Reprinted from the International Medical Magazine, March, 1892. 
TREATMENT BEFORE AND AFTER LAPAROTOMY. 
Professor of Gynaecology in the Long Island College Hospital, Brooklyn, New York. 
ALEXANDER J. C. SKENE, M.D., 
One meets not infrequently with urgent cases demanding laparotomy 
which must be taken as they are and operated upon at once. The majority 
of cases, however, can be kept under observation long enough to obtain a 
clear idea of .their characteristics. When the diagnosis of the local condi- 
tion is made, the general state of the patient should be carefully examined 
into. The advantage accruing from acting on this principle was recently 
impressed upon my mind in a case of a large fibro-cystoma of the uterus 
which required removal. While under preparatory treatment the patient’s 
temperature rose to 103.5° F,, and there was much pain in the abdomen. 
Septic peritonitis was suspected, but the temperature came down and again 
went up, showing that the trouble was a zymotic one, and it yielded 
promptly to the use of quinine. Had I operated without knowing that 
she was disposed to this form of fever, I doubt if she would have recovered 
as promptly as she did. 
The state or condition of the nervous system should be investigated, 
and, if found defective, should be corrected as far as possible. Many 
patients leave home to be under the care of the special surgeon, and this, 
together with the dread of the treatment, often deranges the nervous sys- 
tem. All this can be overcome, usually, while other preparatory treatment 
is instituted. Time should be given for the patient to become accustomed 
to her surroundings and to gain confidence in the nurse and surgeon. 
During this time the true state of her nervous system may be ascertained. 
If she is sleepless and depressed, relief should be given by nerve sedatives 
and tonics. Quite often the damaged state of the nervous a stern is due 
to impaired nutrition, and will be relieved by improving the digestion. 
Occasionally the nervous trouble is primary, and requires direct attention. 
Opium in small doses is most reliable in prod . ang sleep and relieving 
depression, but it deranges digestion and nutrition in some cases, and on 
that account other remedies should be employed. Sulphonal does remark- 
ably well as a sleep-producer, and is much preferable to bromide, chloral, 
or any combination of such remedies. It produces the desired result in 
the great majority of cases that are not kept from sleep by severe pain. 
This remedy is worthy of note as rather jnew,_andlis. certainly will 
cause sleep with no other perceptible> effect,"bid/- * ! V” 2 
ALEXANDER J. 0. SKENE, M.D., ON 
To those restless, anxious patients who find the days very long even 
when they sleep at night, and with whom opium does not act well, I have 
given large doses of lupulin and small doses of cannabis indica. If these 
do not answer, opium should be tried. 
One of the greatest advantages of this preparatory treatment is that the 
effect of opium on the case in hand can be observed, so that, if it becomes 
necessary to use it in the after-treatment, the surgeon knows how far to 
depend upon it and what effects may be expected. 
The nutritive system often requires attention, and in the majority of 
cases nutrition is impaired because of derangement of the digestive organs. 
In others the general nutrition is good, while the digestive organs alone are 
at fault. 
The time during which the trouble calling for surgical treatment has 
existed makes the difference in the general condition of the patients. 
There are two classes of cases usually met in practice which require 
attention in regard to digestion and general nutrition : First, those who 
have not been long under the influence of the affection, and who need very 
little treatment, except to relieve constipation and perhaps subacute indiges- 
tion. Such cases are often left without any preparatory treatment except a 
cathartic the day before the operation. This may be safe enough, but in 
the majority of cases the tongue is coated, the bowels sluggish, the appetite 
variable, and the kidneys act imperfectly. These conditions can all be 
relieved by a few small doses of the mild chloride of mercury, followed by 
a saline laxative. If this does not clear the tongue, improve the state of 
the stomach, and increase the action of the kidneys, the treatment should 
be repeated in a few days. Second, the more advanced cases, which show 
general malnutrition as well as an impaired digestion. These require more 
care and for a longer time. It sounds well to say of such patients that, the 
cause being one of neoplasm, if this is removed the malnutrition will be 
cured; but the chance of the patient being able to stand the operation 
may be improved by overcoming the constitutional derangements as far 
as that is possible. Gastric sedatives, such as bismuth or cerium, may 
relieve the irritation and improve the appetite, and tonic laxatives, such as 
nux vomica, belladonna, and rhubarb, will relieve constipation far better 
than salines. 
To empty the bowels in the best way immediately before the operation 
is of great importance. The routine dose of castor oil or some other 
cathartic the day before the operation may or may not answer the purpose. 
I think that, as a rule, it does about as much harm as good. If a cathartic 
is called for at all, it should be given two or three days before the operation, 
so that any intestinal disturbance that it may have caused will have time to 
subside. 
The objects attained in the management of the bowels are threefold : 
first, to clear out the canal; second, to establish as far as possible normal 
secretion; and, third, to remove the causes of flatulence, whatever they TREATMENT BEFORE AND AFTER LAPAROTOMY. 
3 
may be. In the choice of a laxative or cathartic, one should be sought 
which will meet all these indications. In cases showing deranged secretion, 
indicated by the state of the tongue and appetite, an alterative dose of 
mercury should precede the cathartic, as already suggested. The mercury, 
being a reliable disinfectant, will also meet another indication, the relief of 
flatulence. The selection of a cathartic to be given just before the opera- 
tion is important. Castor oil is the best in case there is constipation or a 
suspicion of fsecal impaction. The only difficulty is that many patients 
strongly object to it. When it can be taken, it should be given two nights 
before the operation. This gives time for the oil to act, and also gives the 
bowels a chance to become quiet. The rectum should be washed out the 
night before the operation or early in the morning. To feeble patients 
who require a cathartic and yet are not strong enough to stand its operation, 
I give half an ounce of castor oil and two drachms of oil of turpentine. 
This is a most valuable preparation, if the stomach will retain it. In fact, 
this is the only cathartic that will act thoroughly in weak, debilitated 
patients without causing depression. The dose of turpentine is large, but 
if less is given it will affect the kidneys and fail to some extent as a cathartic. 
This may be called a tonic or stimulant and cathartic. A similar effect may 
be obtained by giving six grains of rhubarb, one grain of compound extract 
of colocynth, one grain of camphor, and a tenth of a grain of extract of 
belladonna, in pills. There is a little depression following the action of 
this, and it is not so certain in its action as oil and turpentine. 
To those who cannot take either oil or pills without having their stom- 
achs upset I give one or two teaspoonfuls of calcined magnesia and half 
a teaspoonful of charcoal, followed in a few minutes by a glass of warm 
lemonade. This empties the bowels and relieves flatulence very thoroughly. 
This is given in the morning of the day before the operation, the object 
being to have the bowels quiet and empty at the time of operating. 
The condition of the heart and kidneys should be carefully noticed, 
especially that of the kidneys. The urine should be thoroughly examined 
before giving an anaesthetic. lam satisfied that disease of the kidneys is 
the most important of the contra-indications to the use of anaesthetics. If 
any renal disease is found, it should be carefully treated and watched, and, 
if it proves to be acute or subacute, sufficient relief can in time be obtained 
to warrant the operation ; but chloroform might be chosen in place of ether 
as the anaesthetic, and extra efforts should be made to shorten the time of 
operating. I have for a long time made it a rule always to examine the 
urine before giving an anaesthetic, and believe that it should be an in- 
variable practice. I refer to that matter here because I have found many 
who do not think it necessary. 
In regard to the state of the heart, I find that it is often deranged in its 
function from pressure or indigestion, and it nearly always improves under 
treatment. When there is time, I order muscular exercise as well as reme- 
dies to improve nutrition, and find that much improvement in the heart- 4 
ALEXANDER J. C. SKENE, M.D., ON 
action follows. Organic heart-disease, other than extreme hypertrophy, 
dilatation, or aortic stenosis or insufficiency, does not deter me from giving 
an anaesthetic and operating. Many cases having disease of the mitral valve 
take ether very well. 
The day and evening before the operating day call for certain attentions. 
The bath so generally given the night preceding the operation is not always 
advisable. If the patient is accustomed to daily or frequent bathing it may 
be safe to give it, but otherwise it is dangerous. The patient may get cold or 
become exhausted. The bathing should be done, in such cases, several days 
before, and then with great care. When there is marked debility, with 
weak heart, digitalis and nux vomica should be given the preceding day; 
especially is this necessary when the operation promises to be prolonged. I 
formerly gave quinine, believing that it was a good tonic and helped to 
prevent shock, but I am satisfied that digitalis and nux vomica are better. 
The number of doses should depend upon the effect. As soon as the heart- 
action is noticeably improved the drugs should be withheld. 
The food should be of the most nourishing kind and at the same time 
easily digested, or else it should be artificially digested. Sterilized or pep- 
tonized milk, clear soups, tender beef, mutton, eggs, and raw oysters, either 
or all of these, according to the preference of the patient, may be used. 
The time to operate is, as a general rule, midway between the menstrual 
periods. An exception should be made in cases of menorrhagia and dys- 
menorrhoea, in which there is an improvement in the strength towards the 
period of menstruation. Advantage should be taken of that temporary 
improvement by operating immediately before the menses. 
The morning is by far the best time to operate. The patient is then at 
her best, and the stomach is empty,—a condition very necessary to the taking 
of an ansesthetic. This would not be referred to here were it not for the 
fact that a great many surgeons in this country operate late in the day. 
There are many disadvantages in so doing. The patient suffers from 
anxious anticipation, and becomes fatigued if food is not given ; and it 
given, it is not, as a rule, either digested or absorbed, and the stomach acts 
badly during and after the anaesthesia under such circumstances. 
There are certain points in the management of the patient during the 
operation which may be briefly mentioned. 
I am led to dwell a moment on the general therapeutics of abdominal 
section, for the reason that my attention and that of my assistants has been 
so fully engrossed with the details of antisepsis and the technique of the 
operation that many important items in the general therapeutics have been 
at times overlooked. It is likely that a similar experience may fall to the 
lot of others. 
The patient should be kept warm, but the room should be cool, not over 
70° F. A very warm room has been advised, and there are many surgeons 
who still prefer it, believing that there is danger of chilling the patient by 
exposing the abdominal organs to cool air. This can be obviated in other TREATMENT BEFORE AND AFTER LAPAROTOMY. 
5 
ways, by keeping the patient’s head and feet warm by hot water if need be, 
and protecting the trunk with rubber cloth. Chilling the peritoneum is 
avoided by the use of warm sponges. One large sponge should be placed 
in the wound as soon as the tumor is removed. This prevents the escape 
of the intestines, and protects the peritoneum from the air. The sponges 
are held at the proper temperature by being kept in an empty pail which is 
placed in a larger pail filled with hot water. The sponges are thus ke]et dry, 
while the water in the chamber around the inner pail keeps up the warmth. 
In case the operation is a long one, the water surrounding the sponge-pail 
can be renewed. 
Warm ether is also of value in avoiding shock and chilling the patient. 
This is obtained by using my ether-inhaler, in which the ether is vaporized 
in a reservoir and conveyed to the patient through a rubber tube. This 
warms the ether sufficiently to make it agreeable and safe, I have on 
former occasions spoken of the advantages of this ether-inhaler, by which 
the anaesthetic can be given pure, or diluted with pure air to any degree, 
and without the reinspiration of the expired air. I may add here that 
experience only tends to confirm ray confidence in that method of using an 
anaesthetic such as sulphuric ether. 
Regarding the after-treatment, the bed in which the patient is placed 
should be warmed to about the normal surface temperature. This can be 
done by hot-water bags under the bedclothes. The bags should be moved 
about, so that the heating shall be uniform. The patient’s head should be 
covered with a soft woollen shawl or soft blanket. The hands should be 
kept under the bed-covers and not disturbed. The pulse should be Matched 
at the temporal artery. A hot-water bag may be placed near the feet, but 
not in contact with them. I have repeatedly seen the feet burned by placing 
a hot-water bag close to the skin. This will not occur when the bag is 
wrapped in flannel. The air in the room should be kept at about 70° F., 
and ventilation secured without having the patient in a draught. For a 
number of hours ether is thrown off with the expired air, and it is difficult 
to keep the air in the room agreeable. It is fortunate if the patient sleeps 
after the operation, and no effort should be made to awaken her, as is fre- 
quently done, to find out how she feels. 
During the first twenty-four hours or more, the more rest that can be 
obtained the better. Absolutely nothing should be, given in the way of 
food or medicine unless there is some urgent demand for either. Nausea 
and vomiting, which occasionally occur, should be counteracted with sips 
of hot water if the patient is anxious to have something to drink,—not 
otherwise. 
Keith usually gives a hypodermic dose of morphine immediately after 
the operation, to control the restlessness which supervenes when the patient 
comes out of the anaesthesia. This is not always necessary. I wait and 
see if there is much restlessness or pain, and if there is, the morphine is 
given. Especially is this necessary if there be pain. Nervous restlessness 6 
ALEXANDER J. C. SKENE, M.D., ON 
alone can often be controlled by the efforts of a judicious, experienced 
nurse. When this fails, morphine should be given ; but if the patient can 
be controlled until night, it is better to withhold the morphine until then. 
This expectant treatment should be continued until the stomach has 
become reliable and gas has passed from the bowels ; and it will be found in 
many cases that nothing else is required during the first forty-eight hours. I 
am sure that great harm is done by giving nourishment and medicines when 
there is no demand for either. I certainly have seen more harm come 
from doing too much at first than from doing too little. There are excep- 
tions to this rule of doing nothing. In case the vomiting continues, and is 
not relieved by hot water, I use the following: Magnesise carb., sij ; mag- 
nesise sulph., shj; aqute raenth. pip., Siij. Of this, a teaspoonful may be 
given every one, two, or three hours in a dessertspoonful of water. This 
prescription is used in the Samaritan Hospital in London. 
A mustard plaster to the pit of the stomach is also useful. When these 
remedies fail, and the patient complains of burning in the stomach, dessert- 
spoonful doses of iced water may be used. When the patient is depressed, 
ten drops of whiskey in a teaspoonful of water every few minutes will be 
of service. In desperate cases I have given a large quantity, as much as 
the patient could drink, of lukewarm water and a little table salt. This is 
thrown off promptly, and sometimes gives relief. It should not be repeated. 
If relief is obtained and the nausea returns, the stomach should be washed 
out in the usual way. 
When the vomiting is attended with abdominal pain, morphine hypo- 
dermically will give relief in many cases. 
The foregoing treatment has reference to guarding the patient from 
shock. 
There remain for consideration peritonitis and septicaemia, which may 
occur after laparotomy. 
From recent reports in the literature of medicine it appears that a new 
departure has been taken in the after-treatment of cases of ovariotomy and 
similar operations. In place of giving opium and keeping the bowels at 
rest for several days, the bowels are moved early, and opium is withheld. 
Cases which show signs of septicaemia or peritonitis are given saline 
cathartics. It is claimed that free action of the bowels effects a kind of 
drainage which arrests the tendency to inflammation of the peritoneum, and 
also favors the elimination of septic material. This appears rational on 
theoretical grounds, especially in view of the fact that in well-marked 
septicsemia there is frequently a spontaneous serous diarrhoea, which occa- 
sionally is followed by a lowering of the temperature for a time. It is 
seldom, however, that permanent improvement occurs after elimination by 
purgation. Whatever theories or facts may be advanced in favor of this 
plan of treatment, one should gladly accept it, or any other which might 
prove better than the old ways of managing such cases. But I have failed 
to see that this new treatment has many advantages. TREATMENT BEFORE AND AFTER LAPAROTOMY. 
7 
So far as I can learn, the results, on the whole, do not compare well 
with those of other surgeons who give opium and let the bowels and the 
stomach rest until the first dangers are past. Furthermore, I have found 
in my own practice that as soon as there are evidences of peritonitis or sepsis 
the stomach is disturbed and will not retain saline cathartics, or anything 
else, for that matter. To state this in another way : as soon as the indica- 
tions for cathartics appear, it is impossible to have the patient retain them, 
in the great majority of cases. 
Perhaps the advocates of this treatment may be able to anticipate the 
coming storm, and, by giving salines, ward it off; but I have not been able 
to do so. 
Regarding the use of opium, or rather the discarding of it, in the after- 
treatment of laparotomy cases lam still more conservative. While there 
are a number of reasons why it should be used, I have not yet heard of any 
good reason why it should not be, in certain cases. 
That there are patients who do not need opium, and others with whom 
it does not agree, must be admitted; but the majority require it to relieve 
pain, produce sleep, and, above all, to secure rest and quiet, which are so 
necessary to recovery after major operations. These effects of opium, it may 
be claimed, simply contribute to the comfort of the patient, but do not secure 
safety or aid in recovery. Granting that such may be the case, the humane 
surgeon will find in this good reason for the use of opium ; but I am confident 
that opium has a therapeutic value in addition to that of relieving suffering. 
The danger from shock which arises from major operations is, I am 
sure, controlled by opium better than by any other drug. Bo also is the 
depression from anaemia resulting from hemorrhage. All careful observers 
have noticed that the rapid, feeble pulse has become fuller, slower, and 
steadier under the influence of opium. The anxious, pinched face also 
changes to a better expression. This has led me to look upon opium as 
the most reliable of all heart tonics in the depression which follows these 
operations. When the organic nervous system is tottering under the op- 
pression of severe injuries to the abdominal and pelvic viscera, opium is the 
greatest sustaining agent. Alcohol, no doubt, will bridge over a moment 
of extreme and immediate danger, but its effects must almost always be 
supplemented with opium in order to obtain a continuous sustaining effect. 
Perhaps more important still is the question, Does opium have the 
power of preventing peritonitis and septicaemia, or of controlling their fatal 
tendencies? To judge fairly of the therapeutic effects of opium in surgery, 
it is necessary to keep in mind the fact that after an operation there are 
injured or damaged tissues left that must be repaired. These tissues may 
or may not be affected with septic material, but in either case the safety 
of the patient depends upon these wounded tissues being speedily closed in 
by reparative material, which restores continuity of tissue and at the same 
time protects the normal surrounding tissue from inflammation and the 
patient from general septicaemia. Now this process, by which the general 8 
TREATMENT BEFORE AND AFTER LAPAROTOMY. 
system is protected from the dangerous effects of local injuries, requires 
time,—less time than is required to restore the injured tissue or heal the 
wounds; but it is the most important time, because upon the completion of 
this protection depends to a great extent the safety of the patient. Wounds 
may do badly, but, if an exudation has been thrown around them which 
protects from septicaemia, recovery may be expected. Of course, the 
modern surgeon protects his cases from sepsis by his cleanly operating; but 
in spite of his best efforts there may be trouble occasionally, and then the 
great point is to gain time for this natural protective process, which comes, 
or should come, first in the order of restoration. The principal condition 
necessary to secure the protective factor in the general process of repair is 
repose or quietude of the nervous and circulatory systems, and opium is the 
most potential agent in effecting this condition. The process of repair is 
arrested when the nervous system is in turmoil and the circulation is run- 
ning wild, and opium should be used to give the necessary rest. It is a 
fatal mistake to. wait until there is evidence of inflammation or septicsemia. 
It should be given to control the nervous excitation which generally pre- 
cedes these complications. Opium fails to do all that it is capable of doing 
if it is not given in time, and it is therefore condemned as useless when the 
fault lies in the mode of using it. 
The time to give it, then, is an important question. Some of the most 
successful surgeons give it immediately after the operation, and that is best 
when the case is bad and there is shock. In easy cases I prefer to wait 
until the other effects pass off to some extent; and if there is distress or 
pain present, then is the time to give opium, and the effect should be kept 
up until there is no danger of complications, so far as the condition of the 
patient indicates. 
The way of giving it is of some importance, no doubt. I prefer to 
give it at first hypodermically, and keep up the effect in that way, or by 
rectal injections of opium and warm water. 
Having advocated the use of opium and objected to the use of purga- 
tives early in the treatment of this class of surgical cases, the question 
which follows is: When shall the opium be withdrawn and cathartics re- 
sorted to ? Opium should be withdrawn gradually, as the constitutional 
and local evidences of inflammation subside, and then cathartics or laxatives 
should be given. To state this in another way: opium should only be 
given when there are indications for its use, and it should be abandoned so 
soon as these indications subside. The bowels should rest until the time for 
peritonitis is past, or, if there has been inflammation or sepsis, when the 
acute symptoms and signs of these have subsided.