TREATMENT AFTER OPERATION.—The following symptoms may require treatment: Shock and Collapse.—Nothing is so effectual in warding off or in treating shock and collapse as the administration of normal saline solution or, better still, of Bayliss' solution as described above. If the collapse is very profound, the intravenous method may he used and about 5 pints trans fused. In performing this operation, the strictest antiseptic precautions must be observed, the whole apparatus sterilised by boiling and the patient's skin and surgeon's hands carefully sterilised also. The vein selected is usually that crossing the bend of the elbow. It should be made prominent by pressure on it above the elbow and should then be exposed by an incision along its course. Avoiding any wounding of its wall, the vein is then carefully dissected free from its bed for the distance of r inch, and a ligature, preferably of iodine catgut, is placed under it at each end of the freed portion. The lower ligature is tied to prevent flow of blood from the distal end. A nick is then made in the wall with scissors or scalpel, and through this the canula attached to the funnel and rubber tube is pushed into the proximal end of the vein beyond the ligature there, which is then tied around the end of the canula. Care should be taken that the funnel and tube are full of saline solution, which should be welling out of the canula as it is being pushed into the vein, otherwise there is risk of introducing air-bubbles into the circulation, with a possibly fatal result. After the requisite amount of fluid has been transfused the canula is withdrawn and the ligature tied so as to occlude the upper end of the vein. The operation may be repeated if necessary on the opposite arm.
Should there be insufficient time, facilities or assistance to carry out the rather elaborate technique which is necessary for successful saline trans fusion, saline solution may be transfused under the breasts, and in women this affords a fairly satisfactory and rapid method of increasing the quantity of fluid in the circulation. The apparatus required consists of a hollow needle or needles attached to rubber tubing which is connected with a clean jug or reservoir full of sterilised saline solution. (Down Bros.
make a very satisfactory apparatus.) The gland should be lifted up from the chest wall with the left hand, and the needle thrust almost parallel with the chest wall into the stibinammary tissue. If this precaution is observed, the unpleasant sequela of mammary gangrene will be obviated. The fluid is allowed to flow into the connective tissue by gravity from a height of about 4 to 6 feet above the patient, and from i to 2 pints may be got in at a time.
These measures are suited fur sudden emergencies, but normal saline gives excellent results in most cases of collapse and shock when admin istered by the rectum. The method of continuous administration, if properly carried out, is certainly the most satisfactory. The apparatus required is a vessel to contain the saline, with a thermometer standing in it on which the temperature of the fluid can be easily read. This vessel should stand in a water-bath which is heated by gas or a spirit lamp, and the heat should be so regulated that the thermometer reads about F. From the vessel the saline is conducted by a glass siphon to an india rubber tube on which is a screw-down tap, and which is terminated by a narrow piece of lead pipe bent to accommodate itself to the curve of the anal canal. The tap should be so adjusted that the fluid issues very slowly drop by drop from the end of the leaden tube which is passed through the anus into the rectum. The rate of flow should be regulated by careful observation and should he just short of that which causes escape of the fluid from the anus by the side of the tube. This method is only applicable under constant skilled supervision, but in my experience practically as good results are obtained from the administration every two or three hours of from 1, to i pint of saline, according to the amount of toleration shown by the rectum, through a rubber catheter to which a glass funnel is attached, the fluid being allowed to flow in very slowly.