The principles and practice of modern surgery

by Roswell Park

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.