TREATMENT AFTER CELIOTOMY.
The after-treatment of celiotomy is usually very simple. A special
nurse is required for the first three days. The patient should lie upon
her back for the first two or three days; after this she may be moved
partly upon either side, and a pillow may be placed behind her for
support.
The head may be supported by one or two pillows. Much comfort is
experienced by raising the knees over pillows. The patient often
complains bitterly of backache, which may be relieved by slipping a
folded sheet or towel under the small of the back.
Thirst is always present after celiotomy, and is usually the symptom
of which the patient complains the most. There is much diversity of
practice in regard to the administration of water after celiotomy. The
writer allows no water during the first twenty-four hours. During this
time the lips and mouth are frequently moistened with a cloth wet in
cold water or wrapped about a piece of ice. At the end of twenty-four
hours small quantities of hot water or cold soda-water (1 dram) are
given every fifteen minutes or half hour, and gradually increased as it
is found to be retained by the stomach. Hot water relieves thirst as
well, and is not so likely to cause vomiting, as cold water.
The chief objection to the early administration of water after
celiotomy is that it may cause vomiting. Some operators avoid this by
administering the water by the rectum.
Another reason, more or less theoretical, for withholding water is that
the absorbing power of the peritoneum is greatest when the tissues of
the body contain a deficient amount of water.
Pain after celiotomy seems to bear no relation whatever to the
amount of traumatism that has been inflicted. More discomfort may
be experienced after ventro-suspension of the uterus than after a
hysterectomy. In operations upon the generative organs the chief
seat of pain is in the region of the sacrum. Pain is also felt in
the ovarian region and in the abdominal incision. The pain begins
to abate after the first fifteen or twenty hours. Opium should not
be administered unless it is absolutely necessary to allay nervous
excitement in a cowardly woman. In such a case a small dose (gr. ⅙) of
morphine may be administered hypodermically.
The writer rarely finds it necessary to administer an anodyne. Most
patients are able to endure the pain if they are properly encouraged by
the physician and the nurse.
There are several objections to the administration of opium. It
increases the thirst and it diminishes the functional activity of the
gastro-intestinal tract. It retards the passage of flatus by the rectum
and causes tympanites, and it increases the difficulty of moving the
bowels. It obscures and delays the recognition of symptoms that may
demand immediate treatment. The patient who has had no opium is more
comfortable at the end of three or four days after celiotomy than one
to whom it has been given.
The patient should be encouraged to pass water voluntarily. The
application of hot moist cloths to the external genitals sometimes
facilitates urination. In many cases the use of the catheter is never
necessary. If the urine is not voided about every eight hours, it
should be drawn with the catheter. Catheterization should be done
with strict attention to asepsis. The former frequency of cystitis
from the improper use of the catheter has already been referred to.
Catheterization should never be performed under any circumstances
by the aid of the tactile sense alone. The nurse should always see
what she is doing. The catheter--metal, glass, or preferably soft
rubber--should be sterilized by boiling, and should be preserved in a
1:20 solution of carbolic acid.
The catheter may be lubricated with sterilized oil or glycerin. The
labia should be separated, and the vestibule and the external meatus
should be wiped off with a solution of bichloride of mercury (1:2000).
After the catheter has been used once it should be thoroughly cleansed,
inside and out, and sterilized by boiling before being replaced in the
carbolic solution.
The secretion of urine is always diminished for a few days after
celiotomy, probably on account of the restricted ingestion of fluids.
The writer has found the average secretion in 111 cases of celiotomy on
women to be, during the first twenty-four hours, 13.4 ounces; during
the second twenty-four hours, 14.6 ounces; during the third twenty-four
hours, 19.6 ounces. In considering these numbers it should be
remembered that the gynecological patient passes, before operation, a
daily amount of urine much less than that passed by the average healthy
woman.
Food is usually first administered at the end of forty-eight hours.
If the patient be feeble, nutriment may be given by the mouth or the
rectum before this time. The patient may have any easily digested food
that she wishes, such as buttermilk, soup, beef-tea, milk or milk and
lime-water, soft-boiled egg, etc. The food should be given frequently
in small quantities. Buttermilk is one of the best foods with which to
begin. It gratifies thirst and is more readily digested than milk. Half
an ounce to an ounce may be given every hour until the retentive power
of the stomach is determined.
The bowels should be moved at the end of forty-eight or seventy-two
hours. If the patient is uncomfortable and is unable to pass flatus
freely, or if there is any abdominal distention, the purgative should
be administered at the earlier time (forty-eight hours). If she is
comfortable and passes flatus easily, she may wait for three days.
Purgation is most readily produced with Rochelle salts, given, in doses
of ½ dram in about 3 or 4 ounces of water or soda-water, every hour.
After the patient has taken five or six doses she usually feels the
inclination to have a movement. If she is unable to accomplish this,
she may be assisted with a rectal injection of 1 pint of soap and water
and 2 drams of turpentine. The bowels should be moved at least once in
every forty-eight hours during the remainder of the convalescence.
Sometimes the bowels are more difficult to move, and it is necessary to
repeat the rectal injection at intervals of two or three hours until
a good movement is produced. A compound enema composed of Epsom salts
℥j, glycerin ℥j, turpentine ℥iss, water ℥viij, injected high in the
bowel through a rectal tube, may be effective. If the Rochelle salts
are not retained, or if they fail to act, 1 grain of calomel may be
administered every hour for five or six hours.
If the patient does well, vomiting does not often occur after the first
twenty-four hours, when the effects of the ether have passed off.
When vomiting occurs later than this, it is usually accompanied by
abdominal distention and general abdominal pain. It is then an alarming
symptom, and may indicate the onset of intestinal paralysis and general
peritonitis.
This group of symptoms (vomiting, general abdominal pain, and
distention) demands immediate treatment. A hot mustard plaster or a
turpentine stupe should be placed over the epigastrium, and an enema
of 1 pint of water and ½ ounce of turpentine should be administered,
and should be repeated every three or four hours until a fecal movement
occurs and flatus is freely discharged. At the same time Rochelle salts
should be administered, or, if there is persistent vomiting, 1-grain
doses of calomel. The escape of flatus may be assisted by inserting a
rectal tube. In case of moderate distention or of intestinal pain from
inability to pass flatus, the insertion in the anus of the ordinary
rectal nozzle of the syringe will usually give relief. If this is not
sufficient, the long rectal tube or a large rubber catheter should be
introduced. It should be well greased and passed slowly into the rectum
for a distance of 10 or 12 inches.
The patient is sometimes able to pass flatus when upon her side, though
she may not be able to do so upon her back. Inability to pass flatus
is not necessarily a sign of peritonitis or intestinal paralysis. It
may be caused by the unaccustomed position, or pain or nervousness may
prevent the woman relaxing the sphincter ani.
If the vomiting persists and becomes bilious, relief is sometimes
obtained by thoroughly washing out the stomach through the stomach-tube.
The internal administration of medicines--except the purgatives already
mentioned--is of little use in vomiting of this character.
The pulse after celiotomy usually remains below 100. It often, however,
reaches 115 or 120, and sometimes higher, in patients who have a
favorable convalescence. A rapid pulse unaccompanied by unfavorable
abdominal symptoms often indicates some heart-trouble.
A pulse of over 120 accompanied by abdominal distention and vomiting
should always excite alarm.
Strychnine and digitalis, administered hypodermically, are the most
useful medicines for strengthening the heart and diminishing the
rapidity of the pulse. They should be given in large doses--1/20 of
a grain of strychnine every three or four hours, and 10 minims of
tincture of digitalis at similar intervals.
Hypodermic injections of strychnine are most useful for shock after
celiotomy. This drug may be exhibited until the physiological
action--twitching or jerking of the muscles--is observed. The writer
has administered between 1 and 2 grains during the first twenty-four
hours after celiotomy, with recovery.
The temperature after celiotomy runs no regular course. It usually
remains below 102° F. A greater elevation of temperature than this may
occur during a favorable convalescence; and; on the other hand, a fatal
termination may take place when the temperature remains lower. The
maximum temperature is usually observed about the second or third day.
The temperature often rises on account of very trivial causes. It may
go up one or two degrees if the patient should become constipated, and
will drop as soon as a free fecal movement has taken place.
[Illustration: FIG. 207.--Composite temperature-chart of a series of
150 successful cases of celiotomy: average temperatures, pulses, and
respirations for two weeks after operation.]
The comfort of the patient is much increased by sponging the arms and
legs with tepid water. The nurse should be instructed to sponge the
patient in this way whenever the temperature reaches 102° F.
The patient should maintain the recumbent posture for three weeks after
celiotomy. She may then sit up in bed for two or three days, and if
then sufficiently strong, she may leave the bed.
Too great haste in getting up may result in ventral hernia. The
incision should be strapped with adhesive plaster for five or six
weeks after operation, and the woman should wear some simple form of
abdominal binder for the following six months, or for a year if the
incision be large. She should be warned against resuming hard work,
involving lifting or other abdominal strain, for several months after
operation. She should be told of the possibility of ventral hernia,
and advised to return immediately for treatment should this condition
appear.
The usual causes of death after celiotomy are peritonitis and
hemorrhage. The frequency of hemorrhage as a cause of death is often
overlooked. The writer feels confident that many deaths which, without
post-mortem examination, are attributed to peritonitis, are really
caused by hemorrhage. Without doubt, peritonitis and hemorrhage often
occur together; the blood that escapes into the peritoneal cavity
may be too great in amount for absorption, and may become septic.
The source of the hemorrhage is usually a vessel of the pedicle that
escapes from the embrace of an imperfectly applied ligature. This
accident should not happen if the operator is careful to see that
hemostasis is perfect before the abdomen is closed. Bloody oozing from
a surface of adhesion is not sufficient to cause death, and may be
removed by drainage; the fatal hemorrhage comes from an arterial vessel
that has slipped from its ligature. All ligatured vessels should be
finally inspected immediately before the abdomen is closed. If a stump
is not perfectly dry, a reinforcing ligature should be applied. Care
in this particular will save much subsequent anxiety. If the operator
knows that his ligatures have been securely applied, he can exclude
the possibility of hemorrhage in case alarming symptoms should arise.
If the symptoms of the patient after celiotomy indicate hemorrhage, the
abdomen must be reopened and the bleeding vessels secured.
The causes of peritonitis after celiotomy have already been discussed.
The common symptoms are rapid pulse, abdominal distention and pain with
inability to pass flatus or feces, and vomiting, which may finally
become stercoraceous. The temperature is usually elevated, though it
may remain normal or subnormal. Auscultation of the abdomen reveals
total absence of all peristaltic sounds. If these symptoms are not
arrested by the use of purgatives, turpentine enemata, and the rectal
tube, it is probable that the result will be fatal. Death usually
occurs on the third day.
The mortality after celiotomy depends upon the condition to be treated,
the skill of the operator, and the environment of the operation. Some
operations, like ventro-suspension of the uterus, are attended by no
mortality. The average mortality after celiotomy for large numbers of
gynecological cases of all kinds, in the hands of experienced operators
with good operative surroundings, is about 5 per cent.