The principles and practice of modern surgery

by Roswell Park

Lavage may also be practised to great advantage not merely immediately after the operation, but during the ensuing twenty-four hours, or later should vomiting recur or come on late. On the other hand, where time has not been afforded in which to suitably prepare a patient for operation, it is advantageous to wash out the stomach before administering the anesthetic as well as after. This is recommended as a general measure, and without special reference to those cases where operation is directed to the stomach itself or to the intestinal tract, where it has become an established part of the preparation to carefully cleanse these viscera.

Several points in the performance of lavage will be of great service to patient and operator. It should be performed quickly in order to reduce the length of the discomfort, and the water used should be warm, at least 110° F. If the throat be previously sprayed with weak cocaine solution (2 per cent.), or if a cocaine lozenge be dissolved in the mouth, the tube can be introduced with less gagging and difficulty. The lubricant should be flavored with wintergreen or some other aromatic.

Where vomiting continues in spite of lavage it is advantageous to give a full dose of chloral with a little starch-water in the rectum; 2 or 3 Gm. of chloral, with as much sodium bromide, to which, in case of severe pain, a little opiate may be added, may be profitably used in cases where the patient is restless and where sleep is fitful or perhaps impossible. This will be more beneficial than drugs administered by the mouth. It is seldom rejected, and is very soothing.

Extreme restlessness is undesirable from every point of view. In some cases when it comes on early it is an evidence of insufficient oxygenation and may be combated by the administration of oxygen gas. It frequently accompanies shock and constitutes one of its most disturbing features. It may be combated by a subcutaneous dose of morphine or heroine, or chloral in doses of 2 Gm., with as much sodium bromide, thrown into the rectum with salt solution. The effect may not be as prompt, but it is often much better. Restlessness is not always a symptom of pain, but is occasionally an uncontrollable reflex nervous phenomenon.

After operations physiological rest of the operated part is necessary for the process of prompt repair. After abdominal operations, especially when restlessness and vomiting are combined, much harm may be done if the patient cannot keep the parts quiet.

Pain will often accompany restlessness, and frequently accentuate it, especially when patients have not yet fully returned to consciousness. It may be relieved by warm or cold applications. In some cases an ice-bag may be used as soon as the patient is placed in bed—for example, after breaking up an ankylosis. In mild cases the use of chloral in the rectum, as above, with an opiate added, may be sufficient. When pain is severe hypodermics of morphine or heroine should be given. Secretion should not be disturbed by such drugs as these, yet as between them or permitting patients to suffer intensely, my opinion is that opium should be given judiciously, providing it prove sufficient. In extreme cases morphine seems to be the only medicament upon which complete reliance can be placed. When the opiates seem to produce nausea the difficulties are heightened. It may be decided in some cases to push the opiate to the point of narcotism, preferring to keep the patient in this semistupefied condition for two or three days and until the series of early dangers have been passed. Opiates should be given with great discretion lest the opium habit be encouraged if not formed.

Lately there has come into use a remedy which has little or no unpleasant after-effects, and upon which a good deal of reliance can be placed, namely, aspirin, which may be given in 1 Gm. doses, repeated as necessary. If it be combined with phenacetin, in doses of half that amount, the combination will be more effective than either alone. This will often prove a serviceable substitute for opiates in any form.

After operation upon the lower bowel, or in any part of the pelvis, patients may complain of pain, sometimes severe, referred to the rectum. Relief may be obtained by throwing into the rectum, through a flexible tube, one-half to one pint of warm linseed oil. This will often take the place of an anodyne or a suppository.

The next question is one of catharsis. If the alimentary canal have been properly emptied, as it should have been before the operation, the bowels may be allowed to rest for the ensuing forty-eight hours. At the expiration of that time the lower bowel should be emptied. Whether this be done with laxatives administered by the mouth or by enema will depend on the character of the case and the reliability of the stomach. When vomiting is distressing little can be accomplished from above. In most cases the first effort is to be made by the administration of a thorough colon wash, or by the use of an enema, which may perhaps best consist of ox-gall, glycerin, and a saturated solution of Epsom salt. If this be thrown up high, and retained a while, it will in all probability be effective. Should the operation have been one upon the rectum extra care will be needed for the patient’s comfort, and just preceding the stool a small amount olive oil should be administered through a tube. Many patients will complain of gaseous distention or other discomfort, due apparently to fermentation, and partly perhaps to the air which they have swallowed during the act of vomiting, or because of nausea. No matter how produced it will afford relief to get rid of this gas, and while this may be partly accomplished by an enema, it will be more thoroughly effected by a mercurial, given by the mouth, to be followed by a saline laxative. In order that flatus may escape without effort, a rectal tube may be inserted, which later may be utilized for the administration of an enema. Save in rare instances it is a mistake to allow accumulation of fecal matter, as the stercoremia thus favored may easily lead into a more profound form of poisoning by its interference with elimination and vital resistance.

Attention should be also given to the bladder and to the urine. Renal insufficiency is one of the great dangers pertaining to the use of anesthetics. This may be combated by 2 Gr. doses of sparteine sulphate every three hours (McGuire).