CHAPTER XXV

.

PREPARATION OF PATIENTS FOR OPERATION AND THEIR AFTER-TREATMENT.

At the risk of some repetition it is proposed to epitomize here a few directions on a subject of great importance, to which, as well in theory as in practice, too little attention is often paid. For present purposes patients may be divided into two classes: those who have sustained accidents or sudden surgical diseases, where no time is afforded for preparation; and those who, having chronic conditions, are subjected to surgical measures which are, however, sometimes made abrupt by sudden decision. In the former case the surgeon is compelled to work hastily; for the latter, time for preparation should be always afforded. Experience teaches that a few days, sometimes even a few weeks, may be well spent in preparing a patient for a surgical operation.

In emergency cases, aside from the usual scrubbing and shaving, there may be several matters to which it is well to give attention. The stomach should be washed out just before the administration of the anesthetic, or soon afterward. If there be time the rectum should be emptied, and the bladder always; too much care cannot be given to these performances. The degree of shock should be estimated and appropriate treatment given, according to principles stated in the chapter on Shock.

Foresight will often dictate the _preparation of some part of the body not directly involved_ in the field of injury; for example, in any gunshot or stab wound of the abdomen or in a case of acute pancreatitis the back should be scrubbed and cleansed and the patient laid upon sterilized material, so that should posterior drainage be required it may be promptly made without waste of time required for preparation. In head injuries, if the scalp or cortex of the skull be involved, the entire head should be shaved. In preparation of patients for operation upon the mouth, tonsils, or stomach an antiseptic mouth-wash should be used in order to avoid, so far as possible, contamination from these germ-laden regions. It Is especially in cases undertaken for the chronic pathological conditions that time can be afforded for careful preparation. It may be assumed that every patient suffering from a chronic surgical malady has been so disabled, in at least some function, that elimination has been interfered with. The emunctories of the body comprise essentially the skin, the lungs, the intestines, and the kidneys. Every one of these should be made to perform its work more fully.

The skin should be stimulated by _hot-air baths_, for which purpose patients may be sent daily to the Turkish baths, while others should take their sweats in cabinets or in bed. If it be possible after the skin has been made to perspire profusely the patient should be put into a hot bath and the skin thoroughly scrubbed.

The _lungs_ may be stimulated partly by improving the heart’s action,

## partly by certain exercises, and by getting the patient out into the

open. The intestines should be made to perform their work, preferably by the mildest measures that may prove effective. Mercurials are agents of great value, as they not only stimulate secretions but are antiseptic in their effects. Sodium phosphate is useful when something stronger is not required.

Many patients who are found in this class will have _impaired digestion_, for which a regulated diet should be supplied; and such cases may call for _lavage_, as well as for a careful examination of stomach contents, in order that appropriate aids to digestion may be given. Most patients suffer from intestinal torpor, especially of the large intestine, and the daily administration of a high-up _colon wash_, with the patient in the knee-chest position, will give gratifying results.

It has been suggested that in all operations upon the upper alimentary canal it would be of great advantage to feed the patient during the previous forty-eight hours upon sterilized food.

_A careful study of the urine_ should be made, both quantitative and qualitative. The gross measurement of the amount excreted in twenty-four hours is of importance. It is necessary to know what amount of solids is being daily excreted, as well as the amount of fluid. _Renal insufficiency is one of the difficulties_ with which the surgeon has often to deal, and caution should be used when operating upon a patient suffering from this condition. Extra work is thereby imposed upon other emunctories. A depraved blood circulation through the brain will often impair its function and lead to delirium in mild or serious form. The heart’s action will be impaired and septic infection is made more possible, in spite of every precaution included in antiseptic technique. In the chapter on Infection it was stated that certain cases of surgical sepsis commence as infections from within, due to failure in unloading the body of its content of disease germs.

_Hyperacidity_ should be also corrected. In order that this may be properly done, the urine should be tested by a more accurate method than by litmus paper. The restlessness and consequent wound disturbances which may ensue after operation may be due to _failure in the elimination of uric acid_ and the oxalates; alkaline diuretics, therefore, are an important feature in the preparation of many surgical patients.

_The blood and circulation_ should not be neglected in these cases. These patients are frequently anemic. A high degree of anemia is recognized by methods described in the chapter on the Blood. Much may be done, even in a short time, to improve the quantity and the quality of the blood, by attention to nutrition and elimination. By these same measures the heart’s action will be also greatly strengthened, but much can be accomplished in this direction by the use of digitalis, cactus, or other of the heart stimulants, and by the administration, preferably subcutaneously, of strychnine. This is usually given in too small doses. Two hypodermic injections of ¹⁄₃₀ Gr. (0.002) a day will have a pronounced effect. While the heart is thus fortified as against shock before the ordeal, adrenalin will prove the most effective agent during it and after it is passed.

_Intestinal fermentation_ or decomposition is a prominent feature of many of these cases. If it be possible to select a drug which has antiseptic properties that may be effective in the intestine and in the kidneys, it will come near to being the ideal in this respect. The attendant has here to choose from many remedies, and his choice will depend largely on his personal experience. It is better to use a few remedies and use them well than to be indiscriminate.

Salol, benzosol, betanaphthol, sodium sulphocarbolate, and the salts of mercury and arsenic will furnish sufficient compounds from which to select. When the urine is alkaline, as it often is in certain kidney and bladder diseases, urotropin may be advantageously combined with one of the others.

In the way of general preparation of those patients who have to undergo operations upon the _mouth_, _the nasopharynx_, _the esophagus_, _trachea or larynx_, _and upper alimentary canal_, they should be sent to the dentist in order that their teeth may be put in good condition and accumulations of tartar removed, and then use an antiseptic mouth-wash, or, when necessary, a nasal spray, in order that there may be avoidance of infection from the bacteria which abound in these parts. Patients often have diseased and carious teeth, and, in hospital patients especially, the mouth is often in a dirty condition. So long as any wound surface is so situated as to be in danger of contamination from these sources, this should be minimized as far as possible.

=Prevention of Peritonitis.=--Experiments have been made by Mikulicz with regard to the value of _nuclein_ in producing an _artificial and protective leukocytosis_ before abdominal operations, hoping thereby to accomplish more or less in the way of prevention of peritonitis. The procedure is based upon the well-known property of nucleinic acid, or nuclein, to produce a prompt but transitory increase in the number of leukocytes. To take advantage of this, 3 to 5 Cc. of nuclein solution is administered beneath the skin, say twelve hours and again six hours previous to the operation. Should any septic agent be introduced or liberated during its performance, the leukocytes will be present in additional numbers to act as phagocytes and exert their active protective powers.

AFTER-TREATMENT.

The care of patients _after_ operation is a factor in a surgeon’s success and calls for discrimination and judgment. The fact that the odor of chloroform or ether persists about the patient and in his breath for hours after their administration shows to what extent they have been dissolved and are circulating in the blood. If elimination have already been attended to, and so far improved as to permit the emunctories of the body to do work up to their capacity, these anesthetics may be promptly eliminated. The longer they circulate in the blood the greater the disturbance to other functions and the more difficult it is to get normal function equalized.

The things especially to be guarded against, so far as one may prevent them, are _nausea_, _vomiting_, _extreme restlessness_, _pain_, _inactivity of the bowels_, _insufficiency of the kidneys_, and the toxic action of any antiseptics or drugs which may have been used, _e. g._, iodoform.

_Nausea_ and _vomiting_ after operations are due not so much to mere reflex activity as to the elimination of the anesthetic by the stomach and its irritant action. No matter how produced, such vomiting is of itself most depressing, mentally and physiologically, and is injurious in a large proportion of cases, and efforts should be made to prevent it. So long as it was regarded simply as a reflex act drugs were theoretically sufficient for its treatment, but with the appreciation of its actual causation it will be seen that the irritating material should be removed. This may be done with the minimum of discomfort and the maximum of advantage by means of the stomach tube. Lavage, therefore, constitutes the most rational and effective treatment in cases of postoperative vomiting.

That the anesthetic reaches the stomach by way of the circulation and is excreted by the gastric mucosa has been proved by the studies of Türck. He showed that the same is also true of morphine. He showed, moreover, that the stronger anesthetics disturb the metabolism of the cells and that toxic products are thereby produced which, being reabsorbed, cause an auto-intoxication reducing vital resistance of the blood serum and the tissues. Thus during anesthesia there occurs an atony of the stomach walls with the escape of the anesthetic into the stomach, which, acting as an irritant, leads to an increased amount of toxin production. The discoloration of the gastric mucosa and the capillary hemorrhage which take place, as shown _postmortem_ in cases where persistent vomiting is a feature, illustrate the disturbing effect of the stronger anesthetics upon the stomach itself. This furnishes, then, the reason for _washing out the stomach immediately after stopping the anesthetic_ and before the patient leaves the operating table. It cannot be said that by this measure postoperative vomiting will be abolished, but its frequency will be materially lessened.

Lavage may also be practised to great advantage not merely immediately after the operation, but during the ensuing twenty-four hours, or later should vomiting recur or come on late. On the other hand, where time has not been afforded in which to suitably prepare a patient for operation, it is advantageous to wash out the stomach before administering the anesthetic as well as after. This is recommended as a general measure, and without special reference to those cases where operation is directed to the stomach itself or to the intestinal tract, where it has become an established part of the preparation to carefully cleanse these viscera.

Several points in the performance of lavage will be of great service to patient and operator. It should be performed quickly in order to reduce the length of the discomfort, and the water used should be warm, at least 110° F. If the throat be previously sprayed with weak cocaine solution (2 per cent.), or if a cocaine lozenge be dissolved in the mouth, the tube can be introduced with less gagging and difficulty. The lubricant should be flavored with wintergreen or some other aromatic.

Where vomiting continues in spite of lavage it is advantageous to give a full dose of chloral with a little starch-water in the rectum; 2 or 3 Gm. of chloral, with as much sodium bromide, to which, in case of severe pain, a little opiate may be added, may be profitably used in cases where the patient is restless and where sleep is fitful or perhaps impossible. This will be more beneficial than drugs administered by the mouth. It is seldom rejected, and is very soothing.

_Extreme restlessness_ is undesirable from every point of view. In some cases when it comes on early it is an evidence of insufficient oxygenation and may be combated by the administration of oxygen gas. It frequently accompanies shock and constitutes one of its most disturbing features. It may be combated by a subcutaneous dose of morphine or heroine, or chloral in doses of 2 Gm., with as much sodium bromide, thrown into the rectum with salt solution. The effect may not be as prompt, but it is often much better. Restlessness is not always a symptom of pain, but is occasionally an uncontrollable reflex nervous phenomenon.

_After operations physiological rest of the operated part is necessary_ for the process of prompt repair. After abdominal operations, especially when restlessness and vomiting are combined, much harm may be done if the patient cannot keep the parts quiet.

_Pain_ will often accompany restlessness, and frequently accentuate it, especially when patients have not yet fully returned to consciousness. It may be relieved by warm or cold applications. In some cases an ice-bag may be used as soon as the patient is placed in bed--for example, after breaking up an ankylosis. In mild cases the use of chloral in the rectum, as above, with an opiate added, may be sufficient. When pain is severe hypodermics of _morphine_ or _heroine_ should be given. Secretion should not be disturbed by such drugs as these, yet as between them or permitting patients to suffer intensely, my opinion is that opium should be given judiciously, providing it prove sufficient. In extreme cases morphine seems to be the only medicament upon which complete reliance can be placed. When the opiates seem to produce nausea the difficulties are heightened. It may be decided in some cases to push the opiate to the point of narcotism, preferring to keep the patient in this semistupefied condition for two or three days and until the series of early dangers have been passed. Opiates should be given with great discretion lest the opium habit be encouraged if not formed.

Lately there has come into use a remedy which has little or no unpleasant after-effects, and upon which a good deal of reliance can be placed, namely, _aspirin_, which may be given in 1 Gm. doses, repeated as necessary. If it be combined with phenacetin, in doses of half that amount, the combination will be more effective than either alone. This will often prove a serviceable substitute for opiates in any form.

After operation upon the lower bowel, or in any part of the pelvis, patients may complain of pain, sometimes severe, referred to the _rectum_. Relief may be obtained by throwing into the rectum, through a flexible tube, one-half to one pint of warm linseed oil. This will often take the place of an anodyne or a suppository.

The next question is one of _catharsis_. If the alimentary canal have been properly emptied, as it should have been before the operation, the bowels may be allowed to rest for the ensuing forty-eight hours. At the expiration of that time the lower bowel should be emptied. Whether this be done with laxatives administered by the mouth or by enema will depend on the character of the case and the reliability of the stomach. When vomiting is distressing little can be accomplished from above. In most cases the first effort is to be made by the administration of a thorough colon wash, or by the use of an enema, which may perhaps best consist of ox-gall, glycerin, and a saturated solution of Epsom salt. If this be thrown up high, and retained a while, it will in all probability be effective. Should the operation have been one upon the rectum extra care will be needed for the patient’s comfort, and just preceding the stool a small amount olive oil should be administered through a tube. Many patients will complain of gaseous distention or other discomfort, due apparently to fermentation, and partly perhaps to the air which they have swallowed during the act of vomiting, or because of nausea. No matter how produced it will afford relief to get rid of this gas, and while this may be partly accomplished by an enema, it will be more thoroughly effected by a mercurial, given by the mouth, to be followed by a saline laxative. In order that flatus may escape without effort, a rectal tube may be inserted, which later may be utilized for the administration of an enema. Save in rare instances it is a mistake to allow accumulation of fecal matter, as the stercoremia thus favored may easily lead into a more profound form of poisoning by its interference with elimination and vital resistance.

Attention should be also given to the _bladder and to the urine_. _Renal insufficiency_ is one of the great dangers pertaining to the use of anesthetics. This may be combated by 2 Gr. doses of sparteine sulphate every three hours (McGuire).

Many patients are unable to void urine after operations, particularly after those upon the female genitalia, and _the use of a catheter_ is often necessary. This should be used with antiseptic precautions, both as to the patient, the instrument, and the operator’s hands. Much of this difficulty can be avoided by injecting 20 Cc. of a 2 per cent. sterilized boroglycerin solution through a catheter in the evening after the operation. Its action is usually prompt, and in five to ten minutes the patient spontaneously empties the bladder without unpleasant after-effects.

After abdominal and pelvic operations the patient should not be allowed to urinate, but should be systematically catheterized. The bladder should never be allowed to become distended. The amount and character of urine passed should be carefully noted. In serious cases the amount of solids eliminated should be estimated, in order that it may be kept up to the necessary standard. In fact, efficient and sufficient elimination is more necessary after the prolonged administration of an anesthetic than after almost any other event. When sufficient fluid to keep up the standard cannot be administered by the stomach, it should be introduced into the rectum or given beneath the skin. Two or three enemas of salt solution should be administered each day, and in urgent cases the normal solution should be thrown beneath the skin, and this should be repeated as often and as long as may be necessary. When the patient begins to show evidence of what is vaguely described as uremia, _i. e._, _the toxemia of renal insufficiency_, not only should warm water be used in these ways, but hot-air bed baths should be given twice a day if necessary, in order that some of the work of the kidneys may be assumed by the skin. Hot-air baths stimulate the kidneys as well, and these measures will prove more effective than most of the diuretics, although digitalis and pilocarpine by the skin may be of assistance.

Patients frequently complain of excessive _dryness in the mouth_. This may be relieved by occasionally dropping beneath the tongue one-half of an ordinary hypodermic tablet of ¹⁄₁₀ Gr. pilocarpine; also by mouth-washes which contain a little glycerin, and by keeping the lips moistened with glycerin. _Excessive sweating_ can sometimes be relieved by giving a hot-air bed bath or a hot mustard foot bath, as the extra

## action of the skin thus induced checks the spontaneous drain.

_Delirium and acute mania_ occasionally supervene after operations. It should first be made clear that these are not due to any antiseptic or drug. Iodoform is less frequently used than formerly. Children and aged people become delirious with less provocation than do those in middle life. Such delirium is generally an expression of a toxemia, and, in addition to such other measures as may be necessary, calls for control and restraint and more active elimination, as in so-called uremia. In proportion to the degree of mania must be the restraint prescribed. A restraining sheet or a strait-jacket may be sometimes needed. When these conditions arise in surgical patients more harm will come from the violation of the principle of physiological rest than from the drugs which may be needed to secure it. The milder measures should be first used, abstaining as far as possible from opiates, which are probably the least desirable of all, but which may be occasionally demanded. Chloral, the bromides, cannabis indica, alone or in combination, may be made to render more valuable service. Hyoscine, in doses of ¹⁄₁₀₀ to ¹⁄₅₀ Gr. beneath the skin, will often control when other remedies fail; it may prove invaluable. When delirium tremens complicates a case it may be treated as suggested in the chapter on Various Intoxications.

## Part V.

SURGICAL AFFECTIONS OF THE TISSUES AND TISSUE SYSTEMS.

##