After-treatment of the Various Forms. —The patient should not leave his bed until the subsidence of all trace of in flammation and until proper healing of the wound have taken place, namely: from three to five weeks. Otherwise there is great liability to recurrence or relapse.
The after-treatment is important and should be conducted with great care. The stomach should be given complete rest for twelve hours, cracked ice and water being allowed in moderation. Af ter that, liquid food, beginning with peptonized milk, if there is any tendency to nausea or vomiting, may be given. To keep the intestinal tract as clear as pos sible, a daily injection of lukewarm soap and water is sufficient. The patient should lie on his back the first four days, then begin to change his positions in bed, if he desires, without violence. Opium should be given in small doses: just enough to check peristalsis.
The outside dressing should be changed every day at first, and the packing re moved on the fourth or fifth day after operation. This should be done with great care and the cavity cleansed by dry sponging, no fluids being introduced into the wound. The wound is then repacked and left so three days, and renewed when necessary. As the packing is renewed from time to time, it should be reduced in size at each sitting so as to permit the wound to heal from the bottom.
Apart from the actual tearing of ad hesions or bowel by violent exercise, it is clear that great exertion or strain before the adhesions are properly organized and tough might lead to their stretching so as to form elongated bands, which may subsequently tend to intestinal obstruc tion.
It is therefore obviously prudent to im press upon patients the necessity for moderation in violent exercise for at least one year from the time of the oper ation. William H. Bennett (Clinical Jour., Sept. 7, '98).
After a second catarrhal attack the operation for removal of the appendix when possible ought to be done after all acute symptoms have subsided, and after the patient has been carefully pre pared for it. The diet for four days ought to consist of soups, barley-water, and white meats, avoiding milk and starchy foods. The bowels should be
regulated so that they are thoroughly moved the day before operation. The usual arrangements for the preparation of the skin are carried out, 3 ounces of soup with a tablespoonful of whisky are given as a nutrient enema three-fourths of an hour before operation, and a sub cutaneous injection of grain of strychnine which materially diminishes shock, and this may be repeated in the middle of the operation if necessary. Au incision, varying in length from 2 to 3 inches according to the stoutness of the patient, is made on the outer side of the rectus muscle over AfcBurney's point, dividing skin and fascia, the mus cles are then separated, not cut, and the peritoneal cavity carefully opened in the usual way, a small sponge with string attached is introduced into the abdomen, all small vessels are then tied in order to get rid of the pressure forceps in the neighborhood of the wound, as they might bruise the bowel it it requires to be drawn out in the process of separating the appendix. lie moving the sponge from the abdomen, the appendix is found in connection with one of the longitudinal bands pass ing downward, inward, or backward, and, with care, it is separated. At times it is so adherent that it is wiser to leave it alone and trust to the effect of the exploratory incision. Having separated the appendix and tied its mesentery, it is removed.
The after-treatment of patients who have had this operation performed is the same as is used in other abdominal cases. The patient is to be gently kept under the influence of morphine for two days, and only soups and barley-water (starvation diet) are to be given. After the bowels have been moved on the sixth day, a more generous diet is al lowed, and in three weeks the wound will be firmly healed, and the patient be allowed to be on the sofa wearing an elastic bandage. At the end of the fourth week, if the wound has been small, walking about moderately is per mitted, and gradually the patient re sumes his ordinary work. Generally great improvement in health follows this operation. J. C. Renton (Brit. Med. Jour., May 23, 190]).