not, the tempera- 
 ture of the room must be kept up to 60° or 65° F., and 
 all draughts avoided ; a double fold of gauze should be 
 placed over the mouth of the tube, and it is a good plan 
 to drop a few drops of eucalyptus oil on to the gauze 
 from time to time. If, however, this causes coughing, it 
 must be discontinued. The child should be encouraged 
 to go to sleep after the operation. After the difficulty 
 of breathing has been relieved by the operation many 
 children naturally fall asleep for a few hours, and they 
 should on no account be awakened, as it is the best 
 thing possible for them. Sleep is of the greatest impor- 
 tance, as in most cases the child is very exhausted from 
 the previous difficulty of respiration. The inner tube 
 must at first be removed every two hours, or oftener 
 if necessary, but the child should not be awakened for 
 this purpose. The inner tube must be cleaned in weak 
 
Operations on the Neck 151 
 
 carbolic solution (i in 200) and replaced. Any mucus or 
 membrane that is coughed up should be wiped away at 
 once with a clean piece of turkey-sponge dipped in the 
 carbolic solution. If the tube becomes blocked with any 
 mucus that will not come out, a soft feather may be used 
 to remove it. The feather should, if possible, have been 
 sterilized by immersion in some strong carbolic solution 
 for an hour or more, and then the carbolic washed away 
 with sterile water, or the feathers may be sterilized by 
 boiling. Several of these feathers should be kept at hand 
 immersed in a weak carbolic solution. The feather 
 should be gently inserted into the tube, and then turned 
 round before being removed, so as to catch the mucus, etc. 
 If the breathing becomes harsh and whistling, and there 
 seems to be difficulty in bringing up the secretion, the 
 opening of the tube must be sprayed with a solution of 
 bicarbonate of soda (20 grains to the ounce) for five or 
 ten minutes at a time. This will loosen the secretion or 
 membrane, and allow of its being easily coughed up, or, 
 if desired, the solution can be applied to the trachea with 
 one of the feathers. Careful nursing is of the utmost 
 importance in these cases ; it must not, however, be 
 meddlesome. Especially, the child must not be pre- 
 vented from sleeping. 
 
 The old adage of ' leaving well alone ' is very applic- 
 able to these cases, and the too free use of the feather is 
 particularly to be avoided. If the breathing at any time 
 becomes very difficult owing to the accumulation of 
 mucus, etc., in the trachea and tube, this can be quickly 
 relieved by sitting the patient up, and propping him in 
 that position with pillows. Feeding the patient is usually 
 a difficult matter, and must be undertaken with care. 
 If possible, the patient should be propped up in a sitting 
 position for this purpose, and ted by means of a feeder 
 
152 The After-Treatment of Operations 
 
 with a piece of rubber tube attached to its spout, the end 
 of which is passed to the back of the throat. The feed- 
 ing must be at frequent intervals, and if there is much 
 difficulty in getting the patient to swallow, nasal feeding 
 must be resorted to at once. 
 
 At the end of the first twenty-four or thirty-six hours 
 the outer tube must be removed and cleaned, or a new 
 one introduced. This is usually an easy matter, but it 
 is well to have a director or tracheal dilator at hand in 
 case of any difficulty arising in reintroducing the tube. 
 If the original tube has not got a hole at the bend so as 
 to allow a free air- way by the mouth, one of these tubes 
 should be introduced at this stage if obtainable, or a 
 bivalve tube may be used. If the inner tube of a bivalve 
 tube is removed, the patient can breathe through the 
 mouth if there is no obstruction. On the second day 
 after the operation the mouth of the tube should be 
 blocked up either with a wooden plug or with a piece of 
 wet lint for ten or fifteen minutes at a time, so as to get 
 the patient accustomed to breathing through the mouth 
 again. (For this purpose it is, of course, necessary to have 
 a tube with an upper opening.) Unless the cause of the 
 obstruction is a permanent one, an attempt should be 
 made to remove the tube altogether on the third or 
 fourth day. 
 
 Removal of the Tube. — As stated, this should be done at 
 the earliest possible date. A great deal of trouble will 
 be saved if the patient has been gradually accustomed to 
 breathe through the mouth by plugging up the opening of 
 the tube from time to time. When the tube is removed, 
 a pair of tracheal dilators should be at hand, so that 
 should any difficulty with the breathing occur, the wound 
 can be quickly opened. If on removing the tube spasm 
 occurs, the tube must be reinserted ; an attempt should 
 
operations on the Neck '53 
 
 then be made to remove the tube while the patient 
 is sitting up ; this will sometimes be successful. The 
 surgeon should not leave the patient after the tube has 
 been removed until he is satisfied that the patient is able 
 to breathe comfortably through the mouth. 
 
 If the tube has to be retained for more than a week, an 
 indiarubber tube should be substituted for the metal one ; 
 this may be one of Morant Baker's tubes, or a very good 
 tube can be constructed out of a piece of drainage-tube 
 (see Fig. 20). In infants especially a metal tube 
 should never be retained for more than a week. The 
 author once saw a case in an infant 
 under two years of age where a metal 
 tube had been worn for a fortnight, 
 and in which the end of the tube 
 ulcerated into the innominate artery, 
 and the child bled to death in three 
 minutes. In most cases where there 
 is any difficulty in the removal of the 
 tube, this is chiefly due to nervousness 
 or habit on the part of the child, and 
 is not due to any actual obstruction in 
 the larynx ; care and patience, there- 
 fore, is all that is called for. Occa- 
 sionally, however, there is some actual 
 obstruction in the larynx from ad- 
 hesion or granulations, and it becomes necessary to 
 dilate the trachea above the tube ; this is, however, very 
 rarely the case. A plan which is sometimes useful when 
 there is considerable difficulty in getting the patient to 
 breathe through the mouth is to intube the larynx, and 
 then remove the tracheotomy-tube, the laryngeal-tube 
 being removed at the end of twenty-four or forty -eight 
 hours. 
 
 Fig. 
 
 TO 
 
 24. — Drawing 
 
 SHOW THE 
 
 Method of 
 MAKING A Trache- 
 otomy-Tube out 
 OF A Piece of 
 Drain age-Tube . 
 
154 The After-Treatment of Operations 
 
 Dilating the Larynx. — ^A little chloroform is administered, and 
 after dilating the wound a soft catheter is passed up from it, and 
 the end drawn through the mouth with a clip ; several catheters of 
 increasing sizes may be in this way passed through the larynx until 
 it is sufficiently dilated, or by means of the catheter a silk thread 
 can be passed through from the wound to the mouth, and a small 
 piece of fine Turkey sponge tied on to the end of the thread and 
 drawn up through the larynx so as to clear it or break down any 
 adhesions; or a Macewen's tube can be made use of. 
 
 Artificial Larynx. — This is an apparatus designed 
 with the object of enabHng a patient after his larynx has 
 been removed to swallow without danger of food getting 
 into the trachea, and at the same time, by means of a 
 reed fitted into the exit-tube, enabling him to speak. 
 There are several varieties of artificial larynx, of which 
 probably Gussenbauer's, or Dr. Foulis's modification of 
 it, are the best. They are much too complicated for 
 description here. Some patients can use them with 
 considerable success, but a great many find that they 
 can get on better without; the great difficulty connected 
 with them is that they are very liable to get blocked with 
 mucus. 
 
 (Esophag-otomy. 
 
 The chief difficulty in these cases is the feeding ; if 
 possible, this should be done by nutrient enemata for the 
 first three or four days, and the patient not allowed to 
 swallow anything by the mouth during this time. If, 
 however, this cannot be managed, a soft rubber tube 
 must be passed down the oesophagus either from the 
 mouth or nose, and the patient fed through it. This tube 
 can either be inserted each time the patient is fed, or, if 
 possible, it should be retained, at any rate during the 
 daytime. At the end of the first week or earlier, if the 
 wound is healing well, the patient may be allowed to 
 
Operations on the Neck 155 
 
 swallow liquids in small quantities at a time. These 
 wounds are practically always septic, owing to organisms 
 getting into them from the wound, and it is necessary to 
 see that there is free drainage at the most dependent part 
 of the wound , 
 
 Operations on the Thyroid Gland. 
 
 Complications. — (i) Aphonia ; (2) cellulitis of the 
 neck ; (3) thyroidism ; (4) tetany. 
 
 Fig. 25.^Chart of a Case of Thyroidism. 
 
 Aphonia results from wounding the recurrent laryngeal 
 nerve, or from its becoming involved in the cicatrix. In 
 the first case, the aphonia will come on immediately after 
 the operation, and in the second, some time afterwards. 
 
 Cellulitis of the neck is a very serious complication, 
 and should, of course, not occur ; if it does, the wound 
 must at once be freely opened up and drainage pro- 
 vided for. The possibility of thyroidism occurring after 
 operations on the gland must be borne iij mind. The 
 
ij6 The After-Treatment of Operatic 
 
 ns 
 
 symptoms are similar to those of exophthalmic goitre 
 (without the exophthalmus), but are acute. They come 
 on, as a rule, at the end of the first twenty-four or forty- 
 eight hours after the operation ; the temperature goes 
 up, often to a great height (103° to 105° F.), and remains 
 intermittent fFisr. 25) : the patient becom.es very flushed 
 and uncomfortable ; the pulse is quick and bounding, and 
 there is often marked tachycardia ; the symptoms are very 
 alarming, and may easily be mistaken for the onset of 
 acute sepsis. The pulse and tachycardia are, however, 
 characteristic, and this mistake should not be made. The 
 symptoms, as a rule, subside in the course of a day or 
 two, and no harm results. Should they, however, be 
 serious, as is sometimes the case, the wound must be 
 opened and washed out thoroughly with sterilized water, 
 and then drained or packed Avith gauze to prevent the 
 secretion of the gland getting into the tissues of the 
 wound and being absorbed by the lymphatics. In very 
 bad cases transfusion may be tried. This condition of 
 thyroidism is rarely serious, but one or two cases of a 
 fatal issue have been recorded. The best method of pre- 
 venting toxic symptoms after partial thyroidectomy is by 
 giving the patient plenty of water and keeping the tissues 
 well flushed out. The practice at the ]\Iayo clinic, 
 where large number? of these operations are performed, 
 is to administer i quart of saline slowly per rectum 
 immediately after operation, and to repeat this twice 
 within the next twelve hours. If the patient cannot 
 retain these salines, the fluid should be given subcu- 
 taneously. In the earlier days of the operation, when it 
 was the practice to remove as much as possible of the 
 gland, symptoms like those of myxoedema not infrequently 
 occurred. In these days, however, as a rule, only one 
 lobe is removed, and this danger is consequentl}- absent. 
 It may happen, however, that too much of the gland is 
 
Operations on the Neck 157 
 
 removed, or that the part left is not functional, and then 
 symptoms due to absence of thyroid secretion may de- 
 velop. The symptoms usually come on a few days after 
 the operation, and often take the form of muscular spasm. 
 Laryngeal spasm may occur, and cause acute dyspnoea. 
 There may be tetany of the hands and feet, and there is 
 usually progressive emaciation. The best treatment is 
 large doses of thyroid extract, which may have to be 
 continued indefinitely. 
 
 Tetany may develop after an operation for thyroid- 
 ectomy, and will show itself by attacks of tonic flexion, 
 generally in the muscles of the hands. There may 
 be general convulsions and high fever. The condition, 
 though alarming, is not fatal. It is due to removal of 
 the parathyroid glands. The best treatment is adminis- 
 tration by the mouth of parathyroid extract, or the 
 surgical implantation of a parathyroid gland from an 
 animal into the abdominal cavity. 
 
 Operation for the Removal of Enlargred Glands. 
 
 After the operation the patient should be prevented as 
 far as possible from moving his head, and if the wound 
 is large, sand-bags should be placed for this purpose on 
 both sides of the head and neck. In order that the scar 
 may not be unsightly, the stitches should be removed in 
 three or four days, and the edges of the wound supported 
 by strips of adhesive plaster. If a tube has been put in, 
 it should be removed in twenty-four hours. If, as is 
 usually the case, the glands are tubercular, the patient 
 should be sent to the seaside or to a bracing climate as 
 soon as the wound has healed, and should be kept there 
 for some months. Plenty of fresh air and good food are 
 most important, or more serious tubercular lesions may 
 supervene. 
 
CHAPTER XII 
 OPERATIONS ON THE THORAX 
 
 Amputation of the Breast. 
 
 Complications. — (i) Lung affections ; (2) sloughing of 
 the skin ; (3) sepsis ; (4) fixation of the arm ; (5) venous 
 stasis and oedema of the arm ; (6) lymphadenoma. 
 
 If no drainage-tube has been used, the patient should 
 be made to lie as much as possible on the sound side for 
 the first twenty-four hours to prevent blood, etc., from 
 accumulating in the loose cellular tissue at the axillary 
 end of the wound. Of course, if a drainage-tube has 
 been brought out through the skin in this situation, there 
 will not be the same necessity for this position. If there 
 is much pain after the operation, a hypodermic injection 
 of morphia should be given (|- grain). A good deal of 
 pain is not uncommon at first from the tension of the 
 sutures, especially if much skin has been removed. 
 
 There is frequently a little oozing of blood through the 
 dressings during the first twenty-four hours ; this should 
 be looked for by the nurse from time to time, and when 
 noticed, more wool must be packed on over the part of 
 the dressings where it is taking place. It is better not 
 to redress the wound unless the oozing is considerable. 
 It is a very good plan for the first two or three days to 
 keep large pads of clean wool under the affected side 
 
 IS8 
 
Operations on the Thorax 159 
 
 between the dressings and the bandages. On the day 
 following the operation the patient should be propped up 
 into the half-sitting position with a bed-rest and pillows 
 in order to prevent any tendency to lung complications. 
 
 Lung complications are very liable to occur after 
 removal of the breast, especially in elderly patients, and 
 as carcinoma is a disease which is most common towards 
 the later period of life, many of the patients are elderly. 
 This tendency to lung complications is to be accounted 
 for by the limitation of the thoracic movements, which 
 must of necessity result from the presence of a large 
 wound on the chest. Any deep respiration causes pain, 
 and, as a result, the respirations are shallow and almost 
 entirely diaphragmatic ; respiration is also impeded by the 
 chest being tightly bound up with bandages, etc. It is 
 well to bear this in mind, as otherwise what would have 
 been a successful operation may result in the death of 
 the patient from an intercurrent bronchitis. 
 
 If a tube has been used for drainage, it should be 
 removed on the first or second day after the operation 
 and the wound dressed ; the skin at the axillary end of 
 the wound should be carefully cleaned at the same time. 
 
 In those cases where a large amount of skin has been 
 removed and the axilla freely cleared out, the arm 
 should be fixed after the operation in a position of 
 abduction from the trunk, so as to avoid the formation 
 of adhesions, which will prevent free movement of the 
 arm after the wound has healed. After the first three 
 or four days the arm should be gently moved each day to 
 prevent the formation of adhesions between the skin and 
 deeper structures. These movements must be very slight 
 for the first fortnight, but after this they may be increased 
 in range daily, and the patient encouraged to move the 
 arm freely herself. A certain amount of limitation of 
 
1 6c The After-Treatment of Operations 
 
 movement in the shoulder on the affected side not infre- 
 quently results after this operation owing to the extensive 
 removal of skin, which is often necessary ; but much can 
 be done by early movements to overcome this tendency. 
 Some of the stitches may be removed at the end of the 
 first week, and the remainder at the end of a fortnight. 
 After the wound has healed it is a good plan to have 
 the skin gently moved on the deeper tissues each day 
 to prevent the scar from becoming adherent. It is 
 hardly necessary to mention that the patient should be 
 kept under close observation for several years after the 
 operation, so that should recurrence take place, it 
 may be detected and dealt with at the earliest possible 
 date. 
 
 When an extensive area of skin has been removed with 
 the breast, and a considerable amount of tension has in 
 consequence been necessary to bring the edges together, 
 sloughing of parts of the skin-edges may result. When 
 this is seen to be imminent, the tension must be at once 
 relieved by dividing the sutures. If in consequence of 
 sloughing a large granulating area remains, this area 
 should be covered in by Thiersch's skin-grafting, so as 
 to prevent the contraction that will otherwise result. 
 
 Sepsis after removal of the breast is a very serious 
 complication, owing to the large wound and the extensive 
 lymphatic area opened up. Septicaemia is very liable to 
 follow, and may prove fatal. Pleural effusion on the 
 same side as the wound may also result, and become 
 purulent. 
 
 Operations for Empyema. 
 
 Complications. — (i) Non - expansion of the lung ; 
 (2) persistent sinus ; (3) empyema occurring in the oppo- 
 
Operations on the Thorax i6i 
 
 site side of the chest ; (4) cerebral abscess ; (5) curvature 
 of the spine. 
 
 After the operation there is not infrequently — and 
 especially is this the case with children — a good deal of 
 respiratory embarrassment from the altered conditions of 
 respiration ; slight blueness of the lips may often be 
 noticed, and is evidence of insufficient aeration of the 
 blood in the lungs. This is best met by oxygen inhala- 
 tion. The patient should be allowed to breathe oxygen 
 from an indiarubber-tube attached to an oxygen cylinder 
 whenever the breathing seems difficult or there is 
 
 Fig. 26. — Pollard's Empyema Tube. 
 The square flange should go inside the chest. 
 
 cyanosis ; this helps to tide over the period until the 
 circulation becomes accustomed to the new respiratory 
 conditions. The dressings must be changed frequently 
 if there is much discharge, and the same care should be 
 taken as in deahng with a sterile wound, as it is most 
 important that fresh infection should not be engrafted on 
 to that already present. After the first few days it is 
 usually sufficient to change the dressings once daily. It 
 is most important that the wound in the chest should be 
 kept sufficiently open to allow of free drainage. If after 
 the fluid has drained away the ribs come together and 
 narrow the opening, there should be no hesitation in 
 
 IX 
 
1 62 The After-Treatment of Operations 
 
 enlarging the wound, and, if necessary, taking away 
 more rib. The drainage-tube should be removed each 
 day and cleaned before being reinserted, otherwise it is 
 very liable to become blocked by pieces of pyogenic 
 membrane, etc. 
 
 x\s the discharge diminishes in amount the tube may 
 be removed and a smaller one substituted for it. A very 
 good tube for use in these cases is Mr. Bilton Pollard's 
 (see Fig. 22). It is easily inserted, and has the advantage 
 of being self-retaining. It is best to keep the patient in 
 bed for the first week or ten days, and then if his condi- 
 tion is satisfactory he may be allowed to get up for some 
 part of the day, and allowed to get out of doors for a 
 short time if the weather is favourable. There is no 
 fixed time for which the tube should be retained, but, as 
 a general rule, it may be said that the tube should be 
 removed as soon as the discharge has diminished to a 
 drachm or two of clear fluid. After the tube has been 
 left out, the sinus should be packed with gauze daily so 
 as to insure it healing from the bottom. In children it 
 is often possible to remove the tube in two or three days 
 after the operation. When the dressing is changed, the 
 patient should be turned well over on to the bad side so 
 as to allow any pus to run out, and the patient should be 
 instructed to cough. This will often help to get rid of 
 any pyogenic membrane or pus that is not able to drain 
 away. Occasionally, after an empyema has been opened, 
 there are still symptoms of retained pus, such as high 
 temperatures, fever, etc., even though free drainage has 
 apparently been established. This is generally due to 
 the empyema being loculated, and pus still remaining 
 encysted in some cavity other than that opened. This 
 pus must be sought for and evacuated. The best way of 
 doing this is to push a large catheter in different direc- 
 
Operations on the Thorax 16^ 
 
 tions until the pus is found, or the finger may be used if 
 the external opening will admit of it. 
 
 Non-expansion of the lung after operations for em- 
 pyema is a very serious complication, as it usually leads 
 to deformity of the chest with secondary lateral curvature 
 of the spine, and results in a persistent discharging sinus, 
 which is a continuous source of trouble and inconvenience 
 to the patient. A great deal can be done to assist the 
 lung to expand by sui:able respiratory exercises. The 
 exercises that are suitable for hastening and facilitating 
 expansion of the lung after empyema may, with advan- 
 tage, be divided into two classes : 
 
 (i) Those suitable while there is still an opening into 
 the pleural cavity. 
 
 (2) Those suitable after this opening has closed. (By 
 an opening is meant one which establishes a condition of 
 pneumothorax, and not a sinus shut off by adhesions 
 from the pleural cavity.) 
 
 In (i) we have to deal with a condition of pneumo- 
 thorax, and, consequently, since expansion of the chest 
 will no longer give rise to negative pressure in the 
 pleural cavity on that side, we cannot avail ourselves of 
 the ordinary breathing exercises, and we must make use 
 of the positive pressure produced by the sound lung 
 during expiration to expand the affected one. The 
 patient should be made to expire forcibly against resist- 
 ance. The simplest way of doing this is to make the 
 patient blow forcibly through a small tube held in the 
 mouth, such as a piece of glass tubing. In the case of a 
 child, a good plan is to give it a whistle or trumpet which 
 will not make a noise unless blown hard. The exercise 
 may be modified by telling the patient to make a forcible 
 expiratory effort with the glottis closed, and then to let 
 the air escape slowly through the partly closed lips. 
 
1 64 The After-Treatment of Operations 
 
 These exercises are done with the object of causing 
 positive pressure in the affected lung, and so expanding 
 it. They should be carried out regularly from the first 
 
 day, and gradually increased 
 from day to day. A very 
 simple form of apparatus for 
 assisting in expansion of the 
 lung is shown in Fig. 27. It 
 consists of a large quart bottle 
 with a wide neck, with two 
 glass tubes inserted into it, 
 one of which reaches to the 
 bottom, and the other only just 
 through the cork. To the longer 
 tube a rubber connection is 
 made to a glass mouthpiece. 
 The bottle is nearly filled 
 with water, and the patient 
 is instructed to blow steadily 
 through the tube against the 
 Greater resistance can be 
 
 Fig. 27. 
 
 resistance of the water 
 obtained by using narrow tubing. 
 
 In (2) our object is to obtain expansion of the lung 
 by negative pressure in the pleural cavity as in normal 
 respiration. This can only be done when the pleura as 
 a cavity is closed by the healing of the wound or by the 
 formation of adhesions between the visceral and parietal 
 layers of the pleura. As adhesions are almost always 
 present to some extent, these exercises can usually be 
 commenced before the wound has healed. The following 
 exercises are taken from Dr. H. Campbell's book on 
 respiratory exercises : 
 
operations on the Thorax 165 
 
 ' Breathing Exercises for One or Both Lungs. 
 
 ' I. Exercise for one lung only, in this case to be applied to the 
 affected lung. 
 
 ' One hand is ph.ced in the axilla of the sound side of the chest, 
 and pressed firmly against the chest wall, so as to check its move- 
 ments as far as possible. The opposite arm is then raised from the 
 side until the wrist rests on the head. While the movement of this 
 arm is in progress, an attempt is made to expand to the utmost the 
 corresponding side of the thorax at the same time that the body 
 and head are inclined to the opposite side. 
 
 ' 2. Take the fullest possible thoracic inspiration, followed by an 
 ordinary expiration. 
 
 '3. Expire to the utmost, bending the body somewhat forward; 
 then take an ordinary inspiration, resuming the vertical position. 
 
 ' 4. Take the fullest possible thoracic inspiration, then expire to 
 the utmost, bending the body forward. 
 
 '5. The patient stands erect, and then blows quickly through a 
 small opening produced by pursing the lips. At the same time he 
 bends the head and then the dorsal portion of the spine, whilst 
 with the outspread fingers he compresses the sides of the thorax. 
 Having done this, the fingers are enlaced behind the neck, the 
 mouth is closed, and a very slow and prolonged inspiration taken 
 through the nostrils, whilst at the same time the spine is slowly 
 extended. 
 
 ' Breathing Exercises combined with Active Exercises. — 6. The arms, 
 held stiff, are swung round as far as possible in the sagittal direc- 
 tion. Inspiration accompanies the upward movement, expiration 
 the downward. 
 
 ' 7. The arms, held stiff, are moved from the side of the body 
 outwards in a lateral plane to the vertical, and then returned to the 
 original position. Inspiration accompanies the upward movement, 
 expiration the downward. 
 
 ' 8. The arms, held horizontally in front of the body in the 
 sagittal plane, are swung backwards in the horizontal plane as far 
 as they will go, and then returned to the original position. In- 
 spiration accompanies the former movement, expiration the latter. 
 
 ' 9. The arms are made to swing in the lateral plane and in the 
 same direction, so as to reach the highest possible point on either 
 side, and are then returned to the original position. Inspiration is 
 taken with the ascending movement. 
 
1 66 The After-Treatment of Operations 
 
 ' Passive Respiratory Excixises. — lo. The operator stands behind the 
 patient's head, which should project slightly beyond the couch. 
 The upper arms are then grasped by the assistant, his thumbs 
 looking upwards. The arms are then brought above the head, so 
 as to form a Ywith the body, and strong traction made upon them, 
 the patient meanwhile taking a deep inspiration. They are then 
 brought towards the thorax, and firmly pressed against it, while 
 the patient takes the deep expiration. 
 
 ' II. The operator stands at the side of the patient, and grasps 
 the arms as they rest at each side of the body just above the 
 elbows, his thumbs being uppermost and looking towards the 
 patient. He then moves the limbs in a horizontal plane until the 
 hands meet behind the head of the patient, who meanwhile takes a 
 deep inspiration. This is followed by a deep expiration while the 
 limbs are moved back to the original position, the elbows being 
 firmly pressed against the sides. 
 
 ' 12. The patient lies on the sound side of the chest, with the 
 arms above the head, and the operator, standing behind, places the 
 palm of each hand over the uppermost part of the thorax, so that 
 the roots of the fingers correspond with the axillary line. The 
 side of the thorax is thus grasped between the fingers and thumbs. 
 With every expiration the operator makes firm pressure on the 
 thorax, and endeavours to make the fingers and thumbs meet.' 
 
 Persistent sinus may be due to several different causes, 
 one of which will, of course, be non-expansion of the 
 lung. If the lung has expanded properly, and yet there 
 is persistent septic discharge from the wound, the 
 presence of dead bone must be suspected and looked 
 for by exploring the sinus with a probe. A portion of 
 the rib is often found to be necrosed, the necrosis being 
 most commonly along the lower border of the rib above 
 the sinus. When this is the case, all the necrosed 
 portions of rib must be removed before the sinus will 
 close. Insufficient drainage from the chest is a not 
 mfrequent cause of persistent sinus, and when the dis- 
 charge is intermittent from the sinus — that is to say, 
 when the wound keeps healing up and breaking down 
 again — this cause must especially be suspected; the 
 
Operations on the Thorax 167 
 
 wound under these circumstances should be freely opened, 
 and if a large cavity is found inside the chest, it 
 must be well drained until it has almost closed up, and 
 then made to heal from the bottom by plugging. Other 
 and rarer causes of persistent sinus are tubercular disease 
 of the pleura ; caries of the spine, to which the empyema 
 was secondary ; and the development of calcareous plates 
 in the pleura. 
 
 When empyema occurs on the opposite side, it is 
 probably safer to be content with aspirating the chest for 
 a few days to allow time for the formation of adhesions, 
 so that complete collapse of the lung does not take place 
 when the chest is opened. 
 
 With regard to washing out the pleural cavity after 
 making an opening into the chest, this procedure has 
 been proved to be dangerous, however carefully practised. 
 In many cases no harm results, but in a few, dangerous 
 collapse symptoms and even sudden death have followed 
 after the most careful washing out of the cavity. It 
 is therefore safer to be content, as a rule, with simple 
 drainage. Should it, however, be thought desirable to 
 irrigate the cavity, as is sometimes the case in very foul 
 or purulent empyemata that resist treatment by drainage 
 alone, the patient should be placed in the recumbent 
 position while this is being done, and a free exit must be 
 allowed for the fluid so that there is no possibility of the 
 irrigating fluid causing tension in the pleural cavity 
 while the irrigation is in progress. 
 
 The constitutional treatment of these patients is of the 
 utmost importance ; fresh air and an early change to the 
 seaside are of the greatest benefit in restoring the patient 
 to health. Breathing exercises should be carried out 
 from the first to help the expansion of the lung, and 
 later on proper gymnastic muscular exercises should be 
 
1 68 The After-Treatment of Operations 
 
 enforced to prevent the tendency to contraction of the 
 chest and curvature of the spine. This is particularly 
 important in children who are liable, as the result of 
 empyema, to develop marked deformity of the chest and 
 lateral curvature of the spine. In some cases curvature 
 of the spine after empyema may be looked upon as a 
 beneficial condition ; that is to say, when the lung has 
 not expanded the lateral curvature of the spine allows 
 the chest on the affected side to fall in and close the gap. 
 When the deformity is very marked, however, an attempt 
 should always be made to get rid of it by suitable exer- 
 cises, as the condition is apt to be progressive. 
 
CHAPTER XIII 
 
 OPERATIONS ON THE ABDOMEN : GENERAL TREAT 
 MENT AND COMPLICATIONS 
 
 The After-Treatment of Laparotomy. 
 
 A GREAT deal depends in these cases on the way in 
 which the after treatment is managed — more so, indeed, 
 than after almost any other class of case. The treat- 
 ment, however, must be carried out with intelligence, 
 and must be based upon careful observation of the 
 individual case, as these cases vary very much, and 
 hardly two of them are quite alike. Anything in the 
 way of routine management is to be particularly avoided, 
 and the line of treatment adopted should, so far as 
 possible, be based upon physiological facts, the medical 
 attendant trying to form a mental picture of the con- 
 dition of the abdomen, and treating the case accord- 
 ingly. It should be his object to prevent complications 
 as far as possible, as it is much easier to prevent the 
 complications that are liable to arise than to treat them 
 after they have once become well established. Meddle- 
 some interference must, however, be avoided, and 
 especially the too free use of drugs. When complica- 
 tions do arise the treatment must be vigorous, as, once 
 well established, there may be great difficulty in com- 
 bating them. 
 
 r69 
 
170 The After-Treatment ot Operations 
 
 After the operation the patient should be carried 
 carefully back to bed, and jolting must be avoided, as it 
 is very liable to increase the vomiting. The flannel 
 gown which the patient has worn during the operation 
 should be changed for a clean one, which has been 
 warmed, and hot-water bottles should be applied to the 
 feet and elsewhere if necessary. This should not be 
 overdone, as it is not desirable to make the patient 
 break into a profuse perspiration, which is often the case 
 if the use of hot-water bottles, etc., is carried to excess. 
 Care must be taken also in the use of hot bottles not to 
 burn the patient. Persons who are under the influence 
 of an anaesthetic burn extremely easily, and it is not at all 
 uncommon to see quite extensive burns from this cause 
 in hospital practice. 
 
 A warm nutrient enema should be administered soon 
 after the patient has been got back to bed, and it is 
 a very good plan, if there is any sign of shock, to 
 administer an enema of warm water i pint and brandy 
 I ounce. This may either be combined with a nutrient 
 enema, or given separately. Mr. Watson Cheyne advises 
 an enema containing hot coffee (2 ounces), brandy 
 (i ounce), beef-tea (i ounce), and liquor strycbninae 
 (10 minims). 
 
 If there is vomiting, and it does not stop in a short 
 time, hot flannels may be applied to the epigastric 
 region, and the patient can be allowed to drink some hot 
 water with some bicarbonate of soda dissolved in it ($ee 
 under Post-Anaesthetic Complications). 
 
 In cases where there is constant regurgitation of fluid 
 from the mouth rather than actual vomiting, as is not 
 uncommonly seen in cases of intestinal obstruction and 
 peritonitis, this can often be stopped by just propping 
 the patient up a little so as to allow gravity to act. 
 
Operations on the Abdomen 171 
 
 This is not advisable, however, when there is shock 
 present. A better method of preventing this type of 
 regurgitant vomiting is by washing out the stomach. This 
 should be done before the patient leaves the operating 
 table. If there is much pain after the patient regains 
 consciousness, it may sometimes be relieved by flexing 
 the patient's knees over a pillow, so as to relax the 
 abdominal muscles. A saline enema containing 10 to 15 
 grains of aspirin administered directly after the operation 
 will often relieve pain and avoid the necessity of giving 
 morphia. If very severe, an injection of morphia must 
 be given, but it is as well to avoid the use of opium if 
 possible, as it increases the liability to meteorism. If 
 there is much restlessness, morphia is indicated. It 
 should be given in a dose of from ^ to ^ grain hypo- 
 dermically, according to circumstances. Heroin (J^ to 
 TS S^^^^) "^3-y be used instead of morphia with advan- 
 tage. With regard to position, the patient should, as a 
 rule, be allowed to lie in the most comfortable position, 
 and this will usually be found to be upon the side (see 
 Introductory Chapter). 
 
 Relief of Distension. — In order to prevent the pos- 
 sibility of meteorism, an excellent plan is to pass a small 
 tube, such as the ivory nozzle of an ordinary Higginson's 
 syringe, through the sphincters twice in the twenty-four 
 hours, and leave it in for one hour at a time. It does not 
 cause the least discomfort, and allows of the escape of 
 flatus. When the patient is elderly it is always advisable 
 to pass a catheter once a day for the first few days to 
 make certain that the bladder is being properly emptied. 
 On the second or third day after the operation, and 
 earlier if the patient's bowels have not been well opened 
 previous to the operation, a soap-and-water enema should 
 be administered, and repeated in an hour if there is no 
 
ij2 The After-Treatment of Operations 
 
 action of the bowels. If this fails to act, an oil enema 
 may be given, or a dose of castor-oil (i ounce) given by 
 the mouth, or calomel, \ grain every hour for eight hours, 
 or until the bowels act, may be used instead of the oil, or 
 salts in repeated doses every two hours are preferred by 
 some surgeons. In cases where there is uncomfortable 
 distension of the abdomen after laparotomy the author 
 adopts the following procedure : A turpentine enema, 
 consisting of turpentine gss. and thin gruel 14 ounces, is 
 first given ; if this fails to give relief, a hypodermic injec- 
 tion of I c.c. of pituitary extract is given, followed at 
 once by an enema consisting of fels bovinum, i drachm 
 in i^ pints of water. This results in immediate and com- 
 plete relief of the distension in most cases. Eserine 
 may also be used hypodermically for the same purpose. 
 This question of aperients is a very important one, and 
 surgeons differ very much as to the exact procedure; but 
 it may be stated as a general principle that the sooner a 
 proper evacuation of the bowels has been obtained, the 
 sooner is the patient out of danger. The importance of 
 getting the bowels to act early after abdominal operations 
 is well shown by the following figures, for which I am 
 indebted to Dr. Darwall Smith, who has investigated this 
 subject in an analysis of 42 consecutive cases of abdominal 
 section. 
 
 Of these 42 cases, 13 developed complications in the 
 form of vomiting or distension, or both. 
 
 In II cases the bowels were opened by aperients or 
 enemata on the second or third day, and of these 2 
 developed complications. 
 
 In 20 cases the bowels were similarly opened on the 
 fourth or fifth day, and of these 5 developed complications. 
 
 In II cases the bowels were left to nature, and of these 
 6 developed complications. 
 
Operations on the Abdomen 173 
 
 The generally accepted view among surgeons now is 
 that meteorism or paralytic distension is due to sepsis ; 
 in other words, is a mild form of peritonitis. At any rate, 
 it does not occur if strict aseptic conditions are secured, 
 and the interior of the abdomen is not handled roughly. 
 This complication should not occur now as the result of 
 laparotomies, unless there are septic lesions. 
 
 Our object must be to get, if possible, a natural action, 
 unaccompanied by violent peristalsis. The best way of 
 doing this is by the use of enemata, which are probably 
 the least irritating form of aperient and at the same 
 time produce their effect with the least amount of peri- 
 stalsis. With regard to the use of aperient drugs, 
 salts, especially in small repeated doses, are probably 
 the least irritating to the intestine, and take effect 
 without giving rise to much muscular action of the 
 intestinal wall ; but, unfortunately, they are very liable 
 in some cases to cause vomiting, which it is often par- 
 ticularly desirable to avoid. One of the best ways of 
 administering salts for the evacuation of the bowels in 
 these cases is in small doses dissolved in a large quantity 
 of water, as, for instance — 
 
 '^ Mag. sulph. . „ . . 5ss.-i. 
 
 Sodse sulph. . _ . . 5ss.-i. 
 
 Aquam - - - - - ad gvi. 
 
 Sig. : Every hour till the bowels act. 
 
 The value of saline purgation in the treatment of 
 insipient peritonitis has been repeatedly proved, and 
 there can be no doubt of its usefulness in appropriate 
 cases. The late Mr. Lawson Tait was one of the first 
 surgeons to revive the practice, and he used to speak 
 very highly of the value of saline purgation in the after- 
 treatment of ovariotomy cases. 
 
174 The After-Treatment of Operations 
 
 It has recently been pointed out by McCullum that 
 most of the saline aperients act even more readily if 
 administered hypodermically than if given by the mouth. 
 This method of administration may be tried in cases 
 where salts cause vomiting when given in the ordinary 
 way. 
 
 Castor oil is certainly one of the most reliable and 
 most valuable aperient drugs that we possess, and, 
 when it can be taken, is in many cases preferable to 
 the use of salts. An ounce of the oil may be given 
 on the morning of the third day after the operation. 
 Calomel, especially in small repeated doses, is very 
 useful in some cases, and should be made use of in 
 preference to salts or oil in cases where there is peri 
 tonitis present or suspected ; but as calomel acts largely 
 by virtue of its irritating qualities, causing peristalsis, 
 it must be used with caution. Great judgment and 
 care is necessary in the employment of aperients after 
 laparotomy, and careful observation of cases combined 
 with a knowledge of the physiology of the intestine 
 will be of more service in the treatment of cases than 
 any amount of reading. 
 
 One warning must, however, be given. In the aged 
 and in weakly subjects, too active purgation, especially 
 by irritant drugs, like calomel, etc., should be avoided, as 
 it is liable to set up an intractable diarrhoea which may 
 prove fatal from exhaustion. After the bowels have 
 been opened a mild aperient should be given daily so as 
 to insure a sufficient daily action. For this purpose a 
 teaspoonful of liquid cascara or liquorice powder is as 
 good as anything. 
 
 Treatment of the Wound. — When the abdominal 
 wall has been sewn up in layers, the superficial stitches 
 should be removed in a week, the deep ones, of cotirse, 
 
Operations on the Abdomen 175 
 
 being left. After the stitches have been removed, the 
 wound should be supported with broad pieces of strap- 
 ping so as to prevent any strain being thrown upon 
 the newly-united wound edges, and a firm flannel binder 
 should be worn over this. 
 
 If the abdominal wall has been sewn up with non- 
 absorbable stitches passing through all the layers of the 
 abdominal wall, the stitches should be left in for ten 
 days. If a drainage-tube has been inserted into the 
 wound, it should be removed in twenty-four hours unless 
 there is pus draining away, in which case it should be 
 retained. Drainage of the abdominal cavity is not effi- 
 cient after twenty-four hours, as the tube is shut off by 
 adhesions. 
 
 The period of recumbency necessary after laparotomy 
 depends on several factors. The way in which the 
 incision has been made and closed, the size of the incision, 
 and the condition of the abdominal wall, have to be 
 considered. In the case of a short incision made through 
 the rectus sheath or by separating the muscles and sub- 
 sequently closed-in layers, there is no risk of hernia ; the 
 patient may be got up as soon as the wound has firmly 
 healed, which will be in about ten days, and a belt is 
 quite unnecessary. 
 
 In cases where the wound is large, and has not been 
 made by splitting muscles, it is advisable to keep the 
 patient in bed for a period of three weeks before allowing 
 him to assume the erect position. It is better to err on 
 the side of keeping the patient recumbent a little too 
 long than to run the risk of a hernia. 
 
 In the case of women it is generally advisable to fit 
 a belt, which should be worn for some months after 
 the operation. This is not so much to prevent the 
 formation of a hernia as to enable the patient to get 
 
176 The After-Treatment of Operations 
 
 about without becoming exhausted In many women 
 the abdominal muscles are rather poorly developed, and 
 as a result of the operation or the consequent rest in bed, 
 they are often very weak for some time after. A properly 
 fitting belt will do much to diminish this feeling of 
 weakness, and will be found of great advantage. 
 
 No active exercise or any exertion, such as lifting 
 heavy weights, should be indulged in for at least two 
 months after the operation. 
 
 Diet. — This is one of the most important parts of the 
 after-treatment of abdominal cases, and we must be 
 guided largely by the nature of the case in the selection 
 of a suitable diet. When there is a lesion in any portion 
 of the alimentary tract, our object must be to avoid the 
 use of any diet which will need digestion or necessitate 
 peristalsis by that portion of the intestine. Thus, in 
 stomach cases we should avoid the use of foods which 
 are normally digested by that organ, and in the case of 
 lesions of the small intestine w^e should make use of foods 
 which can, to a large extent, be digested by the stomach, 
 and so on. One thing must especially be avoided — that 
 is, the use of any diet which, in the process of digestion 
 or otherwise, is liable to cause the formation of gas, and 
 so flatulence and distension. 
 
 At the time when the first edition of this book appeared 
 it was the practice to put all laparotomy patients upon 
 special " slop " diets ; considerable importance was 
 attached to the particular kind of diet, and much care 
 was taken in the preparation of diet sheets. Any com- 
 plications which arose were frequently ascribed to the 
 patient's being allowed solid diet too soon. Surgeons 
 have now, for the most part, come to hold a view which 
 is more in accordance with common sense, and only with- 
 hold those articles of diet which they believe may do 
 
Operations on the Abdomen 177 
 
 harm. The author has for some years given up the use 
 of so-called "slop" diets, except in special cases. His 
 practice is to allow no food until the anaesthetic sickness 
 has stopped, and then to give the patient in moderate 
 quantity an ordinary diet such as he has been accus- 
 tomed to. Thus, if there has been no sickness during the 
 night after operation, the patient is allowed a light break- 
 fast consisting of a little bacon, a lightly boiled egg, and 
 bread and butter ; and for luncheon chicken or fish, 
 followed by a milk pudding or a little stewed fruit and 
 custard. 
 
 The author argues that after an operation on the 
 abdomen, or indeed after any operation, it is most desir- 
 able that the patient should not have indigestion or 
 flatulence added to his other discomfort, and that to put 
 a man or woman who has for years been living on an 
 ordinary diet on to a " slop " diet is a certain way of 
 producing indigestion. Anyone who doubts this has only 
 to put himself on a " slop " diet for a couple of days to 
 prove it. He will find that he is suffering from flatulence 
 and. indigestion within a \'ery short time. The author 
 has found that since adopting his present method of 
 dieting patients after laparotomy, discomfort from wind 
 and flatulence has practically disappeared altogether, and 
 with this many other troubles that used to be all too 
 common, such as insomnia, heartburn, and loss of 
 appetite. The above remarks do not, of course, apply to 
 patients who previous to the operation were on a special 
 diet, as the object should be to avoid an alteration of the 
 patient's diet. When, too, the alimentary canal has been 
 seriously interfered with, as in the case of anastomosis, 
 etc., some modification and restriction of diet is advisable, 
 though not to the extent often supposed. One must 
 always remember that it is not the condition (of solidity, 
 
178 The After-Treatment of Operations 
 
 etc.) of the food when eaten that is important, but its con- 
 dition during and after digestion. Ease of digestion is 
 important, but it should be obvious that the most readily 
 digested diet is that to which the individual is accus- 
 tomed. 
 
 When a very severe opcrat'on has been performed, 
 such as one involving surgical shock, or, more particularly, 
 one for the relief of peritonitis or some serious inflam- 
 matory condition of the abdomen, the case is different, 
 and special diet is advisable until normal conditions are 
 re-established. 
 
 It must be remembered that the alimentary tract under 
 these circumstances is not in a normal condition, that 
 digestion is often not complete, and fermentation and 
 other abnormal processes are very liable to take place. 
 Milk, which is a very commonly used diet in these cases, 
 is particularly unfortunate in this respect, as it is very 
 liable not to be properly digested and to undergo fer- 
 mentation, and give rise to the formation of gas, etc. It 
 is probably one of the worst forms of dietary in many 
 of these cases ; and although peptonizing it does a\\ ay 
 to some extent with this disadvantage, it does not do bo 
 altogether, as it is even then liable to undergo fermenta- 
 tion in the stomach and intestines, and, in addition, the 
 peptones used to peptonize it are irritating. One of the 
 safest and most reliable diets is albumin-water. This is 
 made by beating up the white of three. or four eggs in 
 a pint of water, lemon and sugar or other flavouring 
 materials being added according to taste. This is very 
 easily digested, is unirritating, and at the same time is 
 not liable to give rise to the formation of gas during the 
 process of digestion ; 2 pints of albumin-water given 
 during the twenty-four hours represents a fair amount of 
 
Operations on the Abdomen 179 
 
 nutritive material, and, as a rule, is all that is necessary 
 during the first two or three days. About 2 ounces 
 should be given by the mouth every two or three hours 
 while the patient is awake. If desired, the albumin- 
 water may be combined with peptonized milk, but it is 
 better to avoid the use of milk altogether till after the 
 bowels have acted. Another preparation which may be 
 used, and which is very similar to the albumin-water, is 
 plasmon. 
 
 Plasmon* is a pure albumin prepared from the 
 caseinogen of milk. It is a fine white granular powder, 
 which is readily soluble and free from taste or smell. It 
 can be added to almost any form of diet, and, as it con- 
 tains a very high percentage of albumin, forms a very 
 useful method of administering proteid. It has the 
 advantage of being the cheapest form of pure albumin 
 obtainable, as it is prepared from butter-milk, a by- 
 product in the preparation of butter. It is a very 
 easily assimilated form of albumin, and, owing to its 
 method of manufacture, is free from chemicals. In 
 abdominal cases it is best given either as a beverage 
 or as jelly : 
 
 Plasmon - - - - 3 teaspoonfuls. 
 
 Tepid water - - - - ^ pint 
 
 A little water should be added to the plasmon, and 
 then stirred into a thick paste ; the remainder of the 
 water should then be added, and the whole boiled for 
 two minutes. This will give | pint of the liquid. About 
 2 ounces of this should be given to the patient every 
 two or three hours, with more water and some suitable 
 flavouring added according to taste. As a change the 
 
 * There are now many substitutes for Plasmon, such as ovaltine^ 
 aanatogen, etc. 
 
i8o The After-Treatment of Operations 
 
 plasmon may be given as jelly or cocoa, and later, when 
 solid foods are begun, it is a very good plan to combine a 
 certain amount of plasmon each day with the diet. The 
 amount of plasmon which it is advisable to give in the 
 twenty-four hours must, of course, vary a good deal with 
 circumstances, but roughly it should be from three to 
 six teaspoonfuls of the powder. 
 
 A very useful diet for many of these cases, which was 
 first drawn attention to by Mr. H. Gilford [British Medical 
 Journal, November i6, 1901), is grape-sugar. To quote 
 his own words : 
 
 ' In my opinion one of the best of these foods is grape- 
 sugar. Grape-sugar by itself is too nauseous, but com- 
 bined with a flavour, such as that of raisins, it is nearly 
 always palatable. I find, in fact, that it is, as a rule, 
 preferred to nearly all other forms of liquid diet, and 
 patients will often by preference continue taking their 
 "raisin-tea" long after they have become tired of milk 
 and slops. It is made by pouring boiling water on to 
 half its bulk of chopped raisins. This is stewed for about 
 two hours and then filtered. The filtrate may be given 
 either with water or without, and either hot or cold, 
 according to the wishes of the patient. Though it doubt- 
 less contains other substances than grape-sugar, these 
 are apparently present in such small quantities that they 
 may be neglected. Given at first in small doses and 
 afterwards more freely, it is undoubtedly of value. When 
 one remembers the important place which sugar takes 
 among the foods, it seems strange that it should not be 
 more utilized as an article of sick diet. This applies with 
 peculiar force to grape-sugar, seeing that it requires no 
 digestion.' 
 
 A combination of egg-albumin or plasmon with grape- 
 sugar in the form of ' raisin-tea ' is a most excellent diet 
 
Operations on the Abdomen i8i 
 
 for these cases during the first few days. It combines 
 a maximum of nutrition in an easily assimilated form 
 with a minimum of bulk and residue ; it contains both 
 proteid and carbohydrate — the former in an easily 
 digested form, and the latter in a form which requires no 
 digestion at all. 
 
 Beef-tea, which is still so popular as a form of invalids' 
 diet, is practically useless except as a stimulant, and 
 there are many better stimulants than beef-tea. A recent 
 chemical analysis made of the beef-tea in one of the big 
 hospitals revealed the fact that the best beef-tea only 
 contained 3*4 per cent, of proteid, so that beef-tea and 
 the numerous other beef extracts are quite useless as a 
 diet. A recent writer on the subject says: 'AH the 
 bloodshed caused by the warlike ambition of Napoleon 
 is as nothing compared to the myriads of persons who 
 have sunk into their graves from a misplaced confidence 
 in the food value of beef-tea.' 
 
 When stimulants are necessary or advisable, brandy 
 and whisky are the best, and it is better to give them in 
 small repeated doses either separately or combined with 
 the fluid diet than to give them in large doses. Cham- 
 pagne is sometimes valuable, but, as a rule, it is better 
 to avoid the use of gaseous drinks, as they often cause 
 flatulence. 
 
 For the first four or five hours after the operation it is 
 advisable not to give anything by the mouth except 
 water. If the patient is thirsty, some lemon-juice may 
 be added to the water with advantage, or peppermint- 
 water is sOiTietimes very comforting. About a tea-cupful 
 of fluid should be allowed at a time. There is no advan- 
 tage in only giving the fluid in small sips ; such small 
 quantities of water are just as liable as larger quantities 
 to cause vomiting, and the latter will have the advantage 
 
182 The After-Treat m en t of Operations 
 
 of laving the stomach if it is vomited. It is correct in 
 these cases to assume that thirst is the physiological call 
 of the body for more fluid, and therefore it ought to be 
 satisfied as far as possible. Large quantities of fluid at 
 a time are, however, not advisable, as they are liable to 
 cause vomiting by distending the stomach ; but giving 
 water only in teaspoonfuls is neither reasonable nor does 
 it answer any real purpose. A cup of tea with a little 
 sugar but no milk is often very much appreciated when 
 the vomiting has passed off. It should be made weak, 
 and must not be allowed to stand before being drunk. 
 
 Complications of Laparotomy. — (i) Shock ; (2) 
 vomiting; (3) meteorism ; (4) peritonitis ; (5) stitch sup- 
 puration ; (6) faecal fistula; (7) parotitis; (8) weak scar ; 
 (9) intestinal obstruction; (10) adhesions; (11) ventral 
 hernia; (12) acute dilatation of the stomach. 
 
 1. Shock. — This condition has already been treated of in 
 a separate chapter, and will not be further considered here. 
 
 2. Vomiting. — This has also been considered, but it 
 may be mentioned here that in very bad cases of per- 
 sistent vomiting, which will not yield to the ordinary 
 treatment, washing out the stomach with warm water 
 should be tried and repeated at intervals of two or three 
 hours if necessary. Propping the patient up into a 
 semi-sitting position is also sometimes of use. It should 
 be our object to remove the cause of vomiting rather 
 than to check it (see p. 98). 
 
 3. Meteorism. — This is the most dangerous complication 
 that is commonly met with after laparotomy. A good 
 deal has been written on this subject under the name 
 of 'pseudo-ileus,' a new name which seems to have 
 little to recommend it. Tympanites is also another name 
 which has been used to describe this condition. What- 
 ever the exact physiological cause of the condition may 
 
Operations on the Abdomen 183 
 
 bs, whether it is due to paralysis of the intestinal muscu- 
 lature or to some other cause, it is a condition which is 
 not uncommonly seen, and when once well established, 
 it is often extremely difficult to treat. It usually first 
 shows itself about twenty-four to forty eight hours after 
 the operation by distension of the abdomen accompanied 
 by some discomfort. The patient's breath is often foul. 
 
 In the fatal cases this distension steadily increases, 
 and is accompanied by constipation, which may become 
 absolute, the patient dying either from a kind of toxaemia, 
 due, no doubt, to the absorption of poisons from the 
 intestine, or, in some cases, from a variety of peritonitis. 
 A certain amount of flatulence after laparotomy is quite 
 common, especially when the operation has been under- 
 taken for the relief of some septic condition, as, for 
 instance, in the case of appendicitis. 
 
 The modern view of post-operative meteorism is that 
 it is due to sepsis and peritonitis, and that consequently 
 the best way of preventing it is care in operating as 
 regards careful aseptic technique, and especially the 
 avoidance of rough and unnecessary handling of the 
 ab-Iominal contents. 
 
 Our object must be to prevent the onset of this trouble- 
 some complication by appropriate means. The method 
 of passing a tube through the sphincters and leaving it 
 there is certainly one of the best means of securing this 
 end. The late Mr. Herbert AUingham pointed out that 
 it is necessary, for the expulsion of flatus, that the 
 abdominal muscles should contract, and that after a 
 wound has been made in the abdominal wall the patient 
 is unable, or unwilling, to contract these muscles, on 
 account of the pain which it causes him, and in conse- 
 quence flatus tends to accumulate in the intestines. 
 Wherj the tube is in position^ however^ there is a fre§ 
 
1 84 The After-Treatment of Operations 
 
 way through the sphincters, and wind is able to pass, 
 unaided. 
 
 As soon as distension has made its appearance, steps 
 must at once be taken for its relief. An enema should 
 be administered, and probably one of the best enemas 
 for the purpose is a turpentine one, such as that in the 
 old British Pharmacopoeia: 
 
 ^ Turpentine - - - - Bi- 
 
 Gruel - - - . - §xvL 
 
 or a rue enema may be used, as : 
 
 fi Confectionis rutse - - - 5i"- 
 
 Infusum anthemidis - - - ad 5xvi.* 
 
 After the enema has been given, the rectal tube 
 should be passed through the sphincters and left there 
 for an hour, so as to allow of the escape of wind. It is 
 a good plan to let the tube be kept in for one hour out 
 of every six when there is any distension. An excellent 
 plan which the author has used for some years and 
 has hardly ever known to fail in giving instant relief is 
 as follows : If the first enema fails to relieve the dis- 
 tension, a second is given, either of turpentine or, better 
 still, of fels bovinum (B.P.), 2 drachms to warm water, 
 2 pints, and immediately after the enema a hypodermic 
 mjection of pituitary extract, i c.c. This usually results 
 in a free passage of flatus, and may be repeated if the 
 distension shows signs of returning in a few hours. If 
 these measures do not prove effectual in relieving 
 the distension, large oil enem.ata should be used, or 
 castor oil, calomel, or salts given in repeated doses by 
 the mouth until the bowels are open. 
 
 As a rule, the condition will yield to the above treat- 
 
 * St. George's Hospital Pharmacopoeia. 
 
Operations on the Abdomen 185 
 
 ment if it is commenced early and carried out vigorously. 
 In very bad cases powerful enemata, containing large 
 doses of glycerine, or glycerine and magnesium sulphate, 
 are sometimes successful: 
 
 ^ Glycerini . .. - . §i.-i.ss. 
 
 Mag. sulph. .... gss. 
 Aquam - . . . . gvi. 
 
 Recently subcutaneous injections of physostigmin 
 have been used to stimulate peristalsis in these cases, 
 and good results are claimed for this method of treat- 
 ment. The dose is -^3-^- grain, and the injection should 
 be followed in half an hour by a glycerine enema. The 
 injection may be repeated in six hours if unsuccessful. 
 With the same object the author has used hypodermic 
 injections of pituitary extract, I c.c, with very good 
 results. 
 
 Lastly, in very bad cases the advisability of re- 
 opening the abdomen and incising the bowel may be 
 considered. 
 
 4. Peritonitis. — The question of reopening the abdomen 
 will have to be considered. If this is not done, our only 
 hope is in getting the bowels to act. Calomel in re- 
 peated doses is probably the best way of securing this in 
 these cases. 
 
 5. Stitch Suppuration. — This should not occur with 
 proper aseptic technique, but is sometimes the result of 
 too much tension on a stitch. When this is the case, 
 the offending stitch should be divided, so as to relieve 
 the tension. The stitch should not be removed, for fear 
 of carrying septic material into the deeper parts of the 
 wound. When the abdominal wall has been sewn up 
 in layers, suppuration of the deep stiches is a very 
 troublesome complication. This is the great objection 
 to all buried sutures. That it is not always the result 
 
1 86 The After-Treatment of Operations 
 
 of the suture material being septic is certain, as occa- 
 sionally a sinus will form, leading down to the deep 
 sutures, months after the wound has healed up. When 
 this is the case, the old wound must be opened and all 
 the stitches removed. 
 
 Any persistent sinus which refuses to heal should be 
 carefully investigated for the presence of a foreign body, 
 such as a stitch, piece of drainage-tube, lost swab, etc., 
 as this is by far the most common cause of such sinuses. 
 
 6. FiBcal Fistula. — Faecal fistula is most commonly 
 seen after operations for appendicitis, and is then due to 
 an opening either in the remains of the appendix or in 
 the caecum. The first thing to do is to make sure that 
 there is free drainage from the sinus, and that there is no 
 danger of pocketing. For this purpose a drainage-tube 
 should be kept in, and the fistula kept as clean as 
 possible. The majority of these fascal sinuses close 
 spontaneously in the course of a month or six weeks, 
 and often in much less time than this. If there is any 
 tendency to the formation of a bottle shaped cavity, the 
 external opening should be carefully dilated or enlarged 
 by cutting, and the wound drained from the bottom. 
 The diet should be regulated so that it may be easily 
 digested, and the patient should be kept in bed, and, if 
 possible, in such a position that the intestinal contents 
 do not tend to flow into the fistula, but rather to pass by 
 the natural channel. When, in spite of these measures, 
 the t:stula will not close, it generally means that there is 
 some obstruction to the flow of faeces from the part of 
 the intestine above the fistula into that below it ; and this 
 should be investigated, and, if an obstruction is found, 
 an operation must be performed to remove it, or to 
 anastomose the intestine above and below the fistula, or 
 whatever else may seem mo5t suitable, 
 
Operations on the Abdomen 187 
 
 As these fistulas, however, often close of themselves 
 after existing for several months, it is as well to wait for 
 some time before trying to close them by operation, 
 unless there is obvious obstruction and all the faecal 
 material is passing by the wound. In cases of faecal 
 fistula not connected with the appendix or operations for 
 its removal, the same remarks apply, but the cause of 
 the persistence of the fistula may thein be the formation 
 of a spur, and steps must be taken for its removal.* 
 
 7. Parotitis. — This curious complication may occur 
 after any operation, but it is most commonly seen after 
 laparotomy and operations on the pelvic organs. It 
 seems to occur more often in women than in men. 
 Excluding operations on the pelvic organs, it is most 
 commonly seen after operations on the stomach, such as 
 for the treatment of perforated gastric ulcer, etc. Out 
 of 100 cases collected by Mr. Stephen Paget,! the 
 following primary causes were noted : Injury or disease 
 of the alimentary canal, injury or disease of the urinary 
 tract, ditto of the abdominal wall, peritoneum, or pelvic 
 cellular tissue, a blow on the testicle, the introduction 
 of a pessary, menstruation, and parturition. In 93 per 
 cent, of the cases it occurred as an isolated lesion, no 
 other complication being present. There was evidence 
 of a primary septic focus in only fifteen cases. The period 
 at which it comes on after the operation seems to vary 
 very considerably. The commonest time seems to be 
 from a week to ten days after the operation. In some 
 cases the submaxillary glands are affected as well as the 
 parotids. The condition comes on with great swelling of 
 
 * Foret's treatment of faecal fistulas. See the author's book on 
 ' Surgical Diseases cf the Colon ' (Bailliere, Tindall and Cox) 
 
 f ' Parotitis following Injury or Disease ' : Stephen Paget, British 
 Medical Journal, 1887, vol. i., p. 613. 
 
1 88 The After-Treatment of Operations 
 
 the parotid glands, accompanied by the usual signs of 
 inflammation. It closely resembles mumps. There is 
 often pain, and there may be a high temperature. The 
 temperature, however, does not as a rule exceed ioo° F. 
 or 101° F., except in the septic cases. 
 
 The condition often suggests that an abscess is 
 forming ; as a rule, however, the inflammation subsides 
 in the course of a day or so. Suppuration, however, 
 may take place, and the best evidence of this will be the 
 temperature chart. The pus tends to burrow into the 
 external auditory meatus or the pharynx. The cause of 
 the condition is very doubtful. That there is some 
 curious association between the parotid gland and the 
 genital organs is certain, but what this depends upon we 
 do not yet know. The best way of treating the parotitis 
 is by hot fomentations or lead lotions, and a smart purge 
 should be administered. If suppuration takes place, 
 incisions must at once be made into the gland, care 
 being taken not to wound the branches of the facial 
 nerve. 
 
 The exact cause of this curious condition is still 
 uncertain, but there is some reason to suppose that it 
 results from an infection of Stenson's duct consequent 
 upon a septic condition of the buccal cavity. Careful 
 attention to the cleanliness of the patient's mouth is 
 advised as a preventative measure. 
 
 The following curious case of this complication is 
 reported by Fiske Jones (Boston Medical and Surgica-l 
 Journal, November 20, ig:)2) : 
 
 A girl, aged nineteen, had a first attack of appendicitis in 1897. 
 An abscess developed, spreading into the pelvis, which was opened 
 and drained on the tenth day. Fcrty-eight hours after the operation 
 the right parotid gland began to ache and swell. Two days later the 
 left became similarly affected. Within a week the pain and swell- 
 
Operations on the Abdomen 189 
 
 ing began to subside. One year afterwards a second attack of 
 appendicitis occurred. An abscess was opened and drained forty- 
 eight hours after the onset of the symptoms, and two days later the 
 right parotid became inflamed, the opposite gland being involved 
 forty- eight hours after its fellow. In November, 1899, two years 
 and a half subsequent to the first seizure, a third attack occurred ; 
 the appendix was removed, and the pelvis drained. Once more 
 the right and then the left parotid became inflamed. There was 
 no rigor, and the symptoms were comparatively mild. 
 
 8. Weak Scav. — Stretching of the scar, and the forma- 
 tion of a weak spot in the abdominal wall, is most 
 commonly seen when the wound is in the area below the 
 umbilicus, as it is more subject to pressure in this 
 situation. A weak scar is most often seen after opera- 
 tions for the drainage of a septic cavity, and especially 
 after operations for tubercular peritonitis or tubercular 
 lesions of the appendix. It must be treated by strapping 
 the sides of the scar firmly together with adhesive 
 plaster, and making the patient wear a properly-fitting 
 abdominal belt. There must on no account be a pad on 
 the belt to press on the scar, as such pressure is liable 
 to cause atrophy of the tissues, and will tend to still 
 further weaken the scar. In some cases, especially in 
 children, it is better to keep the patients in bed for a 
 time until the scar has to some extent consolidated, and 
 then to let them get up with a belt, which should be 
 worn for six months or more. 
 
 g. Intestinal Obstruction. — Intestinal obstruction is an 
 accident that may follow any abdominal operation, but it 
 is most common after operations on the pelvic organs. 
 It is also not infrequently seen after operations upon the 
 appendix. The symptoms generally commence with 
 colicky pains in the abdomen, accompanied by distension 
 and sickness. There is also increasing difficulty in 
 getting the bowels to act. The patient may have been 
 
190 The After-Treatment of Operations 
 
 going on quite satisfactorily for the first three or four 
 days after the operation, and the bowels have been 
 opened on the third day by means of enemata, and then 
 something appears to go wrong. There is constipation, 
 accompanied by colicky pains, and great difficulty is 
 experienced in getting the bowels to act. This difficulty 
 increases, until in a very short time there is absolute 
 obstruction, and the ordinary symptoms of acute intes- 
 tinal obstruction are developed. The condition is most 
 commonly seen about five or six days after the operation. 
 Although the symptoms develop slowly, the condition 
 when once established is usually that of an acute obstruc- 
 tion. The pathology of the obstruction in these cases 
 is probably, that a coil of intestine becomes adherent to 
 some portion of the field of operation, and kinking takes 
 place in consequence. At first only slight narrowing of 
 the intestinal lumen results, but as the intestine above 
 gets more and more distended, the obstruction increases, 
 until often it becomes absolute. 
 
 As soon as ever the symptoms show themselves, and 
 this condition is suspected, prompt measures must be 
 taken for its relief. At first an attempt should be m,ade 
 to stretch or detach the adhesions by causing peristalsis 
 of the intestine. Large doses of salines may be adminis- 
 tered by the mouth, and turpentine enemata administered 
 by the rectum. Sir Watson Cheyne " draws attention to 
 the value of position in the treatment of this condition. 
 He advises that the patient should be placed in such a 
 position that a certain amount of dragging is produced 
 upon the adherent coil of intestine. Thus, the buttocks 
 should be raised, and, in fact, the patient placed in a 
 modified Trendelenburg position. Should these measures 
 not prove sffectual in getting rid of the obstruction, time- 
 * ' Surgical Treatment ' : Cheyne and Burghard, vol. vi. 
 
Operations on the Abdomen 191 
 
 must not be wasted, but the abdomen should be at once 
 reopened, and the adherent coll detached from the part 
 to which it has become adherent. Once the diagnosis of 
 secondary obstruction has been made, the best treatment 
 is, undoubtedly, to at once reopen the abdomen through 
 the original incision. The cause is most likely to be some 
 adhesion of bowel to the incision or its strangulation in a 
 stitch. The patient should not be exhausted by drastic 
 attempts at purgation before operation is resorted to. 
 
 The following list shows the causes found in 26 cases 
 of post-operative intestinal obstruction collected by 
 G. M. T. Finney:* Kinking, 7 cases; adhesions alone, 7; 
 bands, 3 ; volvulus, 2 ; loop caught beneath adherent 
 loop, I ; cicatricial stenosis, i ; gastro-mesenteric ileus, i ; 
 adynamic ileus, i ; cause unknown, 3, Ten of the 
 patients died, the remainder recovering as the result of 
 a secondary operation. 
 
 The following cases well illustrate the importance of 
 prompt surgical interference : 
 
 Case. — S. W. was operated upon for colotomy on June 6, and 
 on the second day after the operation the bowel was opened and 
 castor-oil administered by the mouth. No action of the bowels 
 took place, and vomiting began twenty-four hours later, and became 
 severe. Further attempts at purgation only increased the vomiting 
 without relieving the bowels. On June 10 the abdomen was re- 
 opened, when it was found that a piece of omentum was caught in 
 the spur stitch, and the drag on this was causing an acute kink in 
 the transverse colon. This was released, but the patient died 
 on the operating table. The operation should have been done 
 earlier. 
 
 Case. — A. M. was operated upon for chronic appendicitis, the 
 appendix being removed, and the abdomen closed without drainage. 
 Two deep stitches of fish-gut were put through all the thicknesses 
 of the abdominal wall, as well as supporting stitches. The patient 
 
 * Any.als of Suvgcry, June, 1906. 
 
192 The After-Treatment of Operations 
 
 did well for twenty- four hours, but then began to get much dis- 
 tended, and all efforts to open the bowels failed. The abdomen 
 was reopened on the third day through the original incision, when 
 it was found that a piece of the wall of the small bowel was caught 
 under one of the deep stitches and strangulated. This was released, 
 and the damaged patch of bowel inverted by stitches. The patient 
 made a good recovery. 
 
 10. Adhesions. — Adhesions, though they may not cause 
 actual intestinal obstruction, are not infrequently the 
 cause of very considerable trouble after some abdominal 
 operations, more especially those which have been done 
 for some inflammatory mischief. After the convalescent 
 period following the operation has passed, the patient 
 begins to get vague pains in the abdomen. These pains 
 are often accentuated by walking and exercise. There is 
 increasing difficulty in getting the bowels to act, and 
 aperient medicines have to be constantly taken. Colicky 
 pains often accompany any action of the bowels, and in 
 some cases the patient gets considerable pain in the 
 lower part of the abdomen if the bladder is allowed to 
 become distended. These symptoms often increase in 
 severity and may make the patient a chronic invalid. 
 The symptoms are due to adhesions between different 
 portions of the intestine or between the intestines and 
 other organs. 
 
 Sometimes the symptoms can be cured by massage 
 and suitable exercises in a gymnasium, and considerable 
 relief usually follows this line of treatment. 
 
 In some of the old-standing cases however it may 
 be necessary to open the abdomen and divide the 
 adhesions. 
 
 Illustrative Case. — A woman, aged thirty, was operated upon for 
 perforating appendicitis with a small abscess in the right iliac fossa. 
 She had had three previous attacks of appendicitis of less severity. 
 She recovered from the operation perfectly well, and had no com- 
 
Operations on the Abdomen 193 
 
 plications. She made, in fact, an uninterrupted recovery, and for 
 a time was lost sight of. When heard of two years later, she said 
 she had had increasing difficulty with the bowels since the opera- 
 tion, and that she had constantly to take medicine before she was 
 relieved. She was unable to stand for more than one or two hours 
 without getting severe pains in the abdominal region, and had 
 frequently to go and lie down. She was also unable to hold her 
 urine for any length of time without pain. All her symptoms 
 pointed to adhesions in the neighbourhood of the right iliac fossa. 
 Careful regulation of the bowels and suitable massage and exercises 
 were effectual in getting rid of all her symptoms. 
 
 11. Ventral Hernia. — A hernia through the scar is a 
 possibiHty after any laparotomy if a large incision has 
 been made. The modern practice of opening the 
 abdomen by splitting the muscles and closing it in 
 layers has done much to prevent the occurrence of this 
 complication. It was a not uncommon complication when 
 the usual practice was to close the abdominal wound 
 with a single row of sutures. It is particularly liable to 
 occur if the wound does not close by first intention. 
 When a hernia occurs the effect of a properly fitting 
 belt should be tried for a time, and if no improvement 
 follows, an operation to close the defect should be under- 
 taken. 
 
 12. Post-operative Acute Dilatation of the Stomach. — This 
 most serious complication may occur after any operation 
 involving the abdominal cavity. It may come on at 
 once or after some days. Vomiting is usual, but not 
 invariable. The distension is very great, and the patient 
 rapidly becomes very ill. 
 
 In many cases death occurs in the course of two or 
 three days, but cases of recovery are known. There 
 is usually no obstruction found post mortem, though 
 in one or two instances internal herniae have been 
 found. 
 
 The best treatment would seem to be lavage cf the 
 
 13 
 
194 The After-Treatment of Operations 
 
 stomach with a stomach -tube two or three times a day 
 till the distension passes off, and subcutaneous infusion 
 with saline solution. 
 
 Operation is not indicated as a rule, but gastro- 
 enterostomy has been done successfully in one or two 
 cases. 
 
 Illustrative Case. — A man aged fifty-eight was operated on for a 
 ;eft inguinal hernia after forty-eight hours careful preparation for 
 operation. The Trendelenburg position was used for about twenty 
 minutes during the operation. After operation gastric distension 
 came on rapidly. There was no vomiting. Relief followed the 
 use of the stomach-tube, and it was used about twice daily for 
 some days. 
 
 The patient recovered. Six months later he was again operated 
 on for a right inguinal hernia, and the same symptoms occurred, 
 though on this occasion local anaesthesia with cocaine was used. 
 
 13. Foreign Bodies left in the Abdomen. — Leaving a foreign 
 body inside the abdomen after an operation is a most 
 unfortunate accident, and one which should never occur. 
 As long, however, as it is human to err, such accidents 
 will occasionally take place, and it is only by the adoption 
 of systematic methods that they can be prevented. 
 
 The foreign bodies which have been left behind are 
 various, and include clips, scissors, sponges, swabs, 
 pieces of rubbgr-tubing, etc. Sponges and swabs have 
 been known to become encysted, and to have remained 
 for long periods in the abdominal cavity without causing 
 any symptoms, and have sometimes been mistaken for 
 tumours at a later date. This is, however, by no means 
 always the case, and very serious complications may 
 follow the leaving of such foreign bodies in the abdomen. 
 Ulceration into the bowel or some other hollow viscus 
 may follow, and may prove fatal ; or an abscess may 
 form beneath the skin, and a sinus develop down to the 
 foreign body. There are a few cases on record where 
 
Operations on the Abdomen 195 
 
 such foreign bodies have been spontaneously discharged 
 from an abscess. Instruments left behind are certain to 
 give rise to very serious complications. 
 
 The best way of preventing an accident of this kind 
 is to adopt a form of operative technique that does not 
 allow the possibility of any mistake. 
 
 The mere counting of sponges and swabs after an 
 operation is not by itself sufficient. A potent cause of 
 such accidents is the practice of cutting in half sponges 
 or swabs during the operation, or of cutting off pieces of 
 gauze to pack round a stump or to arrest haemorrhage. 
 This should never be done. It is very liable to result in 
 something being left behind, and counting the sponges 
 or swabs afterwards will not prevent this if the number 
 has been changed in the course of operation. 
 
 The best plan, if sponges are used, is to use only three 
 or six, and, if more are necessary, to have them in 
 multiples of three ; then, if at the en-d of the operation 
 the sponges are still in multiples of three, none can be 
 left behind. The surgeon should himself be responsible 
 for counting the sponges. 
 
 Another and safer plan is to use square sterilized 
 cloths instead of sponges, with a piece of tape sewn to 
 one corner. The end of the tape is clipped and left 
 hanging down outside the wound. These sterilized 
 cloths are better than sponges for packing off the field 
 of operation, and if used in this way cannot be left 
 behind. 
 
 Another very good plan is to use the end of a roll of 
 sterilized gauze to pack round the site of operation, the 
 roll itself being kept on the towels, and more gauze 
 unwound as it is needed, but the gauze never cut. The 
 portion of gauze at the edge of the wound can be used 
 for swabbing. As the whole of the gauze in use is in one 
 
196 The After-Treatmcnt of Operations 
 
 continuous piece, it is quite impossible for any of it to be 
 left behind so long as it is not cut. 
 
 The clips used in the operation should be in dozens 
 or half-dozens, and should be counted before and after 
 the operation by the surgeon himself. The plan of using 
 a porcelain rack with numbered holes for the clips, as 
 suggested by Mr. Marmaduke Sheild [Lancet, June 11, 
 1904), is an excellent method of preventing this untowar J 
 accident. 
 
 Fig. 28. 
 
 Abdominal Belts for Use after Laparotomy. — 
 There are many different kinds of belts, and the exact 
 form is not of much importance. The principal points 
 of a good belt are an accurate fit and a good support to 
 the lower part of the abdomen immediately over the 
 pelvic brim. A belt which constricts the abdomen with- 
 out supporting it is bad, and will do more harm than 
 good. A good form of belt is shown in Fig. 28. 
 
CHAPTER XIV 
 OPERATIONS ON THE ABDOMEN {continued) 
 
 Cases of Acute General Peritonitis. 
 
 The modern method of treating such cases is to deaV 
 with the cause of the infection as rapidly and effectually 
 as possible, and to drain, by means of tubes, those 
 portions of the abdominal cavity in which pus tends to 
 collect. Everything, however, depends on the after- 
 treatment in these cases. The patient should from the 
 first be nursed in what has been called the Fowler 
 position — that is to say, in the semi-sitting position shown 
 on p. 6. In this position the pus and serous discharge 
 will gravitate into the pelvis, where they can escape, and 
 away from the upper and more dangerous areas of the 
 abdomen. The patient should be kept in this position 
 throughout, and must not be allowed to assume the 
 horizontal position until the peritonitis has subsided. 
 
 The other important point is to administer large 
 quantities of saline solution by the rectum. The best 
 plan is to arrange continuous rectal irrigation. This is 
 done by means of an ordinary irrigator or douche with a 
 vaginal nozzle, which is passed into the rectum. The 
 top of the fluid in the irrigator should not be more than 
 6 inches above the level of the anus, so that the fluid 
 runs in slowly. The irrigator must be kept full of warm 
 
 197 
 
198 The After-Treatment of Operations 
 
 saline solution. From 10 to 20 pints should be allowed 
 to absorb from the bowel during the first twenty-four 
 hours, and continued, if necessary. This is a most 
 valuable means of treating acute peritonitis, as it washes 
 out the poisons in the blood and tissues and helps their 
 elimination. 
 
 The dressings should be changed frequently, and the 
 drainage-tubes shortened and ultimately removed as 
 soon as the discharge from them gets less or ceases. 
 
 It seems certain that the drainage of the peritoneal 
 cavity by means of tubes is not effective for more than 
 about twenty-four or forty-eight hours, and there is, there- 
 fore, nothing to be gained by leaving the tubes in for 
 more than two or three days. 
 
 Very little, if any, food should be given by the mouth 
 for the first two days, but nutrient liquids may be added 
 to the rectal irrigating fluid from time to time. 
 
 The bowels should be moved as soon as possible by 
 means of castor -oil or calomel, and should be kept 
 acting freely during convalescence, so as to prevent, as 
 far as possible, the formation of adhesions. 
 
 Operations on the Stomach. 
 
 Special Complications. — (i) Pneumonia; (2) re- 
 gurgitant vomiting ; (3) haematemesis. 
 
 I. Pneumonia.- — One of the commonest causes of death 
 after operations on the stomach, and more especially 
 operations undertaken for the relief of pyloric stenosis, is 
 pneumonia. The reason for this is that the patients are 
 often old or enfeebled subjects, and that the free move- 
 ment of the upper abdominal muscles and, to some extent, 
 the diaphragm are interfered with owing to the incision. 
 The respirations in consequence are shallow, as the 
 patient is afraid of the pain caused by a deep inspiration, 
 
Operations on the Abdomen 199 
 
 Coughing is for the same reason prevented, and, as a 
 result, mucus collects in the most dependent parts of the 
 lungs and sets up hypostatic pneumonia. The best way 
 of preventing this is to nurse the patient as far as possible 
 in a sitting position ; the knees should be flexed over a 
 cushion or bolster, and the back and head supported with 
 a bed-rest and pillows. 
 
 A good way of preventing pulmonary trouble after 
 operations on the abdomen is to instruct the nurse to get 
 the patient to take a few deep breaths so as to com- 
 pletely fill the chest every few hours. 
 
 2. Regurgitant Vomiting. — This sometimes follows the 
 operation of gastro-enterostomy. When it comes on 
 about two or three days after the operation and there are 
 no signs of peritonitis, it is usually due to the formation 
 of the so-called ' vicious circle ' — that is to say, a kink 
 has formed in the intestinal loop, and the contents of the 
 stomach, instead of passing into the distal portion of the 
 intestine, are passing into the proximal or duodenal por- 
 tion, and so back into the stomach (Figs. 29 and 30). 
 This should be especially suspected if there is much bile 
 present in the vomit. It used to be supposed that the 
 presence of bile in the stomach was the cause of the 
 vomiting, but it has now been shown that this is not the 
 case. The vomiting is probably always due to some 
 blockage in the new anastomotic opening, which may be 
 of either a temporary or permanent nature. The vomiting 
 may be but slight, occurring only a few times and then 
 ceasing altogether, or it may be so serious as to quickly 
 cause a fatal issue. When regurgitant vomiting occurs, 
 the stomach should be washed out, and all feeding by the 
 mouth stopped for a time. Changing the patient's position 
 is sometimes effectual in freeing the bowel. Thus, if the 
 patient has been propped up he should be made to lie down 
 
2co The After-Treatment of Operations 
 
 Fig. 29. — Formation of a ' Vicious 
 Circle ' after Anterior Gas- 
 
 TRO - enterostomy, DUE TO A 
 
 Faulty Operation and Peri- 
 stalsis occurring in Opposite 
 Directions in the Stomach 
 AND Intestine. 
 
 Fig. 30. — Formation of a ' Vicious 
 Circle' after Anterior Gas- 
 tro-enterostomy, due to the 
 Formation of a Spur by the 
 Drag of the Intestine. 
 
 Fig. 31. — Method of Curing a 
 ' Vicious Circle ' by Anasto- 
 mosis between the Afferent 
 and Efferent Loops of Intes- 
 tine. This is the best Opera- 
 tion IN Cases where a 'Vicious 
 Circle ' has formed and a 
 Secondary Operation has 
 become necessary for its 
 relief. 
 
 Fig. 32. — Another Method 
 of Curing or Preventing 
 A 'Vicious Circle.' The 
 Y Operation. 
 
operations on the Abdomen 201 
 
 flat on his back so as to prevent the drag on the loop of 
 intestine. Giving the patient large draughts of water to 
 drink has occasionally stopped the vomiting. The bowels 
 should also be got to act well. If these measures fail to 
 stop the vomiting, another operation should at once be 
 performed to make a free exit for the stomach contents 
 into the bowel. Probably the best operation to perform 
 under these circumstances is to anastomose the loop 
 between the pylorus and stomach to the distal portion 
 of the intestine lower down (Fig. 31). In slight cases 
 of regurgitant vomiting, lavage of the stomach every 
 twenty-four hours will give rehef ; in bad cases opera- 
 tion must be at once resorted to. When persistent 
 vomiting follows other operations on the stomach than 
 gastro-enterostomy, it is probably due to acute gastritis 
 or peritonitis, and must be treated accordingly. 
 
 3. HcBmatemesis. — Vomiting of blood after operations 
 on the stomach is not at all uncommon for the fir^t 
 twenty-four or forty-eight hours. It is generally, how- 
 ever, only the blood which has got into the stomach at 
 the time of the operation, and need not cause alarm. 
 When, however, the blood is bright in colour, and there 
 is reason to suppose that it is the result of oozing from 
 the stomach wound, a little hot water may be given to 
 drink with a view to stopping it, or the stomach may be 
 gently irrigated with warm boracic lotion by means of a 
 soft tube. It is seldom that the bleeding is of any con- 
 sequence. 
 
 Position after Operations on the Stomach. — The 
 best position in most cases is the half-sitting position 
 already mentioned, but the exact position must depend 
 upon the nature of the lesion and its site in the stomach. 
 Thus, in many cases our object should be to keep the 
 patient in that position which will allow of fluids, etc., 
 
20 2 The After-Treatinent of Operations 
 
 most easily finding an exit from the stomach into the 
 intestines. Since the pylorus is to the right side, the 
 right lateral position is, in many cases, advisable, and 
 is always to be preferred to the left lateral or supine 
 positions. The power of the stomach to expel its contents 
 is usually very feeble after any operation upon its walls, 
 and we must try to assist it, as far as possible, by means 
 of gravity. 
 
 It is an excellent plan when patients are being nursed 
 in the sitting position to allow them to sleep at night in 
 the right lateral recumbent position. They not only 
 sleep better in this position, but it prevents the accumula- 
 tion of fluids in the stomach, and insures free drainage 
 from that organ into the intestine during the night. 
 Moving the patient's position from time to time also 
 tends to prevent the formation of bed-sores, which are 
 otherwise very liable to form m the case of old and 
 emaciated subjects. 
 
 Again, in the case of ulcers which have been treated 
 surgically, we must try to keep the patient in such a 
 position that the wound will not be in a dependent part 
 of the stomach, and so will not be constantly in contact 
 with the contents, be it food or mucus. 
 
 As in these cases it is particularly desirable that there 
 should not be any vomiting after the operation, owing to 
 the strain which it might throw upon the stitches in the 
 wall of the stomach, it is best not to give anything by 
 the mouth for the first twenty-four or forty-eight hours, 
 and rectal feeding should be adopted. Patients often 
 complain of great thirst ; this must be appeased by 
 giving warm water enemata, and sometimes a thin slice 
 of lemon to suck will make the patient more comfortable. 
 When the patient is old or much enfeebled as the result 
 of his condition previous to the operation, it is often not 
 
Operations on the Abdomen 203 
 
 wise to depend entirely on rectal feeding even for the 
 first two days, and he should be given small quantities 
 of fluid diet, such as albumin-water every two or three 
 hours, as soon as the results of the anaesthetic have 
 passed off. The diet should be entirely fluid for the first 
 five days or a week after the operation. The sugar diet 
 already mentioned is a very suitable one in stomach 
 cases, and may be combined with albumin-water. The 
 wound in the stomach wall is probably healed at the end 
 of a week or ten days. Mr. Barker* recommends that 
 when the patient after an operation on the stomach 
 complains of a feeling of weight and distension in the 
 region of the stomach, a soft tube should be passed 
 and the fluids contained in the stomach siphoned off. 
 He says that very marked relief from pain and discom- 
 fort often follows this procedure ; it may be employed 
 during the first twenty-four hours, and repeated if neces- 
 sary. 
 
 Operations on the Gail-Bladder and Biliary 
 Ducts. 
 
 Special Complications. — (i) Haemorrhage; (2) 
 biliary fistula ; (3) broncho-pneumonia and pleurisy ; 
 (4) acute dilatation of the stomach ; (5) vomiting. 
 
 I. Hamonhage. — Many of these operations have of 
 necessity to be performed upon patients who are suffer- 
 ing from jaundice, and the coagulability of the blood 
 under these conditions seems to be altered in much 
 the same way as is the case in patients the subject of 
 haemophilia. Oozing from all parts of the wound takes 
 place, and if not stopped often proves fatal. This 
 oozing may not come on for two or three days after the 
 * Lancet, August 22, 1902. 
 
204 The After-Treatment of Operations 
 
 operation. The value of calcium salts by mouth or 
 rectum as a means of preventing hsemorrhage in these 
 cases seems very doubtful, and many surgeons have given 
 it up. Moynihan now advises the use of horse or rabbit 
 serum, of which 20 c.c. are injected subcutaneously five 
 or six hours before operation. Thyroid extract has also 
 been used to shorten the blood coagulability time in these 
 cases with success. 
 
 2. Biliary Fistula. — This is an extremely troublesome 
 affection, which occasionally follows operations on the 
 gall-bladder. As a rule, these fistulae close spontane- 
 ously in the course of a month or two. When, however, 
 this is not the case, it is generally due to there being a 
 block in the common duct, either from an impacted 
 stone, malignant disease of the head of the pancreas, or 
 as the result of adhesions, and, if possible, a further 
 operation should be performed for its relief. 
 
 When the biliary fistula is accompanied by absence of 
 bile in the stools, as shown by clay-coloured faeces, it is 
 practically certain that the cause of the fistula is a block 
 lower down in the biliary passages, and a second 
 operation must be performed. When, however, there is 
 a certain amount of bile in the faeces, it is better to wait 
 for some time, to see whether the fistula will close 
 spontaneously. 
 
 3. Broncho -pneumonia and Pleurisy. — These complica- 
 tions often result from the interference with the move- 
 ments of the diaphragm caused by the operation. They 
 are best guarded against by nursing the patient in a 
 semi-recumbent position. 
 
 4. Acute Dilatation of the Stomach. — This is said to have 
 followed the operation of choledochotomy in some cases. 
 It is best treated by gastric lavage and rectal feeding. 
 
 5. Vomiting. — It may be mentioned here that persistent 
 
Operations on the Abdomen 205 
 
 vomiting may occur after these operations when a large 
 gauze plug has been inserted. The vomiting often ceases 
 after removal of the plug. 
 
 Operations for Appendicitis. 
 
 Complications. — (i) Peritonitis; (2) meteorism ; 
 (3) faecal fistula ; (4) empyema ; (5) thrombosis ; 
 (6) infarction of the lung ; (7) loculation of pus ; 
 (8) adhesions. 
 
 The treatment of the wound is the same as for any 
 other abscess, but it is very important that the drainage- 
 tube should not be left out until all the deeper parts of 
 the wound have healed, as otherwise the opening in 
 the skin is very liable to contract and allow the pus 
 to pocket. Sometimes a week or ten days after the 
 operation, when the patient is apparently almost well 
 again, there is a rise in temperature and pain at the site 
 of the wound — in fact, a recurrence of the original 
 symptoms. This usually means that another abscess 
 has formed in the deeper parts of the wound cavity ; in 
 other words, some pus has pocketed, and got shut oft 
 from the rest of the wound. Under these circumstances 
 the wound should be carefully dilated and explored with 
 the finger or a director until the pus is found, and given 
 a free exit. Great caution must, however, be exercised 
 in doing this, or there will be danger of opening the 
 general peritoneal cavity and setting up peritonitis. 
 
 The rectal tube should always be used after the 
 operation as a precautionary measure against distension. 
 It is particularly in these cases that distension and 
 meteorism are liable to occur. The patient should have 
 the tube placed through the sphincters, and left in for 
 one hour in six hours, commencing soon after the opera- 
 tion (see page 171). 
 
2o6 The After-Treatment of Operations 
 
 It is most important, after all operations for appendi- 
 citis, to get the bowels to act as soon as possible. An 
 enema should be administered on the day after the 
 operation, and, if it fails to act, should be followed by a 
 dose of salts or castor oil. 
 
 In cases where there is a large foul abscess cavity left 
 after the operation, it should be irrigated daily or twice 
 daily. Care must be taken, however, to irrigate gently 
 and to allow a free exit for the fluid, as otherwise there 
 is some risk of forcing the fluid into the general peritoneal 
 cavity, and so perhaps causing general peritonitis. There 
 is no advantage, as a rule, in using antiseptic solutions for 
 irrigating the abscess cavity. In most cases the best fluid 
 for the purpose is normal saline solution ; in cases where 
 the abscess cavity is very foul and sloughy, hydrogen 
 peroxide is often very useful in cleaning up the wound ; it 
 should be used of a strength of 5 volumes. Other 
 solutions which may be used under the same circum- 
 stances are chlorine-water andlysoform in weak solution. 
 
 The author has recently analyzed the after-history in 
 100 consecutive cases of operation for appendicitis in one 
 of the London hospitals, for the purpose of ascertaining 
 the percentage of complications and the after-results that 
 may follow this operation. 
 
 In this series the mortality was 8 per cent. ; of these 
 3 cases died from meteorism and peritonitis, 2 from other 
 forms of sepsis, 2 from bronchitis, and i from infarction 
 of the lung. 
 
 Complications, including several cases of stitch sup- 
 puration, occurred in 48 per cent, of the cases. 
 
 In 4 per cent, the patient developed a secondary 
 empyema on the right side, and in i per cent, a right 
 pleurisy. Infarction of the lung occurred in 5 per cent, 
 of the cases, the infarction occurring in i case on the first 
 
Operations on the Abdomen 207 
 
 day, in 2 cases on the ninth day, in i case on the tenth 
 day, and in i case on the twelfth day ; and of these 5 cases, 
 thrombosis in the lower extremities was detected in 3. 
 
 Loculation of the pus with recurrence of some of 
 the symptoms, and necessitating reopening the wound 
 occurred in 15 per cent, of cases. 
 
 A faecal fistula formed in g per cent. Meteorism 
 occurred as a complication in 7 per cent, of the cases. 
 
 The percentage of complications in this series seems 
 high, but this is accounted for by the fact that, as in all 
 hospital statistics, many cases are included which were 
 in a desperate state when operated upon. 
 
 These statistics were made in 1903, and would not 
 apply to-day, as with the great improvements in technique 
 and in aseptic methods which have occurred since then, 
 combined with the fact that cases of acute appendicitis 
 are now operated upon much earlier than was then the 
 case, complications of all sorts have been enoripously 
 diminished, so that the mortality is now less than i per 
 cent, in the best practices, and complications generally 
 correspondingly less frequent. 
 
 A certain amount of trouble may be experienced in 
 getting the bowels to act for the first few weeks after 
 the operation, owing to the formation of adhesions 
 between the coils of intestine. This is particularly 
 liable to occur if the abscess has tracted down into the 
 pelvis. It can, however, be overcome by the proper use 
 of salts, and in most cases the adhesions will soon stretch 
 and disappear. 
 
 When an abscess has been opened, or there has been 
 much inflammatory mischief around the appendix, 
 adhesions are apt to form in the neighbourhood of the 
 wound, and as time elapses, and these adhesions contract, 
 they may cause a considerable amount of discomfort and 
 
2o8 The After-Treatment of Operations 
 
 pain. In the cases analyzed by the author, symptoms 
 which appeared to be caused by adhesions were present 
 from one to two years after the operation in i8 per cent- 
 (see also p. 192). 
 
 The different complications and the methods of dealing 
 with them have already been referred to in the previous 
 chapter. 
 
 Ventral hernia sometimes follows the operation for 
 removal of the appendix, and it is a peculiar fact about 
 these herniae that they are often very painful. When 
 this is the case, a further operation should be performed 
 for the cure of the hernia. 
 
 Radical Cure of Hernia. 
 
 Special Complications. — (i) Epididymo - orchitis ; 
 (2) retention of urine ; (3) separation of the deep sutures ; 
 (4) persistent vomiting ; (5) recurrence. 
 
 In order to keep the dressings dry it is advisable, in the 
 male, to place a piece of jaconet with a hole in it over 
 the dressings, the penis being made to emerge through 
 the hole. In young children it is so difficult to keep the 
 dressings dry that it is advisable to apply a collodion 
 dressing to the wound in the first instance, and to place 
 a large pad of wool over this, which can be changed con- 
 stantly. The best way of nursing quite young children 
 after operations for the radical cure of hernia is to sling 
 their legs up to a cross-bar over the bed, in the same way 
 as is done in Bryant's method of treating fracture of the 
 femur. This not only enables the small patient to be 
 kept much cleaner than would otherwise be the case, but 
 the flexed position of the thigh acts as a protection to the 
 inguinal rings, and prevents undue pressure being exerted 
 on them, during the period of healing of the wound, from 
 crying, etc. 
 
Operations on the Abdomen 209 
 
 Ihe usual time during which the patient should be 
 kept in bed after these operations is from three weeks to 
 a month. Three weeks is, however, all that is usually 
 necessary. When the patient is first allowed to get up 
 after the operation, a pad of wool held on by a firm 
 spica bandage should be applied over the inguinal 
 canal. This should be worn for the first week. After 
 that all support to the canal can usually be dispensed 
 with. The use of a truss after the radical cure of 
 hernia is inadvisable, as the continuous pressure exerted 
 by a truss tends to weaken the scar and surrounding 
 tissues, and therefore tends towards the recurrence of 
 the affection. Of course, when the operation has been 
 undertaken for the purpose of enabling the patient to 
 wear a truss — that is to say, when, owing to the nature 
 of the case, a real radical cure of the condition was not 
 to be expected, and the operation was undertaken with 
 the object of so improving the local conditions as to 
 allow of a truss keeping up the hernia — the case is 
 different : a light truss, therefore, should be ordered in 
 these cases. The patient after the operation for hernia 
 should be warned against the danger of lifting heavy 
 weights, or exerting himself in any way, for the. first two 
 months or so afterwards, as the parts are not thoroughly 
 consolidated for that time, and any violent exertion is 
 liable to cause the hernia to come down again. 
 
 I. Epididymo -orchitis. — It is not at all uncommon after 
 operations for hernia to find a few days after the opera- 
 tion that there is some swelling and tenderness of the 
 epididymis and testicle on the same side. This is most 
 probably due to the interference with the veins of the 
 cord at the time of the operation, or to the cord being 
 constricted by the ring having been sewn up a little too 
 tightly. The swelling is often considerable, but it is of no 
 
 14. 
 
2 10 The After-Treatment of Operations 
 
 consequence, and all subsides in the course of a day or 
 two. If there is much pain or discomfort, the testicle 
 should be supported by a small cushion or slung up well 
 on to the abdomen by means of a bandage, and evapor- 
 ating lotions applied to relieve the pain. Occasionally 
 this swelling and enlargement of the testis, etc., persists 
 for a week or two, but invariably subsides without any 
 harm resulting. 
 
 2. Retention of Urine. — This is not uncommon tor the 
 first twenty-four hours after the operation. Loosening 
 the bandages is sometimes all that is necessary to enable 
 the patient to pass his water. If simple means fail, a 
 catheter should be passed and the urine drawn off, the 
 usual precautions being, of course, taken to prevent the 
 introduction of organisms into the bladder. 
 
 3. Separation of the Deep Sutures. — This has already 
 been referred to under the head of ' Laparotomy.' It 
 is a particularly annoying complication in these cases, 
 as it may render the operation ineffectual. 
 
 4. Persistent Vomiting. — Leaving out of account the 
 vomiting due to the anaesthetic, peritonitis, or meteorism, 
 which have already been referred to, this complication 
 is usually seen after operations for the cure of large 
 scrotal hernia when portions of the omentum have been 
 ligatured and cut away. The vomiting generally comes 
 on about a week or ten days after the operation, and is 
 accompanied by some tenderness of the abdomen and 
 symptoms which at first are easily mistaken for those of 
 peritonitis. The condition is either due to some sloughing 
 of the omental stump or to the formation of adhesions 
 between it and the surrounding coils of intestine. The 
 condition is not common, but is seen occasionally ; the 
 symptoms generally pass off in the course of a few days, 
 and no harm results to the patient. The patient should 
 
Operations on the Abdomen 2ii 
 
 be put on a fluid diet again if solids have been allowed, 
 and the bowels should be well opened with saline 
 aperients. The symptoms usually subside after the 
 bowels have been well opened. Pain often accompanies 
 the symptoms, and is best treated by hot fomentations; 
 and, if necessary, by the use of morphia. 
 
 5. Recurrence. — The question of recurrence hardly 
 comes within the scope of this work. Fortunately, with 
 the present improved methods of operating it is not very 
 often seen now, but even after the best operations cases 
 will occasionally occur. In the case of hospital patients, 
 many of whom are navvies, whose work entails the lifting 
 of heavy weights, often with the knees bent, and who 
 can seldom afiford to keep away from their work for a 
 sufficient time after the operation to insure the best 
 results from it, it is not surprising that recurrence is 
 sometimes seen ; indeed, it is a matter of surprise that 
 the results under these circumstances are as good as 
 they are. 
 
 Operations on the Kidney. 
 
 Special Complications. — (i) Uraemia; (2) severe 
 pain ; (3) vomiting ; (4) high temperature ; (5) pulmonary 
 embolism ; (6) hgematuria ; (7) renal colic. 
 
 The after-treatment of these cases is practically the 
 same as for laparotomy. When a drain has been placed 
 in the loin, frequent changing of the dressings will be 
 necessary to keep the patient dry, and if there is a ten- 
 dency for the akin round the wound to become sore from 
 the constant irritation of the discharge, a little ointment 
 should be smeared over the skin to prevent this. After 
 nephrectomy everything that is possible should be done 
 to diminish the work of the remaining kidney until it has 
 
212 The After-Treattnent of Operations 
 
 become accustomed to the new conditions. The diet 
 should be bland, and all highly nitrogenous diets are 
 best avoided, as they will give the kidney more work to 
 do in excreting urea than would less nitrogenous diets. 
 Morphia or opium in any form is best avoided, as it tends 
 to diminish urinary secretion. The skin and bowels 
 should be kept acting, so as to relieve the work of the 
 remaining kidney. The amount of urine passed per 
 diem should be measured and charted, so that any 
 diminution in the quantity may be noticed at once. 
 
 1. Uremia. — When the excretion of urine diminishes 
 and uraemia threatens, the case should be treated in the 
 same way as for an ordinary case of uraemia— that is to 
 say, the skin must be made to act by the use of hot-air 
 baths or pilocarpine, and the bowels must be kept acting 
 freely. The application of hot fomentations over the 
 healthy kidney is often useful. 
 
 2. Pom does not always occur, but may be very severe. 
 It is g^ierally of a shooting character, running dow^n 
 into the groin and inner side of the thigh on the same 
 side. Sir William Bennett has pointed out that when 
 this pain is present in a marked degree after the kidney 
 has been stitched into the loin (nephrorrhaphy), a nerve 
 has probably been included in the suture. On one occa- 
 sion, when the pain was especially severe, he found this 
 to be the case. The advisability in such a case of open- 
 ing the wound and dividing the suture will have to be 
 considered. 
 
 Slight renal colic may occur after some operations on 
 the kidney, especially nephrotomy, and is due to the 
 passage of blood-clots down the ureter. This is best 
 treated by hot fomentations, etc. Morphia must not be 
 given if there is any uncertainty as to the condition of 
 the other kidney. If, however, it is known that the other 
 
Operations on the Abdomen 2 1 3 
 
 kidney is healthy, and there has been no diminution in 
 the amount of urine excreted since the operation, it may 
 be given with safety. 
 
 3. Persistent Vomiting after operations on the kidney, 
 and especially after nephrorrhaphy, sometimes occurs, 
 and may accompany the high temperature mentioned 
 below. It is probably due to the same cause. The 
 patient often vomits on and off for some days ; the con- 
 dition is not, as a rule, serious. It is as well to remember 
 the possibility of this complication occurring after opera- 
 tions on the kidney, as otherwise the symptoms may give 
 rise to serious fears of peritonitis. 
 
 4. High Temperature. — A high temperature is not at 
 all uncommon after the kidney has been much inter- 
 fered with. After nephrorrhaphy a high temperature 
 may persist for a week or longer, the temperature often 
 varying from 100° to 103° F. This is probably due to 
 interference with the sympathetic nerves. It need not 
 give rise to alarm, and it is not accompanied by any 
 inflammatory condition. The temperature rises directly 
 after the operation, and remains up. Should the tempera- 
 ture, however, be normal or subnormal for the first few 
 days and then rise, it will not be due to this cause, and 
 sepsis must be suspected and the wound examined, 
 and, if necessary, opened. The patient may, while the 
 temperature persists, feel flushed and uncomfortable. 
 
 5. Pulmonary Embolism. — This is, fortunately, a rare 
 complication. For treatment, see Chapter VII. 
 
 6. Hmnaturia. — This not infrequently occurs after 
 operations in which the kidney has been explored. It 
 is due to oozing from the kidney substance, and, as a 
 rule, stops within forty-eight hours of the operation. If 
 severe, it should be treated by an ice-bag applied to the 
 loin, and calcium chloride by the mouth or rectum, in 
 
214 The After-Treatment of Operations 
 
 large doses. It should never be treated by administer- 
 ing adrenalin or ergot internally, as these drugs raise the 
 general blood-pressure without constricting the renal 
 vessels, and so tend to increase the haemorrhage. 
 
 7. Renal Colic — This may occur after nephrotomy. 
 It may be due to — {a) the passage of a blood-clot down 
 the ureter; {h) a portion of stone which has become 
 detached from the main stone during its removal from 
 the renal pelvis, or even to a small stone which has been 
 overlooked at the operation. 
 
 The best treatment under such circumstances is to 
 relieve the pain by morphia and hot stupes to the loin 
 and abdomen, and at the same time to give the patient 
 plenty of fluid to drink so as to wash out the clot or 
 fragment in the ureter. 
 
CHAPTER XV 
 OPERATIONS ON THE GENITO-URINARY TRACT 
 
 One of the most important things to be attended to in 
 the after-treatment of operations on the genito-urinary 
 tract is to keep the patient as dry as possible. There is 
 a great tendency for the dressings to become soaked with 
 urine, and if such dressings remain long in contact with 
 the skin, especially of old men, it is very liable to get raw 
 and inflamed. And quite apart from this, the constant 
 state of smell and dampness which the patient is in 
 cannot but cause him considerable misery and discom- 
 fort. To prevent this the dressings should be frequently 
 changed, and mackintosh sheets should be arranged round 
 the ends of the tubes, etc., to prevent, as far as possible, 
 the urine getting on to the dressings. It is well to keep 
 the skin powdered with starch or boracic powder. 
 
 Most wounds resulting from operations on the bladder 
 or urethra are left open, and have to heal by granulation. 
 Consequently it is necessary to frequently change the 
 dressings and to keep the wound clean by irrigation. 
 These cases require constant attention and skilled 
 nursing. It is important to see that the patient has a 
 suitable bed. This should be a good height, as a low 
 bed is a great inconvenience ; and it should also have a 
 mattress which does not form a hollow in the middle. 
 
 215 
 
2i6 The After-Treatment of Operations 
 
 A pneumatic ring-pillow with a removable linen cover 
 should be placed under the patient's sacrum. 
 
 The best way to alleviate pain after these operations is 
 by means of suppositories of morphia and belladonna, 
 though the use of opium in any form is best avoided in 
 cases where the kidneys have been interfered with or 
 where they are thought to be diseased. The bowels 
 should always be kept acting loosely for some time after 
 the operation. One of the most important things to 
 assure success in these operations is to keep the urine 
 sweet and to prevent acidity. For this purpose some 
 drug should be given which is excreted in the urine as 
 an antiseptic. Of these there are several, Boracic acid 
 or salol, given in lo-grain doses three times daily, may 
 be used, or urotropine, in 5 to 10 grain doses in an ounce 
 of water, three times daily ; free diuresis is more im- 
 portant than drugs, and to secure this the patient should 
 be encouraged to drink plenty of barley-water or other 
 fluids. Where the urine, in spite of these precautions, 
 remains foul, and cystitis is present, the bladder should 
 be washed out twice a day with some mild antiseptic, 
 such as boracic lotion. 
 
 The use of stronger antiseptics than this is not 
 advisable, as they often give rise to a considerable 
 amount of pain, and are liable to make the cystitis 
 worse. Where the cystitis will not improve with this 
 treatment, solutions of protargol or argyrol (| to i per 
 cent.) may be used with advantage. In washing out 
 the bladder, only 2 or 3 ounces of fluid must be injected 
 at a time and allowed to run out again, this being re- 
 peated until the solution comes back quite clear. The 
 solution should be at a temperature of about 100° F. 
 The best apparatus for washing out the bladder is a soft 
 rubber catheter on the end of a glass funnel. 
 
Genito-Urinary Tract Operations 217 
 
 When the urine is very alkaline, benzoate of ammonium 
 can be combined with the boric acid in lo-grain doses 
 three times a day by the mouth, or urotropine may be 
 used. When the urine is very acid, bicarbonate of soda, 
 in 10 or 20 grain doses, should be given by the mouth, 
 either alone or combined with one of the other drugs 
 mentioned above uritil the urine is rendered neutral. 
 
 Catheter Fever. — After any operation on the 
 urethral tract, or after the passage of instruments, etc., 
 the so-called condition of catheter or urethral fever is 
 liable to occur. It usually comes on during the first 
 thirty-six hours, though it sometimes occurs after the 
 removal of an instrument that has been tied in at the 
 operation, and it is well to be on the look-out for this. 
 It often follows the first act of micturition after the 
 operation. The patient shivers, and has a rigor, followed 
 by a hot stage and profuse sweating ; this condi- 
 tion soon passes off in the majority of cases, and 
 is not dangerous unless followed by suppression of 
 urine, which is very rarely seen, and practically only 
 occurs when the kidneys are diseased — 10 grains of 
 Dover's powder, administered before the operation, 
 will usually prevent the occurrence of these unpleasant 
 symptoms. If a large catheter has been tied in after 
 the operation, the same powder, given that night, 
 will often facilitate its removal next day, and add to 
 the comfort of the patient ; or an excellent plan is to 
 remove the instrument while the patient is sitting in a 
 hot bath. This is a good plan whenever large instru- 
 ments have to be passed or withdrawn from irritable 
 urethras. In order to prevent the occurrence of this 
 complication after operations on the urethral tract, 
 Mr. Freyer* recommends that a draught containing 
 * 'Operations on the Urethra and Prostate,' 
 
2 1 8 The After-Treatment of Operations 
 
 quinine (5 grains) and liquor opii sedativus (15 minims) 
 should be administered on recovery from the anaesthetic, 
 and quinine (10 grains) given daily for two or three days 
 afterwards. 
 
 Occasionally a much more severe condition of this 
 fever is seen. There are repeated attacks of fever, 
 accompanied by high temperature and rigors, or the fever 
 is more or less sustained, and the patient gradually sinks 
 into a low state, with feeble pulse, etc. This is more 
 common in old patients and those who have had a 
 cystitis previous to the operation, or some other septic 
 focus in or near the field of operation. The condition is 
 probably a septic one, and must be treated on those 
 lines. The great danger is suppression of urine and 
 uraemia. When this occurs, it must be treated by 
 purgation and sweating, and, of course^ opium in any 
 form must be absolutely avoided. 
 
 The best way of treating this severe type of urinary 
 fever is by preventing its occurrence, and it ought to be 
 very rare if proper care is taken. Unfortunately, the 
 whole genito-urinary tract is in a septic condition in 
 some of these cases, especially when dealing with old 
 and neglected prostatic trouble, and it is in such cases 
 that it is most commonly seen. 
 
 Diet. — The main object in dieting is to keep the 
 urine neutral and prevent acidity ; therefore it is well to 
 avoid nitrogenous foods as far as possible, and starchy 
 foods should be given. For the first few days after the 
 operation the diet should be a light one, and plenty of 
 fluids may be allowed with advantage, as this helps to 
 wash out the genito-urinary tract. In old and debilitated 
 subjects it is so important to keep up their strength that 
 a low diet is not advisable, and it should be sustaining 
 from the first, and combined with stimulants of a 
 suitable nature, 
 
Genito-Urinary Tract Operations 219 
 
 Suprapubic Cystotomy. 
 
 COMPLICATION'S. — (i) Severe cystitis ; (2) pelvic cellu- 
 litis ; (3) suppression of urine ; (4) epididymitis. 
 
 For the first twenty-four or forty-eight hours the 
 wound is best dressed with absorbent dressings, which 
 must be changed as soon as they become soaked with 
 urine. It is important to remember that because the 
 wound is open and primary union is not aimed at, the 
 
 Fig. 33. 
 
 necessity for careful aseptic precautions in changing the 
 dressings is not lessened, but, on the other hand, is 
 greater. The surgeon should, when possible, see to the 
 dressings himself, or, at least, see that someone who 
 thoroughly understands aseptic technique does so for 
 him. 
 
 After the first twenty-four or forty-eight hours the best 
 plan is to apply some form of apparatus which will drain 
 
220 The After-Treatment of Operations 
 
 away the urine and prevent it from accumulating in the 
 dressings. There are several forms of apparatus for this 
 purpose ; the best, however, appears to be that devised 
 by Mr. Hamilton Irving (see Fig. 33 ). This apparatus 
 consists of a celluloid cap which fits over the w^ound, 
 and is retained in place by straps passing round the 
 body. From this cap there are two outlet pipes com- 
 municating either with a urinal between the patient's 
 thighs or with a receptacle at the side of the bed. There 
 is a removable lid to the cap which allows the wound to 
 be examined or the bladder irrigated without removing 
 the apparatus. It also enables continuous irrigation of 
 the bladder to be very easily arranged for. When this 
 apparatus is used no dressings are required, and all that 
 is necessary is to see that it is kept clean. 
 
 When such an apparatus is not available the dressings 
 must be frequently changed, so as to keep the patient 
 as dry as possible ; but after the first forty-eight hours 
 plain sterilized dressings should alone be used, as medi- 
 cated dressings soon cause soreness and vesication of the 
 skin. 
 
 The drainage-tube should be removed at the end of 
 twenty-four or forty-eight hours, and many surgeons tie 
 a large catheter into the urethra, so as to allow the urine 
 a free escape by the normal channel. 
 
 The time which it takes for the suprapubic opening 
 to close varies from about twelve days to three or four 
 weeks, and even longer in some cases. The patient should 
 be kept in the recumbent position, and not allowed to 
 stand up for a week after the suprapubic wound has 
 healed up, as otherwise there is some risk of its opening 
 again. Care should also be taken to prevent the bladder 
 becoming distended. 
 
 If there is much cystitis and the urine is very foul, 
 
Genito-Urinary Tract Operations 221 
 
 continuous irrigation of the bladder with warm Avater 
 Fhould be arranged for, and urotropine given by the 
 mouth in full doses. 
 
 Suppression of urine has been already mentioned 
 under catheter fever. It is a condition calling for 
 prompt treatment. The main indications are to relieve 
 as far as possible the congestion of the renal tissues by 
 leeches to the loin, and purgation, and at the same time 
 to encourage the excretion of the urea, etc., by the skin 
 and bowel, so as to tide the patient over the dangerous 
 period while the kidneys are not acting. 
 
 Hot antiseptic baths of boracic or very weak per- 
 chloride are a good way of dealing with complications 
 occurring after operations on the urinary tract when the 
 patients are strong enough to stand them; but they are 
 sometimes dangerous in old people, and in any case a 
 competent attendant must be present. 
 
 Prostatectomy. 
 
 Complications. — (i) Haemorrhage; (2) epididymitis; 
 (3) incontinence ; (4) uraemia; 
 
 In the suprapubic operation the treatment of the 
 wound is practically the same as in an ordinary supra- 
 pubic cystotomy. It is the practice of most surgeons to 
 administer urotropine or urotropine and water freely for 
 some days previous to and after the operation. This is 
 advisable, as it tends — at any rate, to some extent — to 
 asepticize the genito-urinary tract. 
 
 The bladder should be irrigated twice daily after the 
 operation, and if there is much sepsis continuous irriga- 
 tion should be arranged for. It is important, however, 
 to avoid any distension of the bladder, especially during 
 the first two days, as it might cause haemorrhage. Any 
 clots which are found to have formed in the bladder 
 
2 22 The After-Treatment of Operations 
 
 must be carefully removed. The irrigation should either 
 be done with sterilized water or with some weak anti- 
 septic solution, such as i in 5,000 potassium per- 
 manganate. 
 
 Irrigation shouid be stopped as soon as the patient 
 commences to pass urine freely per urethram. 
 
 Haemorrhage should be treated by irrigation with 
 hazeline or silver nitrate solution (i in 5,000) as hot as 
 can be borne (110° to 120° F.). The foot of the bed 
 should be well raised. If this fails to control the bleeding, 
 an anaesthetic must be administered, and the bladder 
 firmly packed with long strips of gauze, the ends pf 
 which are left projecting out of the wound; the gauze 
 should be removed in twenty-four hours. 
 
 Incontinence or dribbling away of the urine may occur, 
 and is a very unpleasant complication ; it is due to ex- 
 cessive injury to the neck of the bladder, and destruction 
 of the sphincter vesicae. 
 
 In the perineal operation the tube is generally removed 
 inside a week from the operation, and the wound should 
 be closed in three weeks. 
 
 Lithotrity. 
 
 Complications. — These are the same as for cystotomy, 
 but there is a greater liability to urinary fever and epidi- 
 dymitis. The patient should be kept in bed for a week 
 or ten days ; a large catheter should be tied into the 
 bladder for the first thirty-six hours. He should be 
 instructed to turn on to the side to pass water. Hot 
 fomentations to the abdomen are very comforting to the 
 patient during the first twenty-four hours, and morphia 
 or some opium preparation may be administered if there 
 is pain. The patient should be allowed to sit in a hot 
 hip-bath for fifteen or twenty minutes two or three times 
 
Genitd-Urinary Tract Operations 223 
 
 a day, and instructed to try and pass his water while in the 
 bath. It is sometimes necessary to draw off the urine 
 by means of a catheter for the first few days. Quinine 
 or salicylate of soda may be administered by the mouth, 
 and will do much to prevent the occurrence of fever. 
 Morphia suppositories are very useful in relieving pain 
 after the operation. The diet for the first few days 
 should consist of milk, barley-water, and be combined 
 with stimulants, if necessary. Mr. Jacobson says : * ' It 
 is advisable to once more thoroughly wash out the 
 bladder with the evacuator a week after the operation, as 
 a safeguard against recurrence from small fragments left 
 behind at the operation. 
 
 Internal Urethpotomy. 
 
 Complications. — (i) Haemorrhage; (2) urinary fever ; 
 (3) epididymitis. 
 
 Haemorrhage, should it occur, is best treated by tying 
 in a catheter ; if this proves insufficient a perineal bandage 
 should be applied with a suitable pad so as to compress 
 the bulb of the penis against the catheter. Many 
 surgeons tie in a large catheter after the operation, and 
 leave it in for twenty-four hours ; if this has been done 
 it should be removed in a hot bath, and a large instru- 
 ment, preferably a steel sound, passed every two days 
 at first, and at the end of ten days or a fortnight the 
 patient may be taught to pass it for himself, and told to 
 do so once a week at first, and later at more distant 
 intervals for some months to prevent recontraction of the 
 scar in the urethra. Some surgeons, on the other hand, 
 prefer not to pass any instrument till after the wOund has 
 healed, which will be in about ten days or a fortnight, 
 and then to pass steel dilators (Mr. Freyer recommends 
 * ' The Operations of Surgery,' 1903 edit., vol. ii. 
 
2 24 The After-Treatment of Operations 
 
 Nos. 13 to 15 English gauge) so as to insure the urethra 
 being well dilated, and then to let the patient pass the 
 instrument for himself at intervals for some months 
 afterwards. 
 
 External Urethrotomy. 
 
 Complications. — (i) Pelvic cellulitis and peritonitis ; 
 (2) toxaemia ; (3) sloughing of the rectum ; (4) epididy- 
 mitis. 
 
 If a catheter has been tied in at the operation this 
 should on no account be removed for two or three days, 
 as it will be difficult and may be impossible to replace it. 
 
 If a perineal tube has been tied in it should be retained 
 for four or five days and then removed. At the end of a 
 week or ten days a steel sound should be passed along 
 the urethra into the bladder, and this should be repeated 
 every second or third day till the perineal wound has 
 healed. 
 
 Circumcision. 
 
 The dressing is usually a matter of some difficulty in 
 these cases, as it is difficult to get it to keep on, and it 
 easily becomes soiled. Dry gauze and collodion makes 
 an excellent dressing if the wound heals aseptically, but 
 is extremely troublesome to remove, and sometimes 
 causes pain ; it is also very painful if erections occur. A 
 very good way of dressing these cases is to wrap a 
 narrow piece of dry cyanide gauze round the penis at the 
 site of the wound, and then to put a larger strip over the 
 top of this and overlapping it. A pad of absorbent wool 
 about 2 inches thick and large enough to cover the 
 whole perineum and come well up into the abdomen is 
 next taken, and a hole is made in it with scissors just 
 large enough to admit the penis ; the penis is placed in 
 
Geni to-Urinary Tract Operations 225 
 
 this hole, and then the pad of wool fixed on by taking 
 two or three turns of bandage round the body and thighs. 
 This protects the penis, and adds very materially to the 
 patient's comfort. 
 
 In hospital practice a very good dressing is made with 
 strips of lint soaked in lotio plumbi (diluted one half) 
 wrapped round the penis, and secured to the abdomen by 
 a strip of plaster. The mother is given some of the 
 lotion and instructed to keep the lint moist with it, 
 or carbolic oil may be used in the same way. The 
 patient should be kept in bed for the first forty-eight 
 hours, and on the day after the operation he should sit 
 in a warm bath and soak off the dressings, a new dressing 
 being applied afterwards ; this should be repeated each 
 day till the wound has healed. After the first two or 
 three days an ointment dressing is the most comfortable. 
 If there is much swelling and oedema after the operation, 
 the bath should be used twice daily and weak lead lotion 
 applied. 
 
 After operations on adults it is advisable to administer 
 a dose of bromides at night for the first few days to 
 prevent erections. The patient should keep his bed for 
 the first two days, and remain resting on a sofa for a 
 week, and when he first begins to get about should keep 
 a large pad of wool round the penis to prevent its being 
 knocked, etc. If catgut sutures have been used they 
 may be left to come away of themselves, otherwise the 
 stitches should be removed one or two at a time. 
 
 Radical Cure of Hydrocele. 
 
 The drainage-tube should be removed in twenty- four 
 hours, and the wound sealed up with collodion. Pressure 
 should be maintained by means of wool and bandaging 
 over the wound so as to prevent the collection of blood 
 
226 The After-Treatment of Operations 
 
 or serum in the scrotum, and to promote rapid healing by 
 keeping the sides of the wound cavity in contact. Care 
 must be taken to keep the scrotum well up on to the 
 pubes ; this prevents oedema of the scrotum and pain, and 
 assists to keep the dressings clean. For this purpose the 
 best thing is a small cushion placed between the legs so 
 as to support the scrotum, or a suspensory bandage made 
 of gauze and pulled up firmly is an excellent plan. 
 Some of the stitches may be removed on the fourth day, 
 and the remainder a few days later ; the patient should 
 remain in bed for ten days or a fortnight, and should 
 wear a suspensory bandage for some months. 
 
 Varicocele. 
 
 The treatment is the same as for the above, but no 
 drainage being necessary, the wound should not be 
 examined for five or six days, when the stitches may be 
 removed. The patient may be allowed to get up in a 
 week or ten days. A suspensory bandage should be 
 worn for two or three months after the operation. 
 
 Operations on the Uterus or Appendag-es. 
 
 Retention of urine is common after any operation on 
 the uterus or pelvis, and the greatest care must be exer- 
 cised in relieving it by the catheter, as cystitis is readily 
 set up and seriously complicates the after-treatment ; the 
 most careful aseptic precautions should be taken in using 
 the catheter, and it should always be passed by sight 
 and not under the clothes. The catheter should be 
 passed frequently — every five or six hours — to prevent 
 the bladder from becoming distended, as this will result 
 in much discomfort to the patient. An attempt should 
 be made to get the patient to pass her water while lying 
 
Genito-Urinary Tract Operations 227 
 
 on the side. As already stated many women are unable 
 to pass their urine while in the dorsal recumbent position, 
 and in consequence there is apt to be a collection of 
 residual urine in the bladder even when the catheter is 
 in use. 
 
 The vagina must be kept as clean and aseptic as 
 possible after the operation. This is best done by daily 
 gentle irrigation with some mild antiseptic solution. A 
 pad of cyanide gauze well dusted over with some anti- 
 septic powder should be kept over the vulva and changed 
 twice a day. 
 
 After many operations on the uterus, and especially 
 those in which retaining stitches are placed in the uterine 
 wall, there is very severe pain for some days after the 
 operation. This pain can often be relieved by such 
 drugs as phenalgin and aspirin, in full doses, repeated 
 every four or five hours. Menstruation often comes on, 
 although not due, after such operations, and may be 
 irregular for some time afterwards. 
 
CHAPTER XVI 
 OPERATIONS ON THE RECTUM, AND COLOTOMY 
 
 Operations for Fistula. 
 
 Complications. — (i) Formation of fresh sinuses; (2) 
 bridging of the wound ; (3) excessive tenderness of 
 wound ; (4) exuberant granulations ; (5) wound refusing 
 to heal. 
 
 In my opinion no surgeon should undertake an opera- 
 tion for fistula unless he is able and willing to supervise 
 the after-treatment himself. Too often the surgeon 
 operates upon a case of fistula, and then never sees the 
 case again, or not until the wound has refused to heal. 
 Most of the failures to heal in the case of fistula are due 
 to the fact that those responsible for the after-treatment 
 of the case do not understand what is necessary. In 
 proof of this, the fact may be stated that the average 
 period before healing is complete after an operation for 
 fistula at St. Mark's Hospital is under four weeks, in 
 spite of the fact that probably the practice of this hospital 
 includes most of the worst cases of fistula in London. 
 The actual figures for over 200 of the author's own cases 
 at St. Mark's are as follows : Average period of healing 
 in days — males, 25-1 ; females, 177. Judging from the 
 inquiries the writer has made, the average period before 
 
 22S 
 
Operations on the Rectum 229 
 
 healing is complete after a fistula operation at some of 
 the large general hospitals is nearer two and a half 
 months. 
 
 It is most important that the wound should be kept as 
 clean as possible, and to insure this the dressing should 
 be changed frequently. In the case of a large fistula 
 wound where there is much discharge, the dressing 
 should be changed every six hours, or even oftener ; and 
 in the case of an ordinary fistula wound which is clean, 
 it should be changed at least twice a day. It is never 
 sufficient to dress the wound only once in twenty-four 
 hours, or, as is sometimes the practice adopted, once 
 every two or three days. For the first three or four days 
 the wound should be dressed with hot fomentations, 
 changed as frequently as possible. The fomentations 
 should be applied over the wool which is in the wound, 
 and the latter should be left in situ for the first thirty- 
 six hours, and then changed as soon as it is soiled. The 
 bowels should be opened on the third or fourth day by an 
 aperient dose, aided by a small quantity of olive-oil 
 injected into the bowel. After this, the patient should 
 be allowed to sit in a hot antiseptic bath night and 
 morning. The cotton-wool will soak out of the wound 
 while he is in the bath, and fresh wool should be carefully 
 laid in the wound after the bath. The wound is best 
 dressed with flat strips of wool, which should be of the 
 best quality, and not the cheap fluff so often supplied in 
 these days. A narrow, thin strip of wool should be 
 wrapped around a dressing-probe, and by means of the 
 probe, passed up into the deeper part of the wound until 
 it enters the lumen of the bowel. If the probe is then 
 gently pressed against the wound it can be removed, 
 leaving the wool in position in the wound. The first 
 finger of the left hand passed into the bowel will often 
 
230 The After-Treatment of Operations 
 
 assist in placing the wool accurately in position. With 
 the end of the probe the strip of wool should next be 
 adjusted carefully so that it lies evenly along the floor of 
 the wound. Then a few small flat strips of wool should 
 be laid in any side-tracks or superficial portions of the 
 wound. On no account should the wound be firmly 
 plugged with dressing. Plugging of the wound is a mis- 
 take ; in fact, there is no more effectual method of pre- 
 venting healing. 
 
 When once the surface of the wound is covered with 
 healthy granulations it is important to protect these and 
 the growing edge of the skin from damage each time that 
 the dressing is changed, and for this purpose there is 
 nothing better than a dressing of wool soaked in olive-oil 
 or vaseline. At this stage antiseptics should be avoided, 
 as they tend to damage the delicate granulations and to 
 delay healing. Peroxide of hydrogen, though useful as an 
 application to clean up a sloughy wound, should not be 
 used once the wound has cleaned up, as it tends to 
 produce exuberant and unhealthy granulations. The 
 wound always requires careful watchmg to see that heal- 
 ing is progressing satisfactorily. Occasional stimulation 
 is often required. For this purpose lotiod rubra applied 
 on wool for a day or two, or Friar's balsam applied once, 
 is very useful. Weak silver nitrate, 10 grains to the 
 ounce, may sometimes be used with advantage, but 
 strong silver nitrate should not be used except to destroy 
 unhealthy granulations, as it usually does more harm 
 than good. Scarlet red ointment is sometimes useful ; 
 but it is a mistake to use stimulating applications fre- 
 quently. The wound must be carefully watched for signs 
 of bridging or the formation of new tracks. The latter 
 may always be suspected if the discharge from the wound 
 increases in amount or fails to stop. If a previously 
 
Operations on the Rectum 231 
 
 healthy wound suddenly begins to discharge, it is an 
 almost certain sign that a new track has formed. Any 
 bridges of tissue that are discovered should be broken 
 down with a steel probe or cut through with scissors, and 
 new tracks must be at once laid open. When the wound 
 is quite healthy and nearly healed it is best to apply no 
 dressing at all, but to keep the parts clean, and apply a 
 little vaseline to protect the surface. 
 
 The patient should be kept in bed, or at least in the 
 recumbent position, until healing is quite complete ; and 
 in order that the scar may become firm before it is 
 subjected to much movement, he should not walk about 
 more than is absolutely necessary for another week after 
 this. It is a great temptation to both doctor and patient 
 to allow the latter to get about a little when the wound 
 is nearly healed ; but this wastes time in the long run, 
 and is often responsible for considerable delay in the final 
 healing of the wound. 
 
 During the whole process of healing care must be 
 taken to insure that the stools are quite soft, as a hard 
 stool may delay healing for a week or more. 
 
 Causes for Non-Healing of the Wound after an 
 Operation for Fistula. — (i) Inadequate operation ; 
 (2) insufficient drainage ; (3) too tight plugging of the 
 wound ; (4) bridging of the wound ; (5) some constitu- 
 tional condition of the patient. 
 
 The Operation for Piles. 
 
 Complications. — (i) Pain ; (2) haemorrhage ; (3) ul- 
 ceration ; (4) stricture ; (5) retention of urine ; (6) for- 
 mation of external piles ; (7) fistula or fissure. 
 
 The dressing should be changed twice a day, and the 
 external parts washed with weak carbolic lotion, If a 
 tube has been inserted it should be removed in twenty- 
 
2^2 The Afcer-Treatment of Operations 
 
 four hours. There is no advantage in keeping the patient 
 on a ' slop ' diet. It is better to give ordinary food in 
 small quantities until the bowels are opened, and after 
 this a full ordinary diet. The patient may be allowed to 
 move about freely in bed, so long as he does not disturb 
 the bandages. The bowels are confined for two or three 
 days, and are then relieved by the administration of an 
 ounce of castor-oil, or some other suitable aperient, an 
 injection of three or four ounces of olive-oil being made 
 into the bowel with a soft catheter and funnel at the 
 same time that the aperient is administered. As an 
 alternative to an aperient, the bowels may be relieved by 
 an enema of olive-oil, 6 ounces, and thin gruel, 14 ounces. 
 The bowels should subsequently be kept acting daily 
 with some mild aperient such as cascara or petroleum. 
 In ordinary cases the patient may safely be allowed to 
 use a night commode placed beside the bed. The patient 
 should remain in bed, or at any rate in the recumbent 
 position, until the ligatures have separated, which is 
 somewhere between the eighth and eleventh days. After 
 this he should be kept on the sofa for a day or two 
 longer. 
 
 Operations for piles have in the past had a very bad 
 name for causing a great deal of pain. All operatons 
 for piles used to be accompanied by considerable pain, 
 and it was the custom to give morphia, or some other 
 form of opium, for days after the operation. It is, how- 
 ever, now possible to prevent this pain if the operation 
 is properly performed, and if the after-treatment is 
 thoroughly carried outj and the operation for piles should 
 result in no more pain than one for hernia or varicose 
 veins. The pain after an operation for piles, as, indeed, 
 after most operations, is due to swelling of the tissues 
 and inflammation of the wound. If, after the removal of 
 the piles, the wound is kept clean and the tissues aseptic 
 
operations on the Rectum 233 
 
 for some hours, there is no severe pain. It is obvi- 
 ously impossible to keep the wound clean for a long 
 period. In order to keep it aseptic for a few hours after 
 the operation it is necessary that the patient shall be so 
 prepared for operation that one can be certain no faecal 
 material shall be found in the, rectum, or come into the 
 area of operation, either during or immediately after the 
 operation. By careful attention to details this can be 
 insured. The author has found by experience that if 
 great care is taken, when operating upon piles, to make 
 the wounds through clean tissues and to keep the wounds 
 clean for some hours afterwards, pain is not present in 
 any marked degree in the majority of cases. 
 
 Should the patient complain of pain, 10 grains of 
 aspirin every six hours will often relieve it. If the pain 
 is severe, l grain of morphia should be administered 
 hypodermically. Suppositories containing morphia or 
 other drugs should not be used, as they are not aseptic 
 and they act very slowly. 
 
 For the treatment of haemorrhage after this operation, 
 sec p. 6g. It is important to remember that when 
 haemorrhage occurs after an operation for piles, there is 
 seldom any external evidence of its presence, as unless a 
 tube has been inserted, the blood does not escape from 
 the anus. Should a patient after such an operation 
 become blanched and collapsed, the anus should at once 
 be examined, and a finger passed into the rectum to 
 ascertain if there is any bleeding. If ligatures have been 
 used, they generally separate between the eighth and 
 twelfth days, the average being the tenth day. The 
 patient should not be allowed to get up until all the 
 ligatures have come away ; he may then be allowed 
 to recline on a couch or easy-chair, but should be 
 more or less restricted to the horizontal position 
 
2 34 The After-Treatment of Operations 
 
 until on examination all the wounds are found to have 
 healed. 
 
 Ulceration of the rectum after an operation for piles is 
 a most troublesome complication. It must be treated by 
 frequent irrigation of the rectum with weak antiseptics 
 and improving the patient's general condition by stimu- 
 lants and good food. It can be avoided by careful 
 attention to asepsis during and after the operation. 
 
 Stricture should not occur if the operation has been 
 properly done, but should there be any tendency of 
 narrowing of the anal orifice it must be met by the daily 
 passage of bougies, and the patient should be instructed 
 to pass a bougie for himself until all tendency to con- 
 traction has disappeared. Allingham's bougies, which 
 are only tapered at the extreme end, are the best for this 
 purpose. The results of a stricture of the anus are so 
 serious that the greatest care should be taken to prevent 
 it becoming permanent. Stricture can only occur if the 
 operation has been badly done or there has been ulcera- 
 tion. 
 
 After Whitehead's operation the treatment is the same. 
 A finger should be occasionally passed into the bowel to 
 ascertain if the parts are uniting correctly. The stitches 
 uniting the mucous membrane to the skin should be 
 allowed to come away by themselves. If, as sometimes 
 happens, the mucous membrane tears away and retracts, 
 the condition should not be left to heal by granulation or 
 a serious stricture will probably result. i\n anaesthetic 
 should be administered, and the mucous membrane 
 pulled down and reunited to the skin margin by stitches. 
 
 Retention of Urine. — This is very common for the first 
 day or so after all operations on the rectum, and more 
 particularly if the anterior wall has been interfered with 
 — as, for instance, by the ligature of a pile in this situa- 
 
Operations on the Rectum 235 
 
 tion. The patient should be encouraged to try and pass 
 his water naturally if possible, and may be allowed to 
 kneel up in the bed for the purpose. Should he still be 
 quite unable to pass his water, a soft Jaque's catheter 
 may be passed and the urine drawn off. The retention 
 often lasts for several days. 
 
 Sometimes after an operation for haemorrhoids one or 
 more external piles form at the anal margm. These are 
 due to oedema of the skin at the anal margin from the 
 circulation being interfered with by the removal of the 
 piles. They are not of much consequence, and will 
 subside as the circulation is re-established. The follow- 
 ing ointment applied on a piece of cotton-wool will 
 relieve any pain they may cause, and also hasten their 
 resolution. A compress of lead lotion may also be used 
 for the same purpose. If very large they may be cut off 
 under local anaesthesia. 
 
 ^ Hydrarg. subchlor. 
 
 - 
 
 « 
 
 - gr. iv. 
 
 Pulv. opii - 
 
 • 
 
 - 
 
 . gr. iii, 
 
 Extr. belladonnas - 
 
 . 
 
 - 
 
 - gr. iii. 
 
 Unguent, sambuci 
 
 . 
 
 . 
 
 - 3i. 
 
 Mitte. 
 
 
 
 
 Operations for Fissure. 
 
 The after-treatment is practically the same ; the recum- 
 bent position should be maintained until the wound has 
 healed. The dressing should be changed twice a day, 
 and the parts well washed with warm water. A small 
 wisp of wool placed in the wound with a probe makes 
 the best dressing. 
 
 Colotomy. 
 
 After the operation the patient should have a small 
 pillow placed under the head and a bolster under the 
 knees. If he complains of being uncomfortable from 
 
236 The After-Treatment of Operations 
 
 lying on the back, he may be allowed to turn on the 
 side, providing that he does not turn on to the side on 
 which the colotomy wound is situated. Very httle food 
 should be given until the intestine has been opened, 
 though a little fluid diet may be allowed. Old people 
 should be well propped up, almost into a sitting position, 
 as this will prevent any tendency that they may have 
 towards bronchitis, etc. 
 
 If the patient is comfortable the wound need not be 
 dressed on the day after the operation. On the second day 
 it should be dressed, and the intestine opened for about 
 I inch in a transverse direction with a pair of scissors. 
 After this it is a good thing to open the bowels with 
 9, mild purgative, such as ^ ounce of castor oil. On 
 the tenth day the intestine must be completely divided 
 in a transverse direction, and the clip, or whatever has 
 been used to form the spur, removed. Any bowel that 
 projects above the skin should be cut away with scissors. 
 The best control is obtained by an opening in which the 
 mucous membrane meets the skin at the margin of the 
 opening without there being any prolapse. After this a pad 
 should be applied to the wound, and a firm bandage applied 
 over it to push back the gut and get it to retract back flush 
 with the skin. There is often a little bleeding after the gut 
 is divided. This bleeding generally comes from numerous 
 small points, and if attempts are made to sponge away the 
 clots and clip the vessels, they are often not only unsuc- 
 cessful, but may result in the bleeding being made worse, 
 The best thing to do is to put on a pad of wool, and exert 
 firm pressure with a bandage over the wound. This is all 
 that is usually necessary. Of course, if there is any vessel 
 spurting, it should be caught in a clip, the clip either 
 being left on or the vessel tied in the usual way. If the 
 incision is made at right angles to the line of the gut, 
 
Operations on the Rectum 237 
 
 there is seldom any bleeding of moment. When no spur 
 has been formed, it is sometimes not easy to find the gut 
 when it is desired to open it, as it is covered in lymph, 
 and may be unrecognisable. Under these circumstances 
 an incision must be made with a knife into the centre 
 of the wound, until, by the escape of flatus, it is known 
 that the gut is opened, and then the incision may be en- 
 larged with scissors to the required size. The division of 
 the intestine is quite painless and no anaesthetic is required. 
 After the gut has been opened, the colon should be well 
 cleared of any accumulated faeces it may contain by suit- 
 able purgatives. After this has been done, however, it is 
 best not to make use of purgatives at all, unless absolutely 
 necessary, as they are very liable to set up a sort of 
 diarrhoea, and cause soreness of the skin round the wound. 
 
 If there are faeces in the lower and now useless portion 
 of the colon, they may be washed out by syringing 
 through from the upper opening, or by enemata. In 
 about a fortnight from the operation the wound will be 
 sufficiently healed to have a colotomy belt fitted. The 
 best sort of belt is that with a celluloid cup fitting over 
 the opening in the intestine, and kept in place by a 
 belt with an indiarubber interval in it where the cup 
 comes. These belts are much more comfortable than 
 those with a plug fitting into the gut, and are quite 
 as efficient in preventing the escape of faeces. The 
 same remarks apply equally to both lumbar and inguinal 
 colotomy. 
 
 Colotomy Belts. — These are mainly of two kinds — 
 those with a plug which fits into the opening, and those 
 with a cup which fits over the ends of the gut. The cup 
 is by far the best form. The chief objection to the plug 
 belt or truss is that the presence of the plug in the 
 intestine gives the patient the feeling of a constant desire 
 
2j8 The After-Treatment of Operations 
 
 to evacuate something from the opening ; it also prevents 
 the establishment of any sphincter action at the artificial 
 opening. The cup form does not possess any of these 
 disadvantges. It consists of a celluloid cup with 
 buttons on the outer side, and a belt which fits round the 
 patient's body ; the belt is made of indiarubber where it 
 passes over the cup. This holds the cup in place, and 
 insures it being kept well up against the abdominal 
 wall. 
 
CHAPTER XVII 
 
 OPERATIONS ON THE JOINTS 
 
 There are some features with regard to operations upon 
 joints that require special notice. There are probably 
 no operations in surgery after which sepsis is more 
 dreaded or more prone to occur, if the most rigorous 
 precautions are not taken, than those upon joints. The 
 most scrupulous care is necessary in the dressing and 
 after-treatment of these cases to prevent the possibility 
 of organisms gaining an entrance and setting up sepsis. 
 Again, it is of the utmost importance that the joint 
 should be functional after the operation — that is to say, 
 should be capable of free and painless movement^ and, 
 in the case of the leg, able to support the weight of the 
 body — except, of course, in those cases where the joint 
 is hopelessly disorganized, and the operation has been 
 undertaken with the object of obtaining a stiff joint, as in 
 the case of excision of the knee for tubercle. 
 
 After the cavity of a joint has been opened, or the 
 synovial membrane interfered with, there is a great 
 liability to the formation of adhesions, which, if they 
 form, may lead to more or less permanent crippling, and 
 will, in any case, result in much pain to the patient. 
 Although these adhesions can often be got rid of 
 satisfactorily later, it is much better surgery to prevent 
 
 239 
 
240 The After-Treatment of Operations 
 
 their forming at all. It should therefore be our object 
 to prevent the formation of adhesions by moving the 
 joint slightly each day from the earliest possible date. 
 
 After such operations as wiring the patella for fracture 
 and the removal of a fractured or loose semilunar 
 cartilage, movement of the joint should be commenced 
 on the second or third day after the operation. In order 
 to move the joint, the bandages and outer dressings 
 must be removed, and the attendant should then pass 
 his hand (we will assume that he is dealing with the 
 knee-joint) under the knee, and gently raise it off the 
 back splint (if one has been used), while with the other 
 hand he holds the dressings in place, and supports the 
 wound by firm pressure, so that no tension is put upon 
 the skin in the neighbourhood of the wound. On the 
 first occasion the joint should only be moved slightly two 
 or three times, the knee being gentl}' raised, and then 
 allowed to assume its original position by its own weight. 
 At the same time the patella should be moved from side 
 to side, so as to prevent the formation of adhesions 
 between it and the anterior surface of the femur. 
 
 This must be repeated each day, and after two or 
 three days the patient should be made to move the joint 
 for himself, the attendant at most only steadying the limb 
 and dressings. The joint at this period should be moved 
 through a much larger angle than at first. It is better 
 not to use a splint in these cases, but if one has been 
 used it should be dispensed with as soon as possible. 
 At the end of ten days, when the wound should have 
 healed, the stitches can be removed, and a dressing of 
 collodion and gauze applied in such a way as to hold 
 together the edges of the wound and so support the 
 scar, and prevent its being stretched during movement 
 of the joint. 
 
Operations on the Joints 241 
 
 The patient should now be encouraged to move the 
 joint as much as possible, and a very good plan in the 
 case of the knee is to let the patient sit on the edge of 
 the bed with the leg hanging over the edge, and the foot 
 resting on a stool of appropriate height ; he must then 
 raise the foot off the stool by extending the knee, and 
 then slowly lower it back again on to the stool ; this 
 should be repeated for fifteen minutes twice a day. At 
 this period massage to the muscles moving the joint (in 
 this case those of the leg and thigh) is very beneficial, 
 both in keeping up the tone and development of the 
 muscles and in getting rid of any adhesions that may 
 have formed. The scar should be moved from side to 
 side on the deeper tissues each day to prevent it from 
 becoming adherent to the bone, which otherwise is very 
 likely to take place and be the cause of pain later on. 
 After the removal of a loose semilunar cartilage from the 
 knee there is often a tendency for the scar to become 
 adherent to the inner condyle of the tibia, and if this is 
 allowed to take place a considerable amount of pain and 
 disability may result. 
 
 After the operation for loose semilunar cartilage or 
 fractured patella, the patient may usually be allowed to 
 walk as soon as ever the wound has healed. It is 
 not advisable for the patient to wear any sort of support 
 to the knee as it tends to limit movement and prevent 
 the proper development of the muscles supporting the 
 joint, on the integrity of which the subsequent stability 
 or otherwise of the joint mainly depends. 
 
 Excision of the Elbow. 
 
 After excision of the elbow-joint our object is to form 
 
 a ' false joint,' and therefore movement must be com- 
 
 16 
 
^4^ The After-Treatment of Operations 
 
 menced early. The best plan is to fix the arm in a 
 metal outside splint with a joint opposite the elbow and 
 with a thumb-screw, so that the splint can be fixed at any 
 desired angle at will, olr by loosening which the splint 
 caii be made to move with the arm. Each day the 
 thumb-screw can be loosened and the joint moved with- 
 out removing the splint ; the splint must, however, be 
 removed from time to time, so as to allow of movements 
 of pronation and supination being carried out. In these 
 movements, while the wrist is being rotated the surgeon 
 must fix the ulna, to insure the movements taking place 
 correctly. At first the joint should be only slightly 
 moved, commencing about a week or ten days after 
 the operation, and all movements must be very gentle. 
 As the wound heals the movements should be extended 
 until they are free in all normal directions. The hand 
 should be left free from the first, and the patient en- 
 couraged to use the fingers and wrist freely. 
 
 As soon as ever the parts are sufficiently firm to allow 
 of it, the splint should be left off and the patient made to 
 use the limb ; the arm can be kept in a sling for part of 
 the day at first, and a sling should be used as a protection 
 against injury while out of doors for some months. 
 Later on, when the parts have thoroughly consolidated, 
 massage and regular exercises in a gymnasium are very 
 useful in getting back power and free movement in the 
 arm. 
 
 It will probably be several months before real stability 
 of the new joint is obtained, but in favourable cases the 
 patient should at the end of three or four months be able 
 to use the limb for all ordinary purposes. Special care 
 must be taken to see that the patient is able to get the 
 hand up to the back of the head, as this is often difficult 
 at first, and later on the patient will find it no trifling 
 
Operations on the Joints 243 
 
 inconvenience not to be able to get his hand up to the 
 back of his neck for the purpose of doing up a collar- 
 stud, etc. 
 
 Excision of the Shoulder. 
 
 After excision of the shoulder movement should be 
 commenced early and carried out in the same way as in 
 the case of the elbow, but it is particularly important to 
 insure the movements taking place between the humerus 
 and the scapula, and not between the scapula and the 
 trunk. The surgeon should fix the scapula by holding 
 the angle firmly with his fingers, and then move the arm 
 or instruct the patient to do so for himself ; if this pre- 
 caution is not taken, the movements, and especially that 
 of abduction, are almost certain to take place between 
 the scapula and the trunk instead of at the shoulder- 
 joint. 
 
 The success or otherwise of most operations on the 
 joints depends to such a large extent upon the care with 
 which the movements are carried out during the after- 
 treatment, that .too much care and patience cannot be 
 expended upon them ; and in the case of children, who 
 form the largest percentage of the patients, much 
 patience and perseverance is often necessary in order to 
 obtain the desired result. A certain amount of pain is 
 generally caused by the movements at first ; and if this 
 is sufficiently severe to warrant it, an anaesthetic may be 
 given occasionally to insure that free movement is 
 obtained. 
 
 Excision of the Knee. 
 
 Here, in contradistinction to the case of the arm, our 
 object is to obtain bony ankylosis, and a properly fitting 
 splint which will not allow the bones to get out of 
 
244 The After-Treatment of Operations 
 
 position is of the greatest importance. For this purpose 
 there is probably no better splint than Howe's splint, 
 though any form of well-fitting interrupted splint will do. 
 There is often a considerable amount of pain after all 
 excisions, and, in fact, after all operations involving the 
 cutting of bone. Morphia must be given for its relief, 
 and in the case of young children, to whom it is not 
 advisable to give morphia, a few drops of laudanum, 
 varying according to the age of the patient, should be 
 given in a glass of water. Raising the limb, and espe- 
 cially slinging it well up in a cradle, if the splint will 
 allow of this, often relieves the pain to some extent. It 
 ought not to be necessary to change the dressing for a 
 fortnight after the operation, and then it is often advisable 
 to administer an anaesthetic for the first dressing. This 
 also enables the surgeon to thoroughly examine the 
 wound, and if any recurrent foci are found, to deal with 
 them. At the end of six weeks to two months a well - 
 fitting leather splint, strengthened up the back of the 
 knee with a metal bar, should be substituted for the 
 splint previously used, and the patient can then be got 
 up. In about three months from the operation the 
 patient can usually be allowed to walk, but the splint 
 should be worn for at least a year, and in the case of 
 children for two or three years. In children there is a 
 great tendency for flexion of the knee to take place, and 
 although this can often be prevented by the prolonged 
 use of splints, it cannot always be so prevented, as it is 
 due to the unequal growth of the epiphysis, and in these 
 cases a subsequent partial resection is necessary later on 
 to remedy the deformity. 
 
operations on the Joints 245 
 
 Excision of the Hip. 
 
 After excision of the hip-joint the two most important 
 points that have to be attended to are : (i) To prevent 
 external rotation of the lower fragment ; (2) to prevent 
 flexion of the hip-joint. In fact, the case has to be 
 treated in very much the same way as for fracture of the 
 neck of the femur. 
 
 It is generally advisable to apply an extension by 
 weight and pulley to the foot of the affected limb. The 
 extension strapping should always be carried above the 
 knee, and in children it is better to affix longitudinal 
 pieces of strapping up the sides of the limb and to 
 bandage over these with an ordinary bandage, afterwards 
 applying circular strips of strapping in two or three 
 places so as to prevent its coming undone. The upper 
 ends of the side-pieces should be turned down on them- 
 selves, and fixed with strapping so as to prevent their 
 drawing through. This is much less irritating to the 
 delicate skin of a child than applying strapping all the 
 way up the limb. A long Liston or Dessault's splint 
 should be applied from the axilla to the ankle, so as to 
 prevent flexion at the hip. In young children it is better 
 to use a Phelps's box-splint or a double Thomas's splint. 
 If a long splint is applied it must not be put on so tightly 
 as to interfere with the extension. The body should be 
 steadied by passing a sheet across the trunk and holding 
 it in position with sand-bags on each side of the body, 
 the sand-bags being rolled up in the sheet on each side. 
 To prevent rotation of the limb a cross-bar should be 
 attached to the long splint just above the ankle, or a 
 very good plan is to fix a flat piece of wood at right 
 angles across the back of the knee with plaster of Paris 
 bandages. In some cases the limb can be kept trom 
 
246 The After-Treatment of Operations 
 
 rotating by the use of a sand-bag placed on each side of 
 the thigh. 
 
 The limb after excision should be fixed in a position of 
 slight abduction, as this enables the patient later on to 
 overcome the shortening of the limb, which of necessity 
 follows excision by tilting the pelvis down on the affected 
 side. It is often possible to obtain a more or less 
 movable false joint after excision of the hip by moving 
 the joint two or three times each week after the wound 
 has healed. 
 
 At the end of five or six weeks a Thomas's hip-splint, 
 if it has not been used from the first, may be fitted, and 
 the patient can then be got out of bed. No weight, 
 however, should be borne on the limb for several months 
 even with the splint on. If the child is old enough he 
 may be allowed to get about with crutches and a patten 
 on the boot of the sound leg. In young children it is 
 better to fit £ double Thomas's hip-splint with a pelvic 
 band. After the Thomas's splint has been fitted, the 
 patient should be got out of doors for several hours daily 
 if possible. Some surgeons prefer to use a splint of 
 plaster of Paris or leather, which encircles the pelvis and 
 comes down below the knee. The use of removable 
 splints is, however, always preferable to the use of fixed 
 splints ; when a Thomas's splint, however, fails to keep 
 the limb in good position, a properly-fitting leather splint 
 may be tried. 
 
 Regular massage of the muscles is of the greatest 
 benefit in preventing wasting and in maintaining the 
 proper nutrition of the limb after excision of the hip 
 when the circumstances of the patient will allow of its 
 being carried out. All the muscles of the limb should 
 be massaged regularly two or three times a week 
 throughout the treatment if possible, and when a false 
 
Operations on the Joints 247 
 
 joint is desired suitable movements may be combined 
 with it. 
 
 The after-treatment of osteotomy undertaken for the 
 relief of deformity, as in the case of coxa vara or genu 
 valgum, is practically the same as the treatment of a 
 fracture of the bone in this situation. Special care 
 should be taken to see that the movements of the joint 
 in the vicinity of the operation are maintained during 
 the period of rest necessary for the consolidation of the 
 bone, 
 
 Massag-e. 
 
 Massage is of the greatest value after many operations 
 in bringing the muscles back to their normal condition of 
 tone, etc. Massage does not take the place of active 
 exercise, either in developing the muscles or in improving 
 the general circulation, but it gives us a most valuable 
 means of passing from the condition of complete rest 
 to that of ordinary activity without the transition being 
 too sudden. It also acts as a very good substitute for 
 exercise when rest is necessary. In cases of long and 
 exhausting illness following operations, when the patient 
 is obliged to remain in the recumbent position for many 
 weeks or months, general massage is of great value ; it 
 promotes absorption and secretion, keeps the skin acting 
 properly, and often enables the patient to sleep naturally, 
 besides very considerably diminishing the period of sub- 
 sequent convalescence. 
 
 Massage must be commenced gently at first ; the time 
 occupied and the force used may be increased as the 
 patient becomes accustomed to the treatment. Exhaus- 
 tion must never be produced. Massage should always 
 bQ accompanied by passive or, if possible, active move- 
 
248 The After-Treatment of Operations 
 
 ments of the joints and respiratory exercises. Ten 
 minutes a day is probably enough at first, and this time 
 can be increased up to half an hour or an hour. When 
 possible the massage should be carried out by a properly 
 trained masseur ; if this is not possible the nurse or some 
 intelligent relation of the patient may be instructed in 
 the treatment. There are several varieties of massage : 
 
 Effleurage, or Rubbing. — This consists in stroking 
 and rolling the skin and underlying muscles with the 
 hand, in a direction towards the trunk — i.e., in the direc- 
 tion of the venous circulation. It must be commenced 
 lightly and gradually increased in strength, the hand of 
 the operator being made to grasp the muscles more and 
 more firmly. 
 
 Petrissage, or Kneading. — This consists in knead- 
 ing and squeezing the muscles between the thumb and 
 fingers and the edge of the hand. It has for its object 
 the increase in the flow of blood and lymph through the 
 muscles towards the heart. 
 
 Friction. — This is practised by firmly rubbing the 
 skin in a direction towards the heart with the closed fists 
 or- finger-tips. 
 
 Tapotement. — This consists of rapid blows delivered 
 at right angles to the surface with the edges of the two 
 hands (the ulna border). This method of massage stimu- 
 lates the muscle and causes local contractions. It is one 
 of the more vigorous methods of massage, and must not 
 be used when dealing with damaged tissues or weakly 
 subjects. 
 
 Exercises. 
 
 The use of appropriate exercises after some operations, 
 especially those which affect joints, is of considerable 
 importance. The great point in dealing with injured 
 
Operations on the Joints 249 
 
 joints or muscles is to persuade them to move rather 
 than to compel them to do so. Thus the patient, sup- 
 posing that he is able to move the injured joint within a 
 certain angle, should exercise it by moving it within that 
 angle, and should try each time to increase the range 
 of movement. To assist the patient in this, the best 
 apparatus is a cord running through a pulley, to one end 
 of which a weight is attached, and to the other a suitable 
 handle ; the patient should then use the apparatus in such 
 a way that the weight assists the movement instead of 
 hindering it. For instance, in the case of a more or less 
 stiff knee, the cord from the pulley should be attached to 
 the ankle in such a way that the weight will assist 
 flexion. 
 
CHAPTER XVIII 
 
 THE AFTER-TREATMENT OF AMPUTATIONS, AND 
 SOME SPECIAL OPERATIONS 
 
 Aftep-Treatment of Amputations. 
 
 Complications. — (i) Shock ; (2) haemorrhage ; (3) pain ; 
 (4) adherent cicatrix ; (5) conical stump ; (6) persistent 
 • sinus. 
 
 After the operation the stump should be elevated as 
 much as possible and steadied with sand-bags, as spasm 
 of the muscles is very apt to take place, and this will tend 
 to displace the dressings ; this spasm of the muscles can 
 be relieved to some extent by applying a very hot rubber 
 water-bottle to the outside of the bandages, and by the 
 use of morphia injections. As a rule, the dressings require 
 changing on the day following the operation, as there 
 is generally a considerable amount of oozing during the 
 first twenty-four hours ; the drainage-tube should be 
 removed as soon as ever the amount of oozing is suffi- 
 ciently diminished to warrant it. A kind of dark-brown 
 discharge, which probably comes from the end of the 
 bone, not infrequently persists for a considerable time in 
 unhealthy individuals, and in these cases the drainage- 
 tube must be retained longer. 
 
 After the wound has almost healed and the stitches 
 have been removed, it is advisable in many cases to apply 
 
 25Q 
 
The After- Treatment of Amputations 251 
 
 some sort of support to the flaps to prevent stretching of 
 the scar, and to hasten heahng and consoHdation of the 
 end of the stump. This is particularly the case when 
 a large muscle flap has been formed, as in Faraboeuf's 
 amputation of the leg, Teal's amputation, and most ampu- 
 tations through the thigh. 
 
 The edges of the flaps should be drawn together by 
 large broad pieces of strapping ; the tissues of the stump 
 being well drawn down over the bone before the free 
 
 Fig. 34. — Method of applying Strapping to the Stump. 
 
 end of the piece of strapping is fixed. The stump must 
 next be bandaged from above down — that is, towards the 
 extremity, so as to draw down and support the muscles, 
 and prevent them from pulling the skin and tissues tight 
 over the end of the bone. A linen bag made to fit the 
 stump like a sock should then be placed over all, and fixed 
 by tapes round the waist or joint above the amputation. 
 If no such bag is obtainable an ordinary stump-bandage 
 may be applied. An excellent description of the methods 
 of bandaging stumps after amputation will be found 
 in ' A Manual of Surgical Treatment,' by Cheyne and 
 Burghard. 
 
 Pain. — The pain after amputations is usually of a 
 neuralgic type, and is probably due to the contraction of 
 the scar tissue at the ends of the nerves, which have been 
 
252 The After-Treatment of Operations 
 
 cut ; these attacks of neuralgic or starting pains often 
 persist for several months after an amputation, and then 
 gradually cease. At first they often cause the patient con- 
 siderable distress, but ^his varies very much in different 
 individuals. Hot-water bottles or hot stupes applied 
 over the main nerves above the stump will often reHeve 
 the pain ; thus in the case of the leg the heat should be 
 applied over the sacral region or upper part of the back 
 of the thigh, and in the arm over the clavicle and 
 scapula. 
 
 Adherent Cicatrix. — This is a most troublesome con- 
 dition, and should be prevented by gently moving the 
 scar on the deep tissues daily after the wound has healed ; 
 the patient can easily do this for himself. If the cicatrix 
 is allowed to become adherent, it is often the cause of 
 constant pain and tenderness at the end of the stump, 
 and not infrequently results in chronic and intractable 
 ulceration of the scar later on. Should the cicatrix 
 become adherent, an attempt may be made by gentle 
 massage to loosen it from the bone ; and if this is in- 
 effectual, the scar must be loosened by cutting it away 
 from the bone with a tenatome, and then moving it 
 frequently to prevent it again becoming adherent. 
 
 Conical stump is generally the result of a faulty opera- 
 tion, but in children is liable to occur, however carefully 
 the amputation has been planned. This is due to the 
 growth of the bone, the latter tending to grow through 
 the end of the stump. It may be to a large extent 
 prevented by massage, the stump being massaged towards 
 the end, and not towards the body, care being taken 
 at the same time to prevent the scar from becoming 
 adherent ; or the stump can be bandaged in the way 
 already mentioned to draw down the muscles. 
 
 Persistent sinus after amputation is generally due to 
 
The After-Treatment of Amputations 253 
 
 some deep stitch or ligature acting as a foreign body, or 
 to a piece of necrosed bone ; in either case the cause must 
 be sought for and removed. 
 
 As soon as the wound has thoroughly healed, which 
 will usually be about a month after the operation, 
 the patient should be measured for an artificial limb. 
 In the leg (with the exception of Syme's and Stephen 
 Smith's amputations), with but few exceptions, patients 
 are never able to bear any weight on the end of the 
 stump, nor is it advisable that they should do so ; the 
 weight is taken on the pelvis from the upper end of the 
 socket, and the end of the stump should not come into 
 contact with the end of the socket, but should be free 
 except for contact with the sides. In a below-knee 
 amputation the weight is taken on the sides of the head 
 of the tibia and on the condyles of the femur. 
 
 No bad effects to the stump need be anticipated from 
 fitting an artificial limb at an early date. There is 
 another objection that is commonly brought forward 
 against having an artificial limb fitted at an early date, 
 namely, that so much contraction of the stump takes 
 place after an amputation that the fit of the socket soon 
 becomes loose, necessitating a new limb. This is not 
 the case. It is true that a good deal of contraction 
 does occur and renders the fit loose ; but this will 
 take place however long a period is allowed to elapse 
 before fitting the limb, as a considerable amount of the 
 fat in the stump disappears after the limb has been worn 
 for a short time, and this makes the socket fit loosely. 
 On the other hand, it is most important if the patient 
 wishes to use the artificial limb with success that he 
 should commence to use it before the muscles moving 
 the stump have had time to waste and form adhesions- 
 In order that the patient may obtain the best results 
 
2 54 The After-Treatment of Operations 
 
 from the use of an artificial limb, the muscles acting 
 upon the stump will have to be trained to their new 
 function ; and if they have been allowed to waste to any 
 considerable extent very great difficulty will be experi- 
 enced in getting these muscles to fulfil their new function. 
 The result will be that many patients will give up the 
 attempt in despair, and remain more or less hopeless 
 cripples for the rest of their lives. This is a most 
 important point, especially in old people, who often have 
 neither the pluck nor the adaptable musculature of youth. 
 
 A very considerable time is usually necessary before 
 a patient can become accustomed to the use of an 
 artificial limb, and especially is this the case with the 
 leg, where the weight of the body has to be borne. 
 New centres of equilibrium have to be developed in the 
 brain and spinal cord, muscles have to take on unaccus- 
 tomed functions, and parts previously free from pressure 
 have to bear very considerable pressure without causing 
 pain or becoming sore. Much pluck and perseverance 
 will be required to attain these ends, and it is of primary 
 importance that such a serious check as wasted muscles 
 should not be added to the other difficulties. Should 
 the stump shrink much after the limb has been worn for 
 some time — as is usually the case — it can easily be 
 remedied by having the inside of the socket built up with 
 cork or other suitable material. 
 
 A very close fit is not necessary in an artificial leg, 
 and in the case of an arm a close fit can be secured by 
 means of lacing. When the artificial limb is first worn, 
 all bandages must be dispensed with, and if it is neces- 
 sary to support the scar, a collodion dressing can be used. 
 A woollen sock or socks should be worn over the stump, 
 to prevent the skin from being chafed by contact with 
 the socket. 
 
The After-Treatment of Amputations 255 
 
 Artificial Limbs. 
 
 Artificial Hand or Arm. — No artificial hand can be 
 fitted unless the amputation is at or above the wrist ; 
 however, two or even one finger or stumps of fingers are 
 of more use to the patient than the best artificial hand 
 that has ever been invented. For an amputation in the 
 middle of the forearm the limb is made with a wooden 
 socket coming up to the elbow, into which the stump fits 
 (Fig. 35) ; there is a broad leather strap round the lower 
 part of the upper arm, which is attached to the socket by 
 hinges. The grasp of the artificial hand is obtained by 
 means of a cord attached to a belt round the opposite 
 shoulder ; a very slight movement of the shoulders is 
 
 Fig. 35. 
 
 sufficient to open the hand, and by relaxing the pull on 
 the strap the hand closes by means of a spring. After the 
 patient has become accustomed to using the apparatus a 
 great deal of use can be made of it. 
 
 For an amputation above the elbow the socket is made 
 to come up over the shoulder, and is fixed in place by a 
 strap round the body (Fig. 36) ; a cord is used in the same 
 way as in a below-elbow limb for obtaining the hand 
 movement, and another cord passing behind the shoulder 
 is used for obtaining movement at the elbow. Most of the 
 friction comes upon the sides of the stump, and not 
 upon the end, so that a circular method of amputation is 
 particularly well suited to arm amputations. The im- 
 
256 The After-Treatment of Operations 
 
 portant points about an artificial arm are lightness, 
 simplicity, and a good fit. 
 
 To Measure for an Artificial Arm. — Stump : length from 
 top of shoulder to end, length from point of axilla to 
 end, circumference every 2 inches. Sound arm : length 
 from top of shoulder to base of fingers (the arm being in 
 the extended position), length from point of axilla to 
 
 Fig. 36. 
 
 elbow, and from elbow to wrist, also circumference every 
 2 inches. If a below-elbow amputation, measure also 
 from elbow to end of stump. It is much better for the 
 instrument maker to take the measurements himself 
 when possible. 
 
 Artificial Legs. — It is practically impossible to fit 
 any appliance that will act satisfactorily to any amputa- 
 
The After-Treatment of Amputations 257 
 
 tion of the foot short of a Syme's. Such amputations 
 as Chopart's and Lisfranc's make very unsatisfactory 
 stumps as a general rule ; this is due to the lever formed 
 by the normal foot being destroyed. No artificial ap- 
 pliance can take its place, as there is very little space 
 to v^ork in, and the tapering shape of the stump makes 
 it impossible to get any purchase for the artificial foot. 
 The best appliance for such stumps is a boot into which 
 a piece of cork has been fitted, to 
 fill up the vacant space left by the 
 removal of part of the foot. After 
 a Syme's amputation a very useful 
 artificial foot can be fitted (Fig. 37) ; 
 the shortening of the limb resulting 
 from the operation is generally about 
 2| inches, vi^hich allows room for an 
 artificial ankle-joint to be placed 
 below the end of the stump. A half- 
 socket is made, so as to fit up the 
 calf of the leg and prevent the foot 
 from turning forward ; this socket is 
 held in place by cross-straps over 
 the shin ; the weight is taken on the 
 end of the stump. A Pirogoff stump 
 is not so satisfactory as a Syme, as the shortening of 
 the limb afterwards is only about i to il inches, and 
 this does not allow room for a joint below the end of 
 the stump. The joint has in this case to be fitted 
 outside, and this causes a very unsightly widening of 
 the ankle. 
 
 For amputations below the knee a socket is made into 
 which the stump fits. The weight is taken on the sides 
 of the stump and on the head of the tibia ; the end of the 
 stump should not take any of the weight (at first, at any 
 
 Fig. 37. 
 
258 The After-Treatment of Operations 
 
 rate). The limb is held in place by a short leather socket 
 fitted round the lower part of the thigh and tightened by 
 lacing up the front ; this leather socket is attached to 
 the wooden one by side steel hinges (Fig. 38). This 
 form of artificial leg works very well when the stump 
 below the knee is not too short ; if the 
 stump is short flexion is very liable to 
 occur, and render the wearing of an 
 artificial leg impossible ; also the short 
 stump does not obtain sufficient purchase 
 on the artificial leg to enable the patient 
 to control it. The so-called seat of election 
 probably represents the very worst place 
 that it is possible to remove the leg, if it is 
 desired that the patient should subse- 
 quently use an artificial limb. 
 
 After amputation through the knee-joint 
 the weight can be taken on the end of the 
 stump, the limb being fixed in place by a 
 leather socket fastened round the thigh by 
 lacing. Unfortunately, chafing and sore- 
 ness of the end of the stump are rather 
 liable to occur, and as almost the whole of 
 the weight must of necessity be taken on 
 the end of the stump, this may prove very 
 troublesome ; careful attention to the fit of 
 the limb will do much to get over this 
 difficulty. Special attention should be paid 
 Fig. 38, towards the prevention of any lateral play 
 
 in the socket. 
 
 For amputations above the knee, the weight is taken on 
 
 the pelvis — in fact, the patient may be said to be sitting 
 
 on the top of the socket ; it is therefore very important 
 
 that the upper end of the socket should fit accurately 
 
The After-Treatment of Amputations 259 
 
 and should have a good broad edge behind (Fig. 39). No 
 weight should, as a rule, be taken on the end of the 
 stump, and the latter should not come down to the end 
 of the socket. 
 
 The limb can be held in place either by means of a 
 shoulder-strap or by a broad belt 
 round the waist ; the belt has a .^^^^^»^-~ 
 running cord and pulleys, one end of 
 the cord being attached to the back 
 of the limb socket with a flat elastic j 
 
 strap, and the other attached to the , ! 
 
 front by an adjustable strap. The i" 
 
 belt is by far the better method of \ . ! 
 
 attaching the limb. \ \ 
 
 In having a suitable instrument j 
 
 fitted to a lower limb stump it is ! 
 
 important to see that the artificial 
 leg is strongly made, as the weight 
 that it will have to bear is consider- \ 
 
 able (in fact, the whole weight of / 
 
 the body), and in many positions of ' 
 
 the limb this weight will be acting 
 at great mechanical advantage ; but, 
 at the same time, if the moving I 
 
 parts, and especially the foot, are 
 too heavy the limb will not move x' 
 
 quickly enough for easy progression, 
 and will tend to act like a pendu- '-__„ •'"" 
 lum. The fixed parts of an artificial pj^, 
 
 limb — that is to say, the socket — 
 can be made heavy without any disadvantage ; but it 
 is of the utmost importance that the moving parts should 
 be light, otherwise a most unsightly gait will be the 
 result. 
 
26o The After-Treatment of Operations 
 
 In the better class of artificial limbs sheepskin is 
 shrunk on to the surface of the wood ; this prevents it 
 splitting, and enables the limb to be made very light 
 while maintaining considerable textile strength. 
 
 The important things to notice in examining the fit of 
 an artificial limb are to see that the pressure is distri- 
 buted over a large area, and does not come principally on 
 one or two points, and to see that at first no pressure 
 comes on the end of the stump, with the exception of a 
 Syme's and knee-stump. 
 
 How to Measure for an Artificial Leg. — Length from 
 perineum to floor (when the patient is standing), length 
 from lower edge of patella to end of stump, and on the 
 sound side from same point to floor. If for an above- 
 knee amputation, length from perineum to end of stump, 
 and on sound side from same point to lower edge of 
 patella ; circumference of thigh at base on both sides and 
 every 2 inches all the way down. Then, with the 
 patient sitting, and the knee on the sound side bent at 
 right angles, measure from the back of the knee to the 
 ground and from the top of the knee to the ground. It 
 is much better for the instrument maker to make his own 
 measurements, but when this is impossible, the above 
 will generally prove sufficient. Outlines of the stump 
 drawn on paper placed against the limb should also be 
 sent, and the size of boot should be stated or an old boot 
 sent. 
 
 After-Treatment of some Special Operations : 
 Varicose Veins. 
 
 Complications. — (i) Gaping of the wound after the 
 removal of the stitches ; (2) sloughing of some portions 
 of the skin edges ; (3) cedema of the leg. 
 
 After the operation the limb should be elevated, either 
 
After-Treatment of Special Operations 261 
 
 by supporting the splint on cushions, or by slinging it in 
 a suitable cradle. There is no occasion to change the 
 dressings for ten days or a fortnight after the operation, 
 but it is as well to examine them from time to time to 
 ascertain that they have not slipped, and to see that they 
 are not constricting the limb above. After the stitches 
 have been removed, the edges of the wound should be 
 drawn together with strips of strapping, and the wound 
 itself powdered with boracic powder, and then the leg 
 should be bandaged, from the foot up, with a Domet or 
 flannel bandage. As a rule, it is not advisable for the 
 patient to be allowed to walk for quite three weeks after 
 the operation, as the wound after these operations on the 
 veins heals very slowly. In many cases, when the 
 condition of the veins before the operation was bad, it is 
 best to order an elastic stocking to be worn for six months 
 afterwards. The elastic stocking must not, however, be 
 brought above the knee. Or an excellent substitute for 
 an elastic stocking, and one which is cleaner if the patient 
 is intelligent enough to apply it properly, in an elastic or 
 Velpeau bandage. 
 
 Gaping of the wound when the stitches are removed 
 cannot always be prevented, though it is often due to the 
 edge becoming turned in when the wound is being sewn 
 up. The edges should be brought together as accurately 
 as possible, and held in position with small pieces of 
 strapping. 
 
 Sometimes the edges of the wound are so thin and so 
 badly nourished that sloughing occurs. This consider- 
 ably delays the healing, and it is best, if possible, to keep 
 the patient in the recumbent position for some time 
 longer, or else to prevent movement of the skin by the 
 application of strapping. 
 
 Some oedema of the lesf is not uncommon after 
 
262 The After-Treatment of Operations 
 
 operations on the veins, and especially when the patient 
 is first allowed to get up. Careful bandaging, from the 
 foot up to the knee, is all that is required to prevent 
 this. 
 
 Laminectomy. 
 
 Complications. — (i) Chest troubles ; (2) distension of 
 the abdomen ; (3) diarrhoea ; (4) bed-sore. 
 
 As most of the patients on whom laminectomy has 
 been performed are paralyzed, the greatest care is 
 necessary in the after-treatment, and the most skilled 
 nursing is a necessity. If the intercostal muscles are 
 paralyzed, and the respirations are being carried out by 
 the diaphragm only, chest trouble, usually in the form of 
 moist bronchitis, is very liable to occur. Coughing is, 
 under these circumstances, impossible, and the patient is 
 in great danger of being unable to breathe, owing to the 
 mucus in the lungs obstructing respiration. When this 
 is the case, an attempt may be made to dry up the 
 secretion by the use of drugs, such as belladonna and 
 morphia, and the patient should be turned on to the side, 
 so as to clear one lung. Expectorants must, of course, 
 on no account be given. When the cause of the 
 paralysis is high up in the cord, distension of the 
 abdomen often proves extremely troublesome. The best 
 way of treating this is by the use of the rectal tube, after 
 clearing the lower bowel with enemata. If, as is often 
 the case, this does not prove sufficient, direct pressure 
 on the abdomen while the tube is in place may be 
 tried. The pressure can either be applied directly 
 with the hands, or by passing a towel round the 
 abdomen and splitting the ends of the towel, the ends 
 being then passed through each other, and pulled upon 
 from opposite sides in such a way as to compress the 
 
After-Treatment of Special Operations 263 
 
 abdomen. In any case, the pressure should only be 
 exerted during expiration, as otherwise it may so 
 embarrass the respiration as to prevent the patient from 
 breathing. Even after a successful laminectomy the 
 paralysis seldom passes off for some considerable time, 
 and recovery is usually an extremely slow process. The 
 condition of the muscles should be kept up, as far as 
 possible, by the use of massage and galvanism through- 
 out the after-treatment. 
 
 There is, of course, in all these cases of paralysis, a 
 great liability to bed-sore and cystitis. The greatest 
 care and attention are necessary to prevent these com- 
 plications. 
 
APPENDIX 
 
 Rectal Feeding-. 
 
 This may be either by means of rectal suppositories or 
 by enemata. Rectal suppositories have become very 
 popular of late on account of the ease with which they 
 can be administered and retained ; but owing to the com- 
 paratively small amount of material contained in them, 
 a very large number would have to be given in order to 
 take the place of feeding by the mouth and maintain the 
 patient's weight. A combination of both methods of 
 rectal feeding is probably the best in most cases. If sup- 
 positories are used, alternate ones of meat and milk should 
 be introduced every two hours. A little vaseline is 
 smeared on the suppository, and then it is pushed well 
 up the rectum above the internal sphincter. A soap-and- 
 water enema must be given to clear the rectum once a day. 
 When enemata are used the lower bowel must be 
 well cleared with a copious warm-water enema adminis- 
 tered half an hour before the nutrient. The patient 
 should lie on the left side near the edge of the _ bed, and 
 have the buttocks raised slightly; a No. lo or 12 soft 
 Jacque's catheter should be passed well up into the 
 rectum, a little vaseline or glycerine being first smeared 
 on it to facilitate introduction ; a glass funnel is then 
 attached to the free end of the catheter, and the nutrient 
 enema allowed to flow in slowly. If it is allowed to flow 
 in too quickly there will be difficulty in getting the 
 patient to retain it. After the enema the patient should 
 lie quiet without moving for about an hour. 
 
 264 
 
Appendix 265 
 
 The quantity of the enema should be from about 5 to 
 7 ounces of fluid. If there is difficulty in getting the 
 enema retained, the addition of a little claret or burgundy 
 will often prove effectual, or 10 minims of tinct. opii can 
 be added to the enema. All nutrient enemata should be 
 digested before being used either with Benger's liquor 
 pancreaticus or any of the numerous other peptonizing 
 materials. It has been shown that the addition of 
 common salt to egg-albumin renders it capable of 
 absorption by the rectal wall as readily as peptonizing 
 it would do, and it has not the disadvantage of being 
 irritating, as is the case with most of the fluid peptones. 
 All nutrient enemata should be used at body temperature. 
 
 The ease with which the different food -stuffs are 
 absorbed by the rectum varies greatly. Milk is very 
 extensively used as a medium for enemata, although its 
 proteids are not well absorbed by the rectal wall ; egg- 
 albumin is well absorbed if combined with a certain 
 amount of common salt. Raw-beef juice is probably the 
 best absorbed of any of the proteid-yielding foods. Sugar 
 is well absorbed, but has the objection that it is very 
 irritating to the rectal mucous membrane, and conse- 
 quently is not well retained ; it should only be used in 
 dilute solutions. Raw starch is very easily absorbed, 
 and has not the same objection as sugar ; fats are very 
 slightly absorbed, and are practically useless for rectal 
 alimentation. 
 
 The following enemata are easily absorbed, and can be 
 recommended : 
 
 (i) White of three eggs. (2) Ox serum, 5 ounces. 
 
 Milk, 4 ounces. Milk, 2 ounces. 
 
 Starch (raw), i ounce. Starch, 6 ounces. 
 
 Salt, ^ ounce. 
 
 (3) Grape sugar, 60 grammes. 
 Milk, 250 c.c. 
 
 One of the above enemata should be administered 
 every six hours. 
 
 The following nutrient enema is highly recommended 
 by Ewald : Two tablespoonfuls of wheat-flour are stirred 
 up with 150 c.c. of lukewarm water or milk. To this 
 one or two eggs and a pinch of salt are added, and the 
 
266 The After-Treatment of Operations 
 
 whole is beaten up with 50 c.c. of a 15 per cent, solution 
 of grape-sugar, A little claret may be added. 
 
 If no fluids are being administered by the mouth, a 
 large warm-water enema must be given once or twice 
 daily to supply the proper complement of fluid. 
 
 Nasal Feeding". 
 
 This is most commonly used in children when forced 
 feeding is necessary, and also after certain operations on 
 the mouth, when it is desirable not to allow mastication 
 or swallowing. It is also sometimes necessary after 
 tracheotomy and certain operations on the larynx to pre- 
 vent food getting into the air-passages. The child should 
 be placed lying down on its back, and an assistant should 
 be at hand to hold the head. A soft rubber catheter, 
 No. 4 or 6 (according to the age and size of the child), is 
 then passed along the floor of the nose until it reaches 
 the posterior pharyngeal wall, and then it must be 
 pressed steadily on until the stomach is reached ; a 
 funnel is attached to the end of the catheter, and a fluid 
 feed allowed to run in slowly, the amount introduced 
 being, of course, the same as would be given by the 
 mouth. 
 
 Subcutaneous Feeding-. 
 
 This is not a very common method of feeding, but is 
 one that in certain cases may prove useful. As an acces- 
 sory to rectal feeding, it may prove very useful in cases 
 where a patient is failing rapidly from want of nourish- 
 ment ; and in cases where the patient cannot swallow 
 and the rectum has become irritable and will not retain 
 nutrient enemata it can be used for a few days till the 
 rectum has had time to recover. Patients have been 
 kept alive for many days without losing weight by this 
 method of feeding alone. The food used must be able to 
 be sterilized, and must be of such a nature that it needs 
 no digestion, A 10 per cent, solution of grape-sugar can 
 be used, but is very apt to set up irritation at the site of 
 injection. Sterilized olive oil seems to give the best 
 results : 30 to 40 c.c. of sterilized olive oil should be 
 
Appendix 267 
 
 injected into the subcutaneous cellular tissue of the 
 groin with a sterilized glass syringe. The oil should be 
 injected slowly, and it is best not to inject it all in one 
 place, but to inject the 30 c.c. in two or three different 
 places. The injection should only be done once a day. 
 and the part should be massaged after the injection to 
 promote absorption. 
 
 The following is recommended by Freidrick for use 
 as a subcutaneous food 
 
 Sodium chloride 
 Grape-sugar 
 Peptone 
 Water 
 
 0-2 
 
 3-5 
 
 67 
 
 - to 100 
 
 It should, of course, be sterilized by boiling before 
 injection. 
 
 Diets. 
 
 Meat. — Raw meat is a most useful diet after many 
 operations when the powers of digestion are impaired. 
 The ease with which raw meat is digested, and the small 
 amount of residue which it leaves behind after digestion, 
 makes it a diet of the greatest value in affections of the 
 alimentary tract. The best way of preparing raw meat 
 is to scrape the fibres away from the connective tissue 
 with the back of a knife ; the pulp thus obtained can be 
 mixed with a small quantity of ordinary beef-tea, and 
 flavoured with celery salt or other suitable flavouring. 
 As a rule, it is wise not to tell the patients that they are 
 being fed with raw meat, as some people dislike the idea. 
 Of course, it is most important to insure that the meat 
 comes from a reliable source and is quite fresh. Meat 
 extracts, such as beef-tea, etc., are of no value as foods, 
 and but inferior stimulants; moreover, they are very liable 
 to set up diarrhoea. In order that such extracts as beef- 
 tea, bovril, Liebig, etc., may be made use of as foods, 
 they would have to be administered in the concentrated 
 form by the ounce or more many times a day. 
 
 Milk. — Milk leaves a larger residue in the intestine 
 than most other liquid foods, and is very liable to undergo 
 fermentation and give rise to the formation of large 
 
268 The After-Treatment of Operations 
 
 quantities of gas in the intestinal tract, a most unfortu- 
 nate circumstance after abdominal operations. 
 
 Of all fluid diets milk has probably always been the 
 most popular, though the reason for this is in some ways 
 a little difficult to understand. It must be remembered 
 that milk is not a fluid after it has been swallowed, but 
 that within a quarter of an hour of its having entered the 
 stomach it sets into a tough leathery clot, which may 
 offer very considerable resistance to the digestive action 
 of the stomach. Milk remains a considerable time in the 
 stomach in a semi-solid state ; it would therefore seem to 
 be contra-indicated in all operations on the stomach. 
 There are several ways, however, in which the clotting 
 of milk can be altogether prevented, or can be rendered 
 much less dense and resistant than normally. Thus, 
 simple dilution with water will make the clot less dense 
 and more easily digested. A better way, however, is to 
 dilute the milk with hme-water in the proportion of 
 I part of lime-water to 2 of milk ; this greatly reduces the 
 density of the clot. The addition of soda-water to the 
 milk, or the simple aeration of it by means of a ' sparklet,' 
 will render the clot much more readily digestible. Boiled 
 milk, though outside the stomach it clots less easily than 
 raw milk, in the stomach clots just as readily and into 
 just as tough a mass as raw milk. With regard to the 
 ease and completeness with which milk is absorbed by 
 the intestine, it has been shown that when milk is given 
 entirely by itself it is absorbed worse than any other 
 animal food. Under the most favourable conditions only 
 about go per cent, of the available potential energy ever 
 reaches the blood, the remainder leaving the body as 
 waste. Children, however, seem to be able to absorb 
 milk very much better than adults. 
 
 Milk, though rich in proteids and fats, does not contain 
 enough carbohydrates to make it an ideal diet ; it is there- 
 fore better to combine it with some other diet, such as in 
 bread and milk, and gruel, or to add sufficient sugar to it 
 to raise the proportion of carbohydrates to the proper 
 extent. It is, however, a very valuable diet in many 
 cases after operations. It is easily digested with but 
 little expenditure of energy, and although it leaves a 
 
Appendix 269 
 
 comparatively large residue, it does not cause much peris- 
 talsis of the intestine. The large amount of phosphates 
 contained in milk renders it valuable as a diet in cases 
 where there is much bone formation going on, as after 
 excisions, etc. 
 
 Koumiss. — This is a preparation of milk of great value 
 in cases of wasting disease. It is much more readily 
 digested and absorbed than ordinary milk, and thus allows 
 of very large quantities of nourishment being given to 
 patients whose digestive functions are not working pro- 
 perly, and who would therefore be unable to assimilate 
 such a large amount of nutriment in other forms. 
 Koumiss is prepared from mare's milk by fermentation, 
 and contains about 2 per cent, of alcohol. One of its 
 great advantages as a diet is that the casein is in such a 
 state that it cannot form into clots in the stomach, and 
 is already partly digested. The alcohol and carbonic 
 acid which it contains are of value in assisting its 
 digestion in the intestine. 
 
 Kephir, Avhich is a similar preparation made from 
 cow's milk, is almost as valuable as koumiss, and is 
 easily obtainable in England, The leading dairy com- 
 panies now supply both koumiss and kephir at reasonable 
 prices. 
 
 Eggs. — Eggs are very well absorbed by the intestine, 
 and leave a very small residue. Eggs are much more 
 rapidly digested than milk : i pint of milk remains 
 three and a half hours in the stomach ; tv/o lightly- 
 boiled eggs remain one and three-quarter hours in the 
 stomach. The food value of one egg equals ^ pint of 
 milk. Twenty eggs would be required to supply all 
 the proteid material required by a healthy individual in 
 twenty-four hours. 
 
 To prepare Egg-albumin. — Beat up the white of four 
 fresh eggs in ^ pint of water until the whole is thoroughly 
 mixed, then add lemon and sugar to taste, or, if preferred, 
 salt or celery salt may be added instead. 
 
 Plasmon, which is very similar to egg-albumin, and 
 has the advantage of being cheaper, is prepared as 
 follows : 
 
 Add three tablespoonfuls of tepid water to three tea- 
 spoonfuls of plasmon, stir, and rub into a paste ; then add 
 
2/0 The After-Treatment of Operations 
 
 gradually ^ pint of tepid water, place on the fire, bring to 
 the boil, stirring well all the time, and boil for two 
 minutes. This can now be added to milk or other liquid 
 beverage. When cold the dissolved plasmon will form 
 into a jelly, which when whisked will turn into a thick 
 cream. The jelly or cream can be added to food, or by 
 the addition of water can be made into a beverage and 
 flavoured to taste. 
 
 All the casein preparations, such as plasmon, protene, 
 nutrose, etc., have the disadvantage, as compared with 
 pure egg-albumin, that they clot in the stomach in the 
 same way as milk. Plasmon, which appears in many 
 ways to be the best of these preparations, when tested 
 with rennet does not clot into nearly so firm a mass as 
 pure milk, but into a very light friable clot, and, if lime- 
 water is added, does not seem to clot at all. Plasmon 
 and the other casein preparations are of very little value 
 for rectal alimentation, as they seem not to be absorbed. 
 Egg-albumin is a much better form of proteid for this 
 purpose. 
 
 Gelatin. — Jellies which are made from gelatin form 
 an excellent diet, and are very readily digested ; 4 ounces 
 of good jelly equals if ounces of solids, of which half is 
 gelatin and the rest sugar. Gelatin has the advantage 
 of being digested more readily by the stomach than 
 almost any other food. It was estimated by Uffelmann 
 that peptonization is complete within one hour. Gelatin 
 must not, however, be looked upon as a substitute for 
 proteid, but rather as a useful addition to other diets. 
 Its chief value lies in its property of economizing proteid. 
 It is on this account that it has been called a ' proteid- 
 sparer.' 
 
 Sugar. — One of the great advantages of sugar as a 
 diet is the ease with which it can be absorbed. Grape- 
 sugar (dextrose) can pass into the blood without any 
 digestion, and is therefore valuable in conditions where 
 the digestive power is impaired. It has been repeatedly 
 proved that, as a muscle-former, sugar is extremely 
 valuable, and therefore it would seem to be indicated as 
 a diet in combating muscle waste. The value of sugar 
 as part of an invalid diet is not sufficiently recognised ; 
 
Appendix 271 
 
 the ease with which it is absorbed, its high nutritive 
 value, and its high potential energy, all help to make it 
 one of the most useful forms of diet in convalescent 
 states. 
 
 Unfortunately, all forms of sugar tend to undergo 
 fermentation if long retained in the alimentary tract. 
 Also sugar in a concentrated form is irritating to mucous 
 membranes. It is therefore important when using sugar 
 as a diet not to give it in too large quantities at a time, 
 and not to give it in too concentrated a form. When 
 patients object to a sweet diet, milk-sugar, which is almost 
 free from a sweet taste, can be used in place of other 
 forms of sugar. 
 
 REFERENCES. 
 
 ' Food and the Principles of Dietetics ' : Robert Hutchison. 
 ' Encyclopaedia Medica. ' 
 
INDEX 
 
 AnDOMEN, operations on the, 169 
 Abdominal belts, 196 
 Adenoids, removal of, 131 
 
 hsemorrhage after, 63 
 rash after, 135 
 Adhesions, 192 
 Adrenalin in the treatment of 
 
 shock, 93 
 Amputation of breast, 158 
 of limbs, 250 
 secondary, 49 
 Anaesthesia, complications after, 
 
 97. 
 Aperients, use of, 173 
 Appendicitis, 205 
 Artificial appliances, 145, 154 
 limbs, 255 
 
 when to fit, 253 
 respiration in the treatment 
 of shock, 94 
 
 Bedsore, 18 
 
 Belts, after laparotomy, 196 
 
 colotomy, 237 
 Brain, operations on the, 141 
 Breast, amputation of the, 15S 
 Breathing exercises, 165 
 Bullet wounds, 44 
 
 Calcium chloride in treatment of 
 
 hsemorrhage, 55 
 Carbolic acid poisoning, 128 
 Catheter fever, 217 
 Cervical glands, operation for, 
 
 .^57 
 Circumcision, 224 
 
 haemorrhage after, 67 
 
 Cleft palate, obturators for, 145 
 
 operation for, 144 
 Colic, renal, 214 
 Collapse, 82 
 Colotomy, 235 
 belts, 237 
 Cystitis in women, 4, 226 
 Cystotomy, 219 
 
 Delirium tremens, 22 
 Diet after anaesthetics, 105 
 
 after laparotomy, 176 
 Diets, 267 
 
 Dilatation of stomach, post-opera- 
 tive, 193 
 Distension, 171, 182 
 Drainage in septic bullet wounds, 
 46 
 
 tube, removal of, 34 
 Drug habits, 15 
 
 poisoning, 126 
 Drugs for relief of pain, 13 
 
 in the treatment of shock, 92 
 
 Egg albumin, 178 
 Elbow, excision of, 241 
 Empyema, treatment of, 160 
 Enema ra'^hes, 123 
 Enemata, nutrient, 264 
 Epididymo-orchitis, 209 
 Exercises, 248 
 
 Fsecal fistula, 186 
 Fissure in ano, 235 
 Fistula, biliary, 204 
 
 faecal, 186 
 
 operation for, 160 
 
 273 
 
274 
 
 Index 
 
 Flatulence, 17 
 
 Fomentations, 39^ 46 
 
 Foreign bodies in gunshot wounds, 
 
 44 
 left in abdomen, 194 
 Fractures complicating bullet 
 wounds, 49 
 
 Gall-bladder, operations on the, 
 
 203 
 Gauze in dressing wounds, 38 
 Genito-urinary tract, operations 
 
 on the, 215 
 Glands in neck, removal of, 157 
 Goitre, operations for, 155 
 
 Hsematemesis, 104, 201 
 Hsematuria, 213 
 Hsemophilia, 56 
 Hsemoptysis, 104 
 Haemorrhage, 5 1 
 
 after special operations, 62, 
 203, 222 
 
 constitutional treatment for, 
 72 
 
 internal, 61 
 
 recurrent, 52 
 
 secondary, 57 
 
 from bullet wounds, 58 
 Haemorrhoids, 231 
 Harelip, operations for. 142 
 Head, operations on the, 141 
 Hernia, 208 
 
 cerebral, 142 
 
 ventral, 193 
 Hip, excision of the, 245 
 Hydrocele, 225 
 
 Infarction, 109 
 
 Insanity, post-operative, 20, 103 
 Insomnia, 10 
 
 Intestinal obstruction after opera- 
 tion, 189 
 Iodoform poisoning, 127 
 Irrigation of wounds, 37, 46 
 rectal, in peritonitis, 197 
 
 Jaundice, a cause of hemorrhage, 
 
 Joints, injuries of, 50 
 operations on, 239 
 
 Kidney, operations on the, 211 
 Knee, excision of the, 243 
 
 Laminectomy, 262 
 Laparotomy, 169 
 
 complications after, 182 
 
 diet after, 176 
 
 in children, 8 
 Leucocythemia, 57 
 Lithotomy, haemorrhage after, 67 
 Lithotrity, 222 
 
 Mania, 20 
 Massage, 247 
 Mercurial poisoning, 129 
 Meteorism, 182 
 
 Nasal feeding, 266 
 
 Neck, operations on the, 149 
 
 Nose, operations on the, 139 
 
 Obstruction after laparotomy, 189 
 Obturators for cleft palate, 145 
 CEsophagotomy, 154 
 
 Pain, II, 12 
 
 after special operations, 212, 
 232, 251 
 Paralysis, post-angesthetic, 104 
 Parotitis, 187 
 Peritonitis, 185, 197 
 Piles, operation for, 231 
 
 pain after, 232 
 Pituitary extract for relief of 
 flatulence, 18 
 in the treatment of shock, 
 
 93 
 
 Plugging of rectum, 70 
 Pneumonia, 102, 198 
 Position after operation, 3 
 
 after laparotomy, 7 
 
 after operations on the 
 stomach, 201 
 
 in cases of shock, 85 
 Post-anffisthetic complications, 97 
 Prone position, 4 
 Prostatectomy, 221 
 
 Rashes, post-operative, 116 
 
 due to enemata, 123 
 Rectal feeding, 264 
 
Index 
 
 275 
 
 Rectum, operations on the, 228 
 haemorrhage from the, 69 
 plugging of the, 70 
 
 Retention of urine, 210, 234 
 
 Saline infusion in the treatment 
 
 of shock, 87, 88 
 Scarlet fever, pust-operative, 121 
 Sepsis, 36 
 
 treatment of, 40 
 Septicaemia, 41, 117 
 Septic bullet wounds, 46 
 
 rashes, 116 
 Serum, treatment with, 41 
 Shock, symptoms of, 75 
 
 physiology of, 76 
 
 treatment of, 82 
 
 prevention of, 83 
 Shoulder, excision of the, 243 
 Sinus, persistent, 50, 166, 252 
 Sleeplessness after operation, 10 
 Smoking, 15 
 Stimulants in the treatment of 
 
 shock, 86 
 Stitch suppuration, 185 
 Stitches, removal of, 32 
 Stomach, acute dilatation of the, 
 
 193 
 operations on the, 198 
 Stricture after operation for piles, 
 234 
 
 Strychnine poisoning, 130 
 Subcutaneous feeding, 266 
 
 Telephone probe, 46 
 
 Temperature after operations, 26 
 
 Thirst, 16 
 
 Thrombosis, 106 
 
 Thyroid gland, operations on the, 
 
 Tongue, excision of the, 138 
 Tonsils, removal of, 136 
 
 hemorrhage after, 63 
 Tooth-extraction, 137 
 
 haemorrhage after, 65 
 Tracheotomy, 149 
 Transfusion, 88 
 
 Ursemia, 2I3 
 Urethrotomy, external, 224 
 
 internal, 223 
 Uterus, operations on the, 226 
 
 Vaccines in sepsis, 41 
 
 Varicocele, 226 
 
 Varicose veins, 260 
 
 Vomiting, 98 
 
 persistent, 210, 213 
 regurgitant, 170, 199 
 
 Wounds, 31 
 
 gunshot, 43 
 
 THE END 
 
 Bailliere, Tindall &f Cox, 8, HenHetia Street, Covent Garden, London. 
 

 DUE DATE 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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