Part 16 (1/2)

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:--