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A Weekly Journal of Medicine and Surgery VoL 70, No. 2 J, Whole No. J88I. New York, November 24, 1906. $5.00 Per Annum. Single Copies, lOc. ©rtgtnal Arttrbfl. REPORT OF ONE HUNDRED CONSECU- TIVE LAPAROTOMIES; WITH SOME GENERAL OBSERVATIONS, AND A SPECIAL REFERENCE TO APPENDICITIS. By VICTOR F. MARSHALL, B S. M D.. and EDWARD W. QUICK. M.D., APPLETON, WISCONSIN. SURGEONS TO ST. ELIZABETH'S HOSPITAL. In offering this analysis of one hundred recent con- secutive laparotoiiiies we wish to emphasize certain facts that are already well known to the profession, and, if possible, to add some data that may assist in clarifying some mooted questions in operative sur- gery. The cases come under the following heads : (i) Acute Appendicitis, twenty-one cases; (2) Chronic Appendicitis, eighteen cases; (3) Gall- stones, five cases; (4) Cholangitis (Cholecystitis), two cases ; (5) Gastroenterostomy, two cases ; (6) Intestinal Obstruction, two cases ; (7) Ectopic Preg- nancy, two cases; (8) Hysterectomy (Abdominal), four cases; (9) Large Ovarian Cyst, two cases; (10) Miscellaneous operations on uterus and ad- nexa, including pyosalpin.x, small ovarian cyst ; pro- lapse ovary and displacement of uterus, thirty-one cases; (11) Hernia— Inguinal, six cases; Femoral, two cases; Ventral, three cases. The mortality in this series was 2 per cent. One patient operated upon for acute appendicitis died the second day. This case will be discussed under indications for operation in acute appendix disease. In the second case, a hysterectomy for fibroid weighing I2j/^ pounds, the patient died thirty-six hours after op- eration from shock. This patient had been confined to bed for four months and was exsanguinated. We have endeavored in doing intraabdominal work to use the smallest incision possible and to en- large it to give good view and ample room for what- ever manipulations are necessary. In deep and diffi- cult work no incision is large enough that will not ad- mit the whole hand. That operative rapidity is an ele- ment of success there is no doubt, for the inconve- niences of anesthesia, the chances for infection, the exposure to the air, and the drying of the anatomical parts exposed during the course of an operation are all factors which are unfavorable and increase in importance in geometrical ratio with the duration of the operation. Many simple appendicitis operations are completed in fractions of an hour, while others with extensive adhesions mav consume more than an hour. Facility of technique is cultivated without especial thought as to the exact number of minutes used in the performance of the operation. In this series of cases we have used the following procedure for closing the abdominal wall, employing the Bartlett process catgut for buried sutures : The peritoneum is closed separately, bringing the serous surfaces together to prevent, as far as possible, any adhesions of the abdominal viscera to the line of incision. Whenever necessary, the muscles are ap- proximated with one or more sutures loosely tied. We think the proper approximation of the fascia is the keynote to the prevention of postoperative hernia, and our technique is to overlai) the fascia according to the method popularized by Noble. If adipose tissue is excessive, sutures are placed in it. In small incisions the subcuticular stitch of heavy silkworm gut is used. The cosmetic effect even upon the patient's abdomen is not to be ignored, for ugly scars and stitch marks are offensive. Unless some special indication arises, the wound is not in- spected until the time of removal of suture or su- Buy Thorazine Online tures. Exception, of course, is to be made in those cases in which there is possibility of suppuration. In such cases the figure-of-eight suture is used, so that one or more may be removed if necessary to establish peritoneal drainage. In the series peritoneal drainage was instituted in eleven cases, of which nine were drained by the insertion of a rubber tube. The methods of employ- ing the tubes were as follows : ( i ) Simple fenes- tration and wrapping with gauze; (2) split tubes with gauze wicks; (3) cigarette drain made with alternate layers of gauze and dental rubber. The Mikulicz drain was used in one case of ovarian cyst in which there were dense adhesions and persistent hemorrhage — Case No. 40. We will refer to this later Thorazine Uses under intestinal obstruction. One, Case No. 15, was drained by ^-inch gum rubber tubing, fen- estrated, from the abdominal wall externally through vagina. This case was an infected ecoptic pregnancy, which came to operation with a tem- perature of 103° and a pulse of 130. In Purchase Thorazine Online several evidently similar cases we were some- what in doubt as to Generic Thorazine the advisability of employing drainage, and in these cases we found the progress quite as satisfactory as in those in which drainage had been employed, and our tendency is to use drainage less often than formerly. During our student career ten years ago the rec- Order Thorazine Online ognized teaching was to keep all laparotomy patients quiet in bed for twenty-one days. We are follow- ing, however, more recent thought in this connec- tion, and have shortened this irksome period Thorazine 10 Mg markedly. In all simple laparotomy cases with small incisions, Thorazine Bipolar and in which extensive work is not done upon the viscera, the Buy Thorazine patients are placed in sitting posture upon the third or fourth day and permitted to be up Thorazine 200 Mg upon the sixth day, usually leaving the hos- pital before the tenth day. The other cases are a law unto themselves, depending upon their general condition. Great latitude is permitted patients as regards movement in bed after the first day. As soon as the vomiting ceases following anes- thesia, and in those cases in which no vomiting has occurred, water is permitted by mouth in small quantities at frequent intervals. .•Xn exception to this is made in those cases in which the operation 8io MEDICAL RECORD. [Nov. 24, icjot) involves the upper portion of the gastrointestinal tract. The withholding of water in times past frorn laparotomies has been the cause of untold suffering. We believe this practice was Chlorpromazine Thorazine founded largely upon error. What is absorbed freely by the duodenum and should be given freely after vomiting has ceased. One point which stands out prominently is the fact that in but a very small percentage of cases was it necessary to use hypodermic injections of morphine to control pain. It has been our custom to use primarily aspirin in 10- to 15-grain doses, and if this is not effective, codeine sulphate gr. one-half hypodermically is given ; if both fail to produce rest and quiet, morphine is given. In ninety-four cases anesthesia was induced by ether, the open method being used. In the remain- ing six cases chloroform was used for the following reasons : In three cases there was present at the time of operation a mild bronchial affection ; in three Buy Cheap Thorazine cases the operation was performed by lamplight in homes. A decided preference is given to ether for anesthesia, and, whether well founded or not, we shall act upon the belief for the present that ether is a safer general anesthetic than chloroform, due regard being paid to the respiratory, cardiac, and renal lesions. All anesthesias are preceded half an hour by a hypodermic injection of morphine gr. 1/4 and atropine gr. i/ioo. One of the routine rules followed in the after- treatment of our patients is the use of a rectal in- jection of eight ounces of physiological salt solution every three or four hours until all symptoms of shock and the feeling of thirst have disappeared. Hy- podermoclysis was used in four cases. Intravenous transfusion was not found necessary in any of the Thorazine 25 Mg cases of the above series. Whenever tympany be- came a source of Thorazine 50 Mg discomfort to the patient before the bowels had freely moved, the rectal tube was inserted high to facilitate the passage of flatus, which usually Thorazine 100 Mg gave immediate relief. In all of the cases twenty-four hours after opera- tion calomel was given in i/io gr. doses, repeated hourly until one grain had been given, followed in two hours after Thorazine Chlorpromazine the last dose by two drams of mag- nesium sulphate. Exception to this is made,_ of course, in major-operations on the gastrointestinal tract. When an unsatisfactory result occurred, a high rectal enema of magnesium sulphate, glycerin, and water, in the usual proportion of 2, 4, and 6 ounces, respectively, was given. During the day' preceding the operation the pa- tient is given light diet and allowed an abundance of good water and a warm general bath. A mild ca- thartic in the Order Thorazine form of castor oil or magnesium sul- phate is also given this day, followed by an enema the morning of the operation. Castor '-l is gener- ally given \n the foam of beer or with extract^ of malt. The field of operation is prepared the evening before bv first shaving, and by thorough washing with green soap and water, and then the application of soap poultice to the abdomen until entrance into operating-room. The abdomen is then washed once more with a soft or gauze and soap, followed by sterile water, and this in turn by ether, alcohol, and corrosive sublimate one part to one thousand. In emergencv operations the preliminary prepara- tion was necessarily omitted, and in this series we have noted no difference between the two methods in obtaining primary union. Four sterile towels are placed about the field of operation with just enough space exposed. Over the towels is placed a sterile sheet with an opening sufficient in size to do what- ever is necessary. Upon completion the wound, un- Purchase Thorazine less drainage has been instituted, is sealed Thorazine Online with gauze and collodion, which is not removed until the time of removal of suture or sutures. The hands are prepared by washing in an abundance of soap and water, using a brush which is not coarse. iVfter thorough washing for fifteen minutes the hands are immersed in corrosive sublimate, Thorazine Iv one part to three thousand, and kept there several minutes. After washing again in sterile water and drying with a sterile towel, dry rubber gloves are put on. The rubber gloves are sterilized with dressings in the autoclave, and in the past two years that we have been using this method of sterilizing them we have as yet found no reason to change. There were no cases of stitch abscess when drainage was not necessary. Eight patients were operated upon in private houses, with no deaths, while the remaining ninety-two were operated upon in the hospital, with two deaths. The above number is too small to use as a legitimate base of comparison.

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