A System of Operative Surgery Part 16

When there is abdominal distension, this may be relieved by the pa.s.sage of a rectal tube at intervals of three hours, and if this fails a turpentine enema should be given.

Patients should always be encouraged to empty their bladder naturally: many are unable to pa.s.s water whilst lying on their backs. In these cases the urine is drawn from the bladder by a carefully sterilized gla.s.s catheter. Before pa.s.sing the catheter, the nurse carefully wipes away the mucus from the urethral orifice. Cleanliness and care with the catheter must be enforced: cyst.i.tis causes much misery. During the first few days the quant.i.ty of urine pa.s.sed by the patient is measured, and recorded in the notebook.

The temperature should be observed every four hours during the first week and recorded. The first record after the operation is usually subnormal, and in twelve hours it rises to normal or beyond. During the first twenty hours it may rise to 100 without causing alarm; beyond this, if accompanied by a rapid pulse, an anxious face, and distended belly, it will cause anxiety to the surgeon. A temperature of 101 or 102 unaccompanied by other unfavourable symptoms is not a cause for alarm, unless maintained.

The state of the pulse is a valuable guide and more trustworthy than the temperature. When the pulse remains steady and full there is no cause for alarm. When it increases in frequency to 120 or 130 beats per minute, and is thin and thready, then there is danger, even if the temperature is only slightly raised.

On the seventh or eighth day the sutures will require removal.

Occasionally a haematoma forms in the wound; and in patients in whom the operation has been performed for septic conditions, st.i.tch abscesses will occur. In septic cases the sutures require to remain a few days longer, to allow the wound to unite more securely.

When ooph.o.r.ectomy, ovariotomy, or hysterectomy is followed by a non-febrile convalescence the patient may be allowed to leave her bed on the fourteenth day, and at the end of another week she may return to her home or go to the seaside according to circ.u.mstances. When the wound has healed by primary union, and this is usual where aseptic methods have been followed and buried sutures employed for the fascial and muscular layer, an abdominal belt is unnecessary. When suppuration has taken place in the wound and healing has been r.e.t.a.r.ded, especially in a patient in whom operations have been performed for septic conditions, it is a useful precaution to advise her to wear a well-made belt. This is more necessary for women who have to get their living by hard work.

COMPLICATIONS OF ABDOMINAL GYNaeCOLOGICAL OPERATIONS

=Metrostaxis.= After ovariotomy and ooph.o.r.ectomy, unilateral or bilateral, blood sometimes escapes from the uterus in the course of the first week, and simulates menstruation: it sometimes occurs within forty-eight hours of the operation, and is usually ushered in with a rise of temperature (100-101).

=Bed-sores.= These sometimes give trouble when operations are performed on elderly or enfeebled patients, especially when they are thin and have incontinence of urine. With due watchfulness and care on the part of the nurse a bed-sore ought rarely to occur.

=Post-anaesthetic paralysis.= Paralysis following operations on the pelvic organs occurs in connexion with the upper and lower limbs; it is an awkward and avoidable complication. Some of the simplest cases are those which arise from the pressure upon an individual nerve, such as the ulnar, circ.u.mflex, or musculo-spiral, due to the arm coming in contact with the sharp edge of a metal operating table. When the patient's legs are flexed across the sharp edge of the table and fixed, as in the Trendelenburg position, during a long operation, the external popliteal nerve is liable to be pressed upon by the condyles of the femur. This will lead to paralysis of the muscles supplied by it. In some instances the paralysis is bilateral. Paralyses of this kind are identical with what are known as 'sleeping palsies'. The more serious paralyses are directly due to the Trendelenburg position, in which there is a great tendency for the arms to be displaced over the head and hang downwards or abducted, as this position causes the clavicle to compress the nerves of the brachial plexus upon the first rib, or the scalenus anticus muscle, and perhaps, as some observers believe, between the clavicle and the transverse processes of the fifth and sixth cervical vertebrae.

Most of the writers on this subject attribute the paralysis more particularly to drawing the head to one side when the patient lies in the Trendelenburg position with abducted upper limbs, as it tends to stretch the lower cervical nerves of the opposite side, especially the fifth. This stretching is probably a greater factor in producing paralysis than pressure.

The form of paralysis produced in this way is that known as Erb's palsy, and the muscles particularly concerned are the deltoid, brachialis anticus, biceps, and the supinator longus. Sometimes the spinati are involved. Occasionally the paralysis is bilateral. A case has been reported in which there was a total lesion of the brachial plexus, including the muscles of the shoulder girdle.

The following facts serve to show that stretching rather than pressure is responsible for this cla.s.s of paralyses. A patient had undergone a v.a.g.i.n.al operation in the crutch position, when the a.s.sistant drew her along the table by means of his fingers hooked in the axillae over the folds of the pectoral muscles: next morning both upper limbs were found to be paralysed, and they remained in this condition many weeks.

In some of the lighter forms the paralysis pa.s.ses off in a few days, but cases are known in which it has persisted for many months, and as it renders the limb useless for a time it is a serious matter.

Halstead refers to a case of bilateral peroneal paralysis following salpingectomy in the Trendelenburg posture which disabled a patient for six months.

On the whole prognosis is favourable, and recovery the rule.

Budinger has described a case in which the upper limb was paralysed after an abdominal operation. The patient died some weeks later, and a clot of blood was found pressing on the surface of the brain at a spot corresponding to the arm centre.

REFERENCES

BuDINGER. uber Lahmungen nach Chloroformnarkosen. _Archiv f. klin.

Chir._, 1894, Bd. xlvii. 121.

COTTON, F. J., and ALLEN, F. W. Brachial Paralysis--Post-narcotic.

_Boston Med. and Surg. Journal_, 1903, cxlviii. 499.

HALSTEAD, A. E. Anaesthesia Paralysis. _Surgery, Gynaecology, and Obstetrics_, 1908, vi. 201.

TURNEY. Post-anaesthetic Paralysis. _Clinical Journal_, 1899, xiv. 185.

=Giving way of the wound.= After cliotomy the patient runs a risk of the wound being burst open, and this accident seems particularly liable to happen in cases where catgut has been selected for the suture material. Accidents of this kind belong to two categories:--

1. Many cases occur in patients from violent coughing or vomiting, as the straining causes the knots of the sutures to slip.

2. In feeble patients, and those debilitated by anaemia, diabetes, &c., and especially in septic wounds, the union of the edges of the incision unite very slowly; if the sutures are taken out on the eighth day, as is the custom, the wound is liable to burst asunder. This accident is p.r.o.ne to occur in patients whose abdominal wall has been greatly distended by a large tumour, and especially by pregnancy. On the whole the accident is more p.r.o.ne to complicate Caesarean section than any other operation on the pelvic organs, and cases have been reported in which there has been a repet.i.tion of the accident. The largest collection of case-reports in which the wound has burst open after cliotomy has been made by Madelung; a perusal of his paper shows that it is an accident with a high mortality. It is a fact that cases of this kind are rarely published, and from inquiries I find that it is of common occurrence. It has certainly diminished since surgeons have widely adopted the method of securing the wound with buried suture, but this is not always a preventative. The complication which makes the accident so unfortunate for the patient is the protrusion of the intestines.

In dealing with this condition the surgeon carefully and gently cleans the extruded intestines and omentum with sterilized water, returns them into the abdomen, and resutures the wound.

REFERENCES

MADELUNG, O. Ueber den postoperativen Vorfall von Baucheingeweiden.

_Verhandlung. d. Deutschen Gesellsch. f. Chir._, Berlin, 1905, x.x.xiv, 2. Theil, p. 168.

=Haemorrhage.= However carefully an operation may be conducted or whatever material may be employed for ligatures, there is a liability of bleeding after the patient has been returned to bed. Severe internal bleeding is usually due to the slipping of a ligature from an ovarian pedicle, or a uterine artery: it may come from a v.a.g.i.n.al artery, especially in total hysterectomy, and occasionally from a vessel in an adhesion which has been missed in the course of the operation, for oozing which is scarcely appreciable when a patient is collapsed may become very free when reaction occurs.

Severe internal bleeding is manifested by very obvious signs: pallor, cold skin, rapid but feeble pulse, restlessness, and sighing respiration. When these symptoms are manifested the wound must be reopened, the blood and clot removed, and the bleeding point secured. It often happens, where the bleeding is due to the slipping of a ligature from the uterine or ovarian artery, that by the time the surgeon reopens the wound the patient is so bloodless that there is difficulty in determining the source of the bleeding. In very bad cases it is a wise plan to arrange for an a.s.sistant to perform the intravenous infusion whilst the surgeon deals with the bleeding vessel. (See Vol. I, p.

405.)

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 a.n.u.s 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 b.r.e.a.s.t.s. 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 haemorrhage.= For many years I have maintained that two factors which have enabled hysterectomy to vanquish ooph.o.r.ectomy in the treatment of uterine fibroids are _rigid asepsis_ and _perfect haemostasis_. 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 st.i.tch-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 st.i.tch-abscess in cases of diffuse pelvic inflammation due to infection by the gonococcus.

=Pneumonia.= This is a serious and not infrequent sequel of cliotomy, 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 anaesthetic, 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 a.s.sociated 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 p.r.o.ne to decompose and cause the temperature to rise.

On several occasions in which blood has been effused freely into the pelvic cavity, either as a consequence of tubal pregnancy, or as a sequel to an operation, such as an abdominal myomectomy, and the blood has been allowed to remain, or it has been inefficiently drained, the patients have died from septic pneumonia.

In cases of septic thrombosis the patients run a definite risk from pulmonary embolism. When the embolus is large the patient sometimes dies in a few minutes (see p. 101); but even in cases where the embolus is too small to promptly destroy the patient's life, its lodgment in the lungs entails in some instances a very serious illness, and occasionally a fatal termination.

=Parot.i.tis.= Septic parot.i.tis, or, as it is sometimes called, symptomatic or secondary parot.i.tis, to distinguish it from mumps, is an occasional sequel to abdominal operations of all kinds. Careful observations have shown that parot.i.tis is more common after operations for septic conditions, and, although it occasionally occurs after operations which run an afebrile course, the conditions underlying it are mainly septic in character.

Septic parot.i.tis is distinguished from mumps in the following points:--

It occurs as a complication of some other affection, is in itself non-contagious, and occasionally suppurates. There are two views held in regard to its etiology: some hold that it is due to direct infection of the duct (Stenson's) of the parotid gland by micro-organisms from the mouth, whilst others maintain that the path of infection is mainly by the blood-stream.

Two able investigations have recently been published in regard to this condition, in which one writer (Bucknall) supports the view that it is an ascending affection from the mouth, and the other (Tebbs) brings forward evidence that the elements of infection reach it by the blood-stream.