Sidebilder
PDF
ePub

Stimulation. In order to increase the general resistance to infection, early free stimulation is employed in addition to the saline and whiskey already mentioned. Subcutaneous injections of strychnine gr. 1-30 to gr. 1-20, repeated every three hours, are usually given for twelve to twenty-four or even thirty-six hours, after which the same drug is given by the mouth, until the patient's general condition is satisfactory.

Pain.--When there is a probability that there will be much pain, morphine is given before the effect of the anesthetic has passed off. It is repeated in sufficient doses to keep the patient comfortable. This is done even in cases of peritonitis. The results reported in cases of peritonitis when treated by Ochsner's method have shown the value of intestinal rest, and I do not hesitate to use morphine after operations to relieve all pain so far as possible. It does not appear that morphine impairs the blood or lympathic circulation of the peritoneum or intestines, and if it does not, I can see no contraindication to its use.

Laxatives.-Borrowing again from Ochsner's teaching, little magnesium sulphate is used to secure movements of the bowels. That salines have any specific influence on peritonitis does not appear to be the case. No attempt is made to have every patient's bowels move by a time-table, daily or otherwise. The wide individual variations in the frequency with which this function is performed, need not be worried about or altered because a patient has had an operation. The rectal tube is used in the customary way when necessary for accumulated gas in the cecum. Inflamed intestines have more time to rest when laxatives are not given for thirty-six to forty-eight hours. Then an enema is given; or an enema follows a single dose of calomel (grs. ii to iv), or some mild laxative, as, for example, the pill of aloes and mastich; or a laxative alone is given.

Posture. The position of post-operative cases is changed frequently when mechanical conditions permit it. It appears to me to be as desirable to change the position of unconscious and weak surgical cases frequently, as it is to do so in cases of typhoid fever. In such cases, lying a long time on the back should be avoided as much as possible, particularly when they are unconscious, on account of the greater likelihood that in this position mouth secretions or vomitus may be inhaled. It may be questioned whether the imporvement in results noted, when Fowler's position is used, is not due rather to improved pulmonary and circulatory conditions than to modifications in the amount of toxin absorbed from the

peritoneal cavity. I have never used Fowler's position, nor its opposite suggested by Clarke, of Johns Hopkins; but I do slightly raise the head and upper part of the body with a back rest, and frequently change the patient's position onto the side. With a sufficiently firm abdominal bandage, there has been no occasion to fear a reopening of abdominal wounds. Backaches and tender spots from pressure are very much diminished in frequency and in intensity.

[ocr errors]

Dressings. The chief remaining source of post-operative pain comes from the dressings. Roughness and carelessness and lack of manual dexterity on the part of wound-dressers are errors that can be remedied. The patient usually knows what is done at the dressing, and from this is apt to form his own opinion as to the skill employed at the operation which he neither saw nor felt. When applying dressings at the close of an operation it is often wise to think of how they are to be removed, if the latter is to be done painlessly. When gauze is stuffed into a wound, its removal should be effected under an anesthetic, or delayed until it has been loosened from the tissues with which it is in contact. Drainage tubes and cigarette drains (gauze wrapped in gutta-percha tissue) can usually be removed practically painlessly. Ordinarily they do not need to be reintroduced and their former sites can be cleansed thoroughly without pain, by flushing with saline solution introduced through a small glass tube or a rubber catheter. It is needless to say that the patient should be comfortably disposed in a good light, and that injured limbs should be steadily held by assistants during the entire dressing. The plan for the new dressing should be prepared before any part of the old one is disturbed.

Rest. In general, I endeavor to arrange the after-treatment of operative cases so that the patients shall not be disturbed at frequent intervals for various purposes. They need time to rest, and, if possible, should sleep a good deal. In most cases one can secure three-hour periods without disturbance for anything. The rest and the sleep (the latter secured by drugs when necessary), certainly favor the recovery of the patient.

Food.-Patients whose intestines are not worried by salines, and whose bellies are not distended by gas, are usually pretty ready to eat, and they are allowed food early in such quantities as they can take. Solid food often seems to agree better than liquids. Of course, while there is vomiting, and the stomach digests nothing, no food is given by mouth. The more septic the case the more need for feeding it, to increase the resistance to infection.

Long staying in bed is not resorted to unless the patient is too enfeebled to do otherwise. The practice of getting post-typhoidal septic cases out of bed and feeding them, deserves careful consideration on the part of the surgeon.

It is of the utmost importance to adapt the treatment to each individual case, and abandon, so far as possible, purely routine treatment.-Atlanta Journal-Record of Medicine.

The Modern Management of Malarial Anemia.

One of the most obstinate forms of anemia with which the physician has to contend is that which succeeds malarial infection. This particular form of anemia is, unquestionably, due directly to the structural changes induced by the protozoon parasite.

While a mild form of anemia is a common, if not invariable, consequence of malarial infection, there is a severe type, termed malarial anemia, which not infrequently occurs. This latter variety usually responds slowly to curative measures; and, since its existence renders the individual a fit subject for recurring malarial manifestations upon the slightest exposure, the importance of its cure can not be too strongly emphasized.

The doctrine of the latency of malarial poisoning in the human body is rapidly gaining in popularity. Some authorities even go so far as to claim that a person who has once been inoculated with the malarial protozoa never completely recovers.

Whether this be true or not, it is certain that the protozoon parasite does exert an influence which tends, for a great length of time, to lower vitality and render feeble the powers of resistance to renewed attacks. This is especially true in the case of women, children and persons of advanced age.

Recent investigators unite in ascribing the cause of malarial anemia to the liberation of hemoglobin from the red corpuscles in the blood vessels. The pigmentation resulting from this liberation of hemoglobin is one of the characteristics of malarial infection. And while the coloring matter may remain in the blood stream, it usually infiltrates into the cells and neighboring tissues. The deposit of pigment is especially great throughout the tissue of the liver and spleen.

The thickening and softening of the mucous membrane of the stomach, which always attends malarial infection, seems likely to contribute, at least to some extent, to the development of anemia. In every instance the degree of the anemia is in direct ratio to

the amount of the hemoglobin liberated from the red corpuscles. And this fact explains the philosophy of effecting repair by the administration of iron, the hemoglobin-contributor.

Whether or not the protozoon parasite is ever completely eliminated from the economy remains an unanswered question. But it is now universally conceded that the protracted administration of iron does render the individual partly, if not completely, exempt from a return of malarial manifestations of an aggravated type. Far more so, in fact, than does quinine. Indeed, we have good cause to believe that iron does exert a destructive influence upon the malarial protozoa and increases the immunity of the individual.

While it is the chief aim of the physician to make up the deficiency of the hemoglobin in these subjects by the administration of iron, it is distinctly important, coincidently, to increase the appetite and augment the capacity to appropriate the food ingested.

To this end, discrimination in the selection of the form of iron to be employed is vitally essential. The acid solutions of the drug. are ineligible because of the fact that they can not be engaged for a long period without harmfully affecting the secretion of the digestive juices and adding to the morbid state of the mucous surfaces of the alimentary tract.

Furthermore, the continued use of acid products of any sort are certain to diminish the alkalinity of the blood, thus depressing, to a very considerable extent, the nutritive processes. Then, too, headache which is an ever disturbing factor in these cases, is intensified by all substances of an acid reaction.

The strongly alkaline preparations of iron, while less objectionable than the acid ones, are open to fault for the reason that they induce constipation, and in this manner favor auto-intoxication.

By far the most effectual form of iron in the treatment of malarial anemia is that which is neutral in reaction and available for immediate absorption. The organo-plastic form of iron, as found in Pepto-Mangan (Gude), certainly fulfills the requirements of the physician with greater promptness and uniformity than any other product thus far evolved.

This preparation-Pepto-Mangan (Gude)-is by all means the most potent hemoglobin-producing form of iron, and it undoubtedly surpasses other ferruginous products as an invigorator of the digestive and nutritive functions. These assertions are easily confirmed by the microscope.

It is also an accepted fact that Pepto-Mangan (Gude) does not induce constipation, and it seems to materially hasten repair of the mucous surfaces of the alimentary tract resulting from the structural changes incident to the malarial infection.

In short, Pepto-Mangan (Gude) is of inestimable value in the treatment of malarial anemia by virtue of its manifold advantages over other preparations of iron.

If this preparation is administered for the proper length of time, the individual gains substantially in strength, flesh, physical and mental energy.

Entero-Colitis.

BY O. W. COBB, M. D., EASTHAMPTON, MASS.

I was called last August to see an eight months' old boy who was said to be dying of cholera infantum. He had been treated by two capable men, both of whom agreed that the child could not possibly outlive the day. Every conventional remedy had been tried and the favorite methods of both men had been exhausted. They frankly admitted that all had been done that could be done. I found the patient almost moribund and displaying all the symptoms of a child dying of what I diagnosed as entero-colitis. The symptoms, to my mind, were classic, despite the previous diagnosis. The case was turned over to me at 9 A. M., August 7th. A trained nurse was already on this case. She is an unusually competent woman, in whom I have the most implicit confidence. Then began one of the hardest battles of some years in my practice. I ordered high enemas of Glyco-Thymoline in 25 per cent solution and warm. Used four ounces at a time with a soft rubber catheter, once every three hours. The child could retain nothing, was in frightful pain and passing constantly thin, foul-smelling discharges, tinged with blood. The child was emaciated to the last degree, and for several days before I was called had been in a semiconscious state. The poor little baby was a pitiful sight. For nourishment I ordered several combinations to be administered, an ounce at a time, as a rectal clyster following the enemas of Glyco-Thymoline.

I know it is not good practice to give hypodermics to an infant, but this was a grave case. My predecessor had ordered gr. 1-64 morphine, gr. 1-960 atropin, sub. q. every four hours if needed, with strychnine 1-240 gr. if necessary. I continued this, as the

« ForrigeFortsett »