3o mins. Liquor Morphix with 3o or 4o grs. Sodium Bromide may be given at bed-time in severe cases. 20 grs. 'Friona] in mild degrees of insomnia answer all requirements if the patient is not kept awake by any form of pain or acute discomfort. Often the real cause of the insomnia is a purely mental one, the patient dreading the ordeal of lying awake all night, in which case a minute dose of any harmless hypnotic may act powerfully by suggestion after cold sponging has been carried out.
Meleorism,or Tympaniles.—This may he relieved, sometimes effectually, by a large warm water enema containing Tincture of Asafetida or Oil of Turpentine, when the colon is the seat of the distension. A safer practice is to wash out the bowel with plain water, and leave in a small quantity of water containing i dr. tincture of asafoetida. A large light warm poultice over the abdomen, Leiter's Tubes or an iced poultice may be tried.
When the distension is mainly situated in the small intestines the rational treatment would be to administer an intestinal antiseptic, and Oil of Turpentine in zo-min. capsules is a favourite. A capsule containing 5 mins. Oil of Cinnamon or of Cloves is more reliable and avoids the danger of irritation of the neck of the bladder, which follows turpentine some times. Freshly dried Charcoal in very fine powder may be given in drachm doses wrapped up in moistened wafer paper.
Peritonitis.—Signs of local inflammation of the peritoneum may be taken as a warning that the ulcers are deep, and that perforation is liable to occur, hence the necessity of the greatest 'caution as regards the amount and nature of the food, and the utmost circumspection in any attempt to change the position of the patient's body; the bath must in such cases be abandoned for the cold pack.
Ice to the abdomen is clearly indicated, but often the local pain and tenderness are best relieved by warm applications. As a rule poultices are not well borne owing to their weight; a layer of Spongiopiline wrung out of hot water or a thin stratum of the Cataplasma Kaolini or Anti phlogistine may be applied and kept in position by a light abdominal binder.
General peritonitis is usually the result of perforation, though it may arise from rupture of the spleen, a mesenteric gland abscess, suppurating gall-bladder or appendix, in which cases the treatment suitable for per foration is demanded.
is the gravest of all possible complications, and accounts for about one-fourth of the total mortality of the disease. As soon as collapse, rapidity of pulse, and suddenly appearing local or general abdominal pain occur, with rigidity of the abdominal muscles on the right side and immobility or paralysis of the muscles on both sides of the abdomen during breathing, the diagnosis may be accepted as estab lished. This is still further verified at a later stage by the usual constitu
tional symptoms of general peritonitis, as thready pulse, pinched features, absence of liver dulness, etc., but the consensus of opinion is in favour of immediate operation without waiting for these latter signs. There cannot be a question about the urgent necessity of operating at the earliest possible moment. .Drugging with opium or morphia to relieve pain once the diagnosis has become established is a most reprehensible practice, as the narcotic masks the symptoms and signs and misleads the surgeon. Only when the collapse is great at the onset, where a large perforation has oc curred, is the physician justified in postponing operation till a rally occurs. Even when there may be a reasonable doubt about the accuracy of the diagnosis, most authorities would shrink from the responsibility of vetoing a laparotomy.
The best procedure is to make an incision in the abdominal wall in the neighbourhood of the right semilunar line under a general anaesthetic, or if this is not admissible under local anxsthesia, and, after exposure of the caxiim, to look out for the perforation by examining the ileum, com mencing at the appendix, after which the upper part of the colon should be explored. The perforation being discovered and its margins cleansed by gently removing purulent lymph and fitcal matter, it should be invaginated by Lembert sutures. Where there is great injury of the bowel and the con dition of the patient justifies a prolonged operation, a resection of the damaged gut may be performed, but as a rule, owing to the serious primary tondition, it will be advisable in such case to fasten the loop of the damaged bowel in the abdthninal wound, and establish a temporary artificial anus. Any suspicious portion of the intestine which appears to be about to perforate may at the same time be invaginated with sutures. The peritoneum should as rapidly as possible be cleansed with gentle friction by sterile gauze wipes and drainage provided. Some surgeons abstain from any attempt at suturing the perforation, and treat each case by performing an enterostomy, which at a later date may be successfully dealt with.