In very feeble patients a nutrient enema may be administered about two hours before the operation.
A hypodermic injection of 1/20 grain of strychnine is often useful upon the morning of the operation when the patient is in poor condition.
Preparation of the External Genitals and Vagina.—The pubis and the external genitals should be shaved. The woman should be drawn down to the edge of the bed, and the anus, the external genitals, and the vagina should be scrubbed with green soap. The vagina should be washed throughout. The nurse may do this by inserting one or two fingers, or she may retract the perineum with the Sims speculum, and scrub the vagina, the fornices, and the vaginal cervix with cotton held in forceps.
The scrubbing should be followed by a vaginal douche of a gallon of hot water to wash out the soap, and then by a douche of two quarts of bichloride solution (1:2000). One hour before operation the vaginal douche of bichloride should be repeated, and the nurse should introduce in the vagina as far as the cervix a light vaginal tampon of gauze wet with the bichlorid solution. In every abdominal operation on women it is desirable that the external genitals and the vagina should be clean. It may be necessary to pass the catheter or to perform some vaginal manipulation, or the vagina may be opened during the operation.
If the vagina is small or virginal, or if the woman is nervous, the nurse may be unable to perform the method of cleansing just described; and it is then necessary for the operator or the assistant to clean the vagina after the woman is anesthetized. Such cleansing should always be performed, in addition to the cleansing by the nurse, whenever a vaginal operation is performed or it is expected that the vagina will be opened from above. Thorough vaginal sterilization is most easily accomplished when the patient is under the influence of ether, as the perineum is easily retracted and the vagina becomes more patulous. The woman should be placed in the lithotomy position, and the washing should be performed with two fingers or with a soft brush like a jeweller’s brush, or with cotton in forceps. If necessary, the perineum should be retracted with the speculum. Green soap should be used, and the vaginal walls, the fornices, and the cervix should be thoroughly scrubbed. The soap should then be carefully washed out, and the scrubbing should be repeated with bichloride-of-mercury solution (1:2000).
The cleansing of the external genitals and the vagina is best done by the nurse after the final movement of the bowels and immediately before the woman has her general bath.
Sterilization of the Abdomen.—The patient should have a warm bath from head to feet upon the morning of the operation. The abdomen, from the ensiform cartilage to the pubis, should be scrubbed with a nail-brush. Special care should be devoted to cleansing the umbilicus. After this bath the patient should be dressed in a clean flannel undershirt and night-gown and should be placed in a clean bed.
The nurse should then wash the abdomen, from the ensiform cartilage to the pubis and from flank to flank, and the upper third of the anterior aspect of the thighs, first with turpentine, second with green soap, and finally with ether, devoting special care to the umbilicus. The abdomen should then be covered with a large wet bichloride dressing (1:2000), which should not be removed until the patient is upon the operating-table. A towel wrung out of the bichloride solution and held in place by a bandage or binder will answer the purpose. A second cleansing of the abdomen by the operator or the assistant should be done after the patient is upon the table. The surface should be washed with green soap and sterile water, then with ether, and finally with the solution of bichloride of mercury. The washing should not be restricted to the central abdomen, but should extend over the upper parts of the thighs and the flanks, which may be exposed during the operation.
Fig. 195.—Tait’s hemostatic forceps.