THE MANAGEMENT OF PATIENTS BEFORE AND AFTER LAPAROTOMY

FrederickHolme Wiggin
1898 The Lancet  
1173 border of the kidney should be selected for incision in nephrotomy. The advantages depending on the anatomical arrangement of the blood-vessels within the kidney of an incision along this border are considerable. Moreover, through no other single incision can a complete examination of the cavity and substance of the kidney be so conveniently -made. After removing a calculus from the renal pelvis, if the -convex border has not been incised the interior of the kidney should be palpated
more » ... d be palpated either through the opening or if this be too small to admit the finger then by invaginating the infundibulum. When the renal cavity is sacculated and suppurating it should be freely irrigated with a hot weak solution of Condy's fluid, perchloride, or carbolic acid. In a few instances the calyces have been found packed with a putty-like mass of muco-pus, which was thoroughly cleared out with the finger and little swabs of cotton-wool. In every case a drainage-tube is inserted into the wound around the kidney, but not into the kidney cavity itself. I prefer a tube to iodoform gauze, which, by sucking up and retaining the serum and blood, keeps the surfaces of the wound apart and prevents immediate healing. In closing the parietal wound I transfix the whole of the layers, skin, muscles, and fasciss, with the same sutures carried by means of Hagedorn's large curved needles. I have for some considerable time abandoned the use of buried sutures for the separate layers of muscles and fasciae. The length of time required for convalescence of course varies. In cases of simple nephrolithotomy patients are often able to sit up on the eleventh or twelfth day with their wounds :soundly healed, and many have 'returned to their homes between the second and third weeks after the operation. Nephrectomy is frequently as rapidly followed by complete recovery. When the kidney and the perinephric tissues are much disorganised healing is apt to take place for the most part by granulations and then four or five weeks are required. IN the early days of the decade now drawing to a close it was generally considered to be a fact that operations within tne abdominal cavity could only be performed with a reasonable degree of safety to the patient when undertaken in expensively constructed special rooms attached either to public or private hospitals. But as time has gone on and our knowledge of bacteriology has increased antiseptic surgery has been gradually replaced by aseptic work, and we have found, especially those of us whose fortune it has been to perform operations of the class under consideration in ordinary dwellings, that although the personal effort and responsibility are increased, abdominal operations can be performed with as little, if not less, danger to life in a properly prepared room in the patient's dwelling, as in the best equipped modern hospital. This, coupled with the fact that abdominal wounds are more frequently closed without drainage and therefore allowed to heal under one dressing than was formerly the case, seems to make it evident that the time is not far distant, if indeed it has not already arrived, when patients suffering from abdominal disorders will ordivarily prefer to be operated upon in their own homes rather than to go among strangers in a strange land at this critical time. Hence it will come to pass that the general practitioner in the near future will more often have an important part to play in the management of patients, both before and after the performance of laparotomy, than has hitherto been customary. On this account chiefly the discussion of this important subject has seemed timely, for it is my belief, founded on a considerable experience, that the patient's welfare depends not only upon the technique of the operation itself being properly carried oat hat also upon the successful management of many 8o-c'il!ed minor, and therefore neglected, details both before and after the operation. Yeara ago I, then under the pupilage of that great surgeon Professor James R. Wood, learned that the most successful surgeon was he who could best carry out not only the major' but the minor details of his work; and this must be my excuse, if one is needed, for the minuteness with which the minor points of routine work are about to be gone into. Preparation of the patient.-When the condition for which the operation is to be undertaken is chronic, and all the time desired can be had for the preparation of the patient for the ordeal which he is to undergo, much can be done which will not only diminish the risk about to be incurred by him but which will ultimately hasten convalescence. In such a case it is for the patient's welfare that the hospital where the operation is to be performed should be reached, or the trained nurse employed if the patient is to remain at home, at least one week prior to the date fixed upon for the operation. This allows the individual to become accustomed to the attendants or the environment" which is of undoubted importance, as it tends to lessen the dread and nervous tension, both of which are great in such a crisis even under the best of circumstances. Daring this. week the sufferer should be encouraged to spend the greater part of the time in bed for the purpose of getting thoroughly rested, as patients too often come under operation physically exhausted. During this period massage may be employed to advantage in lieu of physical exertion as it improves the circulation, promotes digestion and the general bodily welfare. As far as is compatible with a healthy mental condition, visitors and friends should be egcluded. -A daily record of the patient'a bodily temperature, pulse, and respirations should be kept. An examination of theheart and lungs and a final analysis of the urine should be made at this time. As it is of great importance that the intestinal canal should be thoroughly collapsed at the time of operation, careful attention should be paid to unloading and emptying the bowels as well as to getting the digestive organs in good working order. This is best accomplished. by giving early in the week several small doses of calomel and soda daily for three days. There are to be followed each morning by a saline, and this, in turn, on each of three sue-(3 to 4 quarts of saline solution, 1 drachm to the quart). The rectum should be finally washed out with a pint of the same solution six hours before the performance of the operation. The large enema just alluded to is best given with the patient lying on the left side, a fountain syringe being used for this purpose the reservoir of which should not be elevated more than 3 ft. above the patient's body. A bulb syringe should not be used for this purpose, for in the first place it. injects the fluid irregularly and with too much force and consequently only a small quantity can be employed; in thesecond place it is apt, if carelessly used, to permit the entrance of air into the bowel. An extreme instance of this sort came under my observation some years since. A nurse having been directed to give a patient an enema undertook to force fluid contained in a pitcher into the gut by means of a bulb syringe. She worked away vigorously for a time, directing all her attention to the patient, who complained bitterly, but she failed to notice until it was too late that the distal extremity of the tube had escaped from the liquid and the patient's abdomen was greatly over -distended. The family physician was hastily summoned and with some difficulty relieved the patient from a very severe attack of wind colic. The water for the enema should have a temperature of 100° F., and should be introduced into the canal slowly, being frequently intermitted as the patient complains of a feeling of distension or of intestinal colic. Both of these sensations pass off with the cessation of the flow and by persevering in this way three or four quarts of saline solution can usually be introduced into the colon in the course of half an hour with but slight discomfort to the patient. The patient should be encouraged to retain the fluid for another fifteen minutes before it is allowed to escape. The administration of these enemata should be supervised by the physician, as the nurse seldom knows how to accomplish the introduction of the desired quantity of fluid into the intestinal tract, or if she has the knowledge and experience she has not sufficient authority over the patient to effect the desired result. I have often been told by nurses entrusted with this duty that they have given the enema of four quarts not as ordered but in divided doses, thinking probably that as " twice two equals four " they had performed their duty in a satisfactory manner. It is this misunderstanding that so often causes the
doi:10.1016/s0140-6736(01)88785-7 fatcat:m6344ck2s5ftto4skqadhzjtce