Front matter
\ 31 ■ : "' 1111 ' ■ '
bHHHM if
Jill ■11
Preface To Second Edition
The exhaustion of entire First Edition within a year following its appearance is a source of much gratification, and leads the Author to believe that his effort to produce a work of practical value to the profession has been in a measure accomplished.
The Second Edition has been in part carefully rewritten and all recent advances which in the Author's personal experience are worthy of acceptance (such, for instance, as Moorhof's method of treating tuberculous joints and bone cavities — Mayo Robson's postoperative treatment of operations on gallbladder and ducts — Joseph Bloodgood's treatment following thyroidectomy — Fenwick on vital points in prostatectomy — Mayo on removal of varicose veins — Bartlett on postoperative hernia etc.) have been added, together with several new illustrations which will tend to render the work of still greater value.
Nathan Clark Morse.
Eldora, Iowa, March i, 1907.
Vll
Preface To First Edition
The average graduate in surgery knows but little concerning the proper management of postoperative treatment of surgical cases; most of his time in college being engrossed with what appears to be the more important matter of surgical technic, pathology and bacteriology. He realizes the great importance of minor details only when, in actual practice, he is thrown upon his own resources, and the skill he may then acquire is obtained through personal experiences with suffering patients. He may visit the greatest clinics and witness the most brilliant operative technic, but the curtain falls and his observation ceases on the removal of the patient from the operating amphitheatre.
I have long regarded postoperative care and treatment as being equal, if not of greater importance, than mere brilliant technic. Faulty technic may complicate or retard recovery, but faulty postoperative management has robbed many surgeons of what should have been successful results.
The practice of asepsis and antisepsis has removed many complications which heretofore so commonly followed surgical operations. But from my own experience and the observation of cases occurring in the practice of some of our best surgeons I am forced to conclude that infection is often unavoidable and frequently occurs under the most favorable circumstances. It is these cases that frequently tax to the utmost the skill and ingenuity of the postoperative attendant.
Surgeons differ radically over the management of similar cases, each basing his opinion on conclusions evolved from personal experience, hence the meagre information given this important subject by the average modern text-book is frequently conflicting and therefore a disappointment to the student and busy surgeon.
I have long felt the need of a work of this character, and have attempted to compile a rational system, a text-book or guide to the proper postoperative management or treatment, which, so far as I have been able to ascertain, is the first work devoted exclusively to this subject brought before the profession.
ix
X PREFACE TO FIRST EDITION.
The character of the work admits of little originality. What follows is, therefore, an epitome of the various methods used or adopted by modern American and European surgeons, much of the information being derived from personal letters, text-books, medical journals, etc., supplemented when possible by what my own experience has led me to believe is rational and practical.
I have intentionally omitted all reference to surgical pathology and bacteriology, confining myself as strictly as possible to the subject under consideration.
Nathan Clark Morse.
Eldora, Iowa, October i, 1905.
Chapter I. Page
PREPARATION OF THE PATIENT FOR SURGICAL OPERATION,. . . . 1-6
General remarks; rationale of preparatory treatment as advocated by the author, i. — When complicated by phthisis, Bright's disease, jaundice, diabetes, etc., 2. — Remedies usually employed to overcome constipation, debility, anemia, etc., 2. — Kelly's purgative draft, 2. — Method of preparation for laparotomy. Franklin H. Martin, 3. — A. J. Ochsner method, 4; Joseph Price method, 4; Sir Frederick Treves method, 6.
General remarks, 7. — For operation on eye, 8; mouth, nose, and throat, 8. — Mayo's preparation for stomach operations, 8. — Preparation of cervix and uterus, 9; bladder, urethra, and kidneys, 9.
Preparation of Field by Different Surgeons, 9-18
Howard Kelly's method, 9. — Joseph Price method, n. — Method of Nicholas Senn, n. — Treves' method, 13. — Keen's method for cerebral operation, 14. — Ochsner's method, 15. — Method of Robert T. Morris, 15. — Final considerations, 16. — Solutions to be used in the peritoneal cavity, 16. — Remarks on drainage by Joseph Price, 17. ,
Chapter II. Postoperative Wound Sutures, Drainage And Dressings, 19-31
Postoperative wound sutures, 21. — Character of sutures, 21. — Double ligature of arteries, 21. — Method advocated by author for closure of abdominal wounds, 21, 22. — Lister's stitches of relaxation or button sutures, 21. — Irrigation of wound during operation, 22. — Objections thereto, 22. — Remarks on drainage of wounds, 29. — Material for drainage, 30. — Antiseptic gauzes recommended by various surgeons, 30, 31. — Essentials requisite for good wound dressing, 30.
Chapter III. Postoperative Complications, 33 - 7 6
Postoperative temperature and treatment, 35. — Diarrhea, 35. — Postoperative infection, 36; treatment of, 38. — Hemorrhage, 39. — Bleeding from bones, 40. — Hemophilia, 40. — Secondary hemorrhage, 40. — Hemorrhage after nasal operations, 41. — Hematemesis, 42; prognosis and treatment, 43. — Intestinal paresis, or pseudo-ileus, 43; causes of, 44; symptoms of, 45; Wiggin's method of treatment, 46; use of eserin as recommended by Arndt, 46. — Postoperative lung complications, 47. — Pneumonia, symptoms, and treatment, 48. — Rochester's method of treatment, 49. — Embolism and thrombosis, 51. — Gangrene, 54. — Cystitis and treatment, 55. — Neurasthenia, 58. — Postoperative insanity, 62. — Delirium, 63. — Jaundice 63. — Erysipelas, 64. — Peritonitis, 67. — Postoperative bed-sores and treatment, 75.
xi
Xll CONTENTS.
PAGE
Chapter IV
GENERAL PRINCIPLES OF AFTER-TREATMENT AND POSTANES- THETIC COMPLICATIONS, 79-97
General remarks concerning care of patient immediately following operations, 79. — Pallor and feebleness of pulse following anesthesia, 80. — Posture of patient, 80. — Prone position, 81. — Fowler's semi-erect position, 81. — Lateral position, 82. — Postoperative nausea and vomiting, 83; special method of prevention and treatment, 84.
General consideration of shock, 85. — General symptoms, 86. — Preventive measures, 87. — Surgical shock due to vasomotor depression, nervous exhaustion, without serious hemorrhage, 89. — Treatment, 89. — Acute dilatation of the stomach, symptoms and treatment of, 94. — Postoperative thirst, 95. — Morphin, indications for its postoperative emplovment, 96.
Chapter V. Treatment Of Aseptic And Septic Wounds, 100-109
Postoperative treatment of wounds, 100. — Treves' method of wound treatment, 103. — Tillman's paper dressing, 103. — Pryor's treatment of septic conditions after plastic operations, 105. — Principles which govern the treatment of infected wounds, DaCosta, 106. — Sterilized olive oil in septic wounds, 108.
Chapter VI
Hypodermoclysis, 113. — Formula for normal salt solutions, 113. — Intravenous injections, 115. — Character and temperature of solutions for, 116. — Rectal alimentation, 117. — Philadelphia General Hospital formula for rectal feeding, 119. — Subcutaneous feeding, 120. — Inunctions for, 120. — Bandaging, principles of, and various methods, 120. — Support and compress bandaging, 121. — Elizabeth Trotter abdominal bandage. 127. — Munger's invalid bed, 129. — Crosby's bed, 130. — Sick-bed chair, 130. — Hospital lifter, 130, 132. — Medico-mechanical apparatus, 133.
Chapter VII. Healing Of Granulating Wounds, 139-146
Kocher's method, 139. — Harmful action of chemical irritants, 139. — Outten's method to enforce healing, 139. — Skin grafting, 141; Reverdin's method, 141. — Thiersch's method, 141; preliminary preparation of surface, 142. — Operation of grafting, 143. — Cutting of grafts, 143. — Application of, 144. — Dressings, character of, and method of applying, 144. — Changing first dressings, 145. — After-treatment in general, 145. — Transplantation in mass, 146; use of Cargile membrane in, 146.
CHAPTER VIII. Postoperative treatment of operations on scalp, 149
Operations upon the Skull and Brain, 149
General remarks on postoperative treatment following operation on the skull and brain, 149. — Significance of sudden rise of temperature after, and treatment, 149. — Complications following operations on brain, 150. — Postoperative hernia cerebri, 151. — Trephining, 152; closure of wound, method of, 152; after-treatment of, 152. — Methods of preventing postoperative brain adhesions, 153.
CONTENTS. Xlll
PAGE
Operations upon the Jaw, 155
Superior maxilla, excision of, 155. — Excision of lower jaw, after-treatment of, method of dressing, feeding, etc., 156.
Excision of Tongue, 158
General considerations, 158. — After-treatment, 159, 160.
Cleft Palate, 162
After-treatment, Cheyne, 162. — Postoperative complications, 162. — Results, 166.
Hare-lip, 167
After-treatment of, 167. — Lord Lister's method of dressing and after-treatment, 167.
Operations on Nose, 168
Paraffin injection for deformities, 168.
CHAPTER IX. OPERATIONS (Continued), 173-194
Tracheotomy, Laryngotomy, After-treatment of, 173
Jacobson's method, 175. — Dietetics, 176.
Intubation, 1 76
O'Dwyer's method, 176. — Time for removal of tube, 178. — Feeding after
intubation, 179.
ESOPHAGOTOMY, 179
After-treatment of, 179. — Davis apparatus in after-treatment, 179.
Operations on the Thyroid Gland, 180
Recurrent hemorrhage after, 180. — Bloodgood's method of after-treatment, 181. — Complications, 181, 182.
Mastoid Abscess, 182
After-treatment, 182. — Complications following operation, 183.
Empyema or Pleurotomy, 183
Christie's, Jr., method of drainage, 185. — Senn's method of double tube drainage and after-treatment, 185.
Breast Amputation, 188
After-treatment of, 189. — Bodine's triangular splint and method of dressing after, 189. — Author's method of dressing, 191.
Chapter X. Operation On The Stomach, Liver, And Intestines, 197-224
General remarks, 197. — Gastric lavage, importance of, after operation on the stomach, Ochsner. 198. — Posture of patient following stomach operations, 198. — Employment of laxatives, 198. — Rectal feeding and method of introduction of, 199. — Von Leube's formula, 199. — Mayet's pancreatic formula, 199. — Rennie's formula for rectal feeding, 200. — Terrier and Hartmann's, 200. — Smith's, 200. — Robb's, 200.
Cholecystotomy, 201
General consideration of, 201. — Morrison's method of drainage of gallbladder, 202. — Kehr's method of drainage, 204. — Cook's method of drainage, 206. — After-treatment in general, 206. — Mayo Robson's method, 207.
Abscess of the Liver, 208
Rhoades' method of procedure in, 208. — After-treatment, 209. — Hepatic toxemia, 211.
XIV CONTENTS.
PAGE
Gastrostomy, Gastrostomy, Pylorectomy, 213
General remarks, 213. — Feeding of patient and after-treatment in general, 214. — Leakage of gastric juice, 215.
Intestinal Anastomosis, .215
Use of Murphy's button and after-treatment in general, 215. Colostomy, 217
Methods of performing, 217. — After-treatment in general, 219. — Treves' method and after-treatment, 219. — Martin's method of colostomy for acute obstruction, 221. — Senn on intestinal obstruction, 222. — Postoperative enterostomy, 223.
Chapter XI. Laparotomy And Operations On The Abdomen, 227-256
Remarks on postoperative treatment in general, 227. — Abdominal flushing, 227. — Gruzdeff, drainage, 228. — Care of bowels, 228. — Urine, 229. — Laparatomy for septic conditions, 229. — Position of incision, 230. — Laparotomy in peritonitis, 231. — McBurney's method in multiple abscess, 231. — Postoperative laparotomy for intestinal adhesions, 232. — Prevention of postoperative adhesions, 233.
Aeter-treatment or Abdominal Section, 234
Method of Treves, 234.
Appendicectomy, 238
General principles governing postoperative treatment, 238. — Multiple abscess following, 239. — After-treatment, method of Ochsner, 241. — Method of Brewer, 241.
Postoperative Treatment of Ovariotomy, Howard Kelly, 243
Pyosalpinx, 251
After-treatment of, 251. — Pelvic abscess, method of drainage in, 251. — Senn on abdominal drainage in general, 254. — Combined tubular and capillary drainage, 256.
Hernia, 256
E. Wyllys Andrews' method of operating for, 257. — After-treatment, 259. — Complications following, 261. — Postoperative hernia, causes and prevention of, 263. — Umbilical hernia, Mayo's method of after-treatment, 266.
Chapter XII. Operations Upon The Uterus, Vagina, Bladder, And Kid- Neys, 269-290
Postoperative treatment, of abdominal hysterectomy, 269. — Vaginal hysterectomy, forceps method, 269; suture method, 270. — Alexander's operation for retroversion, postoperative treatment, 272. — Trachelorrhaphy, after-treatment of, 272.
Nephrotomy, Postoperative Treatment, 273
Nephrectomy, postoperative treatment, 274. — Abscess of kidney, drainage
Operations upon the Bladder, 275
General remarks, 275. — Suprapubic cystotomy, Ochsner's after-treatment of, 276. — Sir Frederick Treves' method of after-treatment. 279. — Stevenson's suprapubic drainage-tube, 280. — Temporary drainage, 281.
LlTHOLAPAXY, 281
Keegan's method of after-treatment, 282. — Sir Henry Thompson's method of after-treatment, 282.
CONTENTS. XV
PAGE
Perineal Lithotomy, 283
Postoperative treatment of, 284. — Complications following, 285.
Perineorrhaphy, 286
Martin's method of after-treatment, 286.— Removal of sutures, 289. — Kelly's method of after-treatment, 289.
Chapter XIII. Operations Upon The Rectum, Prostate Gland, Urethra
AND SCROTUM, 293-315
Postoperative treatment of 'hemorrhoids, 293. — Ligature method by Allingham, 293. — Clamp and cautery method, after-treatment advocated by Pennington, 294. — Secondary hemorrhage in, 296. — Abscess and fistula following, 297. — Stricture following, 297.
Extirpation of the Rectum, 297
After-treatment of, 297. — Kraske's method of treatment, 298. — Vaginal extirpation of rectum, Murphy's method, 298. — Postoperative complications, 299.
Fistula in Ano, 299
After-treatment of, 300. — Postoperative treatment, method of ^Grant, 300. — Elastic ligature method, 301.
Urethrotomy, 302
General remarks on, 302. — Postoperative extravasation of urine after, 305.
After-treatment in Removal of Prostate Gland : , 306
Moynihan's method of after-treatment, 306. — Technic of suprapubic prostatectomy (E. Hurry Fenwiek), 307. — Postoperative treatment of suprapubic prostatectomy, 307. — Perineal prostatectomy, 307. — Ferguson's method, 308. — Postoperative treatment in operation on scrotum, 310.
Castration, 311
Postoperative treatment, 311. — Complications following, 311. — Erasion of the epididymis, 312.
Hydrocele, 314
Circumcision, 314
Postoperative treatment, Cheyne, 314. — Method of after-treatment advocated by Bransford Lewis, 315.
Chapter XIV. Miscellaneous Operations, 319-350
Ligation of Arteries and After-treatment, 319
Abscess, 319
General considerations of, 319. — Pulmonary abscess, 320. — Psoas abscess, 321. — Retrorectal abscess, 321.
Bubo, 324
Krull's method of treatment, 324.
Gasserian Ganglion, 325
Excision of, drainage, and after-treatment, 325. Laminectomy, 328
Closure of wound and postoperative treatment, 328. Spina Bifida, 329
Postoperative treatment of, 330.
XVI CONTENTS.
PAGE
Hypospadias or Ectopia Vesicle, 330
Postoperative management of, 330.
Symphysiotomy, < 331
Mechanical aids in, 332.
Varicose Veins of the Leg 2>Z2>
Mayo's method of removal, ^Z-
Tuberculosis of the Joints, 335
Rest cure in, 335. — Mechanical aids in, 336. — Abscess of hip-joint, English method of treatment, 337. — Postoperative treatment in general, 338. — Phelps' method with carbolic acid, 339. — Bier's treatment, 340. — Iodoform-glycerin injections in tuberculous joints, Ochsner's method, 340. — Whitman's method of treatment in hip abscess, 342. — Relative efficiency of traction and splinting in, 344. — Thomas brace, 344.
Chapter XV. Modern Treatment Of Compound Fractures, 353-385
Method advocated by Nicholas Senn, 353. — Drainage and counter-openings in, 355. — After-treatment in general, 356. — Antiseptic irrigation and continuous irrigation of wounds, 357. — Comminuted compound fracture of the skull, 359. — Compound fracture of the leg, 360. — Immobilization of fractures, 363. — Postoperative treatment of compound fractures of the arm at or near the elbow, 366. — Postoperative treatment of fractures of thigh, 367. — Ambulatory treatment of fractures of thigh, 369. — Fractures in childhood, 369. — Cabot's posterior splint, 370. — Complications during and after repair of fractures, 373. — Postoperative treatment of fracture of patella, 379. — Shortening following fracture of the long bones. 382.
Chapter XVI
General remarks, 389. — Value of periosteum in 391. — Procedure for a normal operation, 393. — Value of typical methods, 394. — Author's dressings, 397. — After-treatment of septic cases, 399. — Postoperative complications, 399. — Faulty stumps, 399. — Postoperative changes following amputations, 401. — Special amputations, 402.
Amputation at Shoulder, After-treatment, 402
Interscapulothoracic Amputation, After-treatment, 402
After-treatment of Amputation at Hip-joint, 403
Amputation of the Thigh, After-treatment, 405
Amputation of Fingers and Thumb, 406
Amputation of Toes or Portions of Foot, 408
CHAPTER XVII. Excision of Joints, 413
Kocher method of excision, 413. — Essentials of after-treatment, 413. — Excision of shoulder-joint, 414. — Postoperative treatment of, 415. — Postoperative results, 416. — After-treatment of excision of elbow, 416. — Postoperative mechanical aids in, 417, 418.
CONTENTS. XV11
PAGE
Resection of Joints, 418
Resection of wrist-joint, 418. — Resection of hip-joint, general considerations of, 420. — Postoperative treatment of, 420. — Ambulatory splint in, 420. — Excision of knee-joint and postoperative treatment, 423. — Cheyne's method of after-treatment, 424. — Excision of ankle-joint, 426.
Chapter XVIII. Osteomyelitis, Operations For Club-foot, Osteotomy
FOR GENU VALGUM, ETC., 433~453
Osteomyelitis, 433
Chronic osteomyelitis, general remarks, B. H. Nichols, 434. — After-treatment, 436. — Moorhof's method of treatment, 438.
Club-foot, 444
Postoperative treatment, 444. — Retention brace, 446. — Taylor's brace, 446. — Methodical manual correction, 447.
Talipes Calcaneus, After-treatment, 449
Tendo-Achillis, transplantation of, 449.
Osteotomy for Curved Tibia and Fibula, 450
Stillman's brace in, 451.
Osteotomy for Genu Valgum, After-treatment of, 452
Erichsen's brace, 452.
Chapter XIX. Value Of Rontgen-ray In Postoperative Treatment
MANNER OF APPLICATION, 457-467
RONTGEN-RAY THERAPY, 45 7
General consideration, 457. — Dosage and [method of treatment, 458. — Effects of treatment, 462. — Character and kind of tube, 463. — For rectal and vaginal treatment, 466. — Types of epithelioma curable by the Rontgen-ray treatment, 466. — Manner of protecting patient, 467.
CHAPTEK XX.
COMPENSATIVE OR ARTIFICIAL APPLIANCES, 471-478
Where and how to amputate, 471. — In amputation of leg, 472. — Amputation of thigh, 473. — Amputation at the^knee, 473. — The position of the cicatrix, 474. — General remarks concerning, 476. — Preparation of stump for artificial limb, 477. — Artificial hands and arms, 477.
Chapter XXI. Postoperative Dietetics, 481-487
General rules for postoperative feeding, 481. — Diet for laparotomy patients, 483. — After operations upon stomach, 484. — After operations upon intestines, 484. — After operations upon gallbladder, 485. — After operations upon mouth, 485. — After operations upon head, 486. — Use of alcohol after operations, 486. — Feeding of nutrient enemas, 486.
Chapter I. Preparation Of Patients And Of The Field Of Operation
CHAPTER I.
PREPARATION OF THE PATIENT.
GENERAL REMARKS.
The proper preparation of patients for surgical operation is of such importance and has such bearing upon the postoperative treatment, that we shall be pardoned for devoting the time and space necessary for a brief review of the subject. The rationale of preparatory treatment is based upon the principle that the entire system should be as nearly normal as is possible. Robert T. Morris says: "All the avenues of elimination must be open and active, in order to overcome conditions that lead to autointoxication, and render infection the more probable."
If digestion is faulty, the diet should be restricted, and the condition relieved. If the liver is torpid and constipation present, laxatives are indicated, or brisk purgation necessary, in order that the intestinal tract may be rid of toxic matter. Should the kidneys be at fault, the judicious use of diuretics may prove of value. A general bath every third or fourth day, or oftener, with friction or massage, increases the action of the skin and relieves the kidneys. The plan of general preparation of patient herein advocated is that which is uniformly used at the Eldora Emergency Hospital, and applies to all except emergency cases in which immediate operation is imperative.
The patient upon entering the hospital is given a warm bath, ordinary castile soap with a good flesh-brush being sufficient. If the patient is a female, a hot douche of one ounce of sodium bicarbonate to one gallon of water is given, followed by a douche containing one-half ounce of creolin to one gallon of water, or a one percent solution of lysol ; after which the patient is dressed in a clean gown and sent to a room or ward. A complete history of the case is obtained, and a careful physical examination is made to determine the nature or extent of the operation required and the general condition of the patient. Should this examination reveal the existence of phthisis, Bright's disease, jaundice, diabetes or any other condition that would render the operation unusually hazardous, the preparatory treatment must be directed specially to that condition.
A chemic (and later, if necessary, a microscopic) examination of the urine is made, and the quantity of urine passed in twenty-four hours is carefully noted. If immediate operation is not necessary, and the general health of the patient is impaired, she is at once placed in bed, and tonics and restoratives are administered. If the appetite is lost, a good preparation of cod-liver oil, with tincture of nux vomica, Colombo, or gentian, is helpful. If the urine is scanty or deficient in quantity, copious and frequent drafts of water, plain or carbonated, are insisted upon, and are of special value if the patient is a nervous woman. Constipation is overcome by the daily administration of compound licorice powder, preparations of cascara sagrada, or compound aloin pills. If anemia is marked, fresh gelatin- coated Blaud's pills or capsules, with or without arsenic, have proved in our hands of greater value than many of the modern preparations of iron. If there is marked debility with anemia, not dependent upon hemorrhage or septic conditions, in addition to the above, inunctions of leaf lard (Boody) applied to the back, chest, and inside of the thighs, followed by massage, with daily rectal enemas of normal salt solution, will prove beneficial. If, however, the anemia and exhaustion are the result of hemorrhage, exhaustive discharges, or septic absorption, immediate operation is indicated, after which the system will be in better condition and respond more readily to tonics and restoratives during convalescence.
Five or six days prior to all abdominal operations the entire intestinal tract should be gently but thoroughly evacuated. A calomel purge, administered in the evening and followed the next morning by a dose of magnesium sulfate or castor oil, is usually sufficient.
Kelly recommends the old-fashioned black draft with carminative; viz.:
Magnesium sulfate, 5 j
Senna, 3iij
Manna, 5 ij
Boiled water, Oj.
Boil and strain, and give 2 ounces every two hours.
The patient is then placed upon a highly nourishing liquid diet (soups and broths), but no milk is allowed. On the evening of the second day preceding the operation a second laxative should be given, in order that the bowels may be free from accumulations; and during this time, in
PREPARATION OF THE PATIENT. 3
addition to tonics and reconstructives, we generally prescribe five-grain doses of beta-naphthol bismuth, preferably in capsules, with or without extract of cascara sagrada, as an intestinal antiseptic and laxative. Patients very much exhausted, or those advanced in years, who are to be operated upon early in the morning, may require nourishment during the night; beef-tea or clear soup, and, in extreme cases, brandy or whisky at intervals of three or four hours, may be given with advantage, up to two hours preceding anesthesia. The evening before the operation, after a light supper, another bath is given, after which the patient is placed in bed, and if nervous, twenty to thirty grains of sodium bromid is given to induce sleep. No food or broths of any kind are allowed during the night, but the next morning, not later than four hours prior to the administration of the anesthetic, a cup of hot coffee, black tea, or beef broth is given ; otherwise the stomach is kept empty. No purgatives are administered the evening before the operation, nor do we permit flushing of the rectum or enemas of any kind on the morning of the operation, as they frequently annoy both patient and operator.
METHODS OF PREPARATION OF PATIENT BY VARIOUS
SURGEONS.
For Laparotomy. — Franklin H. Martin's method is as follows: The intestines are emptied by mercurials and "salines. The first night of preparation six grains of blue mass is given. The next morning at six o'clock seidlitz powders are given every hour until the bowels move, or feel as though they would move with the aid of a small enema. This should insure a thorough action throughout the entire length of the intestinal canal. If, with the above treatment, the movements are such as to insure a thorough evacuation and to start a free flow of bile, as indicated by the yellow, glistening appearance of the stool, no further catharsis is necessary. The lower bowel should be thoroughly evacuated, however, by the employment of large enemas of soap and water, repeated four or five times during this second day of preparation. The last enema should be given late in the afternoon of the second day of preparation, if the operation is to be done the following morning, or the next morning if the operation is to be done in the afternoon. The bowels are rendered less septic by large doses of bismuth and salol. During the first and second days of preparation ten grains of salol and twenty grains of bismuth subnitrate should be given every six hours.
The bowels are stimulated by means of carminatives, alcoholic stimulants, and strychnin. The second day of preparation oil of cloves, in capsules, is given. In delicate women strychnin is commenced three days before the operation in ^r-grain doses every eight hours, and gradually increased in quantity until ^Vgrain doses are given. The bowels are rendered less septic by feeding the patient on a sterilized milk diet for two days before the operation.
For Laparotomy. — Ochsner's method is as follows:
"As a rule, long-continued preparatory treatment leaves the patient in a much less favorable condition for a surgical procedure than a short and simple preparation, which serves to put the kidneys, the skin, and the alimentary canal in condition favorable to the elimination of the waste products.
"Two or three days preceding the operation, the patient should be placed on a light diet consisting of sterilized food, and allowed an abundance of good water, preferably hot, in order to favor elimination through the kidneys. A nonirritating cathartic should be given, and, if possible, a warm general bath. For several years I have given, as a rule, two ounces of castor oil in the foam of beer or malt extract, the day before the operation, and a large soap-and- water enema on the morning of the operation. In this manner the patient is relieved in a relatively short time of all waste matter and is measurably removed from the likelihood of absorbing the products of decomposition which may be present in the alimentary tract. So large a dose of castor oil does not, as a rule, give rise to great disturbance, pain, or exhaustion. I have also found that the foam of beer or malt extract disguises the oil so thoroughly that patients who are ordinarily nauseated will bear this without annoyance. In the vast majority of patients this amount of preparation suffices to relieve the body of any burden it may possess which might interfere with the process of healing. In other words, the patient approaches the operation in a comparatively clean condition ; his strength has not been impaired by confinement, and the nervous system has not suffered by looking forward to the operation for a long time."
For General Surgical Operations. — Dr. Joseph Price, of Philadelphia, says: "There are two considerations to be borne in mind in the preparation of patients for operation. In Europe and America it is the rule to admit the patient to the hospital a few days before the operation is to be performed: (i) In the interval between admission and operation the patient is bathed, scrubbed, douched if the operation will involve in any way the vaginal tract, and is purged with calomel
PREPARATION OF THE PATIENT. 5
and rochelle salts. (2) The proper preparation for plastic work, in addition to that which is required for general surgical procedures, requires especial brush-scrubbing and irrigating of the mucous passages; and that all scar-tissue should be freed to favor easy approximation of the walls of fistulas.
"In abdominal work purgation conduces to favorable postoperative conditions, prevents bowel distention, reverse peristalsis, persistent nausea and vomiting, and renders unnecessary the premature administration of laxatives; in short, the emptied bowel is at rest, as it should be, for the first twenty-four to thirty-six hours after operation. If the bowel is thoroughly emptied and bathed with bile, fermentation and consequent distention do not occur. To fortify the statement that thorough preparation previous to operation is necessary I may add that in 100 patients brought into the hospital suffering from such conditions as suppurative tubo-ovarian disease, diseases of the uterus rendering hysterectomy necessary, appendicitis, gallbladder disease, etc., and prepared during two days and a night previous to operation, there was no perceptible distention in any case, and no alarming postoperative complications.
"It is an error to administer purgatives and enemas soon after operation, or to resort to other persistent efforts to move the bowel ; this should have been accomplished before operation, by the use of calomel and rochelle salts, since these, in my opinion, give the best results. Furthermore, calomel stimulates hepatic activity, and the presence of plenty of bile in the lower bowel prevents fermentation and greatly lessens the tendency to distention.
"The 'let alone' treatment after operation gives the best results, but the free use of fluids before operation stimulates the circulation, flushes out the kidneys, and increases the eHmination of toxins. It is interesting to note that surgeons who prepare their patients after the above method, and withhold drink (?) for the first twenty-four hours after section, have the largest records for renal secretion in ounces, viz., an ounce or more each hour. Withholding fluids ( ?) after operations requiring drainage, favors the early removal of the drains.
"The peritoneum is a huge lymph sac and it rapidly digests healthy and noninfectious exudates. This prevents the accumulation of such leakage or exudate, and hinders the development of more virulent germs. Leakage from perforation is primarily safe, but later germs develop in the form of savages, and it requires drains or gill-nets to capture them."
Treves' Method of Preparation. — Sir Frederick Treves' method is as follows:
Period Before the Operation. — "The most thorough examination possible of the patient should be made before an operation is undertaken. To carry this out, it is well that the individual should be under observation for some time before he appears in the operating room. In the case of those who have been long confined to bed, it is obvious that the sooner they are relieved, the better. On the other hand, in the matter of operations of expediency upon patients who may be termed healthy, it is well that they should pass through a period of rest before the operation is performed. Operations hurriedly undertaken are not unfrequently regretted.
"In hospital practice it is better not to operate upon a man who comes straight to the wards from some active outdoor work, who is robust and has been living heartily, and who has still the vigorous throb of exercise in his blood and in his limbs. The practice is frequent, for the operation has been previously arranged, and the man does not want to lose even a few hours' work. Such a patient is placed in an infinitely better condition by a few days' rest in a hospital ward. He here becomes accustomed to his surroundings ; he has time to be rid of the refuse matter in his tissues, which can no longer be cast off by muscular exertion; his hearty appetite is enabled to adapt itself to his present requirements; the excreta can be dealt with; and time is allowed (and it is needed in some hospital patients) to make clean the skin. To all the organs, to the still strongly-beating heart, and to the overworked muscles, there is allowed a period of repose. When the operation day arrives, the patient has become acclimatized, strict confinement to bed and a limited diet do not involve so very sudden a change, he has adjusted himself to his new environment, and the ordeal is met after a period of physiologic rest.
The opening of the book is shown; the full text loads in the reader.
Loading the full text…
The end
You’ve reached the end of Postoperative treatment; an epitome of the general management of postoperative care and treatment of surgical cases as practised by prominent American and European surgeons.