Should it be deemed needful for some of the above reasons to make use of drainage, a glass tube, open at both ends and about six inches in length, is passed through the salicylated cotton or other dressing, then between the two lowest stitches, down to the bottom of Douglas's pouch. A wire suture is first introduced between these sutures and left untwisted, its object being to close firmly the opening left by the removal of the tube and to hasten its union. Otherwise, a weak cicatrix results, tending to the subsequent formation of hernia. Keith's drainage-tube of three sizes is the one that I prefer. Its lower end is perforated with holes, and its upper end has a shoulder which keeps it from slipping into the abdominal cavity, and also enables it to hold a piece of thin rubber sheeting about eighteen inches square. In the centre of this a small circular hole is made, which, by stretching, is sprung over the tube. The mouth of the tube is covered by a cup-shaped sponge wrung out of a 5 per cent. solution of carbolic acid, and over this the sheeting is folded four times. The flannel binder may either be pinned over the drainage-tube, or else it may be slit at the site of the tube and passed on each side of it, leaving the sponge and rubber sheeting outside of the dressing. They are then best held in place by a narrow strip of flannel, so as to permit inspection without interfering with the main dressing. Several times a day the sponge is removed, squeezed out, cleansed in a 5 per cent. solution of carbolic acid, and replaced. This in a hospital had better be done under the spray. Bloody serum collecting in this tube is sucked out either by a fine rubber tube attached to a syringe, or else by the long nozzle itself of the ordinary uterine syringe.
To prevent injurious pressure on the rectum, the tube must be lifted up occasionally about half an inch, and allowed to slip back of its own accord. It can be removed whenever the discharge has been reduced to not more than one or two drachms, and this usually happens within the first forty-eight hours. After its removal the opening left in the wound is closed by twisting the free ends of the wire suture placed there for this purpose.
AFTER-TREATMENT.—The subsequent treatment needs the greatest attention. The first care is to establish reaction. This is best done by stimulants, such as brandy and whiskey given in iced soda-water. Enemata of beef-tea and brandy or of milk and brandy will also be of advantage, while artificial heat is kept up. For the vomiting, which comes partly from the anæsthetic and partly from shock, repeated deep inspirations should be tried. They help by getting the blood rid of the anæsthetic as soon as possible. Chloral may also be given, or small lumps of ice may be swallowed. Sips of very hot water, or a tablespoonful every hour of a mixture containing equal parts of lime-water and of cinnamon-water, may also do good. A hypodermic of morphia will often allay vomiting, and I have seen it yield to small doses of atropia, and also to two grains of pure pepsin given every two hours in a tablespoonful of raw-beef juice. Twenty drops of ether given by the mouth will sometimes relieve it, and so also will a few drops of chloroform confined by a watch-glass over the pit of the stomach. In some cases I have tried, with the best results, the following effervescent mixture, recommended by Chèron:59
| Rx. | Potassii bicarb. Potassii bromidi. aa | gr. xxxij; |
| Aquæ, | fluidounce ij. M. |
| Rx. | Acidi citrici, | drachm j; |
| Syrupi, | fluidounce j; | |
| Aquæ, | fluidounce iv. M. |
A dessertspoonful of the former is added to a tablespoonful of the latter, and given every hour. For vomiting, especially of the bilious variety, Lawson Tait recommends Monson's pepsin wine, given every ten minutes in drachm doses with a little ice-water.
59 Archives de Tocologie, Février, 1883, p. 122.
Flatus is another annoying symptom, which, however, can very generally be dispelled by turning the patient over on her side and inserting a flexible catheter high up in the rectum. If this fails to relieve it, enemata of turpentine may be tried, or five-drop doses of the tincture of nux vomica may be given every two hours. Should the abdomen become painfully bloated, the binder must be loosened and the adhesive straps nicked in several places. The painful tension on the stitches can be relieved by drawing the knees up and supporting them over a pillow doubled on itself. Should the flatus not yield, and symptoms of obstruction set in, the bowels must be opened at all hazards. Castor oil and Epsom salts are good cathartics for this purpose. When vomiting accompanies obstruction, calomel answers best, because it is not so liable to be rejected.
For the first thirty-six to forty-eight hours after the operation nothing whatever should be given to the patient excepting cracked ice, sips of hot tea or of barley-water, and an occasional teaspoonful of old whiskey. After that time tablespoonful doses of milk, of beef-tea, of thin oatmeal gruel, or of barley-water can be given every hour or two. The diet may then be cautiously increased, and especially after wind begins to escape from the rectum, the patient being enjoined not to hold it back from motives of delicacy. If the condition of the patient is such as to demand more nourishment, it had better be taken by the rectum. For a week the urine should be drawn off by the nurse, and the bowels kept quiet by a morning and an evening suppository. No other anodyne need be given unless called for by pain, wakefulness, or restlessness. Should the body-heat indicate a temperature of 101° or over, a bladder filled with broken ice, or, what is far better, a rubber ice-cap, should be kept on the head of the patient as long as it feels comfortable and does not chill her. If the temperature does not fall, and peritonitis or other septic symptoms set in, ice should also be applied to the pit of the stomach. Quinia and morphia must then be given in very large doses, preferably by the rectum, together with ten drops of the tincture of digitalis every hour until the pulse-rate is lessened and the temperature falls.
When a full week has elapsed the bowels should be opened; and, as this is a matter of importance, and is occasionally attended with symptoms of obstruction and with a good deal of constitutional disturbance, a few words will not come amiss. If the hardened feces can be softened down and dislodged by enemata, this is perhaps the best plan, clysters of ox-gall and water or of glycerin and water being the most efficient. But in my experience enemata have so often failed that I rarely resort to them in the first instance. If the woman's stomach is not irritable, I prefer to give her an ounce of castor oil. This is disguised in the compound syrup of sarsaparilla or in some other suitable vehicle, as warm milk, and is brought to her without any previous warning early on the morning of the eighth day. Should it be deemed unwise to try the oil, two Lady Webster pills and two compound cathartic pills can be given at bedtime of the seventh day, or a pill containing three grains of the compound extract of colocynth with one grain of the extract of hyoscyamus may be swallowed every four hours. The compound licorice powder of the German Pharmacopoeia, to which has been added potassium bitartrate, also answers well, provided the patient's stomach will bear teaspoonful doses every four hours. Should these remedies fail to act, they must be supplemented by enemata.