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.