than blood-letting. A given quantity should be drawn, and the same quantity of normal salt solution be ready with proper instruments to be returned into the vein from which the blood. is drawn. The normal salt solution will aid us by its physiological stimulation, as well as its physical action by flushing out the system.

5. To avoid and care for complications. The complications. coming in the scope of this paper will be where the membrane begins in the larynx (laryngeal diphtheria), or where it extends downward. If these conditions cannot be met by the timely treatment outlined above, we may give an occasional emetic for its mechanical effect in removing the membrane. Our last resort will be intubation and tracheotomy. Such complications as lobular pneumonia, neuritis, nephritis, heart failure, etc., now become new diseases, and must be treated of under their respective heads, and do not fall under the scope of this article.

PREPARATION OF THE PATIENT FOR
SURGICAL OPERATION.

Anesthesia and the Prevention of Shock.*

BY STEPHEN E. RICE, M.D.

MEMPHIS.

PREPARATION of the patient includes—

1. General measures directed to building up the patient. 2. Local measures to render the field of operation aseptic. In the first place we must understand our patient thoroughly. A systematic examination of all the organs should be made, with especial attention directed to those points which a consideration of the family and previous personal history would lead us to suspect. The mental condition should be considered, so that any deviation from normal may receive our attention in time to avoid a post-operative dementia. If there is a disposition to melancholy, a short period among bright, happy scenes may restore to normal. Perhaps there is hysteria; then quiet and repose are indicated. The heart, lungs, spleen and

* Read before the Memphis Medical Society, January 21, 1902.

liver are carefully examined, and if diseased, or their function disturbed, appropriate remedies are prescribed. A subacute bronchitis or area of delayed resolution in the lungs should postpone the operation for several weeks to test a course of alteratives; if there is failing compensation, as denoted by a weak pulse and sluggish capillary circulation, a period of rest will steady the heart and enable it to stand the shock of operation; if the spleen is markedly enlarged, as is not infrequently the case in this climate, a prolonged course of arsenic should be given, and in some cases a month or so should be spent in a higher altitude. In considering the liver, we not only take into consideration the size as indicated by palpation and percussion, but whether the bile it secretes is poured out in a normal quantity into the intestines; we may judge of this by the color and condition of the feces and the presence or absence of fermentative gases in the bowel. When not conducted into the intestines in proper quantity, it is taken up by the blood and eliminated by the kidneys, so that we have a ready chemical test to determine if the liver is acting properly; if we can find a trace of bile in the urine, it indicates that the liver is not acting well.

Dr. Augustin Goelet suggests that as long as the addition of a few drops of c. p. nitric acid to urine causes a yellowish or brownish discoloration, the operation should be delayed, and active cholagogue cathartics administered, contending that a proper discharge of bile into the intestines is essential not only to render the tract aseptic, and thus avoid gaseous distension during and after operation, but also as a preventive of many of the unpleasant effects of the anesthesia. He attributes attacks of syncope and sudden arrest of respiration during anesthesia to improper preparation in this direction. He also considers prolonged nausea and headaches following the anesthesia to be due to the same cause.

For the condition of the kidneys, we depend entirely on the urinalysis. Tests should be made for albumin and sugar, the reaction, specific gravity, and the quantity of urea passed in twenty-four hours; also a microscopical examination for pus, blood, and epithelium and tube casts. If the results of examination indicate an acute nephritis, rest, diet and treatment

should be prescribed until the acute symptoms have abated. Of course we cannot hope to get rid of a chronic nephritis, nor frequently of all evidence of an acute attack, but if there is deficient excretion of urea, with or without organic lesion, we must delay operation until proper treatment has restored the normal function and tone of the organ. In other words, an organic lesion does not necessarily contraindicate operating, but a serious functional disorder is an absolute contraindication for the time it exists, save for those in extremis.

Now, having assured ourselves that every essential organ is acting satisfactorily, we may proceed to certain general rules for governing the last three or four days prior to operating. Each day an active cathartic sufficient to produce two free movements should be given, and in the evening preceding the operation the lower bowel should be washed out thoroughly with a copious warm water enema. The diet should be regulated; foods that ferment readily, such as sweets and starches, and those that have a bulky residue, should be eliminated.

We desire to have the intestines flat and empty of both food and gas at the time of operation; so if in spite of a carefully regulated diet, free catharsis, and an active liver, some distension persists, it is well to give an intestinal antiseptic, such as betanaphthol or bismuth salicylate, three or four times a day, and at the same time use a large high rectal enema containing turpentine or asafetida once daily, until the abdomen becomes flat and soft.

Only soft or liquid food, according to the patient's strength, should be given on the day preceding the operation, and nothing within six hours of the time of operating.

The skin should be given especial attention as an important organ of elimination, sponge baths once daily, either hot or cold, according to the patient's temperament, and where possible, massage and occasional applications of a mild faradie current will bring about free action of the skin glands and thus relieve much of the strain on the kidneys during the period of severe depression immediately following operation, when life and death are so evenly balanced that every grain of poison promptly removed by active organs of elimination

is equal in value to two grains of stimulus, for it removes the clog from a struggling heart when stimulation would but embarrass the more.

The measures I have considered heretofore have been directed to building up the vitality of the patient for the purpose of overcoming the shock of operation, and for resisting the invasion of microorganisms should they be present. We will now consider the means by which we can remove or destroy these microorganisms, so that the field of operation will be aseptic. The patient should have no suppurating areas on the skin; should be given a tub bath on two successive days in hot water, and should be well scrubbed with aseptic soap. The soap is one of the hardest things about an operating room to maintain sterile; the only satisfactory plan I have used is to keep a sterilized liquid soap in a 3 or 4-ounce bottle with a stellichoute stopper, which permits of shaking out a small quantity without contaminating the rest. The method of dipping soiled fingers into a bowl of soap is very objectionable. On the day preceding operation, if the field of operation includes a growth of hair, this should be shaved off smoothly and an aseptic soap plaster applied for two hours. The plaster is then removed and the parts thoroughly scrubbed with hot water and a good stiff brush. The object of this is to soften the cuticle and remove the upper layer with the dirt, grease and disease germs it always harbors; alcohol and then ether is poured on to dissolve out any particles of grease left from the scrubbing, and finally a douching and rubbing with 1-3000 bichlorid of mercury or some other active antiseptic, to destroy the organisms left exposed by the scrubbing. It is almost impossible to remove all microorganisms by mechanical means, they burrow so deeply into the tissues, so it is necessary to supplement our cleansing processes with an active germicide which will destroy most of the organisms and inhibit the development of others.

Finally, a gauze pad saturated in 1-3000 bichlorid of mercury is placed over the surface prepared and held in position until the patient is brought to the operating table. Then, if we feel satisfied that it has remained undisturbed, it is removed, the parts rinsed with sterilized water to remove the mercury,

then with alcohol, and again with sterilized water, and the operation may begin. If there is any doubt of the bichlorid pad having been misplaced, it would be well to scrub with sterile soap and water, rinse with alcohol and then with sterilized water.

As far as the shock of an operation is concerned, one of the best preventives is a thorough preliminary improvement of the patient's health. The operation should be conducted as promptly as possible, and care should be exercised to prevent undue traumatism. Vital parts should not be left exposed to the air, but wrapped in towels wrung out of hot water. The parts of body not being operated on should be kept well covered, and if necessary hot bags or bottles applied to maintain warmth. It is well to give grain strychnin sulphate at the beginning and repeat every twenty or thirty minutes. during the operation, and if the pulse or respiration flags it may be given in larger quantities with other stimulants. Possibly the best stimulant for the depression of a prolonged or severe operation is saline hypodermoclysis, both to maintain strength and to promote reaction. The temperature of the room should be around 75°F. Even though somewhat warm for the operator, it is best for the patient.

In regard to the anesthetic, I shall not start a discussion into the relative merits of chloroform and ether. It has been threshed over so often that it would not be profitable. I use ether unless there is a distinct contraindication, as in atheroma, bronchitis or nephritis, when I operate hurriedly and do not have time to examine into the condition of the kidneys, and also when the anesthetist has never given ether but is experienced in the use of chloroform.

There are several important points to note in the administration of any anesthetic. First of all, the anesthetist should understand the physiological effects of the anesthetic in its various stages; he should give his entire attention to watching these effects so that he may have the patient thoroughly insensible during the course of the operation, and yet by knowing and regarding the symptoms of approaching danger, not push beyond the second stage. The anesthetist should be entirely responsible for the condition of the patient during