the time of operation to a minimum, by permitting the child to almost completely come out of the state of anesthesia by the time the operation is finished, and by applying the sutures so that the patient can move about freely, and if possible to sit up in bed, soon after the operation has been terminated. Protection of the mother in the after-care of infants. In nurslings it is, moreover, most important to secure the co-operation of the mother. The latter should never be permitted to undertake the care of the infant after a serious operation, because the resulting fatigue and anxiety will surely have a harmful effect upon the milk, and the child will consequently suffer from gastric disturbances in addition to those naturally resulting from the effects of the operation. These conditions should be carefully explained to the mother so that her natural anxiety for the safety of her child will serve to improve its prognosis rather than to reduce its chances. In many instances we have seen a worn-out mother improve remarkably in health during the time her child has been confined to the hospital, and with the improvement of her general condition the child’s nutrition is always greatly bettered. The mother should not live in the hospital, but conveniently near so that she can come to the hospital at regular intervals, varying from three to four hours, according to the age and condition of the child. It is well for the mother to have a definite program which she must follow absolutely. She should never be permitted to carry or hold the child except while actually nursing it. Before she nurses the child the first time in the morning she should drink a pint of hot milk or gruel so that she will not be in a depressed state during the act of nursing. After nursing the child she may take a walk in the open air, then breakfast liberally, then rest for at least one hour and return to the child just in time for the next feeding. Her luncheon is again followed by a period of rest. In the middle of the afternoon the mother may take some nourishment, preferably a pint of milk, with bread. She may take a liberal meal in the evening, nursing the child at regular intervals varying from two to four hours according to the requirements of the little patient, the time of nursing being so arranged that the mother can obtain from seven to ten hours of uninterrupted sleep. She should always take some nourishment before retiring. Both the mother and the child will form regular habits during the time the latter is in the hospital and the health of the former, and the nutrition of the latter invariably improve to a marked extent under these circumstances, Importance of safeguarding blood supply. For all patients it is wise to guard against the loss of an unnecessary amount of blood; but this is especially true in children and in those advanced in years, because many of these do not recover readily from an anemia caused by a great exsanguination. Every operation should be carefully planned with the idea of preventing the unnec- essary loss of blood. Usually this end can be accomplished if the surgeon lays out a thoroughly systematic course for his operation, because the source of hemorrhage in every operation can be anticipated by applying two pair of forceps to each one of the larger vessels before it is severed, and quickly applying clamps to the oozing surfaces as the operation progresses, in all parts of the body in which it is not possible to entirely prevent hemorrhage during operation by the application of elastic constriction. If the surgeon has assistants who have learned how to concentrate their attention during the progress of the work, much is gained in saving blood because they will anticipate the surgeon and will stop all hemorrhage almost instantly at those points in which one cannot apply forceps before severing the tissues. Slow vs. rapid operating. There are two errors which will be referred to again presently which the surgeon should not fall into in his attempts to prevent loss of blood, namely: too rapid and too slow operating. The former is certain to lead to calamity occasionally in individual cases, although the majority of patients will undoubtedly do well under very rapid technique. The slow operation is especially likely to result in secondary post-operative complications such as pneumonia and nephritis. It is important to take a reasonable attitude regarding this feature. It is possible to be guilty of insane haste on one side and of imbecile deliberation on the other. OBESITY Special care required. Patients who are very obese, especially those beyond middle age, require particular consideration, Their resistance is diminished; they recover from shock less speedily; they frequently take the anesthetie badly; and they are more liable to pneumonia following the use of ether than patients with a normal amount of fat. Still it is only seldom that the presence of obesity will contra-indicate an operation entirely. Ordinarily it would simply indicate the use of especial care. In many of these patients it is possible to reduce the weight to a great extent before operation by following a systematic plan of dieting, combined with exercise and baths. Anti-Obesity Diet. There are three breakfasts, three luncheons and three suppers; any one of which you may choose, but you must never eat more than is contained in any one of these meals. In place of any one of these meals at any time you may substitute one pint of buttermilk if you like. In addition to any one of these meals you may take one of the following articles but nothing more: 1 orange, % grape fruit without sugar, one baked apple without sugar, one dish of spinach, one dish of head lettuce with pepper, salt and lemon juice but no oil. Breakfast.—No. 1. One or two soft-boiled eggs, one small piece of toast. No. 2. Half a pound of lean steak, one baked apple. No, 3. Half a pint of hot milk and one small piece of bread. Luncheon.—No. 1. Half a pint of soup and one small piece of bread. No. 2. Half a pound of fresh fish broiled, one dish of lettuce with pepper, salt and lemon juice. No.3, One pint of buttermilk and one small piece of bread. Supper.—No. 1. Half a pound of beef, one dish of spinach or one dish of turnips or one dish of boiled onions. No, 2. Half a pound of lean mutton, one dish of cabbage or one dish of cauliflower or of squash. No, 3. Half a breast of chicken, one dish of lettuce with pepper, salt and lemon juice, or fruits cooked without sugar, or one dish of cooked vegetables or one glass of fruit juice. Aside from the above the patient may eat grape fruit or oranges if he desires in connection with any meal. You should drink nothing at all during your meals nor for one hour before or after eating. No water, tea, coffee or fluids of any kind. Between meals you may drink a small amount of water, either hot or cold, flavored with lemon or orange juice. Take absolutely nothing containing alcohol. Take breathing exercises regularly morning and evening. Take a walk out of doors every day. Increase the length of your walk gradually and also the speed. . In planning the operation in these cases the wound should be so sutured that the patient can move about freely in bed and if possible sit up directly afterwards, especially for the purpose of preventing hypostatic pulmonary congestion following operation. In most of these cases it is well to elevate the head of the bed from four to eighteen inches. TUBERCULOSIS General operations inadvisable. In patients suffering from tuberculosis an operation is usually borne well if it removes the tubercular tissue. If this is not removed by the operation such patients frequently do not do well. Consequently the presence of tuberculosis is only a contra-indication to opera- tion in a limited variety of cases. In patients suffering from pulmonary tuberculosis long-continued operations are contra-indicated chiefly because the disease in the lungs is likely to make progress during the time that the patient is recovering from the depressing effects of the operation. It is difficult to say whether ether anesthesia is really in itself harmful 24 GENERAL SURGICAL CONSIDERATIONS in these cases. It has been suggested that anesthesia by inhalation be not employed in such instanees and that local, spinal or reetal anesthesia be substituted in all cases in which pulmonary tuberculosis is present. Preliminary general treatment. It is generally possible to place these patients under preliminary hygienie, dietetic and often under climatic treat- ment for the cure of the pulmonary tuberculosis before they are subjected to surgical operations. In many the local condition, if it is also due to tuber- eulosis without mixed infection, will recover simultaneously with the pu nary tuberculosis. This is true especially in cases suffering from joint tuberculosis in which perfect immobilization has been accomplished while the pulmonary condition is under the above form of treatment. Surgical relief in the tuberculous. Many of the older surgeons have noted the fact that patients suffering simultaneously from a mild form of pulmonary tuberculosis improved rapidly after operations removing extremities contain- ing a tuberculous joint, as for instance an amputation of the hand in case of tuberculosis of the wrist, or amputation through the lower third of the thigh in ease of tuberculosis of the knee. On the other hand they found that similar cases became worse rapidly and resulted fatally in a short time in those in which an attempt at excision of the joint was practised. Later on when these latter operations were performed under antiseptic precautions if they healed primarily the pulmonary condition usually improved rapidly, while if they suppurated the opposite was true. Dr. Emil Beck has given a very ingenious explanation for these facts. He supposed that in every patient suffering from tuberculosis there is an attempt by nature to provide a sufficient amount of antitoxin, that the tuber- culosis tissue removed by amputation leaves more of the substance in the blood to combat the disease in the lungs and elsewhere, and that for this reason healing occurs. On the other hand if the organism is burdened by any additional task, as for instance the combating of a mixed infection, the balance changes in favor of the disease and the patient succumbs to pulmo- nary tuberculosis. The shock of a long-continued bloody operation would undoubtedly have the same effect. CACHEXIA DUE TO MALIGNANT GROWTHS A contraindication. Ordinarily the presence of cachexia in patients suf- fering from malignant growths is a distinct contra-indication to operation, because these patients do not bear operations well and with few exceptions derive very little benefit therefrom. This is, however, not the case in ulcerat- ing carcinoma in which the cachexia is due largely to the absorption of prod- ucts of decomposition, which can often be safely eliminated by an operation. Again, in cases in which the malignant growth interferes with nutrition by obstructing some portion of the alimentary canal this rule does not always hold good, because frequently the improved nutrition greatly overbalances the traumatism resulting from the operation. In a general way it may be stated that so long as the condition in a given case seems to indicate the possibility of removal of all of the malignant tissue the operation is warranted provided it does not necessitate the removal of a part of the body which is necessary for the continuance of life. In some cases the apparent cachexia can be removed before operation by appropriate treatment. Example: gastric carcinoma. In cases of carcinoma of the stomach, for instance, the patient frequently absorbs a quantity of decomposing substanee GENERAL SURGICAL CONSIDERATIONS 25 during a considerable period of time, and as a result of this his condition becomes markedly cachectic. In many such the tumor may still be confined to the stomach. If operated at once the resistance of the patient may be so low on account of the condition described above that he may succumb to the shock of the operation. If the same patient has gastric lavage performed three times daily at intervals of eight hours, or four times daily at intervals of six hours, two hours after receiving some concentrated sterile food, his condition will improve to a surprising extent in from one to two weeks. The ingestion of small doses of oil of eucalyptus, from five to twenty drops after each gastric lavage, is of further aid in the disinfection of the stomach cavity. In the meantime the patient’s strength can be further sup- ported by giving rectal feeding in the form of one ounce of some one of the various concentrated liquid predigested foods in the market dissolved in three ounces of normal salt solution, administered slowly as an enema through a small rubber catheter introduced into the rectum for a distance of not more than three inches. One danger in preliminary treatment. One danger must be borne in mind in connection with this form of preliminary treatment. In many instances the general welfare improves to so marked an extent that some doubt may arise concerning the original diagnosis, and this may occasion postponement of the operation until the carcinoma has advanced to a hopeless point. It is always bad practice to postpone operations of any kind in patients suffering from malignant growths, because after such a growth has once begun to invade the surrounding tissues there is no stopping of its progress except by its complete removal or by the death of the patient, hence the importance of not losing valuable time before an attempt is made to remove the growth. During the time that the patient is under ‘observation prior to operation it is well to administer from 500 to 1,000 ce. of normal salt solution, by means of Murphy’s proctoclysis, from four to six times each day. It is well to add to each application from 30 to 60 ce. of one of the various recognized concen- trated liquid foods. The use of this proctoclysis has a tendency to fill the blood vessels and to greatly improve the resistance of the parts. Blood transfusion may be employed previous to operation in these cases. It is often of great value in preparing cachectic and anemic patients for opera- tion. The technique is described elsewhere. SPEEDINESS IN OPERATING Two viewpoints. The question of time is of sufficient importance to demand some consideration. It is only necessary to look upon an operation from the two sides which have a bearing in order to come to a proper esti- mation of the importance of this element: 1, from the merely mechanical or technical point of view, and, 2, from the point of applying this to the patient. . From the technical standpoint it is plain that a skilled mechanie not only does his work well, but accomplishes it in a relatively short time, while one unskilled will have much less satisfactory results by taking a much longer time; skill, accuracy and facility naturally going hand in hand in bringing about the highest possible outcome. Careful haste. Ilowever, a hasty mechanic may complete a badly-con- structed product in a relatively short period of time; and it is consequently necessary, from a purely technical standpoint, to distinguish clearly between speed which is the result of skill and dexterity, and speed resulting from 26 GENERAL SURGICAL CONSIDERATIONS carelessness, wanton haste and lack of thoroughness. From a strictly technical standpoint, then, we have a right to demand the greatest speed compatible with careful, thorough work. When we come to apply this directly to the patient still further elements will be introduced. Hasty and careless work is more harmful because of the needless trauma. tism which it is likely to produce, and this may in turn result in shock or in the injury of structures needlessly implicated. The patient may not receive the full amount of benefit through lack of thoroughness, some conditions being overlooked and neglected on account of undue haste. Dangers of slowness. On the other hand, it is almost equally bad to pro- long an operation needlessly, because this exposes the patient to a number of unnecessary dangers: 1, A prolonged anesthesia increases the danger immediately, and many times the patients will recover from a short anesthesia with scarcely any discomfort, while they will suffer greatly from nausea and vomiting after a prolonged anesthesia. If ether is employed, a pro- longed anesthesia is much more likely to be followed by bronchitis or pneu- monia than a short one. 2, Other things being equal, the amount of shock is
Key Takeaways
- Minimize trauma during surgery to aid recovery, especially for infants and children.
- Protect mothers from undue stress post-operation by providing structured care routines.
- Use hemostatic forceps and clamps to control bleeding effectively.
- Avoid unnecessary delays in operations but ensure thoroughness to prevent complications.
- Manage cachexia due to malignant growths through pre-operative treatments.
Practical Tips
- For post-operative care, establish a structured routine for the mother that limits her physical strain and ensures proper nutrition.
- Use hemostatic tools like forceps and clamps to reduce blood loss during surgery without compromising thoroughness.
- Plan surgeries carefully to minimize trauma, especially in vulnerable patients like infants and those with obesity or cachexia.
Warnings & Risks
- Avoid unnecessary operations on patients with severe cachexia due to malignant growths as they may not recover well from the procedure.
- Be cautious when using hemostatic remedies; some may have limited effectiveness or side effects, especially in prolonged use.
- Do not postpone necessary surgeries for too long, as this can worsen patient conditions.
Modern Application
While many of these techniques are rooted in historical practices, the principles of minimizing trauma and ensuring thoroughness remain crucial. Modern surgical techniques have advanced significantly, but the importance of careful planning, efficient execution, and post-operative care remains essential for successful outcomes.
Frequently Asked Questions
Q: How can a mother's anxiety affect her child after surgery?
The chapter emphasizes that a mother’s anxiety can negatively impact her milk quality and the child’s recovery. It is important to carefully explain the situation to the mother so that her natural concern for her child can actually improve its prognosis rather than hinder it.
Q: What are some key factors in reducing blood loss during surgery?
The chapter suggests using hemostatic forceps and clamps, applying elastic constriction to extremities, and anticipating bleeding points by using two pairs of forceps on larger vessels before severing them. These techniques help minimize unnecessary trauma.
Q: How can a patient with cachexia due to malignant growths be prepared for surgery?
The chapter recommends pre-operative treatments such as gastric lavage, rectal feeding, and administering concentrated liquid foods to improve the patient’s condition before surgery. This helps reduce the risk of complications during and after the operation.
Q: What are some signs that a patient might be at high risk for hemorrhage during surgery?
The chapter notes that patients with conditions like icterus or leukemia may have a higher tendency to bleed. It suggests determining the coagulation time of the blood before operating and using methods like transfusion to manage this risk.
Q: How can a surgeon ensure speediness in surgery without compromising quality?
The chapter advises surgeons to plan operations carefully, use skilled assistants, and avoid both excessive haste and unnecessary delays. It emphasizes the need for a balance between efficiency and thoroughness to prevent complications.