The next question is one of pain. Patients should not be allowed to suffer when morphine is at hand, and this would always be true were it not that morphine has, at times, undesirable effects, both in checking intestinal activity and in “locking up the secretions.” Moreover, it frequently nauseates. On the other hand, patients who have undergone serious operations need to be kept absolutely quiet, and to be prevented from tossing and moving themselves in bed. Some expedient then is called for in many cases, and one may, if he choose, begin with the milder of these—such, for example, as the administration of 2 Gm. each of chloral and sodium bromide, with or without chloretone, in a little saline solution or sterile water, thrown high in the rectum. When pain is not severe this is frequently sufficient to soothe and allay, and often to produce sleep. It reduces or prevents the nausea with which many patients suffer. This, too, may be given before the patient leaves the table. Such an enema, with or without asafetida or other soothing drugs, may be repeated as often as indicated, and does much to quiet a rebellious stomach.
It is assumed here that the reader is already familiar with the precautions advised before the administration of anesthetics and that it is now simply a question of after-treatment. (See [Chapter XX].) My own advice is not to withhold morphine in those cases which seem to require it, remembering, at the same time, that suitable management of the stomach is required. It is inadvisable to permit the patient to take any fluid in the stomach for several hours, for even plain water will upset a stomach which has seemed to be perfectly calm and controllable. According to the degree of nausea and discomfort should the stomach be used, the patient’s need for fluids being supplied by more or less copious saline enemas. So soon as the stomach becomes quiet ice pellets or small quantities of water, as hot as can be borne, may be used, the latter frequently proving the more acceptable.
Until the bowels are freely moved whatever food may be administered should be fluid, and, under most circumstances, not more than forty-eight hours should elapse after any operation before the intestinal canal is emptied. Milder degrees of nausea may be treated by the use of milk of magnesia, of small doses of orthoform, or by a mixture which the writer is fond of using, in each dose of which the patient receives 0.02 of cocaine, one minim of carbolic acid, and one or two minims of dilute hydrocyanic acid, in a small amount of water. I have found this in many instances very soothing.
The after-management of many of these cases includes also the treatment of shock and collapse, which have been considered in a previous chapter. It should include, also, suitable attention to the bladder, and a catheter should be used within the first ten or twelve hours if no urine be passed, and as often thereafter as may be necessary. Catheterization should be conducted with the same precautions as indicated at any other time. Other details of after-treatment, such as the removal of drainage materials, change in position of the patient, etc., have been discussed. Stitches of chromic catgut need no further attention, while those of silk or thread will need removal. It is to be emphasized that the great danger of the so-called stitch-hole abscesses comes not so much from the material first employed as from failure to protect it and guard it against the possibility of subsequent infection. Non-absorbable sutures in the abdominal wall are usually allowed to remain from ten to twelve days, but any stitch which is seen to fail in accomplishment of its purposes should be immediately removed, as should also stitches around which a drop of pus is seen to be escaping.
Certain abdominal wounds, especially in fleshy individuals, seem to heal perfectly, then part a little and give vent to material which is hardly pus, but appears more like liquefied or altered fat. Such, in effect, it often is, and the condition implies a necrosis of a certain amount of fatty tissue, with its liquefaction and escape instead of absorption. In this way a small cavity will be left which should heal by granulation, and this may be hastened by the use of mild nitrate of silver solution.
A patient having been removed from the operating table in a satisfactory condition the principal danger is that of internal hemorrhage, which, though fortunately rare, is disturbing when it does occur. In fact, severe abdominal hemorrhage is one of the most serious of surgical accidents, either primary or secondary. It may occur from wounds of all descriptions, as the result of erosion, perhaps of a foreign body, even of a drainage tube, from the slipping of a ligature, from reaction after shock, the heart recovering its vigor and pumping blood out from the vessels which had not previously oozed. In other instances, of course, it may be the result of rupture of an abdominal aneurysm or the twisting of the pedicle of an abdominal tumor. Constitutional causes which contribute toward it are jaundice, both with or without accompanying cholemia (mentioned more particularly in the section on the Biliary Passages), hemophilia, scurvy, and that form of myelogenous leukemia for which splenectomy has been occasionally performed. In all these cases the patients are abnormally prone to bleed freely. When this condition is suspected it is well to determine the coagulation time of the blood. If this be over six minutes the calcium salts, with iron and fruit acids, should be administered some time previous to operation.
The most important symptoms of postoperative or internal abdominal hemorrhages are rising pulse, with fall in temperature, pallor, and that marked reduction of blood pressure which gives rise to the ordinary symptoms of shock or collapse, along with extreme restlessness and disturbance of vision or almost complete blindness. When there has been any notable collection of blood within the abdomen there may be found dulness on percussion over the flanks. Richardson has spoken of the nurse’s duty and the surgeon’s duty under these conditions, the former being to recognize the indications of increasing shock and alteration in pulse rate, the latter being to adopt every expedient for the checking of hemorrhage, including, in many cases, prompt re-opening of the abdomen. The more promptly this measure is instituted when demanded the greater the probability of saving the patient.
The principal danger after all abdominal operations, next to the possibility of hemorrhage, which rarely occurs, is that of peritonitis, a danger so imminent in the pre-antiseptic era as to have made the abdomen an almost sacred cavity, but one which is now almost abolished by perfection of aseptic technique, yet calling for never-ending care and attention to detail, and occurring occasionally in spite of all the precautions which the most experienced and conscientious operator can take. This condition is to be feared when vomiting continues or comes on afresh, and in the presence of tympanites, with a steadily rising pulse. The first appearance of these threatening signs will be always a warning, although not invariably an indication of danger, since the condition producing them may be averted by catharsis or by meeting some special indication. Septic peritonitis, the great dread of the abdominal surgeon, and practically the only form with which he as such has to deal, will be considered by itself a little later. Yet it is always a question whether it is advisable, even in these cases, to administer powerful cathartics which provoke undue intestinal motion and favor the distribution of infection. While it is true that opium masks symptoms and leads to erroneous conclusions the same is frequently true of cathartics. From them a really obstructed or really paralyzed bowel suffers harm rather than good. They are too sparingly absorbed, and if absorbed their effect is bad. It is much better in these cases to wash out the stomach with a weak soda solution, and then keep it empty, emptying the lower bowel by the same means, and thus placing as much as possible of the intestinal tube at rest. With from 1000 to 2000 Cc. saline solution introduced beneath the skin each twenty-four hours patients can be kept from starving for a sufficient length of time to permit of other treatment for the condition.