Intravenous injection is the best method of treating patients when the loss of blood has been great. It is unwise to transfuse more than three pints into the veins, or the lungs will become waterlogged and the patient will be later in great peril. When the loss is moderate in amount and the patient is not greatly enfeebled, a pint or more of saline solution may be poured into the abdomen before closing the incision, and this may be supplemented by the administration of six or more ounces of the solution by the anus at two-hourly intervals until the force of the circulation is restored.
In some instances the subcutaneous injection of normal saline solution may be employed. A suitable region is the loose tissue under and around the breasts. When this method is adopted the skin should be rendered antiseptic, otherwise troublesome abscesses and cellulitis will arise in the subcutaneous tissue at the situation where the saline solution has been injected.
Intrapelvic hæmorrhage. For many years I have maintained that two factors which have enabled hysterectomy to vanquish oöphorectomy in the treatment of uterine fibroids are rigid asepsis and perfect hæmostasis. In the early days of intrapelvic surgery there used to be much discussion on the subject of free blood in the pelvic cavity: some practical surgeons urged that it was harmful and would induce peritonitis, and others took the opposite view. From my own observations I came to the conclusion that effusions of blood in the abdomen were often quickly absorbed, but that this was not invariable; and that post-operative collections of blood were very liable to become septic, especially when drainage was employed. I also pointed out that the large effusions of blood in the abdomen due to tubal abortion, or to the rupture of a gravid tube, are often attended with fever, and in some instances the temperature rises to 103°. In such cases, when operative interference is undertaken, the deliquescent clot present in the pelvis often gives off a musty odour. Much light has been thrown on this condition by Dudgeon and Sargent, who have specially investigated the bacteriology of intraperitoneal effusions. These observers have isolated from intraperitoneal effusions of blood a white staphylococcus, which makes its appearance in the blood within a few hours of being effused, and they are of opinion that the febrile disturbances so frequently found after effusions of blood into the peritoneal cavity are due to the presence of this organism.
Apart from the pathological importance of these observations there is a point of practical value connected with them. The white staphylococcus will infect sutures and give rise to stitch-abscesses in the wound; in view of this fact it behoves the surgeon who has to deal with a stale effusion of blood in the pelvis and evacuates it by an incision through the abdominal wall, that in closing the incision he should employ through and through sutures, and not attempt to suture it layer by layer. I have noticed the same tendency to stitch-abscess in cases of diffuse pelvic inflammation due to infection by the gonococcus.
Pneumonia. This is a serious and not infrequent sequel of cœliotomy, especially when it concerns diseased conditions in the upper half of the abdomen: pneumonia occurs frequently as a sequel to ovariotomy, hysterectomy, and allied operations, and occasionally has a fatal ending. It may arise from inhalation, or may be due to the dorsal position (hypostatic pneumonia), or it may arise from infection.
Inhalation pneumonia is not uncommon, and although it is often attributed to the anæsthetic, especially ether, it is doubtless due to a combination of causes, such as a cold room, undue exposure of the body, septic teeth, the chilling effects of ether on the tissues of the lung, and occasionally to a dirty face-piece belonging to the ether or chloroform apparatus.
Hypostatic congestion of the lungs is liable to occur in the aged and in debilitated patients; it is a complication in such cases always to be guarded against.
Embolic pneumonia is the most serious form, and occurs as a sequel to operations for septic conditions, such as pyosalpinx, suppurating ovarian cysts, septic fibroids, and post-operative sepsis; it is also associated with thrombosis, especially when the pelvic veins contain septic clot.
In the preceding section attention was drawn to the appearance in intra-abdominal blood-effusions of a white staphylococcus: such collections of blood are prone to decompose and cause the temperature to rise.