The After-treatment in Operative Surgery. 
BY 
PROFESSOR OF SURGERY IN THE PHILADELPHIA POLYCLINIC AND IN THE WOMAN’S 
MEDICAL COLLEGE OF PENNSYLVANIA. 
JOHN B. ROBERTS, M.D., 
FROM 
THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES, 
March, 1892. Extracted from 
The American Journal of the Medical Sciences for March, 1892. 
1 
THE AFTER-TREATMENT IN OPERATIVE SURGERV 
PROFESSOR OF SURGERY IN THE PHILADELPHIA POLYCLINIC AND IN THE WOMAN’S MEDICAL 
John B. Roberts, M;D., 
COLLEGE OF PENNSYLVANIA. 
It is ray custom to send word to the relatives or friends, waiting out- 
side the operating-room, that the operation has been concluded as soon 
as I begin to apply the sutures. This is a comforting piece of informa- 
tion to those whose anxiety is, perhaps, not realized by the operators 
and assistants. 
I never leave a patient who has been under ether without first assur- 
ing myself that the pulse is good and seeing that he is conscious, unless 
I leave a competent physician in attendance. The directions for after- 
treatment, unless a trained nurse is present, are usually given in writing 
and in as detailed a manner as possible. 
For the treatment of shock I elevate the foot of the bed, have cans 
or bottles of hot water placed about the body, and, if necessary, admin- 
ister digitalis, atropine, ammonia, or strychnine, either by the mouth or 
hypodermatically. I seldom give any form of alcoholic stimulant during 
or after etherization, because I believe alcohol and ether to be so similar 
in physiological effect that their joint administration is unscientific 
and, perhaps, harmful. An enema or suppository of quinine I often 
use after operation, and sometimes before, to diminish or avert shock. 
In moderate degrees of shock I simply let the patient alone, since time 
is all that is required to restore the functions to their normal vigor. 
Too much is often done in cases of operative or accidental shock, because 
the physician is over-anxious and does not give the system time to react; 
hence the patient is “ inundated ” with broths, milk, coffee, and stimu- 
lants, and, perhaps, poisoned by over-dosing Avith drugs. 
The preliminary hypodermatic injection of morphine and atropine, 
always given a quarter or a half hour before commencing anaesthesia, 
probably lessens the shock, and without much doubt diminishes the tend- 
ency to vomiting after etherization has been discontinued. 
For the nausea and vomiting which occurs after inhalation of ether, 
I usually do nothing except to have the patient’s head so placed that 
any ejected material may easily escape from the mouth. Little actual 
vomiting occurs if the patient has been given the preliminary hypo- 
1 Eead before the Philadelphia Academy of Surgery, November 2, 1891. 2 
ROBERTS, AFTER-TREATMENT IN SURGERY. 
dermatic injection ; and especially so if he has taken no food for several 
hours before the time of operation. The practice of giving drugs to 
combat the vomiting is, I believe, unnecessary and unreasonable, unless 
the vomiting should be prolonged and evidently depressing to the 
patient. Draughts of hot water for the relief of ether vomiting are 
given by some physicians, and in some cases may be desirable, as retch- 
ing when the stomach is empty is often more disagreeable than vomiting 
water which has been put into the stomach. 
I prefer the room kept at a temperature of about 70°, with plenty of 
fresh air so admitted that the patient shall not be directly in a draught. 
Too much air is better than too little. The cold rooms and wards found 
in English homes and hospitals would, however, be objectionable to the 
average American patient. A hygienic rule which gives to every hos- 
pital bed about 100 square feet of floor surface, or about 2000 cubic feet 
of air space, is desirable. In many places it is impossible to procure 
this desirable condition. It is to be recollected that the height of a 
ceiling, without floor space, does not necessarily give good ventilation. I 
always prefer operating in a hospital rather than in a private house, 
since the after-treatment can be much better carried out in a modern 
well-conducted hospital than in any other place. A room in which the 
sun enters is preferable to one on the shady side of the house. It should 
be free from contamination by water-closets or badly-drained washstands. 
I believe that curtains and bed-hangings are not objectionable if the 
operation is conducted and wound-dressings arranged on thorough 
aseptic or antiseptic principles. The absorbent materials employed in 
furnishing our houses are objectionable because they retain dust-particles, 
but this microbe-bearing dust is harmless if it does not come in contact 
with the wound. I frequently say to my students that I would willingly 
operate in an arnpitheatre containing many thousand persons, if the dust 
was not stirred up by draughts and the stamping of feet; provided that 
the seat of operation, my finger-nails, instruments, dressings, and assist- 
ants were thoroughly aseptic or antiseptic. I further believe that pretty 
articles of furniture, pictures, and even flowers, if the odor is not too 
strong, add to the comfort of the patient by diverting his attention from 
himself. Freedom from excitement is desirable during convalescence, 
but the occasional visits of judicious and cheery friends relieve raonotoray 
and do no evil. Such friends bring items of news and interest to the 
invalid which cannot be gotten from those he sees daily. An intelligent 
nurse, previously unknown to the patient, may increase the value of her 
ministrations by a wise exercise of conversational powers. 
The nursing in operative cases should, in my opinion, usually be done 
by someone not connected with the patient by ties of relationship or 
friendship. The ideal attendant, who is calm, deliberate, wise, firm and 
gentle, can do much toward hastening the recovery of the patient, and ROBERTS, AFTER-TREATMENT IN SURGERY. 
3 
certainly adds greatly to his comfort. Ido not consider these qualifica- 
tions to belong to a nurse who takes the temperature every few minutes, 
who uses the catheter every few hours, or who wakens the patient at 
night to ask how he feels. 
It goes without saying, that the excretions and soiled dressings should 
be well disinfected and promptly removed. 
The best posture for the patient after operation depends somewhat on 
the character of the operative procedure to which he has been subjected. 
A comfortable position without causing muscular strain, and the one 
which favors drainage, when that is demanded, is the preferable one. 
It is not necessary that the patient should lie absolutely rigid and motion- 
less upon his back in any case. It is not an uncommon thing for me to 
find that after operation a patient has lain for eighteen or twenty-four 
hours, scarcely moving a muscle, except those of the arras and legs. 
This, practically always, is unnecessary and unreasonable, and is due to 
fear on the part of the patient or nurse. It is sometimes the result of 
unnecessary precautions drilled into nurses’ minds by surgeons after ab- 
dominal operations. The patient can, with safety, be turned a little by 
having a pillow pushed under the hip and shoulder of one side. This 
prop may be changed from one side to the other, at intervals, thus secur- 
ing him much comfort. A change of posture, with or without friction 
of the limbs and trunk with whiskey or alcohol, relieves the points of 
pressure on the mattress, and prevents the muscles from becoming stiff. 
Many patients are not allowed to sit up as soon as they might, and are 
kept in bed far too long. Amputation of a breast with clearing out of 
the axilla, for instance, is not a cause for retaining the patient long in 
bed. In such a case there is no objection to the patient sitting up on 
the second day, or going about the house and garden in two or three 
days, if the temperature and pulse are normal. Of course, this matter 
must necessarily be varied with the character of the operation, the 
course of the case, and the temperament of the patient. lam convinced, 
however, that too many restrictions are often put upon patients because 
of the traditions of surgeons before the aseptic era. 
Many cases need little or no medicinal treatment subsequent to opera- 
tion, The wound, if it continues free from suppurative or septic infec- 
tion and is not irritated by too tight sutures, is practically painless. 
The immediate smarting of the wound, often very slight and at times 
altogether absent, is to a great degree avoided by the preliminary hypo- 
dermatic injection of morphine and atropine. Acute pain after operation 
usually means that the sutures are too tight, the dressings badly applied, 
or that the wound is not free from bacterial infection. 
Because of the discomfort occasioned by the surroundings and the 
restraint of the dressings, and because of the nerve strain of the day, I, 
as a rule, give bromide of potassium and chloral toward bedtime of the 4 
ROBERTS, AFTER-TREATMENT IN SURGERY. 
day of operation, and, perhaps, also the next night. I usually give 
forty grains of potassium bromide and fifteen or twenty grains of chloral- 
Sometimes it is necessary to repeat this dose once or twice during the 
night, at intervals of about an hour. This anodyne I administer more 
for the purpose of allaying the nervous excitement than because there 
is actual pain. It has not the objection of morphine, which diminishes 
the secretions, constipates the bowels, and impairs the appetite. 
Ordinary cases need no other medicinal treatment, except an occa- 
sional laxative to keep the bowels open. I agree with Dr. Agnew, a 
former president of this Academy, who says: “So long, however, as a 
patient is doing well, drugs are an impertinence.” 
If there has been much bleeding, I give iron and quinine as a tonic, 
and occasionally I use these drugs as a placebo when there has been no 
special hemorrhage. Opiates are always to be avoided in the after- 
treatment, if possible. The stress recently laid upon this point by ab- 
dominal operators is simply an axiom of good general surgery which I 
have long followed. The use of frequent doses of opiates indicates in 
most medical and surgical conditions an unwise physician or surgeon. 
Their administration masks symptoms, interferes with secretion, and is 
liable to establish the opium habit. If lam obliged to use morphine or 
opium, I do not give it hypodermatically, as this method is the most 
seductive. The name of the drug used is not mentioned in the patient's 
hearing. 
The various antipyretics now so fashionable, I practically never use. 
The elevation of temperature, which occurs in aseptic cases within about 
thirty-six hours after operation, which is supposed to be due to absorption 
of fibrin ferment, needs no treatment; nor does fever resulting from 
nervous excitement. A rise of temperature presumably due to septic 
changes in the wound is to be treated by renewal of the dressings, irri- 
gation of the wound, cutting of sutures, or cleansing of drainage-tube 
rather than by medicines which act simply by depressing the temper- 
ature. They afford the surgeon a false sense of security and may mask 
the true condition of the wound. Like opiates, they conceal truth, per- 
turb the normal functions, and simply combat a symptom which is 
meant by Nature to call the surgeon’s attention to the fact that his work 
needs revision. 
A smoker may be allowed his cigar a few hours after operation, unless 
there is special objection to its action upon his nervous system. A cigar, 
when the patient is accustomed to the use of tobacco, will often take the 
place of an anodyne. 
The bladder must be emptied and the bowels opened, of course, and 
I make it a rule to especially inquire, of both patient and nurse, as to 
these matters. There is no need, in most cases, however, of a nurse 
catheterizing a patient within a few hours after operation. Retention of ROBERTS, AFTER-TREATMENT IN SURGERY. 
5 
the urine for twelve or fifteen hours will, in ordinary eases, do no harm, 
and the early use of a catheter, except, perhaps, in abdominal operations, 
is an unnecessary annoyance, and a discomfort to the patient. It is, 
also, liable to make necessary the frequent use of the catheter when such 
necessity would not have arisen if the urine had not been drawn for the 
first time. 
The question of diet is an important one, as to which surgeons vary 
very much in practice. Ordinarily, I allow no food for six or eight 
hours after the recovery from etherization, and I instruct the friends of 
the patient that no harm will be done if food is not taken until the next 
day. In abdominal cases I insist that no food whatever shall be taken 
for at least twenty-four hours. I usually prescribe milk and broth as 
the diet for the first few days, but I rather avoid milk in abdominal 
cases. I rarely use extracts of beef or any of the pre-digested foods; 
but this, perhaps, is due more to the fact that I find milk or broth made 
in the household quite sufficient for my purpose, than that I have any 
objection to these articles. 
A liberal diet of easily digested food, such as milk, toast, baked pota- 
toes, and light puddings, is not objectionable after three or four days; 
in truth, I defer a great deal to the patient’s wishes and taste in this 
particular. The old idea that patients must be half starved to prevent 
inflammation, is erroneous, since any violent inflammation which occurs 
subsequent to operation is practically always mycotic. 
In the American edition of Druitt’s Surgery, of 1887, appears the fol- 
lowing remarkable statement: “ When septic inflammation is to be 
found, starvation diet may be a very important preventive, as it seems 
to be in compound injuries of the skull.” This relic of ancient surgery, 
which it surprises me to find in a book published so recently, is, I fear, 
accepted by not a few operators to this day. 
Sucking ice does not allay thirst as quickly as water, A large amount 
of water may be given if it is administered in comparatively small 
quantities at a time. Intensely cold water is, of course, objectionable. 
The administration of water is especially necessary if there has been 
much bleeding during or before the operation. Patients are often dis- 
tressed by the enforced absence from water at times insisted upon by 
the attendant during the first few days after an operation. 
Alcoholic stimulants are used by me to a very limited degree in the 
after-treatment of operations, as I believe they are frequently given in 
larger quantities and oftener than is at all necessary. The practice of 
giving all surgical patients milk punch or wine-whey is reprehensible. 
In large wounds I generally remove the first dressings at the end of 
twenty-four hours, because of the oozing which usually takes place. 
If the wound has been washed or irrigated with antiseptic solutions, 
the oozing is liable to be abundant and saturates many thick- 6 
ROBERTS, AFTER-TREATMENT IN SURGERY. 
nesses of gauze. The removal of the soiled dressings at this time 
enables me to apply clean antiseptic gauze, to cut tight sutures, if any 
be too tight, and to take out a drainage-tube if there is no further use 
for it. In addition to this, it allows the dressings to be applied more 
neatly and satisfactorily than can be done when the patient is recover- 
ing from etherization. If the wound is one in which little oozing is 
expected, no change is made in the dressing at this time; and in all 
cases no change in the dressings is made after the first twenty-four 
hours, unless a rise in temperature, discomfort of the patient, or soaking 
of the discharge to the surface indicates a necessity for so doing. Tl)e Al]Qeri Joiirijal 
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